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Mustafa HJ, Aghajani F, Patrick E, Baerz MM, Arias‐Sánchez P, Khalil A. Perinatal outcomes following fetoscopic laser surgery for early twin-to-twin transfusion syndrome: Systematic review and meta-analysis. Acta Obstet Gynecol Scand 2024; 103:824-831. [PMID: 38415823 PMCID: PMC11019523 DOI: 10.1111/aogs.14806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 01/08/2024] [Accepted: 01/31/2024] [Indexed: 02/29/2024]
Abstract
INTRODUCTION Our objective was to investigate outcomes in twin-to-twin transfusion syndrome (TTTS) treated with fetoscopic laser surgery (FLS) at <18 weeks vs ≥18 weeks, and to conduct subgroup analysis of TTTS with FLS at <16 weeks vs 16-18 weeks. MATERIAL AND METHODS PubMed, Scopus and Web of Science were searched systematically from inception until May 2023. Primary outcome was survival, and secondary outcomes included preterm premature rupture of membranes (PPROM), preterm birth and gestational age (GA) at delivery. RESULTS Nine studies encompassing 1691 TTTS pregnancies were included. TTTS stage III was significantly more common in TTTS pregnancies treated with FLS at <18 weeks (odds ratio [OR] 2.84, 95% confidence interval [CI] 1.24-6.54), and procedure duration was shorter at <18 weeks (MD -5.27 minutes, 95% CI -9.19 to -1.34). GA at delivery was significantly earlier in TTTS pregnancies treated with FLS at <18 weeks (MD -3.12 weeks, 95% CI -6.11 to -0.13). There were no significant differences in outcomes, including PPROM, PPROM at <7 days post-FLS, preterm birth at <28 and <32 weeks, delivery at <7 days post-FLS, and survival outcomes, including fetal demise, live birth and neonatal survival. Similarly, TTTS stage III was more common in TTTS with FLS at <16 weeks than at 16-18 weeks (OR 2.95, 95% CI 1.62-5.35), with no significant differences in the aforementioned outcomes. CONCLUSIONS In early TTTS treated with FLS, outcomes were comparable between those treated at <18 weeks compared with ≥18 weeks except for GA at delivery, which was 3 weeks earlier. In the subset treated at <16 weeks vs 16-18 weeks, the procedure was feasible without an increased risk of very early preterm birth or perinatal mortality.
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Affiliation(s)
- Hiba J. Mustafa
- Division of Maternal‐Fetal MedicineIndiana University School of MedicineIndianapolisIndianaUSA
- The Fetal Center at Riley Children's and Indiana University HealthIndianapolisIndianaUSA
| | - Faezeh Aghajani
- BCNatal Fetal Medicine Research Center, Hospital Clínic and Hospital Sant Joan de DéuUniversitat de BarcelonaBarcelonaSpain
| | - Elise Patrick
- Indiana University School of MedicineIndianapolisIndianaUSA
| | - Maryam M. Baerz
- School of MedicineIran University of Medical SciencesTehranIran
| | | | - Asma Khalil
- Fetal Medicine Unit, St George's HospitalSt George's University of LondonLondonUK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research InstituteSt George's University of LondonLondonUK
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Cruz-Martínez R, Gil-Pugliese S, Enciso-Meraz JM, Villalobos-Gómez R, López-Briones H, Martínez-Rodríguez M, Bermúdez-Rojas MDLL, Medina-Jiménez V, Coronel-Cruz F, Pineda-Alemán H, García-Espinosa M, Helue-Mena A, Márquez-Dávila A, Gutiérrez-Gómez I, Chávez-González E, Rebolledo-Fernández C. Management of Late Twin-to-Twin Transfusion Syndrome beyond 26 Weeks: Comparison between Fetoscopic Laser Therapy versus Traditional Management. Fetal Diagn Ther 2023; 50:464-471. [PMID: 37517395 DOI: 10.1159/000533202] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 07/14/2023] [Indexed: 08/01/2023]
Abstract
INTRODUCTION A proportion of monochorionic diamniotic (MCDA) twin pregnancies complicated by twin-to-twin transfusion syndrome (TTTS) can present after 26 weeks of gestation. The aim of this study was to compare perinatal outcomes of late TTTS treated by fetoscopic laser coagulation versus traditional management with amniodrainage and/or emergency preterm cesarean delivery (CD). METHODS Retrospective cohort from January 2012 to January 2023 of consecutive MCDA twin pregnancies complicated by TTTS after 26 weeks and evaluated in our referring centers. We analyzed perinatal outcomes of cases treated with fetoscopic laser surgery at our national referral fetal surgery center in Queretaro, Mexico, and compared them with those managed with traditional management (amniodrainage and/or emergency preterm CD). The primary outcome was survival at discharge and the secondary outcome was gestational age (GA) at birth. RESULTS Among the study population, 46 TTTS cases were treated by fetoscopy at 27+6 (26+0-31+0) weeks+days and were compared with a group of 39 cases who underwent emergency preterm CD. In comparison to the group who underwent traditional management, the group treated by laser fetoscopy showed a significantly higher GA at birth (32+3 vs. 29+1 weeks+days, p < 0.001), lower frequency of preterm delivery below 37 weeks (91.3% vs. 100%, p = 0.06), 34 weeks (63.0% vs. 100%, p < 0.001), 32 weeks (50% vs. 74.4%, p = 0.02), or 30 weeks (28.3% vs. 53.8%, p = 0.01), and significantly higher perinatal survival (89.1% vs. 71.8%, p < 0.05 of at least one twin; and 65.2% vs. 38.5%, p = 0.01 of both twins, respectively). CONCLUSION MCDA twins complicated with TTTS can be treated with fetoscopic laser surgery between 26 and 31 weeks of gestation, which is a feasible and safe option, and such cases are associated with a higher GA at birth and better perinatal survival than those managed with amniodrainage and/or emergency preterm CD.
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Affiliation(s)
- Rogelio Cruz-Martínez
- Departament of Maternal-Fetal Medicine, Children's Women's Specialty Hospital "Dr. Felipe Núñez Lara", Queretaro, Mexico
- Fetal Medicine and Surgery Center, Fetal Medicine Mexico Institute, and Fetal Medicine Mexico Foundation, Guadalajara, Mexico
| | - Savino Gil-Pugliese
- Fetal Medicine and Surgery Center, Fetal Medicine Mexico Institute, and Fetal Medicine Mexico Foundation, Guadalajara, Mexico
| | - Juan Manuel Enciso-Meraz
- Department of Maternal-Fetal Medicine, Western National Medical Center, Mexican Institute of Social Security (IMSS), Guadalajara, Mexico
| | - Rosa Villalobos-Gómez
- Fetal Medicine and Surgery Center, Fetal Medicine Mexico Institute, and Fetal Medicine Mexico Foundation, Guadalajara, Mexico
| | - Hugo López-Briones
- Fetal Medicine and Surgery Center, Fetal Medicine Mexico Institute, and Fetal Medicine Mexico Foundation, Guadalajara, Mexico
| | - Miguel Martínez-Rodríguez
- Departament of Maternal-Fetal Medicine, Children's Women's Specialty Hospital "Dr. Felipe Núñez Lara", Queretaro, Mexico
- Fetal Medicine and Surgery Center, Fetal Medicine Mexico Institute, and Fetal Medicine Mexico Foundation, Guadalajara, Mexico
| | | | - Virginia Medina-Jiménez
- State Center for Timely Prenatal Screening, Maternal, and Child Hospital Specialty, Leon, Mexico
| | - Fausto Coronel-Cruz
- Department of Maternal-Fetal Medicine, General Hospital of Mexico "Dr. Eduardo Liceaga", Mexico City, Mexico
| | - Hugo Pineda-Alemán
- Fetal Medicine and Surgery Center, Fetal Medicine Mexico Institute, and Fetal Medicine Mexico Foundation, Guadalajara, Mexico
| | - Maritza García-Espinosa
- Department of Maternal-Fetal Medicine, High Specialty Medical Unit Gineco Obstetrics Hospital No. 4, Mexican Institute of Social Security (IMSS), Mexico City, Mexico
| | - Antonio Helue-Mena
- Department of Maternal-Fetal Medicine, National Medical Center "La Raza", Mexican Institute of Social Security (IMSS), Mexico City, Mexico
| | - Alejandra Márquez-Dávila
- Fetal Medicine and Surgery Center, Fetal Medicine Mexico Institute, and Fetal Medicine Mexico Foundation, Guadalajara, Mexico
- Department of Maternal-Fetal Medicine, National Medical Center "La Raza", Mexican Institute of Social Security (IMSS), Mexico City, Mexico
| | - Iván Gutiérrez-Gómez
- Department of Maternal-Fetal Medicine, National Medical Center "La Raza", Mexican Institute of Social Security (IMSS), Mexico City, Mexico
| | - Eréndira Chávez-González
- Fetal Medicine and Surgery Center, Fetal Medicine Mexico Institute, and Fetal Medicine Mexico Foundation, Guadalajara, Mexico
- Division of Health Sciences, Department of Biomedical Sciences, Tonala Center, University of Guadalajara, Guadalajara, Mexico
| | - Carlos Rebolledo-Fernández
- Departament of Maternal-Fetal Medicine, Children's Women's Specialty Hospital "Dr. Felipe Núñez Lara", Queretaro, Mexico
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Oliver E, Navaratnam K, Gent J, Khalil A, Sharp A. Comparison of International Guidelines on the Management of Twin Pregnancy. Eur J Obstet Gynecol Reprod Biol 2023; 285:97-104. [PMID: 37087836 DOI: 10.1016/j.ejogrb.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/28/2023] [Accepted: 04/04/2023] [Indexed: 04/09/2023]
Abstract
OBJECTIVES To review current international clinical guidelines on the antenatal and intrapartum management of twin pregnancies, examining areas of consensus and conflict. METHODS We conducted a database search using Medline, Pubmed, Scopus, Academic Search Complete, CINAHL and ERCI Guidelines website. Guidelines were screened for eligibility using our inclusion and exclusion criteria. Those deemed eligible were quality assessed using the AGREE II tool and relevant data was extracted. RESULTS We identified 21 relevant guidelines from 16 countries including two international society guidelines. There was consensus in determination of chorionicity and amnionicity within the first trimester, fetal anomaly scan between 18 and 22 weeks and the recommended screening for twin-to-twin transfusion syndrome (TTTS). For those that provided intrapartum guidance, there was agreement in recommending caesarean section to deliver monochorionic monoamniotic (MCMA) twins, epidural anaesthesia for intrapartum analgesia and the use of cardiotocography (CTG) for intrapartum fetal monitoring. The main areas of conflict included cervical length screening, frequency of ultrasound surveillance, timing of delivery of dichorionic twin pregnancies and circumstances for recommending vaginal delivery. There was a lack of advice on intrapartum management. CONCLUSIONS This review has highlighted the need for unified international guidance on the management of twin pregnancy. Comparisons of current guidance demonstrates a lack of confidence in the management of labour in twin pregnancies. Further evidence on intrapartum care of twin pregnancies is needed to inform practice guidelines and improve both short and long term maternal and fetal outcomes.
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Takano M, Nakata M, Ishii K, Wada S, Sumie M, Yamamoto R, Ozawa K, Sakuma J, Nagasaki S, Sago H. Outcomes of fetoscopic laser surgery for twin-to-twin transfusion syndrome between 26 and 27 weeks of gestation in Japan. J Obstet Gynaecol Res 2021; 47:3821-3827. [PMID: 34227180 DOI: 10.1111/jog.14922] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 06/09/2021] [Accepted: 06/26/2021] [Indexed: 12/31/2022]
Abstract
AIM The purpose of this study was to investigate the outcomes of fetoscopic laser photocoagulation (FLP) for twin-to-twin transfusion syndrome (TTTS) in Japan. METHODS The retrospective cohort study (2012-2018) was conducted in monochorionic twin pregnancies that underwent FLP for TTTS between 26 and 27 weeks from 2012 to 2018. The perioperative data, maternal complications, gestational age (GA) at delivery, neonatal complications, and survival of infants at 28 days of age were analyzed. At term-equivalent age, severe neurological complications were identified by imaging study. RESULTS Of 644 patients, 28 (4.3%) underwent FLP between 26 and 27 weeks, and 26 were analyzed. FLP procedures were technically successful in all cases. There were no cases of major maternal complications after surgery. Preterm rupture of membranes occurred in 34.6% of cases, and the mean GA at delivery was 33.2 ± 3.1 weeks. The survival of both twins was found in 23 (88.4%) cases, and the perinatal survival rate of at least one twin at 28 days of age was 100%. Severe neurological complications were found in six (12.2%) cases out of 49. CONCLUSIONS FLP for TTTS between 26 and 27 weeks provided a good prognosis and caused no major maternal complications. However, severe neurological findings were found in 12% of infants.
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Affiliation(s)
- Mayumi Takano
- Department of Obstetrics and Gynecology, Toho University Faculty of Medicine, Tokyo, Japan.,Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - Masahiko Nakata
- Department of Obstetrics and Gynecology, Toho University Faculty of Medicine, Tokyo, Japan.,Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - Keisuke Ishii
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Seiji Wada
- Division of Fetal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Masahiro Sumie
- Department of Obstetrics, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Ryo Yamamoto
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Katsusuke Ozawa
- Division of Fetal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Junya Sakuma
- Department of Obstetrics and Gynecology, Toho University Faculty of Medicine, Tokyo, Japan.,Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - Sumito Nagasaki
- Department of Obstetrics and Gynecology, Toho University Faculty of Medicine, Tokyo, Japan.,Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - Haruhiko Sago
- Division of Fetal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
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Spruijt MS, Lopriore E, J Steggerda S, Slaghekke F, Van Klink JMM. Twin-twin transfusion syndrome in the era of fetoscopic laser surgery: antenatal management, neonatal outcome and beyond. Expert Rev Hematol 2020; 13:259-267. [PMID: 31971028 DOI: 10.1080/17474086.2020.1720643] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Introduction: Twin-twin transfusion syndrome (TTTS) is a devastating complication of monochorionic twin pregnancy and remains a major challenge for worldwide fetal medicine specialists. In TTTS, intertwin transfusion through vascular anastomoses in the shared placenta leads to severe hemodynamic imbalance. This review summarizes the current knowledge of TTTS.Areas covered: The most recent insights concerning the management of TTTS, as well as fetal and neonatal complications are described. Relevant articles were selected based on a Pubmed search using the keywords below. Understanding of the underlying pathophysiology has improved greatly as a result of placental injection studies. Advancements in antenatal management have led to increased perinatal survival and a decreased incidence of neonatal complications, including brain injury and neurodevelopmental impairment.Expert opinion: Further opportunities for improvement comprise technological innovations in laser procedures and the prevention of preterm rupture of membranes with subsequent prematurity. A noninvasive treatment such as high-intensity focused ultrasound (HIFU) seems to hold promise for the future treatment of TTTS. Fetal MRI studies are important to improve our understanding of fetal brain injury and should relate their findings to long-term neurodevelopment. International collaboration and centralization of care are of paramount importance to ensure the best care for our patients.
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Affiliation(s)
- Marjolijn S Spruijt
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Enrico Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Sylke J Steggerda
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Femke Slaghekke
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeanine M M Van Klink
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
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Early postnatal cardiac manifestations are associated with perinatal brain injury in preterm infants with twin to twin transfusion syndrome. Sci Rep 2019; 9:18505. [PMID: 31811241 PMCID: PMC6898644 DOI: 10.1038/s41598-019-54951-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 11/12/2019] [Indexed: 11/09/2022] Open
Abstract
Altered hemodynamics associated with twin to twin transfusion syndrome (TTTS) can be manifested in the fetal and neonatal heart. This study evaluated the association between cardiac manifestations immediately after birth and brain injury in preterm infants with TTTS. Medical records of preterm infants who were born at <35 weeks of gestation with TTTS and admitted to the neonatal intensive care unit at Seoul National University Children's Hospital between January 2011 and January 2018 were reviewed. TTTS was prenatally diagnosed and staged according to the Quintero criteria. Echocardiographic findings, brain ultrasound and MRI imaging findings were analyzed. Fifty-three infants were enrolled in this study. Thirty-two infants (60.3%) were treated by fetoscopic laser coagulation. Brain injury developed in 15 infants (28.3%). Hypotension within the first week and immediate postnatal cardiac manifestations were more prevalent in the brain injury group. In the multivariate analysis, acute kidney injury and cardiac manifestations, such as ventricular dysfunction and tricuspid regurgitation, were statistically associated with brain injury in the study population. Immediate postnatal cardiac manifestations, such as ventricular dysfunction and tricuspid regurgitation, can serve as surrogate markers for perinatal hemodynamic disturbance, which are associated with early neonatal brain injury in preterm infants with TTTS.
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Nicholas LD, Fischbein RL, Bhamidipalli SS. Twin anemia-polycythemia sequence and routine monitoring practices amongst maternal-fetal medicine specialists in the United States: an initial investigation. J Perinat Med 2019; 47:388-392. [PMID: 30763267 DOI: 10.1515/jpm-2018-0240] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 12/30/2018] [Indexed: 01/08/2023]
Abstract
Background The purpose of this initial investigation was to begin to understand the routine twin anemia-polycythemia sequence (TAPS) monitoring practices of maternal-fetal medicine specialists (MFM specialists) in the United States in the absence of a formal guideline. Methods This study used an anonymous, online survey of 90 MFM specialists who were practicing in the United States. A $5 gift card to an online store was used to incentivize participants. Descriptive statistics were calculated. Results All MFM specialists reported at least some familiarity (100.00%) with TAPS. Most participants (92.94%) were familiar with methods for monitoring patients for TAPS and nearly all (97.50%) responded that they use 'Doppler MCA-PSV' to make a prenatal TAPS diagnosis. Nearly two-thirds of MFM specialists surveyed (65.06%) reported performing regular TAPS monitoring for patients with monochorionic-diamniotic (MCDA) pregnancies. Conclusion Despite no formal guidelines, the majority of American MFM specialists surveyed are using routine TAPS screening in their management of MCDA twin pregnancies, suggesting that the MFM specialists included in this study consider it a valuable diagnostic tool. Future research should further explore this possible trend toward routine TAPS monitoring amongst MFM specialists in the United States, as well as the potential value of routine TAPS monitoring in MCDA pregnancy.
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Affiliation(s)
- Lauren D Nicholas
- Department of Liberal Arts, Social Sciences Program, D'Youville College, 591 Niagara Street, Buffalo, New York, NY 14201, USA
| | - Rebecca L Fischbein
- Department of Family and Community Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
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Abstract
PURPOSE To present a case of twin-to-twin transfusion syndrome (TTTS), followed by discussion of the etiology, pathophysiology, prenatal diagnosis, management, complications, prognosis, and family considerations. METHODS A literature review was conducted using MEDLINE, PubMed, CINAHL, ProQuest, and Google Scholar. The search resulted in 593 articles; 25 relevant articles were chosen. RESULTS Approximately 1 of every 250 cases of monochorionic twins acquire TTTS. The progression of TTTS is unpredictable; nontreatment and early onset have been associated with >90 percent mortality of both twins. Neurodevelopmental impairment, preterm birth, renal hypoperfusion, growth restriction, cardiomyopathy, and hydrops fetalis have been associated with TTTS. LIMITATIONS A paucity of research and case reports exists, limiting recommendations for optimal diagnosis, management, and treatment regimens. IMPLICATIONS FOR PRACTICE TTTS is unpredictable in progression; earlier identification of chorionicity, diagnosis of TTTS, and improvement of treatment and management have the potential to improve the mortality and morbidity outcomes associated with TTTS.
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Djaafri F, Stirnemann J, Mediouni I, Colmant C, Ville Y. Twin-twin transfusion syndrome - What we have learned from clinical trials. Semin Fetal Neonatal Med 2017; 22:367-375. [PMID: 29122542 DOI: 10.1016/j.siny.2017.08.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Monochorionic twin pregnancies are at increased risk for adverse outcome compared to dichorionic twin pregnancies and singletons. Monochorionic-specific complications include twin-twin transfusion syndrome (TTTS), twin anemia-polycythemia sequence, single intrauterine fetal demise and its consequences on the co-twin, and selective intrauterine growth restriction. Whereas the natural history of monochorionic-specific complications carries a high risk of fetal death or severe neurologic disability, a framework now exists, based on well-designed clinical trials, for optimal treatment of these entities. Fetoscopic selective laser coagulation of anastomotic vessels on the chorionic plate has been clearly demonstrated to improve survival and neurologic outcomes for Quintero stage ≥2 TTTS. However, many challenges remain unsolved, the most important of which is preterm premature rupture of membranes. Further improvement in the outcomes of monochorionic pregnancies will require improvements in the rate of premature delivery, and improved diagnosis and treatment strategies for early and late onset TTTS.
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Affiliation(s)
- Fatiha Djaafri
- Obstetrics and Maternal-Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France
| | - Julien Stirnemann
- Obstetrics and Maternal-Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France; EA7328, Faculté de Medicine Paris Descartes, Paris, France
| | - Imen Mediouni
- Obstetrics and Maternal-Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France
| | - Claire Colmant
- Obstetrics and Maternal-Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France
| | - Yves Ville
- Obstetrics and Maternal-Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France; EA7328, Faculté de Medicine Paris Descartes, Paris, France.
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Spruijt MS, Tameeris E, Zhao DP, Middeldorp JM, Haak MC, Oepkes D, Lopriore E. Incidence and Causes of Intentional Fetal or Neonatal Demise in Twin-Twin Transfusion Syndrome. Fetal Diagn Ther 2017; 43:19-25. [PMID: 28285310 DOI: 10.1159/000461580] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 02/08/2017] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The aim of this study is to evaluate the incidence and causes of intentional fetal and neonatal demise in twin-twin transfusion syndrome (TTTS). MATERIAL AND METHODS All TTTS pregnancies managed at our centre between 2000 and 2014 were included. We evaluated incidence and causes of intentional fetal/neonatal demise, defined as termination of pregnancy, selective fetal reduction, or withdrawal of neonatal intensive care. RESULTS Intentional fetal/neonatal demise occurred in 9.8% (110/1,122) of fetuses and was due to termination of pregnancy (2.2%), selective fetal reduction (4.2%), or withdrawal of neonatal intensive care (3.4%). Reasons for termination of pregnancy included complications of laser treatment (72.0%), severe fetal anomaly (20.0%), and unwanted pregnancy (8.0%). Reasons for selective fetal reduction were technical difficulties to perform laser surgery (51.1%), fetal complications (38.3%), and parental preference for fetal reduction rather than laser treatment (10.6%). Reasons for withdrawal of neonatal intensive care treatment were severe cerebral injury (47.4%), severe pulmonary complications (15.8%), birth asphyxia (5.3%), multiple complications of TTTS and/or prematurity combined (21.1%), or other (10.5%). CONCLUSIONS Intentional fetal or neonatal demise in TTTS occurs frequently and is often due to complications after laser surgery and/or severe (cerebral) injury in affected fetuses or neonates.
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Affiliation(s)
- Marjolijn S Spruijt
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Centre, Leiden, The Netherlands
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Loureiro B, Martinez-Biarge M, Foti F, Papadaki M, Cowan FM, Wusthoff CJ. MRI Patterns of brain injury and neurodevelopmental outcomes in neonates with severe anaemia at birth. Early Hum Dev 2017; 105:17-22. [PMID: 28107673 DOI: 10.1016/j.earlhumdev.2017.01.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 12/31/2016] [Accepted: 01/04/2017] [Indexed: 10/20/2022]
Abstract
AIMS To define patterns of brain injury and associated neurodevelopmental outcomes in infants with severe neonatal anaemia. METHODS We studied 20 infants with severe anaemia at birth (haemoglobin<7g/dL). Clinical details were analysed for causes of anaemia and co-morbidities. All had early brain magnetic resonance imaging (MRI) scans, which were reviewed for injury pattern. Neurodevelopmental outcomes were assessed at a median age of 24months. RESULTS The aetiology of the anaemia was feto-maternal haemorrhage in 17 and antepartum haemorrhage in 3 infants. The predominant site of injury was the white matter, which was affected in all infants, with differing grades of severity and with cystic evolution in 45%. Only one infant showed an injury pattern typical of an acute severe hypoxic-ischaemic insult. Outcomes correlated closely to the severity of MRI findings. Cerebral palsy was seen only with the most severe neuroimaging patterns (n=6). Global developmental delay, learning or behavioural problems and seizures were common with moderate injury. Visual impairment occurred, particularly with posterior injury. Microcephaly developed in 45%. INTERPRETATION Severe neonatal anaemia at birth was associated with a white matter predominant pattern of injury, the severity of which was related to neurodevelopmental outcomes. Early MRI and long-term follow-up are advisable following severe neonatal anaemia.
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Affiliation(s)
- Begoña Loureiro
- Departamento de Pediatría, Hospital Universitario Cruces, Barakaldo, Spain.
| | | | - Francesca Foti
- Department of Mental Health, Azienda Unita Sanitaria Locale di Reggio Emilia, Emilia-Romagna, Italy
| | - Maria Papadaki
- Own private paediatrician practice, Cholargos Attica, Greece
| | - Frances M Cowan
- Department of Paediatrics, Hammersmith Hospital, Imperial College, London, UK
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Campos D, Arias AV, Campos-Zanelli TM, Souza DS, Dos Santos Neto OG, Peralta CFA, Guerreiro MM. Twin-twin transfusion syndrome: neurodevelopment of infants treated with laser surgery. ARQUIVOS DE NEURO-PSIQUIATRIA 2016; 74:307-13. [PMID: 27097004 DOI: 10.1590/0004-282x20160032] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 11/30/2015] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To assess the neurodevelopmental functions of survivors of twin-twin transfusion syndrome (TTTS) treated by fetoscopic laser coagulation (FLC), during the first year of life, comparing them to a control group; and to verify the influence of specific variables on neurodevelopment. METHOD This was a prospective, longitudinal study. The sample comprised 33 monochorionic diamniotic twins who underwent FLC for treatment of TTTS and 22 full-term infants of single-fetus pregnancies. Bayley Scales of Infant and Toddler Development Screening Test were used for evaluation. Prenatal, perinatal and postnatal information were obtained. RESULTS There was an increased frequency of infants in the TTTS group with inadequate performance compared to the control group. The identified variables (fetal donor, low economic income and cardiorespiratory disease) negatively impacted expressive communication and fine motor skills. CONCLUSION Although through follow-up is recommended in all TTTS survivors, particular attention is required for the high-risk group as defined in this study.
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Affiliation(s)
- Denise Campos
- Centro de Investigação em Pediatria, Departamento de Neurologia, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | - Amabile V Arias
- Centro de Investigação em Pediatria, Departamento de Neurologia, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | - Thatiane M Campos-Zanelli
- Centro de Investigação em Pediatria, Departamento de Neurologia, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | - Daniela S Souza
- Centro de Investigação em Pediatria, Departamento de Neurologia, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | - Orlando G Dos Santos Neto
- Hospital da Mulher Prof. Dr. José Aristodemo Pinotti, Departamento de Obstetrícia e Ginecologia, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | - Cleisson Fabio A Peralta
- Hospital da Mulher Prof. Dr. José Aristodemo Pinotti, Departamento de Obstetrícia e Ginecologia, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | - Marilisa M Guerreiro
- Centro de Investigação em Pediatria, Departamento de Neurologia, Universidade Estadual de Campinas, Campinas, SP, Brazil
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13
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Fukami T, Goto M, Matsuoka S, Sorano S, Tohyama A, Yamamoto H, Nakamura S, Matsuoka R, Tsujioka H, Eguchi F. Monochorionic-diamniotic discordant growth in a twin pregnancy with one fetus affected by Ebstein's anomaly of tricuspid leaflets. Clin Case Rep 2016; 4:682-6. [PMID: 27386129 PMCID: PMC4929806 DOI: 10.1002/ccr3.586] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 02/12/2016] [Accepted: 05/03/2016] [Indexed: 12/31/2022] Open
Abstract
Our patient was diagnosed as having discordant twin growth with Ebstein's anomaly in the larger fetus. Cardiac function was deteriorated in accordance with progression of gestational age. Our observation indicated cardiac failure of the larger fetus. The most important issue in this situation is management of the timing of delivery.
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Affiliation(s)
- Tatsuya Fukami
- Department of Obstetrics and GynecologyASO Iizuka Hospital3‐83 Yoshio‐machiIizukaFukuoka820‐8505Japan
| | - Maki Goto
- Department of Obstetrics and GynecologyASO Iizuka Hospital3‐83 Yoshio‐machiIizukaFukuoka820‐8505Japan
| | - Sakiko Matsuoka
- Department of Obstetrics and GynecologyASO Iizuka Hospital3‐83 Yoshio‐machiIizukaFukuoka820‐8505Japan
| | - Sumire Sorano
- Department of Obstetrics and GynecologyASO Iizuka Hospital3‐83 Yoshio‐machiIizukaFukuoka820‐8505Japan
| | - Atsushi Tohyama
- Department of Obstetrics and GynecologyASO Iizuka Hospital3‐83 Yoshio‐machiIizukaFukuoka820‐8505Japan
| | - Hiroko Yamamoto
- Department of Obstetrics and GynecologyASO Iizuka Hospital3‐83 Yoshio‐machiIizukaFukuoka820‐8505Japan
| | - Sumie Nakamura
- Department of Obstetrics and GynecologyASO Iizuka Hospital3‐83 Yoshio‐machiIizukaFukuoka820‐8505Japan
| | - Ryoei Matsuoka
- Department of Obstetrics and GynecologyASO Iizuka Hospital3‐83 Yoshio‐machiIizukaFukuoka820‐8505Japan
| | - Hiroshi Tsujioka
- Department of Obstetrics and GynecologyASO Iizuka Hospital3‐83 Yoshio‐machiIizukaFukuoka820‐8505Japan
| | - Fuyuki Eguchi
- Department of Obstetrics and GynecologyASO Iizuka Hospital3‐83 Yoshio‐machiIizukaFukuoka820‐8505Japan
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14
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Síndrome de transfusión feto-feto: resultados neonatales en un hospital de tercer nivel en la Ciudad de México. PERINATOLOGÍA Y REPRODUCCIÓN HUMANA 2016. [DOI: 10.1016/j.rprh.2016.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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15
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Guintivano J, Kaminsky ZA. Role of epigenetic factors in the development of mental illness throughout life. Neurosci Res 2016; 102:56-66. [DOI: 10.1016/j.neures.2014.08.003] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 07/31/2014] [Accepted: 08/04/2014] [Indexed: 12/15/2022]
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16
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Kim SH, Jung E, Lee MY, Lee BS, Won HS, Kim EAR, Kim KS. The Impact of Introduction of Fetoscopic Laser Surgery on Twin-to-Twin Transfusion Syndrome. NEONATAL MEDICINE 2016. [DOI: 10.5385/nm.2016.23.4.203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Soo Hyun Kim
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Euiseok Jung
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Mi-Young Lee
- Department of Obstetrics and Gynecology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byong Sop Lee
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hye-Sung Won
- Department of Obstetrics and Gynecology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ellen Ai-Rhan Kim
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki-Soo Kim
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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17
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Yang L, Wang J, Ando T, Kubota A, Yamashita H, Sakuma I, Chiba T, Kobayashi E. Self-contained image mapping of placental vasculature in 3D ultrasound-guided fetoscopy. Surg Endosc 2015; 30:4136-49. [DOI: 10.1007/s00464-015-4690-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 11/16/2015] [Indexed: 10/22/2022]
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18
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19
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Park HW, Cho MJ, Kim WY, Kwak BO, Kim MH. Hirschsprung’s disease in twin to twin transfusion syndrome: A case report. World J Gastroenterol 2014; 20:17666-17669. [PMID: 25516683 PMCID: PMC4265630 DOI: 10.3748/wjg.v20.i46.17666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 05/26/2014] [Accepted: 07/11/2014] [Indexed: 02/06/2023] Open
Abstract
Twin to twin transfusion syndrome (TTTS) is caused by aberrant vascular connections between infant twins and results in high morbidity and mortality in the perinatal period. In donor infants with TTTS and symptoms of intestinal obstruction, small-bowel lesions have been reported in most cases. We report on a 33+6 gestational wk donor infant with TTTS who had intermittent obstructive episodes, including delayed meconium passage and colonic dilatation on abdominal X-ray. The diagnosis of Hirschsprung’s disease was based on a lateral pelvic film with a reversed rectosigmoid ratio. A subsequent barium colon study and rectal suction biopsy indicated a short segment aganglionosis of the colon.
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20
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Peeters SHP, Stolk TT, Slaghekke F, Middeldorp JM, Klumper FJ, Lopriore E, Oepkes D. Iatrogenic perforation of intertwin membrane after laser surgery for twin-to-twin transfusion syndrome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 44:550-556. [PMID: 24961923 DOI: 10.1002/uog.13445] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 06/02/2014] [Accepted: 06/09/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To evaluate management and outcome of iatrogenic monoamniotic twins (iMAT) compared with twins with intact intertwin dividing membranes after laser surgery for twin-to-twin transfusion syndrome (TTTS). METHODS This was a retrospective analysis of twins with and without iatrogenic rupture of the intertwin membranes that had been treated for TTTS with laser surgery at our center between 2004 and 2012. Primary outcomes were perinatal survival and severe neonatal morbidity. Secondary outcomes were mode of delivery, gestational age at birth and cord entanglement. RESULTS In total, 338 pregnancies were included. In 67/338 (20%) pregnancies, iMAT was suspected antenatally. In 47 of these 67 (70%), a preterm Cesarean section was performed for monoamnionicity. Perinatal survival was 108/134 (81%) vs 396/542 (73%) in twins with intact intertwin membranes (P = 0.13). Mean gestational age at birth in iMAT was 31 completed weeks, compared to 33 weeks in twins with intact membranes (P < 0.01). At birth, cord entanglement was present in 8/67 (12%) iMAT pregnancies. Severe neonatal morbidity was assessed in 106/110 (96%) in iMAT cases and 392/416 (94%) in controls. The incidence of severe neonatal morbidity was 28/106 (26%) in iMAT vs 72/392 (18%) in controls (P = 0.25). Severe cerebral injury was significantly increased in the iMAT group as compared with controls, at 16/106 (15%) vs 18/392 (5%) (P < 0.01). CONCLUSIONS Iatrogenic rupture of intertwin membranes was suspected in 20% of pregnancies treated with laser therapy for TTTS and was associated with a lower gestational age at birth and increased neonatal morbidity.
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Affiliation(s)
- S H P Peeters
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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21
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Ma J, Coarfa C, Qin X, Bonnen PE, Milosavljevic A, Versalovic J, Aagaard K. mtDNA haplogroup and single nucleotide polymorphisms structure human microbiome communities. BMC Genomics 2014; 15:257. [PMID: 24694284 PMCID: PMC4234434 DOI: 10.1186/1471-2164-15-257] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Accepted: 03/28/2014] [Indexed: 12/13/2022] Open
Abstract
Background Although our microbial community and genomes (the human microbiome) outnumber our genome by several orders of magnitude, to what extent the human host genetic complement informs the microbiota composition is not clear. The Human Microbiome Project (HMP) Consortium established a unique population-scale framework with which to characterize the relationship of microbial community structure with their human hosts. A wide variety of taxa and metabolic pathways have been shown to be differentially distributed by virtue of race/ethnicity in the HMP. Given that mtDNA haplogroups are the maternally derived ancestral genomic markers and mitochondria’s role as the generator for cellular ATP, characterizing the relationship between human mtDNA genomic variants and microbiome profiles becomes of potential marked biologic and clinical interest. Results We leveraged sequencing data from the HMP to investigate the association between microbiome community structures with its own host mtDNA variants. 15 haplogroups and 631 mtDNA nucleotide polymorphisms (mean sequencing depth of 280X on the mitochondria genome) from 89 individuals participating in the HMP were accurately identified. 16S rRNA (V3-V5 region) sequencing generated microbiome taxonomy profiles and whole genome shotgun sequencing generated metabolic profiles from various body sites were treated as traits to conduct association analysis between haplogroups and host clinical metadata through linear regression. The mtSNPs of individuals with European haplogroups were associated with microbiome profiles using PLINK quantitative trait associations with permutation and adjusted for multiple comparisons. We observe that among 139 stool and 59 vaginal posterior fornix samples, several haplogroups show significant association with specific microbiota (q-value < 0.05) as well as their aggregate community structure (Chi-square with Monte Carlo, p < 0.005), which confirmed and expanded previous research on the association of race and ethnicity with microbiome profile. Our results further indicate that mtDNA variations may render different microbiome profiles, possibly through an inflammatory response to different levels of reactive oxygen species activity. Conclusions These data provide initial evidence for the association between host ancestral genome with the structure of its microbiome.
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Affiliation(s)
| | | | | | | | | | | | - Kjersti Aagaard
- Departments of Obstetrics & Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA.
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22
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Baud D, Windrim R, Keunen J, Kelly EN, Shah P, van Mieghem T, Seaward PGR, Ryan G. Fetoscopic laser therapy for twin-twin transfusion syndrome before 17 and after 26 weeks' gestation. Am J Obstet Gynecol 2013. [PMID: 23178244 DOI: 10.1016/j.ajog.2012.11.027] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE The purpose of this study was to compare perinatal outcomes of pregnancies that undergo "early" (<17 weeks' gestation) or "late" (>26 weeks' gestation) fetoscopic laser ablation of placental vascular anastomoses for twin-twin transfusion syndrome (TTTS) with "conventional" cases that were treated at 17-26 weeks' gestation. STUDY DESIGN We conducted a single center, retrospective analysis of 325 consecutive pregnancies that underwent fetoscopic laser therapy for severe TTTS. RESULTS Twenty-four "early," 18 "late," and 283 "conventional" pregnancies with severe TTTS underwent laser therapy. Fetoscopy duration, gestation at delivery, survival rate, and complications were comparable among groups, except for preterm premature rupture of membranes at <7 days after laser therapy, which was more common in the "early" group than in either of the other 2 groups. CONCLUSION Laser therapy for TTTS at <17 or >26 weeks' gestation has similar outcomes to procedures done at 17-26 weeks' gestation. We suggest that conventional gestational age guidelines of 16-26 weeks for laser therapy for TTTS should be reevaluated.
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Affiliation(s)
- David Baud
- Fetal Medicine Unit, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
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23
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van Klink JM, Koopman HM, van Zwet EW, Oepkes D, Walther FJ, Lopriore E. Cerebral Injury and Neurodevelopmental Impairment after Amnioreduction versus Laser Surgery in Twin-Twin Transfusion Syndrome: A Systematic Review and Meta-Analysis. Fetal Diagn Ther 2013; 33:81-9. [DOI: 10.1159/000341814] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Accepted: 07/06/2012] [Indexed: 11/19/2022]
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24
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Hollander RA, Puylaert D, Fabry K, Debeer A, Lewi L, Van de Broek H. Twin-to-twin transfusion syndrome and limb ischemia: a case report. CASE REPORTS IN PERINATAL MEDICINE 2012. [DOI: 10.1515/crpm-2012-0006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Twin-to-twin transfusion syndrome (TTTS) is a severe complication of monochorionic twin pregnancies. This condition is associated with high mortality if untreated. Treatment consists of either serial reduction of amniotic fluid or selective laser photocoagulation (SLP). In utero limb ischemia is a known complication of TTTS. An interaction between this condition and SLP has never been established. Here, we describe the first of twins born at 34 weeks’ gestational age, delivered by emergency cesarean section for fetal distress after a pregnancy complicated by severe TTTS. The first twin, the recipient in the TTTS, showed a necrotic right limb, which was amputated above the knee joint on the 23rd day of life. Anatomic-pathological investigation revealed vascular thrombosis. The foot-length was compatible with a gestational age of 16–18 weeks, the time of limb ischemia, which is well before 26 weeks, when SLP was performed. Therefore, we refute that the fetal limb ischemia was a complication of SLP.
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Affiliation(s)
| | - Dirk Puylaert
- Department of Pediatric Orthopedics, ZNA Queen Paola Children’s Hospital, Antwerp, Belgium
| | - Kristof Fabry
- Department of Pediatric Orthopedics, ZNA Queen Paola Children’s Hospital, Antwerp, Belgium
| | - Anne Debeer
- Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Liesbeth Lewi
- Department of Gynaecology and Obstetrics, University Hospitals Leuven, Leuven, Belgium
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