Treatment of twin reversed arterial perfusion sequence with alcohol ablation or bipolar cord coagulation

A systematic review of early intrauterine intervention at 12 + 0 to 16 + 6 weeks in twin reversed arterial perfusion sequence

There is some evidence that in twin reversed arterial perfusion sequence, intervention at early gestational age could prevent a spontaneous death of the pump twin, achieving a better global survival.

OBJECTIVE

To review the perinatal outcomes of early intervention in pregnancies complicated by twin reversed arterial perfusion (TRAP) sequence.

STUDY DESIGN

A comprehensive search from inception to December 2022 was conducted on databases including MEDLINE, EMBASE, Cochrane Library and LILACS. All studies that reported intervention in twin or triplet pregnancy complicated with TRAP sequence at 12 + 0 to 16 + 6 weeks of gestation were eligible. A descriptive and bivariate analysis was performed.

RESULTS

Out of the 222 full-text articles, 44 studies reporting 108 cases of early intervention in TRAP sequence were included. A successful procedure was achieved in 105 (95.5 %) interventions: 89 (94.7 %) among twin pregnancies and 16(100 %) among triplet pregnancies. An overall livebirth rate was achieved in 75 patients (70.8 %): intrafetal laser group 55 (73.3 %), radiofrequency 10 (76.9 %) and endoscopic laser 3 (75.0 %). The median gestational age at delivery was 38 + 0 (37 + 4 - 39 + 4) weeks. The median treatment-delivery interval was 23 + 2 (IQR, 21 + 0-25 + 6) weeks. The most frequent adverse outcomes reported were preterm labor in 7 (13.7 %) patients. There were no severe adverse maternal outcomes.

CONCLUSION

Early intervention with intrafetal laser and radiofrequency in TRAP sequence achieves a livebirth rate of the pump twin of about 75 %.

Treatment of twin reversed arterial perfusion sequence with radiofrequency ablation and expectant management: A single center study in China

OBJECTIVE

To evaluate the treatment of pregnancies in different stages complicated by TRAP sequence at a single medical center in China.

STUDY DESIGN

A retrospective study evaluating 25 pregnancies with TRAP sequence was performed at Shengjing Hospital in Shenyang, Liaoning between 2012 and 2016. Patients were diagnosed by ultrasound and categorized into three groups (Ia, IIa and IIb) and were expectantly managed or performed RFA (radiofrequency ablation) according to their stage of TRAP sequence. Perinatal outcomes and survival rates were analyzed.

RESULTS

There were four cases in stage Ia, 19 cases in stage IIa, and two cases in stage IIb. Cases in stage Ia were expectantly managed. Among cases in stage IIa, we performed RFA (radiofrequency ablation) in 10 cases and expectant management in 6 cases, with the remainder of the patients refusing intrauterine treatment. We applied RFA to treat one case in stage IIb and the other was managed expectantly. For expectant management group and the RFA group, the survival rates were both 64%(7/11). All pump twins in stage Ia survived and the average gestational age at delivery was 37.9 weeks. In stage IIa, the overall survival rate of the pump twin was 70% (7/10) and the average gestational age at delivery was 35.8 weeks in cases treated by RFA. The survival rate was 50% (3/6) and the average gestational age at delivery was 32.8 weeks in expectantly managed cases in stage IIa. No pump twin survived in stage IIa without treatment (3 cases refused any therapy who were excluded) or in stage IIb.

CONCLUSION

Expectant management is effective for treatment of TRAP sequence in stage Ia. In stage IIa, RFA improves the prognosis of pump twins.

Uncommon complications of monochorionic twin pregnancies: Twin reversed arterial perfusion sequence

Introduction

Twin reversed arterial perfusion (TRAP) sequence occurs when there is one non-viable twin without cardiac structures and a viable pump twin that perfuses the acardiac mass. This study aims to investigate the management and immediate neonatal outcomes for monochorionic multiple pregnancies complicated by TRAP referred to the NSW Fetal Therapy Centre (NSW FTC).

Methods

Retrospective cohort study of multiple pregnancies referred to NSW FTC between April 2006 and April 2014, reviewing data for cases of TRAP sequence (n = 19, including two triplet cases) compared to a timeframe matched sample of uncomplicated monochorionic diamniotic (MCDA) twin pregnancies managed in the unit (n = 45).

Results

Primary management of the 19 TRAP cases was expectant management in 10 (53%), radiofrequency ablation (RFA) in 6 (32%), and bipolar cord coagulation, amniodrainage and termination of pregnancy in 1 case each. 1 of 6 RFA cases had pump twin demise <1 week post-procedure. Average gestation at birth (35.1 ± 5.0 vs. 35.0 ± 2.8 weeks) and mean birthweight (2157 ± 1019 g vs. 2245 ± 537 g) were similar between TRAP pump fetuses and uncomplicated MCDA cases. Pump twin survival was 81% (twins only) compared to 98% for uncomplicated MCDA twins (P = 0.02), and in 5 of 19 (26%) TRAP pregnancies the pump fetus had a congenital anomaly.

Conclusion

Mean gestational age at birth and mean birthweight were similar for both TRAP and uncomplicated MCDA pregnancies. TRAP cases, however, had higher perinatal mortality, and high rates of congenital anomaly. The overall neonatal outcome at NSW FTC for TRAP cases is similar to reported international outcomes.

[Role of twin reversed arterial perfusion syndrome in the development of fetus acardius]

Monochorionic multiple pregnancy has a higher risk for obstetric complications, including those due to the development of twin-to-twin transfusion syndrome and reversed arterial perfusion syndrome (TRAP sequence). The latter occurs in 0.1% of all monochorionic pregnancies. The basis for TRAP sequence is a relationship between arterial and venous anastomoses from the appropriate placental areas, causing a recipient fetus to develop at the expense of a donor fetus. The presence of abnormal anastomoses is considered to be a main cause of acardia. The prognosis for a donor fetus is also unfavorable: the mortality rates in the absence of intrauterine correction are as high as 55%.

Intervention versus a conservative approach in the management of TRAP sequence: a systematic review

OBJECTIVE

In the management of twin reversed arterial perfusion (TRAP) sequence, we wished to (i) determine if intervention is better than a conservative approach and (ii) assess if any of the apparent adverse prognostic indicators could guide intervention.

METHODS

A systematic review was conducted between 1994 and 2014. Data extracted were inspected for heterogeneity. Overall rates and confidence intervals (CIs) for each prognostic factor were calculated. Where there were comparative data, the odds ratio (OR) was calculated.

RESULTS

Twenty-six studies were included in the review. When all cases were considered, intervention either by cord occlusion or by ablation conferred a better survival rate compared with conservative management (OR=2.22, 95% CI 1.23-4.01, heterogeneity I2=37%, P=0.008). This difference was greater in the presence of one or more poor prognostic features (OR=8.58, 95% CI 1.47-49.96, heterogeneity I2=0%, P=0.02). Survival was better using ablative techniques compared to cord occlusion (OR=9.84, 95% CI 1.56-62.00, heterogeneity I2=0%, P=0.01).

CONCLUSION

Intervention either by cord occlusion or by ablation confers a better survival rate compared to conservative management. This appears more compelling if there are one or more poor prognostic features. Ablative techniques are superior to cord occlusion. There were insufficient data to determine which poor prognostic features should guide management.

Twin Reversed Arterial Perfusion (TRAP) Sequence; Characteristic Gray-Scale and Doppler Ultrasonography Findings

Twin reversed arterial perfusion (TRAP) sequence is a syndrome with poor prognosis, seen only in monochorionic monozygotic twin pregnancies. The incidence is one in 35.000 births and one in 100 monozygotic twin pregnancies. It is characterized with a recipient fetus exhibiting lethal anomalies including acardia and a pump fetus. Mortality is usually due to heart failure or premature labor caused by polyhydramnios of pump fetus. Herein, we report a case of TRAP sequence that emphasizes the importance of gray-scale and color Doppler imaging in the diagnosis and management of TRAP sequence.