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Hamer J, Eltaweel N, Man R, Rogerson M, Hodgetts Morton V, Morris RK, Marton T, Gurney L. Placental architectural characteristics following laser ablation within monochorionic twins complicated by twin-twin transfusion syndrome: A systematic review and meta-analysis of outcomes. Acta Obstet Gynecol Scand 2024. [PMID: 38873725 DOI: 10.1111/aogs.14891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 05/27/2024] [Accepted: 05/28/2024] [Indexed: 06/15/2024]
Abstract
INTRODUCTION Twin-twin transfusion syndrome (TTTS) complicates approximately 10%-15% of all monochorionic twin pregnancies. The aim of this review was to evaluate the placental architectural characteristics within TTTS twins following laser and elucidate their impact on fetal outcomes and operative success. MATERIAL AND METHODS Five databases were searched from inception to August 2023. Studies detailing post-delivery placental analysis within TTTS twins post-laser were included. Studies were categorized into two main groups: (1) residual anastomoses following laser and (2) abnormal cord insertion: either velamentous and/or marginal or proximate. The primary outcome was to determine the proportion of TTTS placentas with residual anastomoses and abnormal cord insertions post-laser. Secondary outcomes included assessing residual anastomoses on post-laser fetal outcomes and assessing the relationship between abnormal cord insertion and TTTS development. Study bias was critiqued using the Joanna Briggs Institute checklists and Cochrane risk of bias tool. Random-effects meta-analysis was used, and results were reported as pooled proportions or odds ratio (OR) with 95% confidence interval (CI). PROSPERO registration: CRD42023476875. RESULTS Twenty-six studies, comprising 4013 monochorionic twins, were included for analysis. The proportion of TTTS placentas with residual anastomoses following laser was 24% (95% CI, 0.12-0.41), with a mean and standard deviation of 4.03 ± 2.95 anastomoses per placenta. Post-laser residual anastomoses were significantly associated with intrauterine fetal death (OR, 2.38 [95% CI, 1.33-4.26]), neonatal death (OR, 3.37 [95% CI, 1.65-6.88]), recurrent TTTS (OR, 24.33 [95% CI, 6.64-89.12]), and twin anemia polycythemia sequence (OR, 13.54 [95% CI, 6.36-28.85]). Combined abnormal cord (velamentous and marginal), velamentous cord, and marginal cord insertions within one or both twins following laser were reported at rates of 49% (95% CI, 0.39-0.59), 27% (95% CI, 0.18-0.38), and 28% (95% CI, 0.21-0.36), respectively. Combined, velamentous and marginal cord insertions were not significantly associated with TTTS twins requiring laser (p = 0.72, p = 0.38, and p = 0.71, respectively) versus non-TTTS monochorionic twins. CONCLUSIONS To the best of our knowledge, this is the first review to conjointly explore outcomes of residual anastomoses and abnormal cord insertions within TTTS twins following laser. A large prospective study is necessitated to assess the relationship between abnormal cord insertion and residual anastomoses development post-laser.
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Affiliation(s)
- Jack Hamer
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Nashwa Eltaweel
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Rebecca Man
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Matilde Rogerson
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Victoria Hodgetts Morton
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - R Katie Morris
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Tamas Marton
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
- Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Leo Gurney
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
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da Silva Rocha J, Guedes-Martins L, Cunha A. Twin Anemia-Polycythemia Sequence (TAPS): From Basic Research to Clinical Practice. Curr Vasc Pharmacol 2023; 21:91-105. [PMID: 36718965 DOI: 10.2174/1570161121666230131112930] [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: 09/28/2022] [Revised: 12/30/2022] [Accepted: 12/30/2022] [Indexed: 02/01/2023]
Abstract
Twin pregnancy is associated with an increased risk of perinatal and maternal complications, and early establishment of the chorionicity type defines this risk. In monochorionic (MC) pregnancies, the fetuses share the same placental mass and exhibit vascular anastomoses crossing the intertwin membrane, and the combination and pattern of anastomoses determine the primary clinical picture and occurrence of future complications. Twin Anemia-Polycythemia Sequence (TAPS) was first described in 2006 after fetoscopic laser surgery in twin-to-twin transfusion syndrome (TTTS) twins, and in 2007, the first spontaneous cases were reported, recognizing TAPS as an individualized vascular identity in fetofetal transfusion syndromes. There are two types of TAPS: spontaneous (3-5%) and iatrogenic or postlaser (2-16%). TAPS consists of small diameter arteriovenous anastomoses (<1 mm) and low-rate, small-caliber AA anastomoses in the absence of amniotic fluid discordances. There are certain antenatal and postnatal diagnostic criteria, which have progressively evolved over time. New, additional secondary markers have been proposed, and their reliability is being studied. The best screening protocol for TAPS in MC twins is still a matter of debate. This review provides a survey of the relevant literature on the epidemiology, vascular pathophysiology, underlying hemodynamic factors that regulate mismatched vascular connections, and diagnostic criteria of this condition. The aim is to increase awareness and knowledge about this recently identified and frequently unrecognized and misdiagnosed pathology.
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Affiliation(s)
- Joana da Silva Rocha
- Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto 4050-313, Portugal
| | - Luís Guedes-Martins
- Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto 4050-313, Portugal
- Centro Hospitalar Universitário do Porto EPE, Centro Materno Infantil do Norte, Centro de Medicina Fetal, Serviço de Obstetrícia, Departamento da Mulher e da Medicina Reprodutiva, Largo Prof. Abel Salazar, Porto 4099-001, Portugal
- Unidade de Investigação e Formação - Centro Materno Infantil do Norte, Porto 4099-001, Portugal
- Instituto de Investigação e Inovação em Saúde, Universidade do Porto, 4200-319 Portugal
| | - Ana Cunha
- Centro Hospitalar Universitário do Porto EPE, Centro Materno Infantil do Norte, Centro de Medicina Fetal, Serviço de Obstetrícia, Departamento da Mulher e da Medicina Reprodutiva, Largo Prof. Abel Salazar, Porto 4099-001, Portugal
- Unidade de Investigação e Formação - Centro Materno Infantil do Norte, Porto 4099-001, Portugal
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Espinoza J, Belfort MA, Shamshirsaz AA, Nassr AA, Sanz Cortes M, Donepudi R, Espinoza AF, Ostovar-Kermani TG, Johnson RM, Harman C, Ozdemir H, Turan O. Intertwin differences in umbilical artery pulsatility index are associated with infant survival in twin-to-twin transfusion syndrome. J Perinat Med 2021; 49:1122-1128. [PMID: 34118799 DOI: 10.1515/jpm-2021-0060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/27/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To evaluate the association of intertwin differences in umbilical artery pulsatility index (DUAPI) and infant survival in twin-to-twin transfusion syndrome (TTTS). METHODS Absolute DUAPI was calculated prior to laser surgery. Receiver-operating characteristics (ROC) curve analysis provided an intertwin DUAPI cutoff of 0.4 for the prediction of double twin survival to 30 days of life. Infant survival was compared between women with an intertwin DUAPI <0.4 and ≥0.4 in the whole cohort, in TTTS cases with Quintero stages I/II and in those with Quintero stages III/IV. Regression analyses were performed to evaluate the association of intertwin DUAPI <0.4 and infant survival adjusted for confounders. RESULTS In total, 349 TTTS cases were included. Double twin survival to 30 days was observed in 67% (234/349) of cases. Significant differences in double twin survival was seen between intertwin DUAPI groups in the whole cohort (76.8 vs. 52.2%; p<0.001), in women with TTTS Quintero stage I or II (77.8 vs. 58.5%; p=0.015) as well as in women with TTTS Quintero stage III or IV (75 vs. 49.5%; p=0.001). Intertwin DUAPI <0.4 conferred a threefold increased chance for double twin survival. CONCLUSIONS Small intertwin DUAPI is associated with increased double infant survival in early and advanced TTTS stages.
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Affiliation(s)
- Jimmy Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
- Texas Children's Hospital-Pavilion for Women, Houston, TX, USA
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
- Texas Children's Hospital-Pavilion for Women, Houston, TX, USA
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Alireza A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
- Texas Children's Hospital-Pavilion for Women, Houston, TX, USA
| | - Ahmed A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
- Texas Children's Hospital-Pavilion for Women, Houston, TX, USA
| | - Magdalena Sanz Cortes
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
- Texas Children's Hospital-Pavilion for Women, Houston, TX, USA
| | - Roopali Donepudi
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
- Texas Children's Hospital-Pavilion for Women, Houston, TX, USA
| | - Andres F Espinoza
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | | | - Rebecca M Johnson
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
- Texas Children's Hospital-Pavilion for Women, Houston, TX, USA
| | - Christopher Harman
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Halis Ozdemir
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ozhan Turan
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
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Gou C, Li M, Zhang X, Liu X, Huang X, Zhou Y, Fang Q. Placental characteristics in monochorionic twins with selective intrauterine growth restriction assessed by gradient angiography and three-dimensional reconstruction. J Matern Fetal Neonatal Med 2017; 30:2590-2595. [DOI: 10.1080/14767058.2016.1256995] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Chenyu Gou
- Department of Obstetrics and Gynecology, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Department of Obstetrics and Gynecology, Fetal Medicine Center
| | | | | | - Xiangzhen Liu
- Department of Oral and Maxillofacial Surgery, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Xuan Huang
- Department of Obstetrics and Gynecology, Fetal Medicine Center
| | - Yi Zhou
- Department of Obstetrics and Gynecology, Fetal Medicine Center
| | - Qun Fang
- Department of Obstetrics and Gynecology, Fetal Medicine Center
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The Placenta in Twin-to-Twin Transfusion Syndrome and Twin Anemia Polycythemia Sequence. Twin Res Hum Genet 2016; 19:184-90. [PMID: 27098457 DOI: 10.1017/thg.2016.29] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Twin-to-twin transfusion syndrome (TTTS) and twin anemia polycythemia sequence (TAPS) are complications unique to monochorionic twin pregnancies and their shared circulation. Both are the result of the transfusion imbalance in the intertwin circulation. TTTS is characterized by an amniotic fluid discordance, whereas in TAPS, there is a severe discordance in hemoglobin levels. The article gives an overview of the typical features of TTTS and TAPS placentas.
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Velamentous cord insertion in dichorionic and monochorionic twin pregnancies - Does it make a difference? Placenta 2016; 42:87-92. [PMID: 27238718 DOI: 10.1016/j.placenta.2016.04.007] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Revised: 04/03/2016] [Accepted: 04/05/2016] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To estimate the prevalence of velamentous cord insertion (VCI) in dichorionic (DC) and monochorionic (MC) twins with and without twin-twin transfusion syndrome (TTTS), and to study the associated outcomes. METHODS We recorded the type of umbilical cord insertion in all consecutive DC and MC placentas examined in two European tertiary medical centers. The association between VCI and perinatal outcomes was estimated and compared. RESULTS A total of 1498 twin placentas were included in this study (DC placentas n = 550, MC placentas without TTTS n = 513 and MC placentas with TTTS n = 435). The prevalence of VCI in DC, MC without TTTS and MC with TTTS groups was 7.6%, 34.7% and 36.1%, respectively (P < 0.001). In MC twins (non-TTTS and TTTS groups), VCI was associated with severe birth weight discordance (odds ratio [OR] 4.76 95% CI 2.43, 10.47 and OR 4.52 95% CI 1.30, 28.59, respectively). In MC twins without TTTS, VCI was associated with small for gestational age (OR 1.66, 95% CI 1.12, 2.50). VCI was significantly associated with increased risk of intrauterine fetal demise in MC twins, and this effect was greater in the non-TTTS group (OR 2.71 95% CI 1.38, 5.47). These associations did not occur in DC group. Gestational age at birth was lower in the presence of VCI in the DC and MC twins without TTTS. CONCLUSION Our findings confirm that the prevalence of VCI is higher in MC twins than in DC twin pregnancies. VCI is an important indicator of adverse perinatal outcome, particularly in MC twins.
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Kashireddy P, Larson A, Minturn L, Ernst L. Case Report of Autopsy and Placental Examination After Radiofrequency Ablation of an Acardiac Twin. Lab Med 2015. [DOI: 10.1309/lm4b4du7uimklnai] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Zhao D, Cohen D, Middeldorp J, Klumper F, Haak M, Oepkes D, Lopriore E. The role of veno-venous anastomoses in twin–twin transfusion syndrome. Placenta 2014; 35:334-6. [DOI: 10.1016/j.placenta.2014.03.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Revised: 03/01/2014] [Accepted: 03/05/2014] [Indexed: 11/30/2022]
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Costa-Castro T, De Villiers S, Montenegro N, Severo M, Oepkes D, Matias A, Lopriore E. Velamentous cord insertion in monochorionic twins with or without twin–twin transfusion syndrome: Does it matter? Placenta 2013; 34:1053-8. [DOI: 10.1016/j.placenta.2013.08.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Revised: 08/09/2013] [Accepted: 08/13/2013] [Indexed: 10/26/2022]
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De Paepe ME, Luks FI. What-and why-the pathologist should know about twin-to-twin transfusion syndrome. Pediatr Dev Pathol 2013; 16:237-51. [PMID: 23617829 DOI: 10.2350/13-03-1315-misc.1] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Approximately 20% of all twin pregnancies are monochorionic. Between 9% and 15% of all monochorionic twin gestations are complicated by severe chronic twin-to-twin transfusion syndrome (TTTS), characterized by a gradual shift of blood volume from the donor twin to the recipient twin through placental vascular connections [1 - 3] . The prognosis of severe, untreated chronic TTTS diagnosed in midtrimester fetuses is extremely poor, with mortality rates exceeding 70% [4] . Since publication of the results of the Eurofoetus trial in 2004, laser photocoagulation of the intertwin anastomoses has become accepted as the optimal first-line therapy for severe TTTS diagnosed before 26 weeks of gestation. While laser treatment of vascular communications was initially limited to selected fetal treatment centers, its increasingly widespread use has resulted in the exposure of more pathologists, even in less specialized institutions, to laser-treated placentas. Furthermore, the surge in laser coagulation has revived the general medical, scientific, and public interest in the placental and choriovascular findings in monochorionic twin placentas. The pathologist's understanding of the pathophysiology of TTTS and of TTTS-associated placental pathology, including the findings related to laser ablation of the anastomoses, can be of great benefit to the involved obstetric/neonatal/surgical team and, ultimately, to the patients. In this review, we summarize the current knowledge of the placental contributions to TTTS and other complications of monochorionic twinning and describe the strengths and limitations of placental examination in these settings. It is our expectation that overviews such as this may serve as a template to generate consensus guidelines for standardized and evidence-based pathologic evaluation of monochorionic twin placentas.
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Affiliation(s)
- Monique E De Paepe
- Department of Pathology, Women and Infants Hospital, Providence, RI, USA.
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Lopriore E, Slaghekke F, Middeldorp JM, Klumper FJ, van Lith JM, Walther FJ, Oepkes D. Accurate and simple evaluation of vascular anastomoses in monochorionic placenta using colored dye. J Vis Exp 2011:e3208. [PMID: 21912373 PMCID: PMC3230184 DOI: 10.3791/3208] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
The presence of placental vascular anastomoses is a conditio sine qua non for the development of twin-to-twin transfusion syndrome (TTTS) and twin anemia polycythemia sequence (TAPS)(1,2). Injection studies of twin placentas have shown that such anastomoses are almost invariably present in monochorionic twins and extremely rare in dichorionic twins(1). Three types of anastomoses have been documented: from artery to artery, from vein to vein and from artery to vein. Arterio-venous (AV) anastomoses are unidirectional and are referred to as "deep" anastomoses since they proceed through a shared placental cotyledon, whereas arterio-arterial (AA) and veno-venous (VV) anastomoses are bi-directional and are referred to as "superficial" since they lie on the chorionic plate. Both TTTS and TAPS are caused by net imbalance of blood flow between the twins due to AV anastomoses. Blood from one twin (the donor) is pumped through an artery into the shared placental cotyledon and then drained through a vein into the circulation of the other twin (the recipient). Unless blood is pumped back from the recipient to the donor through oppositely directed deep AV anastomoses or through superficial anastomoses, an imbalance of blood volumes occurs, gradually leading to the development of TTTS or TAPS. The presence of an AA anastomosis has been shown to protect against the development of TTTS and TAPS by compensating for the circulatory imbalance caused by the uni-directional AV anastomoses(1,2). Injection of monochorionic placentas soon after birth is a useful mean to understand the etiology of various (hematological) complications in monochorionic twins and is a required test to reach the diagnosis of TAPS(2). In addition, injection of TTTS placentas treated with fetoscopic laser surgery allows identification of possible residual anastomoses(3-5). This additional information is of paramount importance for all perinatologists involved in the management and care of monochorionic twins with TTTS or TAPS. Several placental injection techniques are currently being used. We provide a simple protocol to accurately evaluate the presence of (residual) vascular anastomoses using colored dye injection.
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Affiliation(s)
- Enrico Lopriore
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center.
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Baschat A, Chmait RH, Deprest J, Gratacós E, Hecher K, Kontopoulos E, Quintero R, Skupski DW, Valsky DV, Ville Y. Twin-to-twin transfusion syndrome (TTTS). J Perinat Med 2011; 39:107-12. [PMID: 21142846 DOI: 10.1515/jpm.2010.147] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Twin-to-twin transfusion syndrome (TTTS) is a severe complication of monochorionic (MC) twin pregnancies, characterized by the development of unbalanced chronic blood transfer from one twin, defined as donor twin, to the other, defined as recipient, through placental anastomoses. If left untreated, TTTS is associated with very high perinatal mortality and morbidity rates, due to a combination of fetal and/or obstetric complications. The reported prevalence is 10-15% of all MC twins, or about 1 in 2000 pregnancies. This consensus document reviews available evidence and offers practical guidance to clinicians by providing recommendations on various aspects concerning diagnosis and management of TTTS.
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Affiliation(s)
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- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland, School of Medicine, Baltimore, MD, USA
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De Paepe M, Shapiro S, Young L, Luks F. Placental characteristics of selective birth weight discordance in diamniotic-monochorionic twin gestations. Placenta 2010; 31:380-6. [DOI: 10.1016/j.placenta.2010.02.018] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2010] [Revised: 02/23/2010] [Accepted: 02/24/2010] [Indexed: 11/24/2022]
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Placental markers of twin-to-twin transfusion syndrome in diamniotic–monochorionic twins: A morphometric analysis of deep artery-to-vein anastomoses. Placenta 2010; 31:269-76. [DOI: 10.1016/j.placenta.2009.12.024] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2009] [Revised: 11/05/2009] [Accepted: 12/22/2009] [Indexed: 11/20/2022]
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Habli M, Lim FY, Crombleholme T. Twin-to-twin transfusion syndrome: a comprehensive update. Clin Perinatol 2009; 36:391-416, x. [PMID: 19559327 DOI: 10.1016/j.clp.2009.03.003] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Twin-to-twin transfusion syndrome (TTTS) is a serious complication in about 10% to 20% of monozygous twin gestations with an incidence of 4% to 35% in the United States. Severe TTTS is reported to occur in 5.5% to 17.5% of cases. TTTS is a progressive disease in which sudden deteriorations in clinical status can occur, leading to death of a co-twin. Up to 30% of survivors may have abnormal neurodevelopment as a result of the combination of profound antenatal insult and the complications of severe prematurity. This article presents an overview of what is known about the pathophysiology and the diagnosis of TTTS, the role of echocardiography in TTTS, treatment options available for TTTS, complications of treatment for TTTS, and short- and long-term outcomes of TTTS.
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Affiliation(s)
- Mounira Habli
- The Fetal Care Center of Cincinnati, Cincinnati Children's Hospital, University of Cincinnati, Cincinnati, OH 45229-3039, USA
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Hack KEA, Nikkels PGJ, Koopman-Esseboom C, Derks JB, Elias SG, van Gemert MJC, Visser GHA. Placental Characteristics of Monochorionic Diamniotic Twin Pregnancies in Relation to Perinatal Outcome. Placenta 2008; 29:976-81. [PMID: 18835495 DOI: 10.1016/j.placenta.2008.08.019] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2008] [Revised: 07/01/2008] [Accepted: 08/25/2008] [Indexed: 11/18/2022]
Affiliation(s)
- K E A Hack
- Department of Obstetrics, Wilhelmina Children's Hospital, University Medical Center Utrecht, Lundlaan 6, 3584 EA Utrecht, The Netherlands.
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Kusanovic JP, Romero R, Espinoza J, Nien JK, Kim CJ, Mittal P, Edwin S, Erez O, Gotsch F, Mazaki-Tovi S, Than NG, Soto E, Camacho N, Gomez R, Quintero R, Hassan SS. Twin-to-twin transfusion syndrome: an antiangiogenic state? Am J Obstet Gynecol 2008; 198:382.e1-8. [PMID: 18395032 PMCID: PMC2678902 DOI: 10.1016/j.ajog.2008.02.016] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2007] [Revised: 01/14/2008] [Accepted: 02/06/2008] [Indexed: 10/22/2022]
Abstract
OBJECTIVE An imbalanced chronic blood flow between the donor and recipient twin through placental vascular anastomoses is the accepted pathophysiology of twin-to-twin transfusion syndrome (TTTS). Vascular endothelial growth factor receptor-1 (VEGFR-1) mRNA is overexpressed only in the syncytiotrophoblast of the donor twin in some cases of TTTS. This study was conducted to determine maternal plasma concentrations of placental growth factor (PlGF), soluble VEGFR-1, and soluble endoglin (s-Eng) in monochorionic-diamniotic pregnancies with and without TTTS. STUDY DESIGN This case-control study included monochorionic-diamniotic pregnancies between 16-26 weeks with and without TTTS. Maternal plasma concentrations of PlGF, sVEGFR-1, and s-Eng were determined with ELISA. A P value < .05 was considered statistically significant. RESULTS Patients with TTTS had higher median plasma concentrations of s-Eng (14.8 ng/mL vs 7.8 ng/mL; P < .001) and sVEGFR-1 (6383.1 pg/mL vs 3220.1 pg/mL; P < .001]; and lower median plasma concentrations of PlGF (115.5 pg/mL vs 359.3 pg/mL; P = .002) than those without TTTS. CONCLUSION We propose that an antiangiogenic state may be present in some cases of TTTS.
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Lopriore E, Sueters M, Middeldorp JM, Oepkes D, Walther FJ, Vandenbussche FPHA. Velamentous cord insertion and unequal placental territories in monochorionic twins with and without twin-to-twin-transfusion syndrome. Am J Obstet Gynecol 2007; 196:159.e1-5. [PMID: 17306663 DOI: 10.1016/j.ajog.2006.10.865] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2006] [Revised: 07/27/2006] [Accepted: 10/11/2006] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The objective of this study was to determine the incidence of velamentous cord insertion and placental territory discordancy in monochorionic twins with and without twin-to-twin transfusion syndrome (TTTS). STUDY DESIGN All consecutive placentas of monochorionic twins delivered at our center between June 2002 and April 2006 were studied with vascular injection of the umbilical vessels with colored dyes. Velamentous cord insertions were recorded and individual placental territories were calculated by computer analysis. RESULTS A total of 76 monochorionic placentas with TTTS and 63 monochorionic placentas without TTTS were studied. The incidence of velamentous cord insertion (per fetus) in the TTTS group and the non-TTTS group was 13% (20 of 152) and 14% (18 of 126), respectively (P = .79). Placental territory discordancy in the TTTS group and the non-TTTS group was 20% and 20% (P = 0.83). In the TTTS group, donor twins had a velamentous cord insertion more often than recipient twins (24% and 3%, respectively, P < .001) and a smaller placental territory (44% and 56%, respectively, P < .001). CONCLUSION Our findings suggest that velamentous cord insertion and unequal placental territory are not critical factors for the development of TTTS.
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Affiliation(s)
- Enrico Lopriore
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands.
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Current awareness in prenatal diagnosis. Prenat Diagn 2006; 26:94-9. [PMID: 16475249 DOI: 10.1002/pd.1027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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