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Gebb JS, Khalek N, Whitehead MT, Oliver ER. Monochorionic Twin Complications and Fetoscopic Interventions. Magn Reson Imaging Clin N Am 2024; 32:513-528. [PMID: 38944438 DOI: 10.1016/j.mric.2024.02.010] [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] [Indexed: 07/01/2024]
Abstract
Monochorionic twins are at risk for complications due to the presence of placental vascular anastomoses, including twin-twin transfusion syndrome, twin anemia-polycythemia sequence, selective fetal growth restriction, and twin reversed arterial perfusion sequence. While ultrasound is the primary modality to screen for the development of these complications, MRI plays an important role in assessing monochorionic twin pregnancies for the development of other complications, such as neurologic injury. In this article, the authors review the ultrasound imaging findings associated with monochorionic twin complications, management options, and the role for MRI in these pregnancies.
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Affiliation(s)
- Juliana S Gebb
- Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 7th Floor, Philadelphia, PA 19104, USA; Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA; Department of Surgery, Children's Hospital of Philadelphia, 3500 Civic Center Boulevard, 2nd Floor, Philadelphia, PA 19104, USA; General, Thoracic and Fetal Surgery, The Hub for Clinical Collaboration@CHOP, 3500 Civic Center Boulevard, 2nd Floor, Philadelphia, PA 19104, USA
| | - Nahla Khalek
- Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 7th Floor, Philadelphia, PA 19104, USA; Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA; Department of Surgery, Children's Hospital of Philadelphia, 3500 Civic Center Boulevard, 2nd Floor, Philadelphia, PA 19104, USA; General, Thoracic and Fetal Surgery, The Hub for Clinical Collaboration@CHOP, 3500 Civic Center Boulevard, 2nd Floor, Philadelphia, PA 19104, USA
| | - Matthew T Whitehead
- Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 7th Floor, Philadelphia, PA 19104, USA; Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA; Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 3rd Floor, Philadelphia, PA 19104, USA; Neuroradiology, The Hub for Clinical Collaboration@CHOP, 3500 Civic Center Boulevard, 2nd Floor, Philadelphia, PA 19104, USA
| | - Edward R Oliver
- Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 7th Floor, Philadelphia, PA 19104, USA; Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA; Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 3rd Floor, Philadelphia, PA 19104, USA.
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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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Shanahan MA, Bebbington MW. Monochorionic Twins: TTTS, TAPS, and Selective Fetal Growth Restriction. Clin Obstet Gynecol 2023; 66:825-840. [PMID: 37910135 DOI: 10.1097/grf.0000000000000821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
With an increasing incidence of twin gestations, understanding the inherent risks associated with these pregnancies is essential in modern obstetrics. The unique differences in placentation in monochorionic twins leads to unique complications, including twin-to-twin transfusion syndrome, the twin anemia-polycythemia sequence, and selective fetal growth restriction. Not only does the understanding of the monochorionic placenta lead to an understanding of the pathophysiology of the complications of monochorionic twins, but it also has led to the development of highly effective directed fetal therapy via fetoscopic laser coagulation used in twin-to-twin transfusion syndrome.
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Affiliation(s)
- Matthew A Shanahan
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston
| | - Michael W Bebbington
- Department of Women's Health, Comprehensive Fetal Care Center, University of Texas at Austin, Dell Medical School, Austin, Texas
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Aertsen M, Melbourne A, Couck I, King E, Ourselin S, De Keyzer F, Dymarkowski S, Deprest J, Lewi L. Placental differences between uncomplicated and complicated monochorionic diamniotic pregnancies on diffusion and multicompartment Magnetic Resonance Imaging. Placenta 2023; 142:106-114. [PMID: 37683336 DOI: 10.1016/j.placenta.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 08/28/2023] [Accepted: 09/01/2023] [Indexed: 09/10/2023]
Abstract
INTRODUCTION Twin-twin transfusion syndrome (TTTS) and selective fetal growth restriction (sFGR) are common complications in monochorionic diamniotic (MCDA) pregnancies. The Diffusion-rElaxation Combined Imaging for Detailed Placental Evaluation (DECIDE) model, a placental-specific model, separates the T2 values of the fetal and maternal blood from the background tissue and estimates the fetal blood oxygen saturation. This study investigates diffusion and relaxation differences in uncomplicated MCDA pregnancies and MCDA pregnancies complicated by TTTS and sFGR in mid-pregnancy. METHODS This prospective monocentric cohort study included uncomplicated MCDA pregnancies and pregnancies complicated by TTTS and sFGR. We performed MRI with conventional diffusion-weighted imaging (DWI) and combined relaxometry - DWI-intravoxel incoherent motion. DECIDE analysis was used to quantify different parameters within the placenta related to the fetal, placental, and maternal compartments. RESULTS We included 99 pregnancies, of which 46 were uncomplicated, 12 were complicated by sFGR and 41 by TTTS. Conventional DWI did not find differences between or within cohorts. On DECIDE imaging, fetoplacental oxygen saturation was significantly lower in the smaller member of sFGR (p = 0.07) and in both members of TTTS (p = 0.01 and p = 0.004) compared to the uncomplicated pairs. Additionally, average T2 relaxation time was significantly lower in the smaller twin of the sFGR (p = 0.004) compared to the uncomplicated twins (p = 0.03). CONCLUSION Multicompartment functional MRI showed significant differences in several MRI parameters between the placenta of uncomplicated MCDA pregnancies and those complicated by sFGR and TTTS in mid-pregnancy.
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Affiliation(s)
- M Aertsen
- Department of Radiology, University Hospitals KU Leuven, Leuven, Belgium.
| | - A Melbourne
- School of Biomedical Engineering and Imaging Sciences, King's College London, UK; Medical Physics and Biomedical Engineering, University College London, UK
| | - I Couck
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - E King
- School of Biomedical Engineering and Imaging Sciences, King's College London, UK
| | - S Ourselin
- School of Biomedical Engineering and Imaging Sciences, King's College London, UK; Medical Physics and Biomedical Engineering, University College London, UK
| | - F De Keyzer
- Department of Radiology, University Hospitals KU Leuven, Leuven, Belgium
| | - S Dymarkowski
- Department of Radiology, University Hospitals KU Leuven, Leuven, Belgium
| | - J Deprest
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium; Centre for the Developing Brain, Division of Imaging Sciences and Biomedical Engineering, Perinatal Imaging and Health, King's College London, King's Health Partners, St.Thomas' Hospital, 1st Floor South Wing, London, SE1 7EH, UK
| | - L Lewi
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
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Clark A, Flouri D, Mufti N, James J, Clements E, Aughwane R, Aertsen M, David A, Melbourne A. Developments in functional imaging of the placenta. Br J Radiol 2023; 96:20211010. [PMID: 35234516 PMCID: PMC10321248 DOI: 10.1259/bjr.20211010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 01/26/2022] [Accepted: 02/22/2022] [Indexed: 12/21/2022] Open
Abstract
The placenta is both the literal and metaphorical black box of pregnancy. Measurement of the function of the placenta has the potential to enhance our understanding of this enigmatic organ and serve to support obstetric decision making. Advanced imaging techniques are key to support these measurements. This review summarises emerging imaging technology being used to measure the function of the placenta and new developments in the computational analysis of these data. We address three important examples where functional imaging is supporting our understanding of these conditions: fetal growth restriction, placenta accreta, and twin-twin transfusion syndrome.
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Affiliation(s)
- Alys Clark
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | | | | | - Joanna James
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Eleanor Clements
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
| | - Rosalind Aughwane
- Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, UK
| | - Michael Aertsen
- Department of Radiology, University Hospitals KU Leuven, Leuven, Belgium
| | - Anna David
- Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, 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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Baschat AA, Miller JL. Pathophysiology, diagnosis, and management of twin anemia polycythemia sequence in monochorionic multiple gestations. Best Pract Res Clin Obstet Gynaecol 2022; 84:115-126. [PMID: 35450772 DOI: 10.1016/j.bpobgyn.2022.03.012] [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: 02/28/2022] [Accepted: 03/11/2022] [Indexed: 11/02/2022]
Abstract
Twin anemia polycythemia sequence (TAPS) is a consequence of unequal sharing of red blood cells between monochorionic twins resulting in anemia in the donor and polycythemia in the recipient twin. Prenatally TAPS can occur spontaneously or complicate incomplete laser surgery for twin transfusion syndrome. While there may be clinical overlap with twin transfusion syndrome or selective fetal growth restriction, diagnosis relies on Doppler measurement of middle cerebral artery peak systolic velocities. Significantly discordant velocities are diagnostic, while severity staging is based on signs of cardiovascular compromise. Conservative management, fetoscopic laser coagulation, selective twin reduction, fetal blood and exchange transfusion, and delivery may be selected guided by the gestational age of diagnosis, the severity of the condition, the likelihood of success, and the patients' priorities. Prenatal curative treatment that minimizes the risk for prematurity and residual morbidity at birth is most likely to offer the greatest short-term and long-term benefits.
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Affiliation(s)
- Ahmet A Baschat
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology & Obstetrics, USA.
| | - Jena L Miller
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology & Obstetrics, USA
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Lewi L. What fetal medicine specialists should know about the monochorionic placenta. Best Pract Res Clin Obstet Gynaecol 2022; 84:17-32. [PMID: 35430160 DOI: 10.1016/j.bpobgyn.2022.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 03/07/2022] [Indexed: 11/28/2022]
Abstract
Monochorionic twins are at risk of transfusion imbalances as long as they are connected to the shared placenta during their intrauterine journey. This review article addresses the macroscopic examination of the monochorionic placenta at the time of birth and explains placental dye injection studies to document the vascular anastomoses and placental sharing. We elaborate on the different types of anastomoses, the importance of how the placenta is divided between the twins, and the angioarchitecture in twin-twin transfusion syndrome, twin anemia polycythemia sequence and selective fetal growth restriction.
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Affiliation(s)
- Liesbeth Lewi
- Fetal Medicine Unit, Dept. Obstetrics and Gynecology, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium.
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9
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Monochorionic diamniotic twin pregnancies. Am J Obstet Gynecol MFM 2021; 4:100501. [PMID: 34649016 DOI: 10.1016/j.ajogmf.2021.100501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 09/07/2021] [Accepted: 10/04/2021] [Indexed: 10/20/2022]
Abstract
About one in five twin pregnancies are monochorionic diamniotic. In these twins, transfusion imbalances may develop due to the invariably present vascular anastomoses. The most severe imbalance is twin-twin transfusion syndrome, which presents as a significant amniotic fluid difference diagnosed on ultrasound scan, usually before 26 weeks. Another transfusion imbalance is twin anemia polycythemia sequence, a severe hemoglobin difference occurring mainly after 26 weeks in previously uncomplicated pregnancies. Fetoscopic laser coagulation of the anastomoses addresses the cause of these transfusion imbalances. Besides transfusion imbalances, the monochorionic placenta may be unevenly divided, or one part may be dysfunctional, leading to an intertwin growth difference of more than 20%. Here, laser ablation of the anastomoses will usually not cure the problem but aims to protect the appropriately growing twin if the growth-restricted co-twin dies. In monochorionic twins, structural anomalies are twice as common as in singleton pregnancies, probably due to a teratogenic effect of the embryonic splitting or because of transfusion imbalances. In contrast, chromosomal anomalies appear less common, possibly because they more likely result in an early demise. Selective reduction is feasible in monochorionic pregnancies but carries increased risks of loss, miscarriage, and early birth than a selective reduction in a dichorionic setting. Finally, if one monochorionic twin dies spontaneously, its co-twin may acutely exsanguinate into the demised co-twin, which may result in the loss of both twins or brain damage in the surviving twin. This update addresses the pathophysiology, diagnosis, and management of these common complications in monochorionic diamniotic twin pregnancies.
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Mao Q, Chu S, Shapiro S, Bliss JM, De Paepe ME. Increased placental expression of angiotensin-converting enzyme 2, the receptor of SARS-CoV-2, associated with hypoxia in twin anemia-polycythemia sequence (TAPS). Placenta 2021; 105:7-13. [PMID: 33497931 PMCID: PMC7833196 DOI: 10.1016/j.placenta.2021.01.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 01/07/2021] [Accepted: 01/08/2021] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Recent reports suggest SARS-CoV-2, the virus causing COVID-19, may be transmittable from pregnant mother to placenta and fetus, albeit rarely. The efficacy of vertical transmission of SARS-CoV-2 critically depends on the availability of its receptor, ACE2, in the placenta. In the present study, we tested the hypothesis that placental ACE2 expression is oxygenation-dependent by studying the expression of ACE2 and associated cell entry regulators in the monochorionic twin anemia-polycythemia (TAPS) placenta, a model of discordant placental oxygenation. METHODS We performed a retrospective comparative immunohistochemical, immunofluorescence and Western blot analysis of ACE2, TMPRSS2 and Cathepsin B expression in anemic and polycythemic territories of TAPS placentas (N = 14). RESULTS ACE2 protein levels were significantly higher in the anemic twin territories than in the corresponding polycythemic territories, associated with upregulation of the key ACE2-related cell entry regulators, TMPRSS2 and Cathepsin B, immunolocalized to villous trophoblastic and stromal cells. Cellular colocalization of ACE2 and TMPRSS2, suggestive of functionality of this cell entry axis, was demonstrated by double immunofluorescence studies. DISCUSSION Placental hypoxia is associated with upregulation of ACE2 expression, concomitant with increased expression of its key cell entry proteases. ACE2-regulated placental functions, both infection- and non-infection related, may be highly oxygenation-dependent.
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Affiliation(s)
- Quanfu Mao
- From the Departments of Pathology and Pediatrics, Women and Infants Hospital; and the Department of Pathology and Laboratory Medicine and the Department of Pediatrics, Alpert Medical School of Brown University, Providence, RI, USA
| | - Sharon Chu
- From the Departments of Pathology and Pediatrics, Women and Infants Hospital; and the Department of Pathology and Laboratory Medicine and the Department of Pediatrics, Alpert Medical School of Brown University, Providence, RI, USA
| | - Svetlana Shapiro
- From the Departments of Pathology and Pediatrics, Women and Infants Hospital; and the Department of Pathology and Laboratory Medicine and the Department of Pediatrics, Alpert Medical School of Brown University, Providence, RI, USA
| | - Joseph M Bliss
- From the Departments of Pathology and Pediatrics, Women and Infants Hospital; and the Department of Pathology and Laboratory Medicine and the Department of Pediatrics, Alpert Medical School of Brown University, Providence, RI, USA
| | - Monique E De Paepe
- From the Departments of Pathology and Pediatrics, Women and Infants Hospital; and the Department of Pathology and Laboratory Medicine and the Department of Pediatrics, Alpert Medical School of Brown University, Providence, RI, USA.
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11
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Shanahan MA, Bebbington MW. Placental Anatomy and Function in Twin Gestations. Obstet Gynecol Clin North Am 2020; 47:99-116. [PMID: 32008674 DOI: 10.1016/j.ogc.2019.10.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
With an increasing incidence of twin gestations, understanding the inherent risks associated with these pregnancies is essential in modern obstetrics. The unique differences in placentation in twins contribute to the increased risks. Monochorionic twins are susceptible to complications because of their unique placental architecture, including twin-to-twin transfusion syndrome, the twin anemia-polycythemia sequence, selective intrauterine growth restriction, and the twin reversed arterial perfusion sequence. Knowing the clinical correlations of placental anatomy in these gestations helps perinatal pathologists perform a more informed placental evaluation, allowing for better care for the mother and her children.
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Affiliation(s)
- Matthew A Shanahan
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Washington University in St. Louis School of Medicine, 660 South Euclid Avenue, Mailstop 8064-37-1005, St. Louis, MO 63110, USA
| | - Michael W Bebbington
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Washington University in St. Louis School of Medicine, 660 South Euclid Avenue, Mailstop 8064-37-1005, St. Louis, MO 63110, USA.
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12
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Wang X, Li L, Zhao Y, Wei Y, Yuan P. Longer distance between umbilical cord insertions is associated with spontaneous twin anemia polycythemia sequence. Acta Obstet Gynecol Scand 2020; 100:229-234. [PMID: 32897576 DOI: 10.1111/aogs.13991] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 09/02/2020] [Accepted: 09/02/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The aim of the study was to investigate the placental characteristics in spontaneous twin anemia polycythemia sequence. MATERIAL AND METHODS A retrospective case-control study of spontaneous twin anemia polycythemia sequence, twin-to-twin transfusion syndrome and normal monochorionic diamniotic twin pregnancies was performed. The primary outcome was placental characteristics. RESULTS The prevalence of artery-artery anastomoses in spontaneous twin anemia polycythemia sequence and twin-to-twin transfusion syndrome groups was significantly lower than in the normal monochorionic diamniotic twin group (40.0% vs 33.3% vs 88.8%, respectively, P < .001). The total number of vascular anastomoses in the spontaneous twin anemia polycythemia sequence group (with range given in parentheses) was significantly lower than in the two control groups (3 [1-6] vs 5 [1-14] vs 6 [1-20], P = .001/<.001/.794). The number of artery-vein anastomoses in the spontaneous twin anemia polycythemia sequence was significantly lower than in the two control groups (2 [1-5] vs 4 [1-13] vs 5 [1-19], P = .011/.001/1.000). The total diameter of all vascular anastomoses was significantly smaller in the spontaneous twin anemia polycythemia sequence than in the two control groups (0.9 mm [0.3-4.7] vs 5.2 mm [0.8-24.6] vs 7.3 mm [1.0-25.1], P < .001/<.001/.104), as was the total diameter of artery-to-artery anastomoses (0.5 mm [0.3-1.3] vs 2.0 mm [0.5-11.8] vs 2.3 mm [0.7-9.7], P = .003/<.001/1.000) and the total diameter of artery-to-vein anastomoses (0.8 mm [0.3-2.1] vs 4.6 mm [0.8-15.3] vs 4.0 mm [0.2-21.8], P < .001/<.001/1.000). The ratio between the distance of the two umbilical cords insertion points and the placental maximum diameter in the spontaneous twin anemia polycythemia sequence group was significantly larger than in the two control groups (0.78 [0.49-0.99] vs 0.64 [0.32-1.00] vs 0.55 [0.05-1.00], P = .033/<.001/.138). CONCLUSIONS In spontaneous twin anemia polycythemia sequence placentas, the number of superficial vascular anastomoses is lower, their diameter is smaller and the distance between the two umbilical cord insertion points is longer.
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Affiliation(s)
- Xueju Wang
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Luyao Li
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Yangyu Zhao
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Yuan Wei
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Pengbo Yuan
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
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Study of the placental characteristics and time of onset of twin-to-twin transfusion syndrome. Placenta 2020; 103:10-15. [PMID: 33068961 DOI: 10.1016/j.placenta.2020.10.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/29/2020] [Accepted: 10/12/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION To investigate the correlation between placental superficial anastomoses, placental territory and the umbilical cord attachment site with the time of onset of twin-to-twin transfusion syndrome (TTTS), and to explore the influence of placental characteristics on the time of onset of TTTS. METHODS A retrospective analysis was performed on 48 cases of TTTS managed conservatively at the Obstetrics Department of Peking University Third Hospital from April 2014 to April 2019. Placental superficial anastomoses, placental territory, the distance between the insertion points of the umbilical cord were measured after placental dye injection. Correlation analysis was conducted between placental characteristics and the time of onset of TTTS. RESULTS (1) The incidence of AA anastomoses was 33.3% (16/48) with a mean total diameter of 2.3 ± 1.4 mm, that of AV anastomoses was 95.8% (46/48) with a mean total diameter of 1.2 ± 0.4 mm, and that of VV anastomoses 22.9% (11/48) with a mean total diameter of 2.3 ± 1.1 mm (2) The time of onset of TTTS was positively correlated with the umbilical insertion ratio (Spearman correlation coefficient = 0.404, P = 0.004), but not correlated with the total diameter of anastomoses in the three different types, or with placental territory discordance. DISCUSSION The time of onset of TTTS was positively correlated with the umbilical insertion ratio, which suggest that the distance between umbilical cord insertion sites may affect the time of onset of TTTS. The smaller the distance between the umbilical cord insertion sites, the earlier the time of onset of TTTS is likely to be.
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Brock CO, Bergh EP, Moise, KJ, Johnson A, Hernandez-Andrade E, Lai D, Papanna R. Middle Cerebral Artery Doppler Velocimetry for the Diagnosis of Twin Anemia Polycythemia Sequence: A Systematic Review. J Clin Med 2020; 9:jcm9061735. [PMID: 32512796 PMCID: PMC7355756 DOI: 10.3390/jcm9061735] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 05/23/2020] [Accepted: 06/03/2020] [Indexed: 01/01/2023] Open
Abstract
Twin anemia polycythemia sequence (TAPS) is a rare complication of monochorionic diamniotic (MCDA) twins. Middle cerebral artery peak systolic velocity (MCA-PSV) measurements are used to screen for TAPS while fetal or neonatal hemoglobin levels are required for definitive diagnosis. We sought to perform a systematic review of the efficacy of MCA-PSV in diagnosing TAPS. Search criteria were developed using relevant terms to query the Pubmed, Embase, and SCOPUS electronic databases. Publications reporting diagnostic characteristics of MCA-PSV measurements (i.e., sensitivity, specificity or receiver operator curves) were included. Each article was assessed for bias using the Quality Assessment of Diagnostic Accuracy Studies II (QUADAS II) tool. Results were assessed for uniformity to determine whether meta-analysis was feasible. Data were presented in tabular form. Among publications, five met the inclusion criteria. QUADAS II analysis revealed that four of the publications were highly likely to have bias in multiple areas. Meta-analysis was precluded by non-uniformity between definitions of TAPS by MCA-PSV and neonatal or fetal hemoglobin levels. High-quality prospective studies with consistent definitions and ultrasound surveillance protocols are still required to determine the efficacy of MCA-PSV in diagnosing TAPS. Other ultrasound findings (e.g., placenta echogenicity discordance) may augment Doppler studies.
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Affiliation(s)
- Clifton O. Brock
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, Houston, TX 77030, USA; (C.O.B.); (E.P.B.); (K.J.M.J.); (A.J.); (E.H.-A.)
| | - Eric P. Bergh
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, Houston, TX 77030, USA; (C.O.B.); (E.P.B.); (K.J.M.J.); (A.J.); (E.H.-A.)
- The Fetal Center Children’s Memorial Hermann Hospital, Houston, TX 77030, USA
| | - Kenneth J. Moise,
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, Houston, TX 77030, USA; (C.O.B.); (E.P.B.); (K.J.M.J.); (A.J.); (E.H.-A.)
- The Fetal Center Children’s Memorial Hermann Hospital, Houston, TX 77030, USA
| | - Anthony Johnson
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, Houston, TX 77030, USA; (C.O.B.); (E.P.B.); (K.J.M.J.); (A.J.); (E.H.-A.)
- The Fetal Center Children’s Memorial Hermann Hospital, Houston, TX 77030, USA
| | - Edgar Hernandez-Andrade
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, Houston, TX 77030, USA; (C.O.B.); (E.P.B.); (K.J.M.J.); (A.J.); (E.H.-A.)
| | - Dejian Lai
- Division of Biostatistics, University of Texas, School of Public Health, 1200 Pressler St, Houston, TX 77030, USA;
| | - Ramesha Papanna
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, Houston, TX 77030, USA; (C.O.B.); (E.P.B.); (K.J.M.J.); (A.J.); (E.H.-A.)
- The Fetal Center Children’s Memorial Hermann Hospital, Houston, TX 77030, USA
- Correspondence: ; Tel.: +1-713-500-5859; Fax: +1-713-500-0799
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Couck I, Jespers A, Deprest J, Lewi L. The vascular equator in monochorionic twin placentas. Placenta 2020; 99:193-196. [PMID: 32988575 DOI: 10.1016/j.placenta.2020.05.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/04/2020] [Accepted: 05/20/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION We aim to examine the location of the vascular equator according to the umbilical cord insertions in monochorionic twin placentas. METHODS We combined two prospective series of monochorionic diamniotic twin placentas of patients included in the first trimester between 2004 and 2008, and between 2016 and 2019. We injected the placentas after birth and divided them into three groups, with respectively concordant (eccentric-eccentric, marginal-marginal, and velamentous-velamentous), intermediate (eccentric-marginal and marginal-velamentous) and discordant (eccentric-velamentous) cord insertions. For each unidirectional anastomosis, we determined the cord-anastomosis ratio and then calculated the mean ratio per placenta in each group. We also calculated the deviation from the midline in all groups. RESULTS 195 placentas were included. In concordant placentas, the mean cord-anastomosis ratio was 0.957 (95% CI [0.908-1.009]). In placentas with intermediate discordance, the mean ratio was 0.886 (95% CI [0.828-0.948]) and in discordant placentas it was 0.797 (95% CI [0,708-0.897]) (p < 0.001). In concordant placentas, the equator was in the middle of the cord insertions with an average deviation of 0.2 cm (95% CI [-0.1 - 0.3]). In the intermediate placentas, the equator deviated on average 0.5 cm (95% CI [0.2-0.8]) and was displaced from the middle towards the most central cord insertion. In discordant placentas, there was an average displacement of 1.0 cm (95% CI [0.50-1.6]). DISCUSSION In concordant placentas, the vascular equator lies in the middle between both cord insertions. In intermediate and discordant placentas, the equator is closer to the more central cord insertion.
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Affiliation(s)
- I Couck
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, 3000, Leuven, Belgium; Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KULeuven, 3000, Leuven, Belgium
| | - A Jespers
- Faculty of Medicine, KULeuven, 3000, Leuven, Belgium
| | - J Deprest
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, 3000, Leuven, Belgium; Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KULeuven, 3000, Leuven, Belgium; Institute for Women's Health, University College London Hospital, London, WC1E 6BT, United Kingdom
| | - L Lewi
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, 3000, Leuven, Belgium; Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KULeuven, 3000, Leuven, Belgium.
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Mao Q, Chu S, Shapiro S, Yao H, De Paepe ME. Discordant placental oxygenation and autophagy in twin anemia-polycythemia sequence (TAPS). Placenta 2020; 90:9-17. [PMID: 32056557 PMCID: PMC7912434 DOI: 10.1016/j.placenta.2019.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 11/07/2019] [Accepted: 11/23/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND (Macro)autophagy is an important process of self-degradation of macromolecules and organelles that ensures cellular homeostasis and energy preservation during stressful conditions. Dysregulated placental autophagy has been implicated in a wide range of pregnancy complications. Recent studies identified hypoxia as a key regulator of trophoblast autophagy in vitro; however, its effects on placental autophagy in vivo remain incompletely understood. In this study, we evaluated the monochorionic twin anemia-polycythemia sequence (TAPS) placenta as model of discordant placental oxygenation to determine the effects of hypoxia on placental autophagy in utero. METHODS We performed a retrospective comparative analysis of tissue oxygenation and autophagy in anemic and polycythemic territories of TAPS placentas (N = 12). Archival tissues were subjected to immunohistochemical, immunofluorescence and Western blot analyses of carbonic anhydrase (CA) IX (hypoxia marker) and key autophagy/lysosomal markers. RESULTS CAIX protein levels were significantly higher in anemic twin territories than in corresponding polycythemic territories, consistent with relative tissue hypoxia. Anemic placental shares further displayed significantly higher levels of LC3I/II (autophagosome markers) and LAMP1/2 (lysosome markers), associated with upregulated expression of lysosome/autophagosome activity-associated markers, transcription factor EB and cathepsin D. The accumulation of autophagosomes and lysosomes in anemic shares was accompanied by elevated p62 protein expression, suggestive of inhibition of the downstream autophagy pathway. CONCLUSIONS TAPS placentas display striking intertwin discordance in tissue oxygenation and autophagic activity and may provide a suitable model for study of the interrelationship between hypoxia, autophagy, and pregnancy outcome in a monochorionic twin setting.
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Affiliation(s)
- Quanfu Mao
- From the Department of Pathology, Women and Infants Hospital, The Department of Pathology and Laboratory Medicine, Alpert Medical School of Brown University, and the Department of Molecular Biology, Cell Biology and Biochemistry, Alpert Medical School of Brown University, Providence, RI, USA
| | - Sharon Chu
- From the Department of Pathology, Women and Infants Hospital, The Department of Pathology and Laboratory Medicine, Alpert Medical School of Brown University, and the Department of Molecular Biology, Cell Biology and Biochemistry, Alpert Medical School of Brown University, Providence, RI, USA
| | - Svetlana Shapiro
- From the Department of Pathology, Women and Infants Hospital, The Department of Pathology and Laboratory Medicine, Alpert Medical School of Brown University, and the Department of Molecular Biology, Cell Biology and Biochemistry, Alpert Medical School of Brown University, Providence, RI, USA
| | - Hongwei Yao
- From the Department of Pathology, Women and Infants Hospital, The Department of Pathology and Laboratory Medicine, Alpert Medical School of Brown University, and the Department of Molecular Biology, Cell Biology and Biochemistry, Alpert Medical School of Brown University, Providence, RI, USA
| | - Monique E De Paepe
- From the Department of Pathology, Women and Infants Hospital, The Department of Pathology and Laboratory Medicine, Alpert Medical School of Brown University, and the Department of Molecular Biology, Cell Biology and Biochemistry, Alpert Medical School of Brown University, Providence, RI, USA.
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Aughwane R, Ingram E, Johnstone ED, Salomon LJ, David AL, Melbourne A. Placental MRI and its application to fetal intervention. Prenat Diagn 2020; 40:38-48. [PMID: 31306507 PMCID: PMC7027916 DOI: 10.1002/pd.5526] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 06/18/2019] [Accepted: 07/08/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Magnetic resonance imaging (MRI) of placental invasion has been part of clinical practice for many years. The possibility of being better able to assess placental vascularization and function using MRI has multiple potential applications. This review summarises up-to-date research on placental function using different MRI modalities. METHOD We discuss how combinations of these MRI techniques have much to contribute to fetal conditions amenable for therapy such as singletons at high risk for fetal growth restriction (FGR) and monochorionic twin pregnancies for planning surgery and counselling for selective growth restriction and transfusion conditions. RESULTS The whole placenta can easily be visualized on MRI, with a clear boundary against the amniotic fluid, and a less clear placental-uterine boundary. Contrasts such as diffusion weighted imaging, relaxometry, blood oxygenation level dependent MRI and flow and metabolite measurement by dynamic contrast enhanced MRI, arterial spin labeling, or spectroscopic techniques are contributing to our wider understanding of placental function. CONCLUSION The future of placental MRI is exciting, with the increasing availability of multiple contrasts and new models that will boost the capability of MRI to measure oxygen saturation and placental exchange, enabling examination of placental function in complicated pregnancies.
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Affiliation(s)
| | - Emma Ingram
- Division of Developmental Biology & MedicineUniversity of ManchesterManchesterUK
| | - Edward D. Johnstone
- Division of Developmental Biology & MedicineUniversity of ManchesterManchesterUK
| | - Laurent J. Salomon
- Hôpital Necker‐Enfants Malades, AP‐HP, EHU PACT and LUMIERE PlatformUniversité Paris DescartesParisFrance
| | - Anna L. David
- Institute for Women's HealthUniversity College LondonLondonUK
- National Institute for Health ResearchUniversity College London Hospitals Biomedical Research CentreLondonUK
| | - Andrew Melbourne
- School of Biomedical Engineering and Imaging SciencesKing's College LondonLondonUK
- Medical Physics and Biomedical EngineeringUniversity College LondonLondonUK
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Cavazza MC, Lai AC, Sousa S, Pina R. Dichorionic pregnancy complicated by a twin-to-twin transfusion syndrome. BMJ Case Rep 2019; 12:12/10/e231614. [PMID: 31666254 DOI: 10.1136/bcr-2019-231614] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Twin-to-twin transfusion syndrome (TTTS) is a serious complication typical of monochorionic pregnancies. Cases in dichorionic pregnancies have been described. The authors present a case report of a presumed TTTS in a dichorionic pregnancy followed at our institution in which the patient presented to the emergency department at 31 4/7 weeks' gestation complaining of lack of fetal movements. Both fetuses did not show any cardiac activity. On the first twin, an oligohydramnios was present and his bladder was not visualised and, on the second twin, a polyhydramnios and an augmented bladder were visualised. Pathological findings of the fetuses were compatible with a diagnosis of TTTS and placental study confirmed the presence of a dichorionic/diamniotic placenta, with superficial vessels crossing the dividing membrane.
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Affiliation(s)
| | - Ana Catarina Lai
- Pathology, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
| | - Sílvia Sousa
- Obstetrics and Gynecology, Centro Hospitalar de Leiria, Leiria, Portugal
| | - Raquel Pina
- Pathology, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
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Fitzgerald B. Histopathological examination of the placenta in twin pregnancies. APMIS 2018; 126:626-637. [DOI: 10.1111/apm.12829] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 01/30/2018] [Indexed: 11/26/2022]
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20
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Chang YL, Chao AS, Peng HH, Chang SD, Su SY, Chen KJ, Wang TH. Effects of inter-twin vascular anastomoses of monochorionic twins with selective intrauterine growth restriction on the contents of placental mitochondria DNA. BMC Pregnancy Childbirth 2018; 18:74. [PMID: 29573746 PMCID: PMC5866522 DOI: 10.1186/s12884-018-1702-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 03/15/2018] [Indexed: 01/06/2023] Open
Abstract
Background Placental mitochondrial DNA (mtDNA) has been proposed to be an indicator for placental hypoxia. This study was designed to evaluate the effect of vascular anastomoses between monochorionic (MC) twins on placental mtDNA. Methods In this study, twin-twin transfusion syndrome (TTTS) treated with laser therapy and MC twins without TTTS (without laser therapy) resulting in two live babies were included in this study. The placental mtDNA fold changes (FC) between the small and large twins were analyzed using real-time quantitative PCR. TTTS twins with selective intrauterine growth restriction (sIUGR) are categorized as group 1, TTTS without sIUGR as group 2, MC twins without TTTS but with sIUGR as group 3, and MC twins without both TTTS and sIUGR as group 4. Results There were seven cases in group 1, eight in group 2, 26 in group 3, and 24 in group 4 cases. The placental mtDNA FC were significantly higher in group 1 (1.57 ± 0.9) compared to that of the group 3 (0.86 ± 0.6). Conclusion In MC twin pregnancies with sIUGR, the placental mtDNA FC between the small and large twins are different between cases with and without inter-twin anastomoses. These findings suggest that the inter-twin anastomoses in the MC twins with sIUGR may provide rescue perfusion from the appropriate-for-gestational-age twin to the sIUGR one. Electronic supplementary material The online version of this article (10.1186/s12884-018-1702-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yao-Lung Chang
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou, College of Medicine, Chang Gung University, No 5, Fu-Shin Road, Gwei-shan, Taoyuan, Taiwan
| | - An-Shine Chao
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou, College of Medicine, Chang Gung University, No 5, Fu-Shin Road, Gwei-shan, Taoyuan, Taiwan
| | - Hsiu-Huei Peng
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou, College of Medicine, Chang Gung University, No 5, Fu-Shin Road, Gwei-shan, Taoyuan, Taiwan
| | - Shuenn-Dyh Chang
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou, College of Medicine, Chang Gung University, No 5, Fu-Shin Road, Gwei-shan, Taoyuan, Taiwan
| | - Sheng-Yuan Su
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou, College of Medicine, Chang Gung University, No 5, Fu-Shin Road, Gwei-shan, Taoyuan, Taiwan
| | - Kuan-Ju Chen
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou, College of Medicine, Chang Gung University, No 5, Fu-Shin Road, Gwei-shan, Taoyuan, Taiwan
| | - Tzu-Hao Wang
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou, College of Medicine, Chang Gung University, No 5, Fu-Shin Road, Gwei-shan, Taoyuan, Taiwan. .,School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan. .,Genomic Medicine Research Core Laboratory (GMRCL), Chang Gung Memorial Hospital, Tao-Yuan, 333, Taiwan.
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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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De Paepe ME, Gündoğan F, Mao Q, Chu S, Shapiro S. Redness discordance in monochorionic twin placentas: Correlation with clinical and placental findings. Placenta 2017; 60:54-60. [PMID: 29208240 DOI: 10.1016/j.placenta.2017.10.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 10/18/2017] [Accepted: 10/21/2017] [Indexed: 11/25/2022]
Abstract
INTRODUCTION/OBJECTIVES Recent studies suggest redness (color) discordance of the placental basal plate may be a marker for twin anemia-polycythemia sequence (TAPS), a recently described complication of diamniotic-monochorionic twinning characterized by marked intertwin hemoglobin (Hb) discordance in the absence of oligohydramnios-polyhydramnios. In this study, we determined the clinicoplacental and choriovascular correlates of basal plate color discordance in monochorionic twin placentas, and assessed its value as postnatal indicator of TAPS. METHODS We performed a clinicoplacental analysis of 100 consecutive non-TTTS diamniotic-monochorionic twin placentas with available photographic documentation of the basal plate. Basal plate redness was quantified by computer-assisted analysis of digital images and expressed as intertwin color difference ratio (CDR). RESULTS The CDR ranged between 1.00 and 3.58 (median CDR: 1.14; 90th %ile: 1.98). Compared to twins with low CDR (N = 90), twins with high CDR (≥2.0; N = 10) had significantly higher hemoglobin difference (11.25 g/dL versus 2.55 g/dL) and significantly fewer and smaller artery-to-artery (AA) and artery-to-vein (AV) anastomoses. Apgar scores and birth weights were equivalent in both groups. Among the 10 twin sets with high CDR, six (60%) qualified as TAPS, as defined by intertwin Hb difference >8 g/dL and absent or very small AA and AV anastomoses. Conversely, 6 of 8 (75%) twin sets with TAPS had a CDR ≥ 2.0. CONCLUSION Intertwin CDR correlates with intertwin hemoglobin difference and chorionic angioarchitecture. A CDR value ≥ 2.0 (the 90%ile value for CDR derived from the present cohort) has high specificity (96%), but relatively low positive predictive value (60%) as indicator of TAPS, as currently defined.
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Affiliation(s)
- Monique E De Paepe
- Department of Pathology, Women and Infants Hospital, Providence, RI, 02905, United States; Department of Pathology and Laboratory Medicine, Alpert Medical School of Brown University, Providence, RI, 02905, United States.
| | - Füsun Gündoğan
- Department of Pathology, Women and Infants Hospital, Providence, RI, 02905, United States; Department of Pathology and Laboratory Medicine, Alpert Medical School of Brown University, Providence, RI, 02905, United States
| | - Quanfu Mao
- Department of Pathology, Women and Infants Hospital, Providence, RI, 02905, United States
| | - Sharon Chu
- Department of Pathology, Women and Infants Hospital, Providence, RI, 02905, United States
| | - Svetlana Shapiro
- Department of Pathology, Women and Infants Hospital, Providence, RI, 02905, United States
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23
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Hussey T, Shah N, Govind A. MCDA twin pregnancy: is it TTTS or TAPS? J OBSTET GYNAECOL 2017; 37:1091-1092. [PMID: 28609165 DOI: 10.1080/01443615.2017.1313824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Thomas Hussey
- a Department of Obstetrics and Gynaecology , North Middlesex University Hospital NHS Trust , London , UK
| | - Neha Shah
- a Department of Obstetrics and Gynaecology , North Middlesex University Hospital NHS Trust , London , UK
| | - Abha Govind
- a Department of Obstetrics and Gynaecology , North Middlesex University Hospital NHS Trust , London , UK
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