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Vassar R, George E, Mogga A, Li Y, Norton ME, Glenn O, Gano D. Fetal Intraparenchymal Hemorrhage Imaging Patterns, Etiology, and Outcomes: A Single Center Cohort Study. Ann Neurol 2024. [PMID: 39215698 DOI: 10.1002/ana.27072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 08/10/2024] [Accepted: 08/15/2024] [Indexed: 09/04/2024]
Abstract
OBJECTIVE This study examines associations among fetal brain magnetic resonance imaging (MRI) injury patterns, etiologies, and outcomes in fetal intraparenchymal hemorrhage (IPH). METHODS This is a retrospective, single-center cohort study of IPH diagnosed on fetal MRI (1996-2022). IPH and associated abnormalities were categorized by 2 pediatric neuroradiologists; electronic medical records were reviewed by 2 pediatric neurologists to classify etiology and outcomes including cerebral palsy, epilepsy, developmental delay, and death. RESULTS Forty-four fetuses with IPH were identified (34 singleton and 10 twin gestations) with MRI at median 24 weeks gestation (interquartile range [IQR] = 22-28 weeks). IPH was commonly supratentorial (84%) and focal (50%) or focal with diffuse injury (43%) and was often associated with germinal matrix hemorrhage (GMH; 75%) and/or intraventricular hemorrhage (IVH; 52%). An etiology was identified in 75%, including twin-twin transfusion syndrome (TTTS, n = 10), COL4A1/2 variants (n = 8), or other fetal/maternal conditions (n = 15). COL4A1/2 variants were associated with focal IPH and the presence of hemorrhagic porencephaly, and intrauterine transfusion was associated with infratentorial hemorrhage. Twenty-two fetuses were liveborn, and 18 pregnancies were terminated. Among those with follow-up ≥ 12 months (median = 7 years), 12 of 13 had cerebral palsy, 6 of 13 had developmental delay, and 5 of 13 had epilepsy. INTERPRETATION An etiology for fetal IPH with or without GMH-IVH is identified in most cases in our cohort and is commonly TTTS, COL4A1/2 variants, or other maternal/fetal comorbidities. Pattern of fetal IPH on MRI is associated with etiology. Cerebral palsy and neurodevelopmental impairment were common in liveborn infants. Genetic studies should be considered in cases of fetal IPH without an otherwise apparent cause. ANN NEUROL 2024.
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Affiliation(s)
- Rachel Vassar
- Department of Neurology, University of California San Francisco, San Francisco, CA
| | - Elizabeth George
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA
| | - Andrew Mogga
- School of Medicine, Albany Medical College, Albany, NY
| | - Yi Li
- Department of Neurology, University of California San Francisco, San Francisco, CA
| | - Mary E Norton
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, CA
| | - Orit Glenn
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA
| | - Dawn Gano
- Department of Neurology, University of California San Francisco, San Francisco, CA
- Department of Pediatrics, University of California San Francisco, San Francisco, CA
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Spruijt MS, van Klink JMM, de Vries LS, Slaghekke F, Middeldorp JM, Lopriore E, Tan RNGB, Toirkens JP, Steggerda SJ. Fetal and neonatal neuroimaging in twin-twin transfusion syndrome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:746-757. [PMID: 38214436 DOI: 10.1002/uog.27583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 11/17/2023] [Accepted: 01/07/2024] [Indexed: 01/13/2024]
Abstract
OBJECTIVES To describe the types of brain injury and subsequent neurodevelopmental outcome in fetuses and neonates from pregnancies with twin-twin transfusion syndrome (TTTS). Additionally, to determine risk factors for brain injury and to review the use of neuroimaging modalities in these cases. METHODS This was a retrospective cohort study of consecutive TTTS pregnancies treated with laser surgery in a single fetal therapy center between January 2010 and January 2020. The primary outcome was the incidence of brain injury, classified into predefined groups. Secondary outcomes included adverse outcome (perinatal mortality or neurodevelopmental impairment), risk factors for brain injury and the number of magnetic resonance imaging (MRI) scans. RESULTS Cranial ultrasound was performed in all 466 TTTS pregnancies and in 685/749 (91%) liveborn neonates. MRI was performed in 3% of pregnancies and 4% of neonates. Brain injury was diagnosed in 16/935 (2%) fetuses and 37/685 (5%) neonates and all predefined injury groups were represented. Four fetal and four neonatal cases of cerebellar hemorrhage were detected. Among those with brain injury, perinatal mortality occurred in 11/16 (69%) fetuses and 8/37 (22%) neonates. Follow-up was available for 29/34 (85%) long-term survivors with brain injury and the mean age at follow-up was 46 months. Neurodevelopmental impairment was present in 9/29 (31%) survivors with brain injury. Adverse outcome occurred in 28/53 (53%) TTTS individuals with brain injury. The risk of brain injury was increased after recurrent TTTS/post-laser twin anemia-polycythemia sequence (TAPS) (odds ratio (OR), 3.095 (95% CI, 1.581-6.059); P = 0.001) and lower gestational age at birth (OR per 1-week decrease in gestational age, 1.381 (95% CI, 1.238-1.541); P < 0.001). CONCLUSIONS Based on dedicated neurosonography and limited use of MRI, brain injury was diagnosed in 2% of fetuses and 5% of neonates with TTTS. Adverse outcome was seen in over half of cases with brain injury. Brain injury was related to recurrent TTTS/post-laser TAPS and a lower gestational age at birth. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- M S Spruijt
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Pediatrics, Division of Perinatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J M M van Klink
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - L S de Vries
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - F Slaghekke
- Department of Obstetrics, Division of Fetal Therapy, Leiden University Medical Center, Leiden, The Netherlands
| | - J M Middeldorp
- Department of Obstetrics, Division of Fetal Therapy, Leiden University Medical Center, Leiden, The Netherlands
| | - E Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - R N G B Tan
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - J P Toirkens
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - S J Steggerda
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
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Zhang YH, Jiao'e P, Chen L, Zhou WX, Zhan H, Chen LQ, Lin J, Wen H. New radiofrequency ablation procedure for selective reduction in complicated monochorionic twin or triplet pregnancy using multistep, incremental expansion technique. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:522-528. [PMID: 37767731 DOI: 10.1002/uog.27508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 09/09/2023] [Accepted: 09/20/2023] [Indexed: 09/29/2023]
Abstract
OBJECTIVE Radiofrequency ablation (RFA) is the preferred approach for selective reduction in complex monochorionic (MC) multiple pregnancies owing to the ease of operation and minimal invasiveness. To optimize the RFA technique and reduce the risk of adverse pregnancy outcome resulting from the heat-sink effect of RFA therapy, we used an innovative RFA method, in which an electrode needle was expanded incrementally and stepwise. This study aimed to assess the efficacy and safety profile of this novel multistep incremental expansion RFA method for selective fetal reduction in MC twin and triplet pregnancies. METHODS This was a single-center retrospective cohort study of all MC multiple pregnancies undergoing RFA between March 2016 and October 2022 at our center. The multistep RFA technique involved the use of an expandable needle, which was gradually expanded during the RFA procedure until cessation of umbilical cord blood flow was achieved. The needle used for the single-step RFA method was fully extended from the start of treatment. RESULTS In total, 132 MC multiple pregnancies underwent selective reduction using RFA, including 50 cases undergoing multistep RFA and 82 cases undergoing single-step RFA. The overall survival rates were not significantly different between the multistep and single-step RFA groups (81.1% vs 72.3%; P = 0.234). Similarly, the rates of preterm prelabor rupture of the membranes within 2 weeks after RFA, procedure-related complications, spontaneous preterm delivery and pathological findings on cranial ultrasound, as well as gestational age at delivery and birth weight, did not differ between the two groups. However, there was a trend towards a prolonged procedure-to-delivery interval following multistep RFA compared with single-step RFA (median, 109 vs 99 days; P = 0.377). Moreover, the fetal loss rate within 2 weeks after RFA in the multistep RFA group was significantly lower than that in the single-step RFA group (10.0% vs 24.4%; P = 0.041). The median ablation time was shorter (5.3 vs 7.8 min; P < 0.001) and the median ablation energy was lower (10.2 vs 18.0 kJ; P < 0.001) in multistep compared with single-step RFA. There were no significant differences in neonatal outcomes following multistep vs single-step RFA. CONCLUSIONS Overall survival rates were similar between the two RFA methods. However, the multistep RFA technique was associated with a lower risk of fetal loss within 2 weeks after RFA. The multistep RFA technique required significantly less ablation energy and a shorter ablation time compared with single-step RFA in selective fetal reduction of MC twin and triplet pregnancies. Additionally, there was a trend towards a prolonged procedure-to-delivery interval with the multistep RFA technique. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- Y-H Zhang
- Zhejiang University School of Medicine, Women's Hospital, Hangzhou, Zhejiang, People's Republic of China
| | - P Jiao'e
- Zhejiang University School of Medicine, Women's Hospital, Hangzhou, Zhejiang, People's Republic of China
| | - L Chen
- Zhejiang University School of Medicine, Women's Hospital, Hangzhou, Zhejiang, People's Republic of China
| | - W-X Zhou
- Zhejiang University School of Medicine, Women's Hospital, Hangzhou, Zhejiang, People's Republic of China
| | - H Zhan
- Zhejiang University School of Medicine, Women's Hospital, Hangzhou, Zhejiang, People's Republic of China
| | - L-Q Chen
- Zhejiang University School of Medicine, Women's Hospital, Hangzhou, Zhejiang, People's Republic of China
| | - J Lin
- Zhejiang University School of Medicine, Women's Hospital, Hangzhou, Zhejiang, People's Republic of China
| | - H Wen
- Zhejiang University School of Medicine, Women's Hospital, Hangzhou, Zhejiang, People's Republic of China
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Prasad S, Beg S, Badran D, Masciullo L, Huddy C, Khalil A. Neurodevelopmental outcome in complicated twin pregnancy: prospective observational study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:189-197. [PMID: 37550962 DOI: 10.1002/uog.27448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 07/08/2023] [Accepted: 07/21/2023] [Indexed: 08/09/2023]
Abstract
OBJECTIVE Twin pregnancy is associated with increased perinatal mortality and morbidity, but long-term neurodevelopmental outcome remains underinvestigated. The primary objective of this study was to investigate the incidence of adverse neurodevelopment after 1 year of age in complicated monochorionic diamniotic (MCDA) twin pregnancies compared with uncomplicated twin pregnancies. METHODS This was a prospective cohort study conducted at St George's University Hospital NHS Foundation Trust, London, UK. Women with a twin pregnancy culminating in at least one surviving child, aged between 12 and 60 months (corrected for prematurity) at the time of assessment, were invited to complete the relevant Ages and Stages Questionnaire® version 3 (ASQ-3) test. The two study groups were: (1) complicated MCDA twin pregnancies, including those with twin-twin transfusion syndrome, twin anemia-polycythemia sequence, selective fetal growth restriction, twin reversed arterial perfusion sequence and/or single intrauterine demise; and (2) uncomplicated MCDA and dichorionic diamniotic twin pregnancies. The primary outcome measure was an abnormal ASQ-3 score, defined as a score of more than 2 SD below the mean in any one of the five domains. Mixed-effects multivariable logistic regression analysis was performed to determine whether a complicated MCDA twin pregnancy was associated independently with an abnormal ASQ-3 score. RESULTS The study included 174 parents who completed the questionnaire for one or both twins; therefore, 327 ASQ-3 questionnaires were available for analysis. Of those, 117 (35.8%) were complicated MCDA twin pregnancies and 210 (64.2%) were controls. The overall rate of an abnormal ASQ-3 score in children born of a complicated MCDA twin pregnancy was nearly double that of those from uncomplicated twin pregnancies (14.5% vs 7.6%; P = 0.056). Children born of a complicated MCDA twin pregnancy had a significantly higher rate of impairment in the gross-motor domain compared with the control group (8.5% vs 2.9%; P = 0.031). Complicated MCDA twin pregnancies that underwent prenatal intervention had a significantly higher rate of abnormal ASQ-3 score compared with those that did not undergo prenatal intervention (28.1% vs 1.7%; P < 0.001). On multilevel logistic regression analysis, complicated MCDA twin pregnancy was an independent predictor of abnormal ASQ-3 score (adjusted odds ratio, 3.28 (95% CI, 3.27-3.29); P < 0.001). CONCLUSIONS This study demonstrates that survivors of complicated MCDA twin pregnancies have a higher rate of adverse neurodevelopmental outcome, independently of prematurity. Long-term neurodevelopmental follow-up in these pregnancies can ensure timely and optimal management of those affected. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- S Prasad
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - S Beg
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - D Badran
- NHS Greater Glasgow and Clyde, Glasgow, UK
| | - L Masciullo
- Department of Obstetrics and Gynecology, Cristo Re Hospital, Rome, Italy
| | - C Huddy
- Department of Neonatology, St George's University Hospital, London, UK
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Twins and Multiples Centre for Research and Clinical Excellence, London, UK
- Fetal Medicine Unit, Liverpool Women's Hospital, University of Liverpool, Liverpool, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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Wu T, Gong X, Wang X, Li L, Chen Z, Yuan P, Xie J, Gong L, Wang X, Zhao Y, Wei Y. Perinatal and neurodevelopmental outcome in complicated monochorionic pregnancy after selective fetal reduction: radiofrequency ablation vs microwave ablation. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 60:506-513. [PMID: 35468234 DOI: 10.1002/uog.24919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 04/02/2022] [Accepted: 04/08/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVES To summarize our experience in the application of radiofrequency ablation (RFA) and microwave ablation (MWA) for selective fetal reduction in complicated monochorionic pregnancies and compare the perinatal outcome of the two techniques. METHODS This was a retrospective study of data from a consecutive cohort of all monochorionic twin pregnancies that underwent selective fetal reduction with RFA or MWA at Peking University Third Hospital, Beijing, China from January 2012 to December 2018. All surviving cotwins were followed up to assess their neurodevelopment using the Age & Stage Questionnaire, Chinese version. Perinatal and neurodevelopmental outcomes were compared between the RFA and MWA groups. We also fitted multivariable models to test the association between procedure-related factors and the main perinatal outcomes, including preterm birth (PTB) < 37 weeks' gestation, intrauterine fetal death (IUFD) of the cotwin, adverse outcome (defined as occurrence of IUFD of the cotwin, termination of pregnancy or PTB < 28 weeks) and overall survival. RESULTS In total, 45 cases (42 twin and three triplet pregnancies) underwent RFA and 126 cases (105 twin and 21 triplet pregnancies) underwent MWA. The overall survival rates in monochorionic diamniotic twin pregnancies were similar between the RFA and MWA groups (61.0% vs 67.0%; P = 0.494). However, pregnancies whose indication for fetal reduction was selective intrauterine growth restriction or twin reversed arterial perfusion had higher overall survival rates (75.5% and 82.6%, respectively) compared with those in other indication groups. A total of 104 children were followed up (20 in the RFA group and 84 in the MWA group); four (20.0%) and eight (9.5%) children were assessed as having overall developmental delay in the RFA and MWA groups, respectively, with no significant difference between the two groups. Multivariable analyses showed that procedure indication, number of ablation cycles and gestational age at procedure were associated significantly with the main perinatal outcomes. CONCLUSIONS RFA and MWA for selective fetal reduction in complicated monochorionic pregnancies can achieve similar overall survival rate and neurodevelopmental outcome, but MWA is associated with a lower risk of preterm birth. Moreover, procedure-related factors are associated significantly with perinatal outcome. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- T Wu
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - X Gong
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - X Wang
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - L Li
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Z Chen
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - P Yuan
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - J Xie
- Department of Maternal and Child Health, School of Public Health, Peking University, Beijing, China
| | - L Gong
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - X Wang
- Department of Maternal and Child Health, School of Public Health, Peking University, Beijing, China
| | - Y Zhao
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Y Wei
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
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Clinical Value and Treatment Progress of Prenatal Ultrasonography in Twin Pregnancy: A Systematic Review. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:6748487. [PMID: 36051930 PMCID: PMC9424050 DOI: 10.1155/2022/6748487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 06/23/2022] [Accepted: 07/01/2022] [Indexed: 11/23/2022]
Abstract
Assisted reproductive technology has continued to develop in recent years, the technology has become more and more mature, and it has improved the total gestational age of the population. Assisted reproductive technology has improved twin pregnancy rates with the use of ovulation-inducing drugs. The risk factor of twins is much higher than singletons, and adverse pregnancy outcomes such as stillbirth and premature birth are more likely to occur than singletons, especially the special complications of monochorionic twins (MC), and the neonatal mortality and morbidity are also increased. Prenatal diagnosis and prognosis of twin pregnancy, as well as therapeutic interventions, are of current concern. Ultrasound can realize the understanding of intrauterine growth and development of twin pregnancy fetuses during pregnancy, can more accurately determine gestational age, organ function, and maturity, and timely detect fetal growth and development abnormalities in twin pregnancy, while the prognosis and treatment still need further improvement. The purpose of this study was to investigate the clinical value and treatment progress of prenatal ultrasound monitoring in twin pregnancy.
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Sileo FG, Curado J, D'Antonio F, Benlioglu C, Khalil A. Incidence and outcome of prenatal brain abnormality in twin-to-twin transfusion syndrome: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 60:176-184. [PMID: 35233861 DOI: 10.1002/uog.24895] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 02/18/2022] [Accepted: 02/21/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVES To evaluate the incidence of antenatally diagnosed brain injury in twin pregnancy complicated by twin-to-twin transfusion syndrome (TTTS) and to quantify the perinatal mortality, morbidity and long-term neurodevelopmental outcome of these fetuses. METHODS MEDLINE, EMBASE, ClinicalTrials.gov and The Cochrane Library databases were searched. Inclusion criteria were studies reporting on brain abnormality diagnosed antenatally in twin pregnancies complicated by TTTS. The primary outcome was the incidence of prenatal brain abnormality. The secondary outcomes were intrauterine demise (IUD), neonatal death, termination of pregnancy (TOP) and long-term morbidity. Outcomes were explored in the population of fetuses with antenatal diagnosis of brain abnormality. Subgroup analysis according to the type of treatment, gestational age, Quintero stage at diagnosis and/or treatment, and cotwin death was planned. Meta-analysis of proportions was used to combine data and pooled proportions and their 95% CI were reported. RESULTS Thirteen studies including 1573 cases of TTTS and 88 fetuses with an antenatal diagnosis of brain abnormality were included in the systematic review. The meta-analysis included only studies reporting on brain abnormality in twin pregnancy complicated by TTTS cases and treated with laser surgery. Overall, brain injury occurred in 2.2% (52/2410) of fetuses (eight studies). Brain abnormality was reported in 1.03% and 0.82% of recipients and donors, respectively. The most common type of abnormality was ischemic lesions (30.4% (95% CI, 19.1-43.0%)), followed by destructive lesions (23.9% (95% CI, 13.7-35.9%)), ventriculomegaly (19.9% (95% CI, 10.6-31.3%)) and hemorrhagic lesions (15.3% (95% CI, 7.1-25.8%)). Spontaneous IUD occurred in 13.4% (95% CI, 5.1-24.8%) of fetuses, while TOP was chosen by parents in 53.5% (95% CI, 38.9-67.8%) cases. Neonatal death was reported by only three studies, with an incidence of 15.4% (95% CI, 2.8-35.4%). Finally, only two studies reported on composite morbidity, with an overall rate of the outcome of 20.4% (95% CI, 2.5-49.4%) and rates of 29.7% and 20.4% in the recipient and donor fetuses, respectively. Due to the small numbers, only composite morbidity was analyzed and no information on neonatal intensive care unit admission, respiratory distress syndrome or other long-term outcomes, such as neurodevelopmental delay and cerebral palsy, could be retrieved reliably. CONCLUSIONS The overall incidence of antenatally diagnosed fetal brain abnormality in twin pregnancy complicated by TTTS treated with laser surgery is around 2% and is mainly ischemic in nature (30.4%). TOP was chosen by parents in more than half of cases (53.5%). No information could be retrieved on morbidity outcomes, highlighting the urgent need for long-term follow-up studies of these children. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- F G Sileo
- Department of Biomedical, Metabolic and Neural Sciences, International Doctorate School in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Modena, Italy
- Unit of Obstetrics and Gynecology, Azienda Unità Sanitaria Locale - IRCCS, Reggio Emilia, Modena, Italy
| | - J Curado
- Gynaecology and Obstetrics Department, Hospital Garcia de Orta, Almada, Portugal
| | - F D'Antonio
- Prenatal Medicine Unit, Obstetrics and Gynecology Unit, University "G. d'Annunzio" of Chieti, Chieti, Italy
| | - C Benlioglu
- Department of Obstetrics and Gynecology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Twins Trust Centre for Research and Clinical Excellence, St George's Hospital, London, UK
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Donepudi R, Hessami K, Nassr AA, Espinoza J, Cortes MS, Belfort MA, Shamshirsaz AA. Co-twin survival after selective fetal reduction in complicated multiple gestations: A systematic review and meta-analysis of survival rate according to indication for intervention. Eur J Obstet Gynecol Reprod Biol 2022; 274:182-190. [PMID: 35661541 DOI: 10.1016/j.ejogrb.2022.05.028] [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: 01/19/2022] [Revised: 05/02/2022] [Accepted: 05/25/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Determine the impact of indication for selective reduction (SR) on co-twin survival in monochorionic gestations undergoing radiofrequency ablation (RFA) or bipolar cord coagulation (BCC). METHODS PubMed and Web of Science were systematically searched from inception of databases to April 2021. Frequency of indications was compared between post-intervention co-twin survival and demise groups undergoing SR. Random-effect model was used to pool mean differences or odds ratios (OR) and corresponding 95% confidence intervals (CIs). Heterogeneity was assessed using the I2 value. RESULTS Of 1060 studies assessed for eligibility, nine studies met criteria. A total of 666 pregnancies underwent RFA (n = 483 co-twin survival) and 235 pregnancies underwent BCC (n = 188 co-twin survival). Twin twin transfusion syndrome (TTTS), as an indication for RFA, was associated with decreased co-twin survival (OR 0.61, 95% CI 0.41, 0.90, P 0.01, I2 0.0%). Other indications for RFA were not associated with significant difference in co-twin survival. With BCC, none of the indications were found to significantly influence the co-twin survival following intervention. CONCLUSION RFA was found to have lower co-twin survival when performed for TTTS. No other indications was associated with differences in co-twin survival. BCC was not associated with any differences in co-twin survival based on indication.
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Affiliation(s)
- Roopali Donepudi
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA.
| | - Kamran Hessami
- Maternal Fetal Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ahmed A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - Jimmy Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - Magdalena Sanz Cortes
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - Alireza A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
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Al-Alaiyan S, Abdulaziz N, Bukhari H, Hawari A, Alturki A, Alghamdi R, Elsaidawi W. Outcome of Twin Pregnancies Complicated by a Single Intrauterine Death. Cureus 2022; 14:e26055. [PMID: 35865421 PMCID: PMC9289511 DOI: 10.7759/cureus.26055] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2022] [Indexed: 11/30/2022] Open
Abstract
Objective Single intrauterine fetal death (sIUFD) occurs in approximately 6% of twin pregnancies. If it occurs in the second and third trimesters, it places the co-twin at substantial risk, including that of preterm delivery and associated comorbidities of prematurity or neonatal death. The aim of this present study was to determine the outcome of surviving co-twins following spontaneous single intrauterine fetal death. Methods This is a retrospective, observational, cohort study that included all twin pregnancies delivered between January 2015 to December 2019 with a gestational age of 24 weeks or more. Maternal data included were: age, medical illnesses, conceivable methods, chorionicity, and complications during pregnancy. Gestational age of intrauterine fetal demise, gestational age of the surviving twin delivery, mode of delivery, and medications used during pregnancy were also recorded. Neonatal data included: gestational age, gender, birth weight, Apgar score, and complications of prematurity. Results Twenty-two pregnancies were found to be complicated by sIUFD and included in the present study (group 1), compared to 26 twins with no sIUFD (group 2). The incidence of sIUFD in twin pregnancies after 20 weeks of pregnancy was 4.4%. The gestational age (weeks) in group 1 was 34.5 (29-39) and in group 2 was 32 (26-38). The frequency of preterm delivery 81.8% in group 1 (59% monochorionic) and 69.2% (100% dichorionic) in group 2. No significant statistical differences were found between the two groups in complications of prematurity. Conclusions We conclude that delaying delivery in twin pregnancies complicated by single intrauterine demise with regular follow-up may lead to delivering infants with fewer complications of prematurity.
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10
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Donepudi R, Hessami K, Nassr AA, Espinoza J, Sanz Cortes M, Sun L, Shirazi M, Yinon Y, Belfort MA, Shamshirsaz AA. Selective reduction in complicated monochorionic pregnancies: a systematic review and meta-analysis of different techniques. Am J Obstet Gynecol 2022; 226:646-655.e3. [PMID: 34678178 DOI: 10.1016/j.ajog.2021.10.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 10/08/2021] [Accepted: 10/10/2021] [Indexed: 01/10/2023]
Abstract
OBJECTIVE This systematic review and meta-analysis aimed to compare the perinatal outcomes of complicated monochorionic pregnancies after selective reduction by radiofrequency ablation, bipolar cord coagulation, and interstitial laser. DATA SOURCES We searched PubMed, Scopus, and Web of Science, from the inception of the database up to April 26, 2021. STUDY ELIGIBILITY CRITERIA Studies comparing at least 2 selective reduction techniques among complicated monochorionic pregnancies and presenting data on perinatal outcomes, including gestational age at procedure, gestational age at delivery, procedure to delivery interval, preterm premature rupture of membranes, preterm birth, survival rate, and birthweight, were eligible. METHODS The random-effects model was used to pool the mean differences or odds ratios and corresponding 95% confidence intervals. Heterogeneity was assessed using the I2 value. RESULTS A total of 10 studies with 734 cases of fetal reduction met the inclusion criteria, of which 9 studies with 674 fetuses were eligible for quantitative synthesis. In 8 studies that compared radiofrequency ablation with bipolar cord coagulation, radiofrequency ablation was associated with increased procedure to delivery interval (days) (mean difference, 13.42; 95% confidence interval, 1.90-24.94; P=.02; I2=0.0%), decreased preterm birth (odds ratio, 0.50; 95% confidence interval, 0.29-0.85; P=.01; I2=3.0%), and decreased preterm premature rupture of membranes (odds ratio, 0.45; 95% confidence interval, 0.27-0.73; P=.001; I2=0.0%). Radiofrequency ablation and bipolar cord coagulation had comparable survival rates (odds ratio, 0.85; 95% confidence interval, 0.54-1.35; P=.49; I2=0.0%). In 3 studies that compared radiofrequency ablation with interstitial laser, there was no significant difference in gestational age at delivery (P=.07) or survival (P=.15). In 3 studies that compared bipolar cord coagulation with interstitial laser, bipolar cord coagulation was associated with a higher survival rate (odds ratio, 3.21; 95% confidence interval, 1.13-9.10; P=.03; I2=0.0%), but the gestational age at delivery was comparable between groups (P=.16). CONCLUSION This study demonstrated that radiofrequency ablation has a greater procedure to delivery interval and decreased preterm premature rupture of membranes and preterm birth than bipolar cord coagulation. Although there was no difference in gestational age at delivery for either bipolar cord coagulation, radiofrequency ablation, or interstitial laser, survival was higher with bipolar cord coagulation than with interstitial laser.
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Affiliation(s)
- Roopali Donepudi
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX
| | - Kamran Hessami
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX
| | - Ahmed A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX; Department of Obstetrics and Gynecology, Women's Health Hospital, Assiut University, Assiut, Egypt
| | - Jimmy Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX
| | - Magdalena Sanz Cortes
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX
| | - Luming Sun
- Department of Fetal Medicine and Prenatal Diagnosis Center, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Mahboobeh Shirazi
- Maternal, Fetal and Neonatal Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Yoav Yinon
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel HaShomer, Israel
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX
| | - Alireza A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX.
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11
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Gebb J, Hwang R, Paidas Teefey C, Soni S, Coleman BG, Zarnow DM, Moldenhauer JS, Khalek N. Magnetic resonance neuroimaging after laser for twin-twin transfusion syndrome with single fetal demise. Am J Obstet Gynecol 2022; 226:728.e1-728.e8. [PMID: 35257667 DOI: 10.1016/j.ajog.2022.02.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 02/03/2022] [Accepted: 02/26/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Neurologic injury in the surviving twin is a risk after single fetal demise in a monochorionic pregnancy. OBJECTIVE This study aimed to describe fetal magnetic resonance neuroimaging findings in pregnancies complicated by single fetal demise after laser photocoagulation for twin-twin transfusion syndrome. STUDY DESIGN This was a single-center retrospective analysis of a cohort of prospectively collected patients in a monochorionic twin registry who had fetoscopic laser photocoagulation for twin-twin transfusion syndrome with single fetal demise at follow-up. Magnetic resonance neuroimaging was offered 3 to 4 weeks after the demise to assess for potential neurologic sequelae. Magnetic resonance images were interpreted by 2 board-certified neuroradiologists and classified as normal, mildly abnormal, or severely abnormal. The groups were compared on the basis of recipient vs donor demise using the Fisher exact test and Mann-Whitney U test. Multivariate logistic regression was performed to determine risk factors for abnormal magnetic resonance neuroimaging. RESULTS In 378 laser photocoagulation procedures, 64 cases (16.9%) of single demise were identified (36 in the donor group and 28 in the recipient group). Of note, 6 patients had rupture of membranes with nonviable delivery (3 from each group). Moreover, 40 patients (69%) underwent magnetic resonance imaging. Of those patients, 12 (30%) had abnormal findings: 10 (83%) were associated with mild changes, and 2 (17%) were associated with severe findings. Abnormal magnetic resonance neuroimaging was seen in 3 of 22 patients (14%) after donor demise and 9 of 18 patients (50%) after recipient demise (P=.02). Logistic regression revealed that recipient vs donor demise was an independent risk factor for abnormal magnetic resonance imaging. In addition, 2 pregnancies with severe magnetic resonance imaging findings had complicated courses. CONCLUSION Mildly abnormal magnetic resonance neuroimaging findings were common after laser photocoagulation for twin-twin transfusion syndrome complicated by single fetal demise and were more common in cases of recipient demise than donor demise. Severe magnetic resonance neuroimaging findings in this series were limited to patients with complicated peri- or postoperative courses.
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Affiliation(s)
- Juliana Gebb
- Department of General, Thoracic, and Fetal Surgery, Richard D. Wood Jr Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| | - Rosa Hwang
- Department of General, Thoracic, and Fetal Surgery, Richard D. Wood Jr Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Christina Paidas Teefey
- Department of General, Thoracic, and Fetal Surgery, Richard D. Wood Jr Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Shelly Soni
- Department of General, Thoracic, and Fetal Surgery, Richard D. Wood Jr Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Beverly G Coleman
- Department of General, Thoracic, and Fetal Surgery, Richard D. Wood Jr Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Deborah M Zarnow
- Department of General, Thoracic, and Fetal Surgery, Richard D. Wood Jr Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Julie S Moldenhauer
- Department of General, Thoracic, and Fetal Surgery, Richard D. Wood Jr Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Nahla Khalek
- Department of General, Thoracic, and Fetal Surgery, Richard D. Wood Jr Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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12
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Bartin R, Colmant C, Bourgon N, Carrier A, Ville Y, Stirnemann J. Selective vs complete fetoscopic coagulation of vascular equator: a matched comparative study. Am J Obstet Gynecol 2022; 227:504.e1-504.e9. [PMID: 35500610 DOI: 10.1016/j.ajog.2022.04.047] [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: 01/21/2022] [Revised: 04/22/2022] [Accepted: 04/23/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Complete coagulation of the vascular equator (as in the Solomon technique) has been suggested to reduce postoperative complications such as twin anemia polycythemia syndrome and the recurrence of twin-twin transfusion syndrome following fetoscopic laser coagulation of chorionic vessels for twin-twin transfusion syndrome. OBJECTIVE We aimed to evaluate the benefit of this technique on perinatal outcomes compared with selective ablation of anastomoses. STUDY DESIGN We conducted a monocentric retrospective study comparing selective laser coagulation of anastomoses to the Solomon technique from January 2006 to August 2020. To adjust for potential confounders, the cases operated by selective surgery were matched to the cases operated with the Solomon technique according to the gestational age at laser therapy, placental localization, and Quintero stage using propensity score matching. RESULTS With a total of 994 cases, 399 matched pairs were included in the analysis. Compared with selective ablation, the Solomon technique was associated with significantly improved survival: the overall twin survival at delivery and discharge was 72% vs 79% (P=.003) and 69% vs 75% (P=.006), respectively; the double twin survival rate at discharge was 55% vs 65% (P=.02), respectively, and the rate of intrauterine death dropped from 18% to 12% (P=.003), respectively. The Solomon technique significantly reduced the rate of twin anemia polycythemia syndrome (10% vs 4%; P=.02), leading to fewer secondary rescue procedures (13% vs 7.3%; P=.01). However, the Solomon technique was associated with an increased risk of preterm rupture of membranes, especially at early gestational ages (3.8% vs 11%; P<.001 for preterm rupture of membranes <24 weeks). Among the survivors at delivery, both the groups had similar gestational ages at birth. Both neonatal mortality and severe neurologic morbidity were similar in both the groups. However, an increased risk of bronchopulmonary dysplasia was found in the Solomon group (4.5% vs 12%; P<.001). CONCLUSION Although the risk of preterm premature rupture of membranes has increased, the introduction of the Solomon technique has significantly improved perinatal outcomes in pregnancies affected with twin-twin transfusion syndrome.
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Affiliation(s)
- Raphael Bartin
- Department of Obstetrics and Maternal-Fetal Medicine, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris and EA7328, Université de Paris, Paris, France
| | - Claire Colmant
- Department of Obstetrics and Maternal-Fetal Medicine, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris and EA7328, Université de Paris, Paris, France
| | - Nicolas Bourgon
- Department of Obstetrics and Maternal-Fetal Medicine, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris and EA7328, Université de Paris, Paris, France
| | - Aude Carrier
- Department of Obstetrics and Maternal-Fetal Medicine, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris and EA7328, Université de Paris, Paris, France
| | - Yves Ville
- Department of Obstetrics and Maternal-Fetal Medicine, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris and EA7328, Université de Paris, Paris, France
| | - Julien Stirnemann
- Department of Obstetrics and Maternal-Fetal Medicine, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris and EA7328, Université de Paris, Paris, France.
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13
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Hochberg A, Silber R, Avnet H, Rosen H, Katorza E, Hoffmann C, Mazkereth R, Lipitz S, Weisz B, Yinon Y. Fetal and neonatal brain lesions following laser ablation for twin-to-twin-transfusion-syndrome as detected by pre- and post-natal brain imaging. Prenat Diagn 2021; 41:1531-1540. [PMID: 34671994 DOI: 10.1002/pd.6061] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 09/25/2021] [Accepted: 10/15/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To determine the rate of and risk factors for fetal and neonatal brain lesions following laser ablation for twin-to-twin transfusion syndrome (TTTS). METHODS A retrospective cohort study of 83 women with monochorionic twin pregnancies who underwent ablation for TTTS at a single tertiary hospital. Post-laser survivors were followed-up with fetal neurosonogram every 2 weeks and fetal brain MRI at 28-32 weeks of gestation; post-natal brain imaging included neurosonogram. Cases with pre- and post-natal brain lesions were compared to those without. RESULTS 153 fetuses survived the immediate post-laser period and underwent brain imaging. Of these, 17 (11.11%) exhibited brain lesions on prenatal imaging studies, and 36 (32.4%) on post-natal ultrasound. Later gestational age (GA) at the time of ablation (23.0 vs. 21.4 weeks, p = 0.0244), post-laser twin-anemia-polycythemia-sequence (TAPS) (29.41% vs. 9.56%, p = 0.035) and birthweight discordancy (30% vs. 9%, p = 0.0025) were associated with prenatal brain lesions. Earlier GA at delivery (31.0 weeks vs. 32.2, p = 0.0002) and post-laser TAPS (25% vs. 9.33%, p = 0.038) were associated with post-natal brain lesions. CONCLUSIONS Survivors of ablation for TTTS are at risk for brain lesions, which can be detected prenatally. Incorporation of neurosonogram and fetal brain MRI into the routine surveillance of such pregnancies should be considered.
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Affiliation(s)
- Alyssa Hochberg
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ronit Silber
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hagai Avnet
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hadar Rosen
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eldad Katorza
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Gertner Institute of Epidemiology & Health Policy Research, Sheba Medical Center, Tel-Hashomer, Israel
| | - Chen Hoffmann
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Radiology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Ram Mazkereth
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Neonatology, Edmond and Lily Safra Children Hospital, Sheba Medical Center, Tel-Hashomer, Israel
| | - Shlomo Lipitz
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Boaz Weisz
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yoav Yinon
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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14
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Takano M, Nakata M, Ishii K, Wada S, Sumie M, Yamamoto R, Ozawa K, Sakuma J, Nagasaki S, Sago H. Outcomes of fetoscopic laser surgery for twin-to-twin transfusion syndrome between 26 and 27 weeks of gestation in Japan. J Obstet Gynaecol Res 2021; 47:3821-3827. [PMID: 34227180 DOI: 10.1111/jog.14922] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 06/09/2021] [Accepted: 06/26/2021] [Indexed: 12/31/2022]
Abstract
AIM The purpose of this study was to investigate the outcomes of fetoscopic laser photocoagulation (FLP) for twin-to-twin transfusion syndrome (TTTS) in Japan. METHODS The retrospective cohort study (2012-2018) was conducted in monochorionic twin pregnancies that underwent FLP for TTTS between 26 and 27 weeks from 2012 to 2018. The perioperative data, maternal complications, gestational age (GA) at delivery, neonatal complications, and survival of infants at 28 days of age were analyzed. At term-equivalent age, severe neurological complications were identified by imaging study. RESULTS Of 644 patients, 28 (4.3%) underwent FLP between 26 and 27 weeks, and 26 were analyzed. FLP procedures were technically successful in all cases. There were no cases of major maternal complications after surgery. Preterm rupture of membranes occurred in 34.6% of cases, and the mean GA at delivery was 33.2 ± 3.1 weeks. The survival of both twins was found in 23 (88.4%) cases, and the perinatal survival rate of at least one twin at 28 days of age was 100%. Severe neurological complications were found in six (12.2%) cases out of 49. CONCLUSIONS FLP for TTTS between 26 and 27 weeks provided a good prognosis and caused no major maternal complications. However, severe neurological findings were found in 12% of infants.
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Affiliation(s)
- Mayumi Takano
- Department of Obstetrics and Gynecology, Toho University Faculty of Medicine, Tokyo, Japan.,Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - Masahiko Nakata
- Department of Obstetrics and Gynecology, Toho University Faculty of Medicine, Tokyo, Japan.,Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - Keisuke Ishii
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Seiji Wada
- Division of Fetal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Masahiro Sumie
- Department of Obstetrics, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Ryo Yamamoto
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Katsusuke Ozawa
- Division of Fetal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Junya Sakuma
- Department of Obstetrics and Gynecology, Toho University Faculty of Medicine, Tokyo, Japan.,Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - Sumito Nagasaki
- Department of Obstetrics and Gynecology, Toho University Faculty of Medicine, Tokyo, Japan.,Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - Haruhiko Sago
- Division of Fetal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
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15
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Rahimi-Sharbaf F, Ghaemi M, Nassr AA, Shamshirsaz AA, Shirazi M. Radiofrequency ablation for selective fetal reduction in complicated Monochorionic twins; comparing the outcomes according to the indications. BMC Pregnancy Childbirth 2021; 21:189. [PMID: 33676436 PMCID: PMC7937193 DOI: 10.1186/s12884-021-03656-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 02/22/2021] [Indexed: 11/24/2022] Open
Abstract
Background To evaluate the perinatal outcomes in women with complicated monochorionic diamniotic twins who underwent selective reduction using radiofrequency ablation (RFA). Methods This retrospective study included patients with complicated monochorionic diamniotic twins between 16 to 28 weeks who underwent selective reduction using RFA. Results During the study period, 143 women with complicated monochorionic twins underwent RFA including 52 with selective fetal growth restriction (sFGR), 48 with twin to twin transfusion syndrome (TTTS), 33 with major fetal anomalies in one of the twins, and 10 with reversed arterial perfusion sequence (TRAP). The overall survival was 71.3% (102/143). The procedures were technically successful in achieving selective termination in all cases. The mean ± SD of gestational age at the time of the procedure was 21.0 ± 2.3 weeks. The mean ± SD of gestational age at delivery was 34.6 ± 3.3 weeks. The mean ± SD of overall procedure-to-delivery time was 12 ± 1.7 weeks. The pregnancy success rates among sFGR, TRAP, TTTS and anomaly groups were 82.7, 80, 73 and 60.7% respectively. There were no maternal complications. Conclusion Radiofrequency ablation for fetal reduction in complicated monochorionic twin pregnancies appears to be a reasonable option. The pregnancy success rate following RFA selective reduction was highest among sFGR and TRAP groups and lowest in the anomaly group.
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Affiliation(s)
| | - Marjan Ghaemi
- Valie-Asr Reproductive Health Research Center, (VRHRC), Tehran University of Medical Sciences, Tehran, Iran
| | | | | | - Mahboobeh Shirazi
- Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran. .,Maternal, Fetal and Neonatal Research Center, Tehran University Of Medical Sciences, Tehran, Iran.
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16
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Dunbar MJ, Woodward K, Leijser LM, Kirton A. Antenatal diagnosis of fetal intraventricular hemorrhage: systematic review and meta-analysis. Dev Med Child Neurol 2021; 63:144-155. [PMID: 33094492 DOI: 10.1111/dmcn.14713] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/18/2020] [Indexed: 12/29/2022]
Abstract
AIM To determine how the severity of antenatally diagnosed germinal matrix-intraventricular hemorrhage (GMH-IVH) relates to morbidity and mortality, and to explore potential risk factors. METHOD We conducted a systematic review and individual patient data meta-analysis of antenatally diagnosed fetal GMH-IVH. The primary outcomes were mortality and morbidity. Potential associations with clinical factors during pregnancy were explored. Analysis employed Fisher's exact test and logistic regression. RESULTS We included 240 cases from 80 studies. Presence of venous infarction was associated with mortality (odds ratio [OR] 4.3, 95% confidence interval [CI] 1.4-13.25), motor impairment (OR 103.2, 95% CI 8.6-1238), epilepsy (OR 6.46, 95% CI 2.64-16.06), and developmental delay (OR 8.55, 95% CI 2.12-48.79). Shunt placement was associated with gestational age at GMH-IVH diagnosis and in utero progression. Many cases had uncomplicated pregnancies but possible co-occurring conditions included twin gestation, small for gestational age, and congenital anomalies. INTERPRETATION Severity of fetal GMH-IVH, specifically venous infarction, is associated with overall mortality and morbidity. Risk factors for fetal GMH-IVH are poorly understood and controlled studies are required. WHAT THIS PAPER ADDS Preterm germinal matrix-intraventricular hemorrhage (GMH-IVH) grading can be applied to fetuses. Many fetal germinal matrix hemorrhages occur in otherwise typical pregnancies. Half of fetuses with post-hemorrhagic ventricular dilatation receive a shunt after delivery. Fetuses with grade I or II GMH-IVH have few sequelae. Fetuses with periventricular hemorrhagic infarction have a high burden of motor impairment.
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Affiliation(s)
- Mary J Dunbar
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Pediatrics, Section of Neurology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Clinician Investigator Program, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kristine Woodward
- Department of Pediatrics, Section of Neurology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Lara M Leijser
- Department of Pediatrics, Section of Neonatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada
| | - Adam Kirton
- Department of Pediatrics, Section of Neurology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada.,Department of Radiology, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, Calgary, Alberta, Canada.,Calgary Pediatric Stroke Program, University of Calgary, Calgary, Alberta, Canada
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17
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Rajagopalan V, Ashouri K, Llanes A, Vanderbilt DL, Lepore N, Bluml S, Lai HA, Wisnowski J, Chon AH, Chmait RH. Fetal neurodevelopmental recovery in donors after laser surgery for twin-twin transfusion syndrome. Prenat Diagn 2020; 41:190-199. [PMID: 33191511 DOI: 10.1002/pd.5866] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 07/21/2020] [Accepted: 10/23/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Fetal magnetic resonance imaging (MRI) and spectroscopy (MRS) provide a unique opportunity to non-invasively measure markers of neurodevelopment in survivors of twin-twin transfusion syndrome (TTTS). OBJECTIVE To characterize fetal brain maturation after laser surgery for TTTS by measuring brain volumes and cerebral metabolite concentrations using fetal MRI + MRS. STUDY DESIGN Prospective study of dual surviving fetuses treated with laser surgery for TTTS. At 4-5 postoperative weeks, fetal MRI was used together with novel image analysis to automatically extract major brain tissue volumes. Fetal MRS was used to measure major metabolite concentrations in the fetal brain. RESULTS Twenty-one twin pairs were studied. The average (±SD) gestational age at MRI was 25.89 (±2.37) weeks. Total brain volume (TBV) was lower in the donors, although cerebral volumes were not different between twin pairs. Recipients showed lower proportions of cortical and cerebellar volumes, normalized to TBV and cerebral volumes. MRS data showed that biochemical differences between twin brains were related to discrepancy in their brain volumes. CONCLUSION Although donors have a smaller TBV compared to recipients, proportionality of brain tissue volumes are preserved in donors. MRS maturational markers of fetal brain development show that recovery in donors persists 4 weeks after surgery.
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Affiliation(s)
- Vidya Rajagopalan
- Department of Radiology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Karam Ashouri
- Department of Radiology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Arlyn Llanes
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Douglas L Vanderbilt
- Department of Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Natasha Lepore
- Department of Radiology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Stefan Bluml
- Department of Radiology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Hollie A Lai
- Children's Hospital of Orange County, Orange, California, USA
| | - Jessica Wisnowski
- Department of Radiology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.,Department of Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Andrew H Chon
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Ramen H Chmait
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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18
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The prevalence of brain lesions after in utero surgery for twin-to-twin transfusion syndrome on third-trimester MRI: a retrospective cohort study. Eur Radiol 2020; 31:4097-4103. [PMID: 33210202 DOI: 10.1007/s00330-020-07452-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 08/22/2020] [Accepted: 11/02/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Due to the increased risk of antenatal brain lesions, we offer a third-trimester magnetic resonance imaging (MRI) scan to all patients who underwent an in utero intervention for twin-twin transfusion syndrome (TTTS). However, the usefulness of such a policy has not been demonstrated yet. Therefore, we determined the prevalence of antenatal brain lesions detected on third-trimester MRI and the proportion of lesions detected exclusively on MRI. MATERIALS AND METHODS We conducted a retrospective cohort study of monochorionic diamniotic twin pregnancies complicated by TTTS that underwent laser coagulation of the vascular anastomoses or fetal reduction by umbilical cord occlusion between 2010 and 2017. We reviewed the third-trimester MRI findings and compared those with the prenatal ultrasonography. RESULTS Of the 141 patients treated with laser coagulation and 17 managed by cord occlusion, 112/141 (79%) and 15/17 (88%) patients reached 28 weeks. Of those, 69/112 (62%) and 11/15 (73%) underwent an MRI between 28 and 32 weeks. After laser coagulation, MRI detected an antenatal brain lesion in 6 of 69 pregnancies (9%) or in 6 of 125 fetuses (5%). In 4 cases (67%), the lesion was detected only on MRI. In the 11 patients treated with cord occlusion, no brain lesions were diagnosed. CONCLUSION The prevalence of brain lesions detected by third-trimester MRI is higher compared to prenatal ultrasonography alone, making MRI a useful adjunct to detect antenatal brain lesions in twin pregnancies after in utero treatment for TTTS. KEY POINTS • In utero interventions for twin-to-twin transfusion syndrome (TTTS) do not prevent the occurrence of antenatal brain lesions. • Fetal magnetic resonance imaging (MRI) has high accuracy in detecting anomalies of cortical development and can be a useful adjunct to ultrasonography in diagnosing certain brain abnormalities. • After laser coagulation of the anastomoses for TTTS, third-trimester MRI diagnosed a brain lesion that was not detected earlier on ultrasound scan in 6% of pregnancies.
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19
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Sebghati M, Khalil A. Reduction of multiple pregnancy: Counselling and techniques. Best Pract Res Clin Obstet Gynaecol 2020; 70:112-122. [PMID: 32859535 DOI: 10.1016/j.bpobgyn.2020.06.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 06/16/2020] [Indexed: 12/01/2022]
Abstract
The incidence of multiple births has risen in the last few decades. This rise is mainly due to the widespread use of assisted reproduction techniques mainly as a result of increasing maternal age at conception. Twin and higher-order multiple pregnancies are associated with increased risk of perinatal, as well as maternal, mortality and morbidity compared to singleton pregnancies. There can also be psychosocial and socioeconomic implications for women and their families. In this chapter, we aim to discuss the risks associated with multiple pregnancies, the pros and cons of fetal reduction, the current techniques used in clinical practice, and how to approach counselling parents, enabling them to make informed decisions.
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Affiliation(s)
- Mercede Sebghati
- Fetal Medicine Unit, St George's University Hospitals, Blackshaw Road, London, UK
| | - Asma Khalil
- Fetal Medicine Unit, St George's University Hospitals, Blackshaw Road, London, UK; Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, Cranmer Terrace, London, UK; Twins Trust Centre for Research and Clinical Excellence, UK.
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20
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Kocaoglu M, Kline-Fath BM, Calvo-Garcia MA, Zhang B, Nagaraj UD. Magnetic resonance imaging of the fetal brain in monochorionic diamniotic twin gestation: correlation of cerebral injury with ultrasound staging and survival outcomes. Pediatr Radiol 2020; 50:1131-1138. [PMID: 32358676 DOI: 10.1007/s00247-020-04661-w] [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: 11/21/2019] [Revised: 02/17/2020] [Accepted: 03/12/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND The current staging system of twin-twin transfusion syndrome (TTTS) is based on the ultrasound criteria and does not consider the cerebral injury. OBJECTIVE To assess the incidence of cerebral damage on fetal MRI and correlate abnormal cerebral diffusion-weighted imaging (DWI) findings with survival outcome and the ultrasound staging of TTTS. MATERIALS AND METHODS We conducted a retrospective review of MRI/DWI of fetal brains and the electronic medical records in monochorionic diamniotic twin gestations. Axial DWI of each fetal brain was performed on 1.5-tesla (T) clinical magnet with b values of 0 s/mm2 and 700 s/mm2. We correlated MRI/DWI abnormalities with the Quintero staging system and survival outcomes of the fetuses. RESULTS Thirty-four pregnancies (68 fetuses) with 42 fetal cerebral abnormalities were identified by MRI/DWI alone. Of these 42 fetal cerebral abnormalities, 33 fetal brain lesions were visible only on DWI (n=25 donor, n=8 recipients; n=30 unilateral, n=3 bilateral; n=26 diffuse, n=7 focal). Quintero staging in these 34 pregnancies was as follows: 9 Stage I, 7 Stage II, 13 Stage III, 4 Stage IV, 1 Stage V. There was no significant correlation between the presence of cerebral infarction or hemorrhage using MRI/DWI and ultrasound staging (P=0.138). The overall survival rate was 63.2% (43/68). There was a significant correlation between the presence of cerebral infarction or hemorrhage on MRI/DWI and delivery status (P=0.009). CONCLUSION Abnormal cerebral imaging findings on MRI/DWI from hypoxic-ischemic injury or hemorrhage can be seen at the beginning of the second trimester and do not correlate with the current ultrasound staging system; however, they do correlate with decreased survival. Fetal cerebral abnormalities could be incorporated into the TTTS staging system as an independent risk factor.
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Affiliation(s)
- Murat Kocaoglu
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH, 45229, USA.
| | - Beth M Kline-Fath
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH, 45229, USA
| | - Maria A Calvo-Garcia
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH, 45229, USA
| | - Bin Zhang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Usha D Nagaraj
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH, 45229, USA
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21
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Matsushima S, Ozawa K, Sugibayashi R, Ogawa K, Tsukamoto K, Miyazaki O, Wada S, Ito Y, Sago H. Neurodevelopmental impairment at 3 years of age after fetoscopic laser surgery for twin-to-twin transfusion syndrome. Prenat Diagn 2020; 40:1013-1019. [PMID: 32362029 DOI: 10.1002/pd.5726] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 12/14/2019] [Accepted: 04/25/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND Data on neurodevelopmental outcomes of children surviving after fetoscopic laser surgery (FLS) for twin-to-twin transfusion syndrome (TTTS) are scarce. METHODS We retrospectively investigated children surviving after FLS for TTTS at 16 to 26 weeks' gestation between 2003 and 2014. Children were evaluated by standardized neurologic examinations using the Kyoto Scale 2001 at a corrected age of 3 years ± 6 months. Neurodevelopmental impairment (NDI) was defined as cerebral palsy (CP), bilateral blindness, bilateral deafness or a developmental quotient (DQ) < 70 points. Brain magnetic resonance imaging (MRI) was performed at term-equivalent age. RESULTS A total of 188 children from 110 twin pregnancies were evaluated. NDI was detected in 16/188 (8.5%) children, including six cases of CP (3.2%). No children had bilateral blindness or deafness. An earlier gestational age at delivery was associated with a higher incidence of NDI (P < .001). Abnormal brain MRI findings were detected in 9/16 (56%) of children with NDI, including 6/6 (100%) with CP. CONCLUSION The incidence of NDI in children following FLS at 3 years old was 8.5%. Prematurity is a strong risk factor for NDI. Brain MRI may predict the development of CP.
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Affiliation(s)
- Sachio Matsushima
- Division of Fetal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Katsusuke Ozawa
- Division of Fetal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Rika Sugibayashi
- Division of Fetal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Kohei Ogawa
- Division of Obstetrics, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Keiko Tsukamoto
- Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Osamu Miyazaki
- Department of Radiology, National Center for Child Health and Development, Tokyo, Japan
| | - Seiji Wada
- Division of Fetal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Yushi Ito
- Division of Obstetrics, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Haruhiko Sago
- Division of Fetal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan.,Division of Obstetrics, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan.,Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
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22
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Spruijt MS, Lopriore E, J Steggerda S, Slaghekke F, Van Klink JMM. Twin-twin transfusion syndrome in the era of fetoscopic laser surgery: antenatal management, neonatal outcome and beyond. Expert Rev Hematol 2020; 13:259-267. [PMID: 31971028 DOI: 10.1080/17474086.2020.1720643] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Introduction: Twin-twin transfusion syndrome (TTTS) is a devastating complication of monochorionic twin pregnancy and remains a major challenge for worldwide fetal medicine specialists. In TTTS, intertwin transfusion through vascular anastomoses in the shared placenta leads to severe hemodynamic imbalance. This review summarizes the current knowledge of TTTS.Areas covered: The most recent insights concerning the management of TTTS, as well as fetal and neonatal complications are described. Relevant articles were selected based on a Pubmed search using the keywords below. Understanding of the underlying pathophysiology has improved greatly as a result of placental injection studies. Advancements in antenatal management have led to increased perinatal survival and a decreased incidence of neonatal complications, including brain injury and neurodevelopmental impairment.Expert opinion: Further opportunities for improvement comprise technological innovations in laser procedures and the prevention of preterm rupture of membranes with subsequent prematurity. A noninvasive treatment such as high-intensity focused ultrasound (HIFU) seems to hold promise for the future treatment of TTTS. Fetal MRI studies are important to improve our understanding of fetal brain injury and should relate their findings to long-term neurodevelopment. International collaboration and centralization of care are of paramount importance to ensure the best care for our patients.
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Affiliation(s)
- Marjolijn S Spruijt
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Enrico Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Sylke J Steggerda
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Femke Slaghekke
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeanine M M Van Klink
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
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23
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Current Practice and Protocols: Endoscopic Laser Therapy for Twin-Twin Transfusion Syndrome. MATERNAL-FETAL MEDICINE 2020. [DOI: 10.1097/fm9.0000000000000035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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24
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So PL, Li KW, Yeung TW, Sin WK. Multicystic encephalomalacia and gastrointestinal injury following single fetal death in first trimester and subsequent fetofetal transfusion syndrome in a monochorionic triplet pregnancy: a case report. BMC Pregnancy Childbirth 2019; 19:311. [PMID: 31455300 PMCID: PMC6712839 DOI: 10.1186/s12884-019-2459-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 08/14/2019] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Monochorionic multifetal pregnancies are at increased risk of adverse perinatal outcome because of placental vascular anastomoses. We present a case of multicystic encephalomalacia and gastrointestinal injury in two surviving fetuses following single fetal death in first trimester and subsequent fetofetal transfusion syndrome in a monochorionic triplet pregnancy. CASE PRESENTATION A 31-year-old nulliparous woman had a spontaneous monochorionic triamniotic triplet pregnancy. Three live fetuses with single placenta were seen at 8-week ultrasound scan. One fetus demised at 11 weeks and 3 days of gestation. Dilated echogenic bowel and ascites were found in one surviving fetus at 23 weeks of gestation. At 28 weeks of gestation, the pregnancy was complicated by fetofetal transfusion syndrome in which discordant amniotic fluid volumes were found. Two days later, emergency Caesarean section was performed because of worsening of fetal Doppler and biophysical profile. One baby was found to have jejunal atresia requiring surgery at 4 days old. He had periventricular leukomalacia and intracranial haemorrhage, but subsequent normal neurological development. Another baby had gastric perforation requiring surgery at 2 days old. He was confirmed to have multicystic encephalomalacia by cranial ultrasound and magnetic resonance imaging. He suffered from developmental delay, epilepsy and cerebral palsy. CONCLUSION This case alerts the obstetricians the possible hypoxic-ischemic injury to the survivors of monochorionic triplet pregnancy after the co-triplet death in the first trimester and fetofetal transfusion syndrome. Antenatal assessment and postnatal follow-up are important for these high-risk multiple pregnancies.
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Affiliation(s)
- Po Lam So
- Department of Obstetrics and Gynecology, Tuen Mun Hospital, 23 Tsing Chung Koon Road, Tuen Mun, Hong Kong, Special Administrative Region of China
| | - Ka Wah Li
- Department of Paediatrics and Adolescent Medicine, Tuen Mun Hospital, 23 Tsing Chung Koon Road, Tuen Mun, Hong Kong, Special Administrative Region of China
| | - Tsz Wai Yeung
- Department of Radiology, Tuen Mun Hospital, 23 Tsing Chung Koon Road, Tuen Mun, Hong Kong, Special Administrative Region of China
| | - Wai Kuen Sin
- Department of Obstetrics and Gynecology, Tuen Mun Hospital, 23 Tsing Chung Koon Road, Tuen Mun, Hong Kong, Special Administrative Region of China
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25
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Vitale G, Pichiecchio A, Ormitti F, Tonduti D, Asaro A, Farina L, Piccolo B, Percesepe A, Bastianello S, Orcesi S, Battaglia D, Cereda C, Martelli P, Mine M, Pinelli L, Tartaglione T, Ghi T, Parrini E, Zuffardi O. Cortical malformations and COL4A1 mutation: Three new cases. Eur J Paediatr Neurol 2019; 23:410-417. [PMID: 30837194 DOI: 10.1016/j.ejpn.2019.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 02/13/2019] [Accepted: 02/17/2019] [Indexed: 01/30/2023]
Abstract
AIM The COL4A1 gene (13q34) encodes the α1 chain of type IV collagen, a crucial component of the basal membrane. COL4A1 mutations have been identified as a cause of a multisystem disease. Brain MRI in COL4A1-mutated patients typically shows vascular abnormalities and white matter lesions. Cortical malformations (specifically schizencephaly) have also recently been described in these patients, suggesting that these, too, could be part of the phenotypic spectrum of COL4A1 mutations. The aim of our work was to retrospectively evaluate COL4A1-mutated subjects diagnosed at our centers in order to assess the frequency and define the type of cortical malformations encountered in these individuals. METHOD We retrospectively reviewed MRI data of 18 carriers of COL4A1 mutations diagnosed in our centers between 2010 and 2016. RESULTS We identified polymicrogyria in two patients, and schizencephaly in the mother of a further patient. INTERPRETATION Our findings confirm that cortical malformations should be considered to fall within the phenotypic spectrum of COL4A1 mutations and show that not only schizencephaly but also polymicrogyria can also be found in mutated individuals. Although further studies are needed to clarify the underlying pathogenetic mechanism, independently of this, the timing of the brain damage could be the crucial factor determining the type of lesion.
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Affiliation(s)
- G Vitale
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - A Pichiecchio
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy; Department of Neuroradiology, IRCCS Mondino Foundation, Pavia, Italy.
| | - F Ormitti
- Neuroradiology Unit, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - D Tonduti
- Child Neurology Unit, V. Buzzi Children's Hospital, Milan, Italy
| | - A Asaro
- Genomic and Post-Genomic Center, IRCCS Mondino Foundation, Pavia, Italy
| | - L Farina
- Department of Neuroradiology, IRCCS Mondino Foundation, Pavia, Italy
| | - B Piccolo
- Child Neuropsychiatry Unit, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - A Percesepe
- Medical Genetics, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - S Bastianello
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy; Department of Neuroradiology, IRCCS Mondino Foundation, Pavia, Italy
| | - S Orcesi
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy; Child and Adolescence Neurology Unit, IRCCS Mondino Foundation, Pavia, Italy
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26
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Meng X, Yuan P, Gong L, Wang X, Wu T, Wei Y, Zhao Y. Forty-five consecutive cases of complicated monochorionic multiple pregnancy treated with microwave ablation: A single-center experience. Prenat Diagn 2019; 39:293-298. [PMID: 30677152 DOI: 10.1002/pd.5423] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 12/24/2018] [Accepted: 01/21/2019] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To describe our preliminary experience in the application of microwave ablation for selective fetal reduction in complicated monochorionic multiple pregnancies. METHODS In this prospective study, 45 consecutive complicated monochorionic multiple pregnancies that underwent microwave ablation for selective fetal reduction from July 2015 to February 2017 were analyzed from the first case onward. All patients were managed at the Peking University Third Hospital in Beijing, China. RESULTS There were 45 cases (twins in 40 and triplets in five) treated by microwave ablation. The median gestational age at surgery was 21.3 weeks (range, 15.9-25.7 wk), with a mean total ablation time of 8.5 ± 4.2 (7.2-9.7) minutes. There were 12 (26.7%) cases of postprocedural fetal loss. Thirty-three women delivered alive at a median gestational age of 37.6 weeks (range, 28.6-40.4 wk). There were no neonatal deaths in our cohort, and the overall survival rate was 73.3% (33/45). Preterm premature rupture of membranes occurred in 9 (20.0%) cases with a median of 7.0 weeks (range, 0.9-16.3 wk) after the surgery. None of the surviving cotwins had evidence of thermal injury or neurological abnormalities. CONCLUSION Microwave ablation appears to be a safe and effective method for selective feticide in complicated monochorionic pregnancies.
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Affiliation(s)
- Xinlu Meng
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Pengbo Yuan
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Lijun Gong
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Xueju Wang
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Tianchen Wu
- Department of Maternal and Child Health, School of Public Health, Peking University, Beijing, China
| | - Yuan Wei
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Yangyu Zhao
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
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27
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Sommer J, Nuyt AM, Audibert F, Dorval V, Wavrant S, Altit G, Lapointe A. Outcomes of extremely premature infants with twin-twin transfusion syndrome treated by laser therapy. J Perinatol 2018; 38:1548-1555. [PMID: 30177860 DOI: 10.1038/s41372-018-0202-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 07/03/2018] [Accepted: 07/17/2018] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To compare short-term and long-term outcomes of preterm infants born at <29 weeks of gestational age (GA) with twin-twin transfusion syndrome (TTTS) treated with laser therapy to preterm twin infants without TTTS. DESIGN Retrospective case-control study comparing 33 preterm TTTS twins to 101 preterm diamniotic-dichorionic (di-di) twins born at our institution between 2006 and 2015. RESULTS GA at birth were 26.4 ± 1.4 weeks (TTTS) and 26.9 ± 1.6 weeks (di-di) (p = 0.07). TTTS premature newborns were less exposed to antenatal steroids (p = 0.01), more frequently born by C-section (p = 0.005), received more surfactant therapy (p = 0.004, and were smaller for GA (p < 0.001). When adjusted for antenatal steroids and birth weight, TTTS status was not associated with increased mortality (HR 1.66, 95% CI 0.77-3.56, p = 0.20). No differences were found on neurodevelopmental outcomes at 18 months of corrected GA. CONCLUSION Premature TTTS newborns treated with fetal laser therapy had similar survival and neurodevelopmental outcomes compared to preterm di-di twins without TTTS.
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Affiliation(s)
- Julie Sommer
- Department of Pediatrics, Division of Neonatology, CHU Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Anne-Monique Nuyt
- Department of Pediatrics, Division of Neonatology, CHU Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - François Audibert
- Department of Obstretrics and Gynecology, CHU Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Véronique Dorval
- Department of Pediatrics, Division of Neonatology, CHU Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Sandrine Wavrant
- Department of Obstretrics and Gynecology, CHU Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Gabriel Altit
- Department of Pediatrics, Division of Neonatology, Montreal Children's Hospital, McGill University, Montréal, QC, Canada
| | - Anie Lapointe
- Department of Pediatrics, Division of Neonatology, CHU Sainte-Justine, Université de Montréal, Montréal, QC, Canada.
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28
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Perry H, Duffy JMN, Umadia O, Khalil A. Outcome reporting across randomized trials and observational studies evaluating treatments for twin-twin transfusion syndrome: systematic review. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 52:577-585. [PMID: 29607558 DOI: 10.1002/uog.19068] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 03/19/2018] [Accepted: 03/27/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE Twin-twin transfusion syndrome (TTTS) is associated with significant mortality and morbidity. Potential treatments for the condition require robust evaluation. The aim of this study was to evaluate outcome reporting across observational studies and randomized controlled trials assessing treatments for TTTS. METHODS Cochrane Central Register of Controlled Trials, EMBASE and MEDLINE were searched from inception to August 2016. Observational studies and randomized controlled trials reporting outcome following treatment for TTTS in monochorionic-diamniotic twin pregnancy and monochorionic-triamniotic or dichorionic-triamniotic triplet pregnancy were included. Outcome reporting was systematically extracted and categorized. RESULTS Six randomized trials and 94 observational studies were included, reporting data from 20 071 maternal participants and 3199 children. Six different treatments were evaluated. Included studies reported 62 different outcomes, including six fetal, seven offspring mortality, 25 neonatal, six early childhood and 18 maternal/operative outcomes. Outcomes were reported inconsistently across trials. For example, when considering offspring mortality, 31 (31%) studies reported live birth, 31 (31%) reported intrauterine death, 49 (49%) reported neonatal mortality and 17 (17%) reported perinatal mortality. Four (4%) studies reported respiratory distress syndrome. Only 19 (19%) studies were designed for long-term follow-up and 11 (11%) of these reported cerebral palsy. CONCLUSIONS Studies evaluating treatments for TTTS have often neglected to report clinically important outcomes, especially neonatal morbidity outcomes, and most are not designed for long-term follow-up. The development of a core outcome set could help standardize outcome collection and reporting in TTTS studies. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- H Perry
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - J M N Duffy
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford, UK
- Balliol College, University of Oxford, Oxford, UK
| | - O Umadia
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - A Khalil
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
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Kirkham FJ, Zafeiriou D, Howe D, Czarpran P, Harris A, Gunny R, Vollmer B. Fetal stroke and cerebrovascular disease: Advances in understanding from lenticulostriate and venous imaging, alloimmune thrombocytopaenia and monochorionic twins. Eur J Paediatr Neurol 2018; 22:989-1005. [PMID: 30467085 DOI: 10.1016/j.ejpn.2018.08.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 08/28/2018] [Accepted: 08/29/2018] [Indexed: 12/17/2022]
Abstract
Fetal stroke is an important cause of cerebral palsy but is difficult to diagnose unless imaging is undertaken in pregnancies at risk because of known maternal or fetal disorders. Fetal ultrasound or magnetic resonance imaging may show haemorrhage or ischaemic lesions including multicystic encephalomalacia and focal porencephaly. Serial imaging has shown the development of malformations including schizencephaly and polymicrogyra after ischaemic and haemorrhagic stroke. Recognised causes of haemorrhagic fetal stroke include alloimmune and autoimmune thrombocytopaenia, maternal and fetal clotting disorders and trauma but these are relatively rare. It is likely that a significant proportion of periventricular and intraventricular haemorrhages are of venous origin. Recent evidence highlights the importance of arterial endothelial dysfunction, rather than thrombocytopaenia, in the intraparenchymal haemorrhage of alloimmune thrombocytopaenia. In the context of placental anastomoses, monochorionic diamniotic twins are at risk of twin twin transfusion syndrome (TTTS), or partial forms including Twin Oligohydramnios Polyhydramnios Sequence (TOPS), differences in estimated weight (selective Intrauterine growth Retardation; sIUGR), or in fetal haemoglobin (Twin Anaemia Polycythaemia Sequence; TAPS). There is a very wide range of ischaemic and haemorrhagic injury in a focal as well as a global distribution. Acute twin twin transfusion may account for intraventricular haemorrhage in recipients and periventricular leukomalacia in donors but there are additional risk factors for focal embolism and cerebrovascular disease. The recipient has circulatory overload, with effects on systemic and pulmonary circulations which probably lead to systemic and pulmonary hypertension and even right ventricular outflow tract obstruction as well as the polycythaemia which is a risk factor for thrombosis and vasculopathy. The donor is hypovolaemic and has a reticulocytosis in response to the anaemia while maternal hypertension and diabetes may influence stroke risk. Understanding of the mechanisms, including the role of vasculopathy, in well studied conditions such as alloimmune thrombocytopaenia and monochorionic diamniotic twinning may lead to reduction of the burden of antenatally sustained cerebral palsy.
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Affiliation(s)
- Fenella J Kirkham
- Developmental Neurosciences Section and Biomedical Research Centre, UCL Great Ormond Street Institute of Child Health, London, United Kingdom; Departments of Child Health, Obstetrics and Gynaecology and Radiology, University Hospital Southampton, United Kingdom; Clinical and Experimental Sciences, University of Southampton, United Kingdom.
| | - Dimitrios Zafeiriou
- 1st Department of Pediatrics, "Hippokratio' General Hospital, Aristotle University, Thessaloniki, Greece
| | - David Howe
- Departments of Child Health, Obstetrics and Gynaecology and Radiology, University Hospital Southampton, United Kingdom; Clinical and Experimental Sciences, University of Southampton, United Kingdom
| | - Philippa Czarpran
- Departments of Child Health, Obstetrics and Gynaecology and Radiology, University Hospital Southampton, United Kingdom
| | - Ashley Harris
- Departments of Child Health, Obstetrics and Gynaecology and Radiology, University Hospital Southampton, United Kingdom
| | - Roxanna Gunny
- Developmental Neurosciences Section and Biomedical Research Centre, UCL Great Ormond Street Institute of Child Health, London, United Kingdom; Department of Radiology, St George's hospital, London, United Kingdom
| | - Brigitte Vollmer
- Departments of Child Health, Obstetrics and Gynaecology and Radiology, University Hospital Southampton, United Kingdom; Clinical and Experimental Sciences, University of Southampton, United Kingdom
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Hecher K, Gardiner HM, Diemert A, Bartmann P. Long-term outcomes for monochorionic twins after laser therapy in twin-to-twin transfusion syndrome. THE LANCET CHILD & ADOLESCENT HEALTH 2018; 2:525-535. [PMID: 30169324 DOI: 10.1016/s2352-4642(18)30127-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 03/09/2018] [Accepted: 04/03/2018] [Indexed: 12/28/2022]
Abstract
Twin-to-twin transfusion syndrome typically occurs in the second trimester in 10-15% of monochorionic twin pregnancies. Vascular anastomoses of monochorionic placentae are the underlying cause of the development of the syndrome. If a blood flow imbalance occurs, one fetus becomes the so-called donor twin and the other the recipient. If untreated, perinatal mortality is 80-90%. Fetoscopic laser coagulation of the vascular anastomoses destroys the cause of the syndrome and leads to dual twin survival rates of around 70% and more than 90% of pregnancies with at least one survivor. However, unequal placental sharing, intrauterine death, and severe prematurity are still limiting factors for further improvement of survival rates and decreases in long-term morbidity. Prematurity and neurodevelopmental impairment affect the donor and recipient twins, whereas cardiovascular failure and obstruction of the right ventricular outflow tract are typical complications of recipients, which can lead to long-term morbidity. In this Review, we summarise the literature on follow-up data for survivors of twin-to-twin-transfusion syndrome after laser therapy, including neurodevelopmental outcomes, cardiovascular outcomes, growth, renal function, and ischaemic events, as well as the potential effects of intrauterine programming on later life.
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Affiliation(s)
- Kurt Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Helena M Gardiner
- Fetal Center at Children's Memorial Herman Hospital, McGovern Medical School at UTHealth, University of Texas Health Sciences Center, Houston, TX, USA
| | - Anke Diemert
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Bartmann
- Children's Hospital, University Hospital Bonn, Bonn, Germany
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Korsakissok M, Groussolles M, Dicky O, Alberge C, Casper C, Azogui-Assouline C. Mortality, morbidity and 2-years neurodevelopmental prognosis of twin to twin transfusion syndrome after fetoscopic laser therapy: a prospective, 58 patients cohort study. J Gynecol Obstet Hum Reprod 2018; 47:555-560. [PMID: 29698746 DOI: 10.1016/j.jogoh.2018.04.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 04/10/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To describe the morbidity and mortality and long-term neurodevelopmental outcomes in children born from a Twin-to-Twin Transfusion Syndrome (TTTS) pregnancy treated using laser fetoscopy in Toulouse. POPULATION AND METHOD All pregnancies with TTTS treated by laser fetoscopy in our centre were included. Antenatal and postnatal morbidity and neonatal morbidity were identified in the medical records retrospectively. The neurodevelopmental outcome was studied using Ages and Stages Questionnaires (ASQ) sent to the parents, an oral interview with the parents and with the child's doctor (last objective neurological examination, rehabilitation needs, learning disabilities). RESULTS Seventy-one pregnancies, or 144 foetuses, were included from 2008 to 2014, overall survival at 2 years was 72.9% and the survival of at least one child at 2 years was 91.5%, severe neonatal morbidity was 11.2% of the children, severe brain damage accounted for 3.6% of children admitted to the hospital unit. It was possible to study the neurodevelopmental outcome for 58 children (55.3%), with a corrected age from 24 to 95 months. Five children (8.6%) had severe neurological abnormalities and 17 (29.3%) had moderate neurological abnormalities. DISCUSSION The mortality, neonatal morbidity and long-term neurological morbidity of our cohort are higher than those of premature infants (EPIPAGE-2 French cohort), which confirms the severity of this syndrome, and are comparable to those of the TTTS cohorts described in the literature.
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Affiliation(s)
- Mélanie Korsakissok
- Children Hospital, University Hospital, Paul Sabatier University, 31000 Toulouse, France.
| | - Marion Groussolles
- Maternal Fetal Medicine Department, Paule-de-Viguier Hospital, University Hospital, UMR 1027, INSERM, Paul Sabatier University, 31000 Toulouse, France
| | - Odile Dicky
- Department of Neonatology, Children Hospital, University Hospital, UMR 1027, INSERM, Paul Sabatier University, 31000 Toulouse, France
| | - Corinne Alberge
- Department of Neonatology, Children Hospital, University Hospital, 31000 Toulouse, France
| | - Charlotte Casper
- Department of Neonatology, Children Hospital, University Hospital, UMR 1027, INSERM, Paul Sabatier University, 31000 Toulouse, France
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Radiofrequency ablation for selective reduction in complex monochorionic multiple pregnancies: A case series. Taiwan J Obstet Gynecol 2017; 56:740-744. [DOI: 10.1016/j.tjog.2017.10.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2017] [Indexed: 01/26/2023] Open
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Chmait RH, Chon AH, Schrager SM, Llanes A, Hamilton AH, Vanderbilt DL. Neonatal cerebral lesions predict 2-year neurodevelopmental impairment in children treated with laser surgery for twin-twin transfusion syndrome. J Matern Fetal Neonatal Med 2017; 32:80-84. [PMID: 28835143 DOI: 10.1080/14767058.2017.1371694] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The objective of this study is to assess whether postnatally detected cerebral abnormalities are predictive of neurodevelopmental impairment (NDI) in survivors of twin-twin transfusion syndrome (TTTS) that underwent laser surgery. MATERIALS AND METHODS Ninety-nine children treated for TTTS had neurodevelopmental assessment at age 2-years (±6 weeks). 'High-risk survivors' had cerebral imaging in the neonatal period. 'High-risk survivors' were defined as (1) delivered at <32 weeks; or (2) cerebral imaging clinically indicated. NDI was a composite outcome of: Battelle Developmental Inventory 2nd edition (BDI-2) score <70, cerebral palsy, blindness, and/or deafness. Multilevel logistic regression with robust standard errors was used to evaluate associations between cerebral lesions and NDI. RESULTS Fifty-six children were 'high-risk survivors' and had neonatal cerebral imaging. Ten twins (18%) had at least one cerebral lesion, including grade 1-2 intraventricular hemorrhage (8), cystic periventricular leukomalacia (2), ventriculomegaly (1), and bilateral subependymal cyst (1). The risk of NDI in the 'high-risk survivors' was 7% (4/56) compared with 0% (0/43) in the remaining group. Among 'high-risk survivors', cerebral lesions were a significant risk factor for NDI (OR = 19.28, p < .001). CONCLUSIONS Among 'high-risk survivors' of TTTS treated with laser surgery, cerebral lesions identified on neonatal imaging were associated with NDI at 2-years.
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Affiliation(s)
- Ramen H Chmait
- a Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology , Keck School of Medicine, University of Southern California , Los Angeles , CA , USA
| | - Andrew H Chon
- a Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology , Keck School of Medicine, University of Southern California , Los Angeles , CA , USA
| | - Sheree M Schrager
- b Division of Hospital Medicine, Department of Pediatrics , Children's Hospital Los Angeles , Los Angeles , CA , USA
| | - Arlyn Llanes
- a Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology , Keck School of Medicine, University of Southern California , Los Angeles , CA , USA
| | - Anita H Hamilton
- c Division of Neurology, Department of Surgery , Keck School of Medicine, University of Southern California , Los Angeles , CA , USA
| | - Douglas L Vanderbilt
- d Division of General Pediatrics, Department of Pediatrics , Keck School of Medicine, University of Southern California , Los Angeles , CA , USA
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Robinson A, Teoh M, Edwards A, Fahey M, Goergen S. Fetal brain injury in complicated monochorionic pregnancies: diagnostic yield of prenatal MRI following surveillance ultrasound and influence on prognostic counselling. Prenat Diagn 2017; 37:611-627. [DOI: 10.1002/pd.5059] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 03/13/2017] [Accepted: 04/21/2017] [Indexed: 12/17/2022]
Affiliation(s)
- Alice Robinson
- Fetal Diagnostic Unit; Monash Health; Clayton Victoria Australia
| | - Mark Teoh
- Fetal Diagnostic Unit; Monash Health; Clayton Victoria Australia
| | - Andrew Edwards
- Fetal Diagnostic Unit; Monash Health; Clayton Victoria Australia
- Department of Obstetrics and Gynaecology; Monash University; Clayton Victoria Australia
| | - Michael Fahey
- Department of Paediatrics; Monash University; Clayton Victoria Australia
- Paediatric Neurology Unit; Monash Health; Clayton Victoria Australia
| | - Stacy Goergen
- Department of Medical Imaging, School of Clinical Sciences; Monash University; Clayton Victoria Australia
- Monash Imaging; Monash Health; Clayton Victoria Australia
- Department of Surgery, School of Clinical Sciences; Monash University; Clayton Victoria Australia
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Abou Chaar MK, Meyers ML, Tucker BD, Galan HL, Liechty KW, Crombleholme TM, Marwan AI. Twin pregnancy complicated by esophageal atresia, duodenal atresia, gastric perforation, and hypoplastic left heart structures in one twin: a case report and review of the literature. J Med Case Rep 2017; 11:64. [PMID: 28314387 PMCID: PMC5357333 DOI: 10.1186/s13256-016-1195-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 12/28/2016] [Indexed: 12/12/2022] Open
Abstract
Background The antenatal diagnosis of a combined esophageal atresia without tracheoesophageal fistula and duodenal atresia with or without gastric perforation is a rare occurrence. These diagnoses are difficult and can be suspected on ultrasound by nonspecific findings including a small stomach and polyhydramnios. Fetal magnetic resonance imaging adds significant anatomical detail and can aid in the diagnosis of these complicated cases. Upon an extensive literature review, there are no reports documenting these combined findings in a twin pregnancy. Therefore we believe this is the first case report of an antenatal diagnosis of combined pure esophageal and duodenal atresia in a twin gestation. Case presentation We present a case of a 30-year-old G1P0 white woman at 22-week gestation with a monochorionic-diamniotic twin pregnancy discordant for esophageal atresia, duodenal atresia with gastric perforation, hypoplastic left heart structures, and significant early gestation maternal polyhydramnios. In this case, fetal magnetic resonance imaging was able to depict additional findings including area of gastric wall rupture, hiatal hernia, dilation of the distal esophagus, and area of duodenal obstruction and thus facilitated the proper diagnosis. After extensive counseling at our multidisciplinary team meeting, the parents elected to proceed with radiofrequency ablation of the anomalous twin to maximize the survival of the normal co-twin. The procedure was performed successfully with complete cessation of flow in the umbilical artery and complete cardiac standstill in the anomalous twin with no detrimental effects on the healthy co-twin. Conclusions Prenatal diagnosis of complex anomalies in twin pregnancies constitutes a multitude of ethical, religious, and cultural factors that come into play in the management of these cases. Fetal magnetic resonance imaging provides detailed valuable information that can assist in management options including possible prenatal intervention. The combination of a cystic structure with peristalsis-like movement above the diaphragm (for example, “the upper thoracic pouch sign”), polyhydramnios, and progressive distention of the stomach and duodenum should increase suspicion for a combined pure esophageal and duodenal atresia.
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Affiliation(s)
- Mohamad K Abou Chaar
- Colorado Fetal Care Center, Colorado Institute of Maternal and Fetal Health, University of Colorado Denver, Anschutz Medical Center, Denver, USA
| | - Mariana L Meyers
- Colorado Fetal Care Center, Colorado Institute of Maternal and Fetal Health, University of Colorado Denver, Anschutz Medical Center, Denver, USA.,Department of Pediatric Radiology, University of Colorado Denver, Anschutz Medical Center, Denver, USA
| | - Bethany D Tucker
- Colorado Fetal Care Center, Colorado Institute of Maternal and Fetal Health, University of Colorado Denver, Anschutz Medical Center, Denver, USA.,Department of Pediatrics, University of Colorado Denver, Anschutz Medical Center, Denver, USA
| | - Henry L Galan
- Colorado Fetal Care Center, Colorado Institute of Maternal and Fetal Health, University of Colorado Denver, Anschutz Medical Center, Denver, USA.,Department of Obstetrics and Gynecology - Maternal Fetal Medicine, University of Colorado Denver, Anschutz Medical Center, Denver, USA
| | - Kenneth W Liechty
- Colorado Fetal Care Center, Colorado Institute of Maternal and Fetal Health, University of Colorado Denver, Anschutz Medical Center, Denver, USA.,Department of Pediatric Surgery, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Center, Denver, USA
| | - Timothy M Crombleholme
- Colorado Fetal Care Center, Colorado Institute of Maternal and Fetal Health, University of Colorado Denver, Anschutz Medical Center, Denver, USA.,Department of Pediatric Surgery, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Center, Denver, USA
| | - Ahmed I Marwan
- Colorado Fetal Care Center, Colorado Institute of Maternal and Fetal Health, University of Colorado Denver, Anschutz Medical Center, Denver, USA. .,Department of Pediatric Surgery, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Center, Denver, USA. .,Surgery and Pediatrics, Colorado Fetal Care Center - Children's Hospital Colorado, 13123 East 16th Avenue, 328, Aurora, Colorado, 80045, USA.
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Loureiro B, Martinez-Biarge M, Foti F, Papadaki M, Cowan FM, Wusthoff CJ. MRI Patterns of brain injury and neurodevelopmental outcomes in neonates with severe anaemia at birth. Early Hum Dev 2017; 105:17-22. [PMID: 28107673 DOI: 10.1016/j.earlhumdev.2017.01.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 12/31/2016] [Accepted: 01/04/2017] [Indexed: 10/20/2022]
Abstract
AIMS To define patterns of brain injury and associated neurodevelopmental outcomes in infants with severe neonatal anaemia. METHODS We studied 20 infants with severe anaemia at birth (haemoglobin<7g/dL). Clinical details were analysed for causes of anaemia and co-morbidities. All had early brain magnetic resonance imaging (MRI) scans, which were reviewed for injury pattern. Neurodevelopmental outcomes were assessed at a median age of 24months. RESULTS The aetiology of the anaemia was feto-maternal haemorrhage in 17 and antepartum haemorrhage in 3 infants. The predominant site of injury was the white matter, which was affected in all infants, with differing grades of severity and with cystic evolution in 45%. Only one infant showed an injury pattern typical of an acute severe hypoxic-ischaemic insult. Outcomes correlated closely to the severity of MRI findings. Cerebral palsy was seen only with the most severe neuroimaging patterns (n=6). Global developmental delay, learning or behavioural problems and seizures were common with moderate injury. Visual impairment occurred, particularly with posterior injury. Microcephaly developed in 45%. INTERPRETATION Severe neonatal anaemia at birth was associated with a white matter predominant pattern of injury, the severity of which was related to neurodevelopmental outcomes. Early MRI and long-term follow-up are advisable following severe neonatal anaemia.
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Affiliation(s)
- Begoña Loureiro
- Departamento de Pediatría, Hospital Universitario Cruces, Barakaldo, Spain.
| | | | - Francesca Foti
- Department of Mental Health, Azienda Unita Sanitaria Locale di Reggio Emilia, Emilia-Romagna, Italy
| | - Maria Papadaki
- Own private paediatrician practice, Cholargos Attica, Greece
| | - Frances M Cowan
- Department of Paediatrics, Hammersmith Hospital, Imperial College, London, UK
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Lecointre L, Sananès N, Weingertner AS, Gaudineau A, Akladios C, Cavillon V, Langer B, Favre R. [Fetoscopic laser coagulation in 200 consecutive monochorionic pregnancies with twin-twin transfusion syndrome]. J Gynecol Obstet Hum Reprod 2017; 46:175-181. [PMID: 28403975 DOI: 10.1016/j.jogoh.2016.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Revised: 10/09/2016] [Accepted: 10/10/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To report preoperative data, surgical characteristics, complications and perinatal outcome of twin-twin transfusion syndrome (TTTS) managed with laser ablation surgery, to analyze predictors of neonatal survival and to compare the 100 most recent cases with the older 100. MATERIALS AND METHODS Observational cohort moncentric study of 200 cases of TTTS consecutively treated with fetoscopic laser coagulation between January 2004 and December 2014. RESULTS There were 49 stage I, 88 stage II, 55 stage III and eight stage IV. Median gestation at time of laser was 20.1±3.0 weeks' gestation (WG) whereas median gestation at delivery was 31.6±5.4 WG. Overall perinatal survival rate was 68.0% and 84.0% have one or more surviving twins. Preterm premature rupture of membranes occurred in 39 cases with and the median gestational age for this complication was 28.8±4.6 SA. Predictive factors to have at least one living birth were Quintero stage and gestational age at delivery. In the most recent period, there were significantly more TTTS Quintero stage I treated with laser, more coagulation by the Solomon technique and a larger number of coagulated vessels. CONCLUSION The neonatal survival of TTTS is improved by fetoscopic laser coagulation, preferely by using Solomon tecnhique. The use of active management of stage I is currently on research.
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Affiliation(s)
- L Lecointre
- Pôle de gynécologie-obstétrique, département d'échographie et de médecine fœtale, CMCO-HUS, 19, rue Louis-Pasteur, 67300 Schiltigheim/Strasbourg, France; Pôle de gynécologie-obstétrique, département d'obstétrique, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France.
| | - N Sananès
- Pôle de gynécologie-obstétrique, département d'échographie et de médecine fœtale, CMCO-HUS, 19, rue Louis-Pasteur, 67300 Schiltigheim/Strasbourg, France; Pôle de gynécologie-obstétrique, département d'obstétrique, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France; Inserm, UMR-S 1121, « Biomatériaux et Bioingénierie », 11, rue Humann, 67085 Strasbourg cedex, France
| | - A S Weingertner
- Pôle de gynécologie-obstétrique, département d'échographie et de médecine fœtale, CMCO-HUS, 19, rue Louis-Pasteur, 67300 Schiltigheim/Strasbourg, France
| | - A Gaudineau
- Pôle de gynécologie-obstétrique, département d'échographie et de médecine fœtale, CMCO-HUS, 19, rue Louis-Pasteur, 67300 Schiltigheim/Strasbourg, France; Pôle de gynécologie-obstétrique, département d'obstétrique, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France
| | - C Akladios
- Pôle de gynécologie-obstétrique, département d'obstétrique, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France
| | - V Cavillon
- Pôle de gynécologie-obstétrique, département d'échographie et de médecine fœtale, CMCO-HUS, 19, rue Louis-Pasteur, 67300 Schiltigheim/Strasbourg, France
| | - B Langer
- Pôle de gynécologie-obstétrique, département d'obstétrique, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France
| | - R Favre
- Pôle de gynécologie-obstétrique, département d'échographie et de médecine fœtale, CMCO-HUS, 19, rue Louis-Pasteur, 67300 Schiltigheim/Strasbourg, France
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Stirnemann J, Chalouhi G, Essaoui M, Bahi-Buisson N, Sonigo P, Millischer AE, Lapillonne A, Guigue V, Salomon LJ, Ville Y. Fetal brain imaging following laser surgery in twin-to-twin surgery. BJOG 2016; 125:1186-1191. [DOI: 10.1111/1471-0528.14162] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2016] [Indexed: 12/01/2022]
Affiliation(s)
- J Stirnemann
- Department of Obstetrics and Gynaecology; Université Paris Descartes; Paris Sorbonne-Cité; Paris France
- EA7328; Université Paris Descartes; Paris Sorbonne-Cité; Paris France
- Hôpital Necker-Enfants Malades; Assistance Publique-Hôpitaux de Paris; Paris France
- Centre National de Référence des Grossesses Monochoriales Compliquées; Paris France
| | - G Chalouhi
- Department of Obstetrics and Gynaecology; Université Paris Descartes; Paris Sorbonne-Cité; Paris France
- EA7328; Université Paris Descartes; Paris Sorbonne-Cité; Paris France
- Hôpital Necker-Enfants Malades; Assistance Publique-Hôpitaux de Paris; Paris France
- Centre National de Référence des Grossesses Monochoriales Compliquées; Paris France
| | - M Essaoui
- Department of Obstetrics and Gynaecology; Université Paris Descartes; Paris Sorbonne-Cité; Paris France
- EA7328; Université Paris Descartes; Paris Sorbonne-Cité; Paris France
- Hôpital Necker-Enfants Malades; Assistance Publique-Hôpitaux de Paris; Paris France
- Centre National de Référence des Grossesses Monochoriales Compliquées; Paris France
| | - N Bahi-Buisson
- Hôpital Necker-Enfants Malades; Assistance Publique-Hôpitaux de Paris; Paris France
- Department of Paediatric Neurology; Université Paris Descartes; Paris Sorbonne-Cité; Paris France
- Université Paris Descartes; Paris Sorbonne-Cité; Paris France
| | - P Sonigo
- EA7328; Université Paris Descartes; Paris Sorbonne-Cité; Paris France
- Hôpital Necker-Enfants Malades; Assistance Publique-Hôpitaux de Paris; Paris France
- Department of Paediatric Imaging; Université Paris Descartes; Paris Sorbonne-Cité; Paris France
| | - A-E Millischer
- EA7328; Université Paris Descartes; Paris Sorbonne-Cité; Paris France
- Hôpital Necker-Enfants Malades; Assistance Publique-Hôpitaux de Paris; Paris France
- Department of Paediatric Imaging; Université Paris Descartes; Paris Sorbonne-Cité; Paris France
| | - A Lapillonne
- EA7328; Université Paris Descartes; Paris Sorbonne-Cité; Paris France
- Hôpital Necker-Enfants Malades; Assistance Publique-Hôpitaux de Paris; Paris France
- Department of Neonatology; Université Paris Descartes; Paris Sorbonne-Cité; Paris France
| | - V Guigue
- Department of Obstetrics and Gynaecology; Université Paris Descartes; Paris Sorbonne-Cité; Paris France
- Hôpital Necker-Enfants Malades; Assistance Publique-Hôpitaux de Paris; Paris France
- Centre National de Référence des Grossesses Monochoriales Compliquées; Paris France
| | - LJ Salomon
- Department of Obstetrics and Gynaecology; Université Paris Descartes; Paris Sorbonne-Cité; Paris France
- EA7328; Université Paris Descartes; Paris Sorbonne-Cité; Paris France
- Hôpital Necker-Enfants Malades; Assistance Publique-Hôpitaux de Paris; Paris France
- Centre National de Référence des Grossesses Monochoriales Compliquées; Paris France
| | - Y Ville
- Department of Obstetrics and Gynaecology; Université Paris Descartes; Paris Sorbonne-Cité; Paris France
- EA7328; Université Paris Descartes; Paris Sorbonne-Cité; Paris France
- Hôpital Necker-Enfants Malades; Assistance Publique-Hôpitaux de Paris; Paris France
- Centre National de Référence des Grossesses Monochoriales Compliquées; Paris France
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Khalil A, Rodgers M, Baschat A, Bhide A, Gratacos E, Hecher K, Kilby MD, Lewi L, Nicolaides KH, Oepkes D, Raine-Fenning N, Reed K, Salomon LJ, Sotiriadis A, Thilaganathan B, Ville Y. ISUOG Practice Guidelines: role of ultrasound in twin pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 47:247-63. [PMID: 26577371 DOI: 10.1002/uog.15821] [Citation(s) in RCA: 345] [Impact Index Per Article: 43.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 11/16/2015] [Indexed: 05/27/2023]
Affiliation(s)
- A Khalil
- Fetal Medicine Unit, St George’s Hospital, St George’s University of London, London, UK
| | - M Rodgers
- The Johns Hopkins Center for Fetal Therapy, Baltimore, MD, USA
| | - A Baschat
- The Johns Hopkins Center for Fetal Therapy, Baltimore, MD, USA
| | - A Bhide
- Fetal Medicine Unit, St George’s Hospital, St George’s University of London, London, UK
| | - E Gratacos
- Fetal Medicine Units and Departments of Obstetrics, Hospital Clinic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - K Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germaniy
| | - M D Kilby
- Centre for Women’s and Children's Health, University of Birmingham and Fetal Medicine Centre, Birmingham Women’s Foundation Trust, Birmingham, UK
| | - L Lewi
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - K H Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, King’s College Hospital, London, UK
| | - D Oepkes
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - N Raine-Fenning
- Division of Child Health, Obstetrics and Gynaecology, School of Medicine, University of Nottingham, Nottingham, UK
| | - K Reed
- Twin and Multiple Births Association (TAMBA)
| | - L J Salomon
- Hopital Necker-Enfants Malades, AP-HP, Universit´e Paris Descartes, Paris, France
| | - A Sotiriadis
- Department of Obstetrics and Gynaecology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - B Thilaganathan
- Fetal Medicine Unit, St George’s Hospital, St George’s University of London, London, UK
| | - Y Ville
- Hospital Necker-Enfants Malades, AP-HP, Université Paris Descartes, Paris, France
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Gaerty K, Greer RM, Kumar S. Systematic review and metaanalysis of perinatal outcomes after radiofrequency ablation and bipolar cord occlusion in monochorionic pregnancies. Am J Obstet Gynecol 2015; 213:637-43. [PMID: 25935786 DOI: 10.1016/j.ajog.2015.04.035] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 03/31/2015] [Accepted: 04/24/2015] [Indexed: 11/29/2022]
Abstract
The aim of this study was to analyze perinatal outcomes after selective reduction in monochorionic pregnancies with the use of either radiofrequency ablation (RFA) or bipolar cord occlusion (BCO). This was a systematic review and metaanalysis that included all studies with ≥5 cases that described perinatal outcomes after BCO or RFA that were identified in PubMed, Embase, Web of Science, COCHRANE, CINAHL, Academic Search Premier, Science Direct, and MEDLINE that were published between 1965 and July 2014. For count data, incidence risk ratios (IRR; 95% confidence interval [CI]) were calculated with BCO as the reference standard. The analysis included 481 cases of BCO and 320 cases of RFA from 17 studies. The mean median gestations at procedure were 21.1 ± 1.2 weeks (BCO) and 18.8 ± 2.5 weeks (RFA; P = .03). The rate of cotwin death was higher in the RFA group (14.7%) vs the BCO group (10.6%; IRR, 1.38; 95% CI, 0.93-2.05; P = .11). The live birth rate was 81.3% for the RFA group and 86.7% in the BCO group (IRR, 0.93; 95% CI, 0.80-1.09; P = .41). BCO had higher neonatal death rates (8.1%) vs RFA (4.5%; IRR, 0.56; 95% CI, 0.30-1.04; P = .07). Overall survival was 76.8% for RFA and 79.1% for BCO (IRR, 0.97; 95% CI, 0.82-1.14; P = .72); however, none of these differences were statistically significant. Preterm premature rupture of membranes occurred in 17.7% of RFA cases and 28.2% of the BCO cases (IRR, 0.63; 95% CI, 0.43-0.91; P = .01). The mean median gestational age at delivery was 34.7 ± 1.7 weeks in the RFA group and 35.1 ± 1.6 weeks in the BCO group. Our data do not demonstrate clearly the superiority of 1 procedure over the other. The clinical situation and preference of the operator are important considerations. Rates of preterm delivery and preterm premature rupture of membranes remain substantial for both procedures.
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Affiliation(s)
- Kirsten Gaerty
- Mater Mothers' Hospital, South Brisbane, Queensland, Australia
| | - Ristan M Greer
- Mater Research Institute, University of Queensland, South Brisbane, Queensland, Australia
| | - Sailesh Kumar
- Mater Research Institute, University of Queensland, South Brisbane, Queensland, Australia; Mater Mothers' Hospital, South Brisbane, Queensland, Australia.
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Lecointre L, Sananes N, Weingertner AS, Kohler M, Guerra F, Fritz G, Viville B, Langer B, Nisand I, Favre R. Fetoscopic laser coagulation for twin-twin transfusion syndrome before 17 weeks' gestation: laser data, complications and neonatal outcome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 44:299-303. [PMID: 24677292 DOI: 10.1002/uog.13375] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Revised: 01/22/2014] [Accepted: 03/14/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To compare laser data, complications and neonatal outcome in pregnancies that undergo 'early' (≤ 17 weeks' gestation) fetoscopic laser ablation of placental vascular anastomoses for twin-twin transfusion syndrome (TTTS) with those from 'conventional' cases treated after 17 weeks. METHODS This was a cohort study of data collected prospectively between January 2004 and December 2012. We included monochorionic diamniotic twin pregnancies complicated by TTTS and treated by fetoscopic laser coagulation. Pregnancies were grouped according to laser treatment ≤ 17 gestational weeks or > 17 weeks and obstetric and neonatal outcomes were compared between groups. RESULTS A total of 178 pregnancies with TTTS underwent laser therapy: 40 at or before 17 weeks and 138 after 17 weeks. There was no statistically significant difference between these two groups with respect to the rate of preterm prelabor rupture of membranes (PPROM), gestational age at PPROM and rate of PPROM occurring in the 7 days following fetoscopic laser coagulation. In the early group, the interval between performing fetoscopic laser coagulation and the time of delivery was significantly longer (104 days vs 74 days, P=0.0002) and the delivery rate within 7 days of laser treatment was significantly lower (2.5% vs 15.9%, P=0.026). There was no significant difference between the two groups with regard to the rates of pregnancy without live birth (15.4% vs 15.4%, P=0.993), with one live birth (84.6% vs 84.6%, P=0.993) and with two live births (64.1% vs 58.1%, P=0.500). CONCLUSION In the event of early TTTS, fetoscopic laser coagulation is technically feasible before 17 gestational weeks and obstetric and neonatal outcomes are comparable with those in cases of laser treatment performed after 17 weeks.
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Affiliation(s)
- L Lecointre
- Fetal Medicine, CMCO-HUS, Schiltigheim/Strasbourg, France
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Kumar S, Paramasivam G, Zhang E, Jones B, Noori M, Prior T, Vasudeva A, Wimalasundera RC. Perinatal- and procedure-related outcomes following radiofrequency ablation in monochorionic pregnancy. Am J Obstet Gynecol 2014; 210:454.e1-6. [PMID: 24315860 DOI: 10.1016/j.ajog.2013.12.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Revised: 10/24/2013] [Accepted: 12/02/2013] [Indexed: 10/25/2022]
Abstract
OBJECTIVE We sought to assess the efficacy, complication rates, and outcomes for complex monochorionic pregnancies undergoing selective fetal reduction using radiofrequency ablation (RFA). STUDY DESIGN In this prospective observational study, 100 consecutive cases of selective fetal reduction using RFA were analyzed. All cases were managed at the Centre for Fetal Care at Queen Charlotte's and Chelsea Hospital in London. Indications for offering RFA, details of the procedure, and pregnancy outcomes were collected and analyzed. RESULTS The main indications for RFA were discordant fetal anomaly and twin-twin transfusion syndrome. Overall live birth rate was 78% and the median gestation at delivery was 35.15 weeks. Delivery <32 weeks' gestation occurred in 17.9% of cases. Postprocedure abnormal antenatal magnetic resonance imaging occurred in 3% of cases. There was no statistical difference in outcomes with regard to gestation when the procedure was performed or the indication for the RFA. CONCLUSION RFA appears to be a reasonable option for selective fetal reduction in complex monochorionic pregnancies with an overall survival rate of 78%.
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Millischer AE, Sonigo P, Ville Y, Brunelle F, Boddaert N, Salomon LJ. Standardized fetal anatomical examination using magnetic resonance imaging: a feasibility study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2013; 42:553-559. [PMID: 23349068 DOI: 10.1002/uog.12415] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Revised: 01/03/2013] [Accepted: 01/11/2013] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To determine whether a standard complete fetal anatomical survey, as recommended for ultrasound examination guidelines, is feasible using a standardized magnetic resonance imaging (MRI) protocol. METHODS Based on guidelines for ultrasound examination, we created a specific MRI protocol for fetal anatomical survey. This protocol was then tested prospectively in 100 women undergoing fetal MRI examination for various specific indications at a median gestational age of 30 weeks. The feasibility of using MRI to perform the fetal anatomical survey was analyzed by two reviewers (A and B) based on 26 predefined anatomical criteria, yielding a score ranging from 0 to 26 (26 meaning successful complete anatomical study). Reproducibility was analyzed using percentage agreement and modified kappa statistics. RESULTS The mean score for the standardized MRI anatomical survey was 24.6 (SD, 1.4; range, 15-26) for Reviewer A and 24.2 (SD, 1.7; range, 15-26) for Reviewer B (P = 0.1). Twenty-two, two and two criteria could be assessed in > 95%, 80-95% and < 80% of cases by Reviewer A and 19, four and three criteria could be assessed in > 95%, 80-95% and < 80% of cases by Reviewer B. For both reviewers, the two most difficult criteria to evaluate were aorta and pulmonary artery. Inter-reviewer agreement was above 90% for 22 of the 26 anatomical criteria and adjusted kappa coefficients for each criterion demonstrated good, moderate and poor agreement for 22, two and two criteria, respectively. CONCLUSION Our data support the hypothesis that standardized fetal anatomical examination might be achieved and reproducible using MRI, although improvement is required for the cardiac part of the examination.
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Affiliation(s)
- A E Millischer
- Service de Radiologie Pédiatrique, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Université Paris Descartes, Paris, France
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Abstract
The objective of this review is to assess the evidence that supports the use of ultrasound in twin pregnancies. Although many of the indications for obstetric ultrasound are the same in both singleton and multiple gestations, there are special considerations as well as unique conditions in twins that require additional imaging studies. The reasons for ultrasound in twins include pregnancy dating, determination of chorionicity, nuchal translucency assessment, anatomical survey, placental evaluation, cervical length assessment, routine fetal growth, and serial surveillance of pregnancies complicated by anomalies, cervical shortening, fetal growth disturbances, and amniotic fluid abnormalities. Twins with monochorionic placentation require heightened scrutiny for monoamnionicity, conjoined twins, twin reversed arterial perfusion (TRAP) syndrome, twin-twin transfusion syndrome, unequal placental sharing with discordant twin growth or selective intrauterine fetal growth restriction (IUGR), twin anemia-polycythemia sequence (TAPS), and single fetal demise. Ultrasound is essential for the detection and management of conditions that can complicate dichorionic and monochorionic twin pregnancies.
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Affiliation(s)
- Lynn L Simpson
- Department of Obstetrics and Gynecology, Columbia University Medical Center, 622 W 168th St, PH-16, NY 10032.
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Hui L, Wick HC, Moise KJ, Johnson A, Luks F, Haeri S, Johnson KL, Bianchi DW. Global gene expression analysis of amniotic fluid cell-free RNA from recipient twins with twin-twin transfusion syndrome. Prenat Diagn 2013; 33:873-83. [PMID: 23640821 DOI: 10.1002/pd.4150] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2013] [Revised: 04/23/2013] [Accepted: 04/25/2013] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The objective of this study was to understand the biological pathways involved in twin-twin transfusion syndrome (TTTS) by performing global gene expression analysis of amniotic fluid (AF) cell-free RNA. METHODS A prospective whole transcriptome microarray study analyzing cell-free RNA in AF from TTTS recipient twins and singleton controls was carried out. Significantly differentially regulated genes in TTTS cases (N = 8) versus matched controls (N = 8) were identified and pathways analyses performed. Significant gene expression differences between stage II TTTS recipients (N = 5) and stage III TTTS recipients with abnormal Doppler measurements (N = 5) were also analyzed. RESULTS Analysis of paired data from TTTS cases and controls revealed differential expression of 801 genes, which were significantly enriched for neurological disease and cardiovascular system pathways. We also identified cardiovascular genes and pathways associated with the presence of critically abnormal Doppler measurements in stage III TTTS recipients. CONCLUSIONS This study provides the first transcriptome-wide data on the impact of TTTS on fetal development. Our results show that gene expression involving neurological and cardiovascular pathways are altered in recipient fetuses prior to surgical treatment. This has relevance for the origins of long-term complications seen in survivors and for the development of future fetal biomarkers.
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Affiliation(s)
- Lisa Hui
- Mother Infant Research Institute, Tufts Medical Center, Boston, MA, USA.
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Merhar SL, Kline-Fath BM, Meinzen-Derr J, Schibler KR, Leach JL. Fetal and postnatal brain MRI in premature infants with twin-twin transfusion syndrome. J Perinatol 2013; 33:112-8. [PMID: 22743408 DOI: 10.1038/jp.2012.87] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To describe the findings on fetal and postnatal magnetic resonance imaging (MRI) in premature infants with twin-twin transfusion syndrome (TTTS) and to determine whether currently used staging systems and other fetal and postnatal factors correlate with brain injury in this population. STUDY DESIGN We performed a prospective study of 22 premature infants with TTTS whose mothers had fetal MRIs. Postnatal brain MRI was performed at term equivalent age (38 to 44 weeks) and medical records were reviewed. Brain injury was scored on fetal and postnatal MRIs using an injury scale incorporating hemorrhagic and nonhemorrhagic injury. RESULT The median (range) gestational age (GA) was 31 weeks (26 to 35) and birth weight (BW) was 1296 g (762 to 2330). In all, 5/22 patients (23%) had brain injury seen on fetal MRI and 15/22 patients (68%) had brain injury seen on postnatal MRI. Quintero stage was the only predictor variable that was significantly correlated with the total brain injury score (P=0.05). CONCLUSION Postnatal brain injury in premature infants with TTTS is correlated with Quintero stage. GA and BW are not predictive of brain injury in this cohort of infants.
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Affiliation(s)
- S L Merhar
- Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
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Abstract
OBJECTIVE We sought to review the natural history, pathophysiology, diagnosis, and treatment options for twin-twin transfusion syndrome (TTTS). METHODS A systematic review was performed using MEDLINE database, PubMed, EMBASE, and Cochrane Library. The search was restricted to English-language articles published from 1966 through July 2012. Priority was given to articles reporting original research, in particular randomized controlled trials, although review articles and commentaries also were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate for inclusion in this document. Evidence reports and guidelines published by organizations or institutions such as the National Institutes of Health, Agency for Health Research and Quality, American College of Obstetricians and Gynecologists, and Society for Maternal-Fetal Medicine were also reviewed, and additional studies were located by reviewing bibliographies of identified articles. Consistent with US Preventive Task Force guidelines, references were evaluated for quality based on the highest level of evidence, and recommendations were graded accordingly. RESULTS AND RECOMMENDATIONS TTTS is a serious condition that can complicate 8-10% of twin pregnancies with monochorionic diamniotic (MCDA) placentation. The diagnosis of TTTS requires 2 criteria: (1) the presence of a MCDA pregnancy; and (2) the presence of oligohydramnios (defined as a maximal vertical pocket of <2 cm) in one sac, and of polyhydramnios (a maximal vertical pocket of >8 cm) in the other sac. The Quintero staging system appears to be a useful tool for describing the severity of TTTS in a standardized fashion. Serial sonographic evaluation should be considered for all twins with MCDA placentation, usually beginning at around 16 weeks and continuing about every 2 weeks until delivery. Screening for congenital heart disease is warranted in all monochorionic twins, in particular those complicated by TTTS. Extensive counseling should be provided to patients with pregnancies complicated by TTTS including natural history of the disease, as well as management options and their risks and benefits. The natural history of stage I TTTS is that more than three-fourths of cases remain stable or regress without invasive intervention, with perinatal survival of about 86%. Therefore, many patients with stage I TTTS may often be managed expectantly. The natural history of advanced (eg, stage ≥III) TTTS is bleak, with a reported perinatal loss rate of 70-100%, particularly when it presents <26 weeks. Fetoscopic laser photocoagulation of placental anastomoses is considered by most experts to be the best available approach for stages II, III, and IV TTTS in continuing pregnancies at <26 weeks, but the metaanalysis data show no significant survival benefit, and the long-term neurologic outcomes in the Eurofetus trial were not different than in nonlaser-treated controls. Even laser-treated TTTS is associated with a perinatal mortality rate of 30-50%, and a 5-20% chance of long-term neurologic handicap. Steroids for fetal maturation should be considered at 24 0/7 to 33 6/7 weeks, particularly in pregnancies complicated by stage ≥III TTTS, and those undergoing invasive interventions.
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Vanderbilt DL, Schrager SM, Llanes A, Chmait RH. Prevalence and risk factors of cerebral lesions in neonates after laser surgery for twin-twin transfusion syndrome. Am J Obstet Gynecol 2012; 207:320.e1-6. [PMID: 23021698 DOI: 10.1016/j.ajog.2012.06.031] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2012] [Revised: 04/17/2012] [Accepted: 06/14/2012] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To identify risk factors for cerebral lesions among survivors of twin-twin transfusion syndrome treated with laser surgery. STUDY DESIGN A multilevel regression analysis examined risk factors for neonatal cerebral lesions identified by imaging. Imaging was routine in "high-risk survivors," defined as those delivered at <32 weeks' gestation, and by clinical indications if born later. Severe lesions were defined as: intraventricular hemorrhage grade III-IV, cystic periventricular leukomalacia, ventriculomegaly and/or hydrocephalus, microcephaly, infarctions, porencephalic/Dandy-Walker cysts, or bilateral other cysts. RESULTS For 262 consecutive laser-treated twin-twin transfusion syndrome patients, 18 neonates had severe lesions identified among 427 individual survivors (4.2%) and 242 "high-risk survivors" (7.4%). Forty-six newborns had any cerebral lesion, resulting in lesion rates of 10.8%-19.0%. Delivery <32 weeks' (odds ratio, 4.95; P < .001) and <28 weeks' (odds ratio, 6.25; P < .001) gestation were associated with increased likelihood of any cerebral lesion. CONCLUSION This cohort showed low rates (4-7%) of severe neonatal cerebral lesions, with prematurity being the primary risk factor.
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Affiliation(s)
- Douglas L Vanderbilt
- Division of General Pediatrics, Department of Pediatrics, Keck School of Medicin, University of Southern California, Los Angeles, CA, USA
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Cerebral Injury in Twin–Twin Transfusion Syndrome Treated With Fetoscopic Laser Surgery. Obstet Gynecol 2012; 120:15-20. [DOI: 10.1097/aog.0b013e31825b9841] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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