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Hoover EA, Yamamura Y, Thompson G. Structural Anomalies in Multifetal Gestations. Clin Obstet Gynecol 2023; 66:781-791. [PMID: 37963346 DOI: 10.1097/grf.0000000000000816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
Multifetal gestations are at increased risk for structural anomalies relative to singletons. Determination of chorionicity is critical, as the risk is highest for monochorionic pregnancies. In a singleton gestation, counseling is structured around optimization of fetal outcomes and careful consideration of the patient's choices in management decisions. However, in multifetal gestations affected by a fetal anomaly, complex counseling with consideration for the pregnancy as a whole is necessary. We review the incidence of structural anomalies in twins and highlight unique considerations including selective termination for discordant anomalies. We emphasize the role of shared decision making between provider and patient.
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Affiliation(s)
- Elizabeth A Hoover
- Department of Obstetrics, Gynecology and Women's Health, University of Minnesota, Minneapolis, Minnesota
| | - Yasuko Yamamura
- Department of Obstetrics, Gynecology and Women's Health, University of Minnesota, Minneapolis, Minnesota
| | - Gwyneth Thompson
- Department of Obstetrics and Gynecology, Southern Illinois University, Springfield, Illinois
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Wojas A, Martin KA, Koyen Malashevich A, Hashimoto K, Parmar S, White R, Demko Z, Billings P, Jelsema R, Rebarber A. Clinician-reported Chorionicity and Zygosity Assignment using single-nucleotide polymorphism-based cell-free DNA Lessons learned from 55,344 Twin Pregnancies. Prenat Diagn 2022; 42:1235-1241. [PMID: 35997139 PMCID: PMC9541063 DOI: 10.1002/pd.6218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 07/06/2022] [Accepted: 07/26/2022] [Indexed: 11/21/2022]
Abstract
Objective Prenatal chorionicity assessment relies on ultrasound, which can be confounded by many factors. Noninvasive assessment of zygosity is possible using single nucleotide polymorphism (SNP)‐based cell‐free DNA testing. Our objective was to determine the relationship between provider‐reported chorionicity and SNP‐cfDNA assignment of twin zygosity. Methods All twin pregnancy blood samples received by a reference laboratory between September 27, 2017 and September 8, 2021 were included. Chorionicity assignment was requested on the requisition, recorded as; monochorionic (MC), dichorionic, or “don't know”. SNP‐cfDNA zygosity results, monozygotic (MZ) or dizygotic (DZ), were correlated with chorionicity assignment. Results 59,471 twin samples (median gestational age = 12.0 weeks at draw) were received and analyzed; 55,344 (93.1%) received zygosity assignment. SNP‐cfDNA reported 16,673 (30.1%) MZ and 38,671 (69.9%) as DZ. Provider‐reported chorionicity was compared to the zygosity assignment for each case. Of 6283 provider‐reported MC twins, 318 (5.1%) were reported as DZ using SNP‐cfDNA. Conclusion(s) One in 20 suspected MC twin pregnancies were reported as DZ using SNP‐cfDNA. Approximately 30% of 55,344 twin pregnancies were found to be MZ, including cases where chorionicity was unknown. SNP‐cfDNA zygosity assessment is a useful adjunct assessment for twin pregnancies, particularly those reported as MC or without determined chorionicity. What's already known about the topic? The assignment of chorionicity early in pregnancy can improve perinatal outcomes of twin pregnancies. Prenatal assessment of chorionicity relies on ultrasound (US), and the accuracy of US can be confounded by many factors, including gestational age (GA) and operator experience. Noninvasive assessment of zygosity is now possible using single nucleotide polymorphism (SNP)‐based cell‐free DNA (cfDNA).
What does this study add? This is the first population‐based study describing the correlation between cfDNA assessment of zygosity and chorionicity. In 55,344 twin pregnancies, approximately 30% were found to be monozygotic (MZ), including cases where chorionicity was unknown. We found that one in 20 suspected monochorionic (MC) twin pregnancies were reported as dizygotic (DZ) twins (DZ) by SNP‐cfDNA testing. SNP‐cfDNA zygosity assessment is a useful adjunct assessment for twin pregnancies, particularly those reported as MC or without determined chorionicity.
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Affiliation(s)
- Anna Wojas
- Department of Obstetrics, Gynecology, and Reproductive Science, Mt. Sinai, New York, NY, USA
| | | | | | | | | | | | | | | | | | - Andrei Rebarber
- Department of Obstetrics, Gynecology, and Reproductive Science, Mt. Sinai, New York, NY, USA
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Abstract
Along with the rise of assisted reproductive technology, multifetal gestations increased dramatically. Twin pregnancies account for 97% of multifetal pregnancies and 3% of all births in the United States. Twins and higher-order multiples carry increased risks of obstetric, perinatal, and maternal complications; these risks increase with increasing fetal number. Neonatal morbidity and mortality in multifetal gestations is driven primarily by prematurity. Both spontaneous and indicated preterm births are increased in multifetal gestations, and only a limited number of strategies are available to mitigate this risk. No single intervention has been shown to decrease the rate of spontaneous preterm birth in most twin pregnancies. Low-dose aspirin prophylaxis is recommended in all multifetal pregnancies to reduce the risk of preeclampsia and its associated complications. Antenatal management of multifetal gestations depends on chorionicity, which should be established using ultrasonography in the first trimester. Unlike dichorionic twin gestations, monochorionic pregnancies experience unique complications because of their shared vascular connections, and therefore, need frequent ultrasound surveillance. Even uncomplicated twin gestations have higher rates of unanticipated stillbirth compared with singletons. Delivery of twin pregnancies is generally indicated in the late preterm to early term period depending on chorionicity and other clinical factors. For most diamniotic twin pregnancies with a cephalic presenting fetus, vaginal delivery after 32 weeks' gestation is a safe and reasonable option with high rates of success and no increased risk of perinatal morbidity.
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Affiliation(s)
- Cassandra R Duffy
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA
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4
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Mok T, Afshar Y, Platt LD, Guo R, Rao RR, Pluym ID, Silverman NS, Han CS. Predicting Adverse Outcomes in Monochorionic-Diamniotic Twins: The Role of Intertwin Discrepancy in Middle Cerebral Artery Doppler Measurements and the Cerebroplacental Ratio. Am J Perinatol 2021; 38:1348-1357. [PMID: 34282577 DOI: 10.1055/s-0041-1732456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE This study was aimed to evaluate the role of intertwin discrepancy in middle cerebral artery peak systolic velocity (MCA-PSV) and cerebroplacental ratio (CPR) for the prediction of adverse outcomes in monochorionic-diamniotic (MCDA) twin pregnancies. STUDY DESIGN A retrospective cohort study of MCDA pregnancies that underwent ultrasound surveillance at a perinatal referral center from 2007 to 2017. Intertwin MCA-PSV discrepancy (MCA-ΔPSV-MoM) was defined as the absolute difference of MCA-PSV multiple of the median (MoM) for gestational age between twins. Intertwin CPR discrepancy (CPR-Δ) was defined as the absolute difference of CPR between twins. The maximum MCA-ΔPSV-MoM and CPR-Δ before and after 26 weeks of gestation were assessed as predictors of pregnancy and neonatal outcomes through simple logistic regression models and Pearson's correlation coefficients. Receiver operating characteristic (ROC) curves were generated to determine the predictive value of maximum MCA-ΔPSV-MoM and CPR-Δ. RESULTS A total of 143 MCDA pregnancies met inclusion criteria. There was a significant association between MCA-ΔPSV-MoM at <26 weeks and the development of twin anemia-polycythemia sequence (TAPS; p = 0.007), intrauterine fetal demise (IUFD; p = 0.009), and neonatal intensive care unit (NICU) admission (p < 0.05). MCA-ΔPSV-MoM at ≥26 weeks was associated with the development of TAPS (p < 0.001). CPR-Δ at <26 weeks was associated with the development of twin-twin transfusion syndrome (TTTS; p = 0.03) and NICU admission (p = 0.02). MCA-ΔPSV-MoM at ≥26 weeks was highly predictive of TAPS (area under curve [AUC] = 0.92). A cut-off of 0.44 would identify TAPS with 100% sensitivity and 73% specificity. CONCLUSION In MCDA pregnancies, intertwin MCA and CPR discrepancies are associated with adverse pregnancy and neonatal outcomes, including TAPS, TTTS, IUFD, and NICU admission. Evaluation of intertwin MCA and CPR differences demonstrated the potential for clinical predictive utility in the surveillance of MCDA twin pregnancies. KEY POINTS · Intertwin discrepancy of MCA-PSV and CPR is associated with adverse pregnancy outcomes.. · Intertwin differences in Doppler ultrasound may occur prior to meeting diagnostic criteria for TTTS or TAPS.. · There is potential clinical predictive utility in MCA and CPR surveillance of MCDA twin pregnancies..
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Affiliation(s)
- Thalia Mok
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Yalda Afshar
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Lawrence D Platt
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California.,Division of Maternal Fetal Medicine, Center for Fetal Medicine and Women's Ultrasound, Los Angeles, California
| | - Rong Guo
- Department of Medicine Statistics Core, David Geffen School of Medicine, Los Angeles, California
| | - Rashmi R Rao
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Ilina D Pluym
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Neil S Silverman
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California.,Division of Maternal Fetal Medicine, Center for Fetal Medicine and Women's Ultrasound, Los Angeles, California
| | - Christina S Han
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California.,Division of Maternal Fetal Medicine, Center for Fetal Medicine and Women's Ultrasound, Los Angeles, California
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Management of Complicated Monochorionic Twin Gestations: An Evidence-Based Protocol. Obstet Gynecol Surv 2021; 76:541-549. [PMID: 34586420 DOI: 10.1097/ogx.0000000000000917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Importance Monochorionic (MC) twins are hemodynamically connected by vascular anastomoses within the single shared placenta. The transfer of fluid or blood from one fetus to the other may result in development of pathologic complications, such as twin-twin transfusion syndrome, twin anemia polycythemia sequence, selective intrauterine growth restriction, and twin reversed arterial perfusion sequence. Monoamniotic gestations, which comprise a small fraction of MC pregnancies, can also present with unique challenges, particularly antepartum umbilical cord entanglement. All these complications carry a high risk of fetal morbidity and mortality if not recognized and managed in a timely fashion. Objective The purpose of this article is to review evidence-based management of complicated MC twin gestations and propose a standardized approach to surveillance. Evidence Acquisition Monochorionic gestations account for the majority of complications that occur in twin pregnancies; however, there is unclear evidence on the appropriate surveillance for and management of specific complications associated with these pregnancies. Results This article summarizes management for each specific type of MC complication in a structured and clear manner. Conclusions Early pregnancy ultrasound, ideally between 10 and 13 weeks' gestation, is critical for the diagnosis and characterization of twin pregnancies. To improve outcomes for MC twins, appropriate fetal surveillance should be initiated at 16 weeks' gestation and continued until delivery.
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Kehl S, Hösli I, Pecks U, Reif P, Schild RL, Schmidt M, Schmitz D, Schwarz C, Surbek D, Abou-Dakn M. Induction of Labour. Guideline of the DGGG, OEGGG and SGGG (S2k, AWMF Registry No. 015-088, December 2020). Geburtshilfe Frauenheilkd 2021; 81:870-895. [PMID: 34393254 DOI: 10.1055/a-1519-7713] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 05/27/2021] [Indexed: 01/17/2023] Open
Abstract
Aim The aim of this official guideline published and coordinated by the German Society of Gynaecology and Obstetrics (DGGG) in cooperation with the Austrian Society of Gynaecology and Obstetrics (OEGGG) and the Swiss Society of Gynaecology and Obstetrics (SGGG) is to provide a consensus-based overview of the indications, methods and general management of induction of labour by evaluating the relevant literature. Methods This S2k guideline was developed using a structured consensus process which included representative members from various professions; the guideline was commissioned by the guidelines commission of the DGGG, OEGGG and SGGG. Recommendations The guideline provides recommendations on the indications, management, methods, monitoring and special situations occurring in the context of inducing labour.
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Affiliation(s)
- Sven Kehl
- Frauenklinik, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Irene Hösli
- Frauenklinik, Universitätsspital Basel, Basel, Switzerland
| | - Ulrich Pecks
- Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Philipp Reif
- Frauenheilkunde und Geburtshilfe, Universitätsklinikum Graz, Graz, Austria
| | - Ralf L Schild
- Klinik für Geburtshilfe und Perinatalmedizin, Diakovere Krankenhaus gGmbH, Hannover, Germany
| | - Markus Schmidt
- Frauenheilkunde und Geburtshilfe, Sana Kliniken Duisburg, Duisburg, Germany
| | - Dagmar Schmitz
- Institut für Geschichte, Theorie und Ethik der Medizin, Uniklinik RWTH Aachen, Aachen, Germany
| | - Christiane Schwarz
- Fachbereich Hebammenwissenschaft, Institut für Gesundheitswissenschaften, Universität zu Lübeck, Lübeck, Germany
| | - Daniel Surbek
- Frauenklinik, Inselspital, Universitätsspital Bern, Bern, Switzerland
| | - Michael Abou-Dakn
- Klinik für Gynäkologie, St. Joseph Krankenhaus, Berlin Tempelhof, Berlin, Germany
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Nicholas L, Fischbein R, Ernst-Milner S, Wani R. Review of International Clinical Guidelines Related to Prenatal Screening during Monochorionic Pregnancies. J Clin Med 2021; 10:1128. [PMID: 33800344 PMCID: PMC7962833 DOI: 10.3390/jcm10051128] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 02/11/2021] [Accepted: 03/01/2021] [Indexed: 12/24/2022] Open
Abstract
We conducted a search for international clinical guidelines related to prenatal screening during monochorionic pregnancies. We found 25 resources from 13 countries/regions and extracted information related to general screening as well as screening related to specific monochorionic complications, including twin-twin transfusion syndrome (TTTS), selective fetal growth restriction (SFGR), and twin anemia-polycythemia sequence (TAPS). Findings reveal universal recommendation for the early establishment of chorionicity. Near-universal recommendation was found for bi-weekly ultrasounds beginning around gestational week 16; routine TTTS and SFGR surveillance comprised of regularly assessing fetal growth, amniotic fluids, and bladder visibility; and fetal anatomical scanning between gestational weeks 18-22. Conflicting recommendation was found for nuchal translucency screening; second-trimester scanning for cervical length; routine TAPS screening; and routine umbilical artery, umbilical vein, and ductus venosus assessment. We conclude that across international agencies and organizations, clinical guidelines related to monochorionic prenatal screening vary considerably. This discord raises concerns related to equitable access to evidence-based monochorionic prenatal care; the ability to create reliable international datasets to help improve the quality of monochorionic research; and the promotion of patient safety and best monochorionic outcomes. Patients globally may benefit from the coming together of international bodies to develop inclusive universal monochorionic prenatal screening standards.
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Affiliation(s)
- Lauren Nicholas
- Department of Social Sciences, D’Youville College, 591 Niagara Street, Buffalo, NY 14201, USA
| | - Rebecca Fischbein
- Department of Family and Community Medicine, Northeast Ohio Medical University, 4209 State Route 44, P.O. Box 95, Rootstown, OH 44272, USA; (R.F.); (R.W.)
| | - Stephanie Ernst-Milner
- Twin Anemia Polycythemia Sequence (TAPS) Support Foundation, Founder, 1326HS Almere, The Netherlands;
| | - Roshni Wani
- Department of Family and Community Medicine, Northeast Ohio Medical University, 4209 State Route 44, P.O. Box 95, Rootstown, OH 44272, USA; (R.F.); (R.W.)
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Society for Maternal-Fetal Medicine Special Statement: Updated checklists for management of monochorionic twin pregnancy. Am J Obstet Gynecol 2020; 223:B16-B20. [PMID: 32861686 DOI: 10.1016/j.ajog.2020.08.066] [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: 11/24/2022]
Abstract
Approximately 20% of twin pregnancies are monochorionic. The management of monochorionic twin pregnancy involves several additional interventions beyond the routine management of singletons or dichorionic twins. In 2015, the Society for Maternal-Fetal Medicine posted checklists for monochorionic/diamniotic twins and monochorionic/monoamniotic twins. The Society presents updated versions of these 2 checklists reflecting recent changes in practice recommendations. Suggestions for implementing the use of the checklists into antenatal care practices are also included.
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9
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Expectant Management of Monochorionic-Triamniotic Triplets Complicated by Selective In Utero Growth Restriction: Report of 2 Cases. Case Rep Obstet Gynecol 2020; 2020:2979261. [PMID: 33062355 PMCID: PMC7548933 DOI: 10.1155/2020/2979261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 09/24/2020] [Accepted: 09/28/2020] [Indexed: 11/18/2022] Open
Abstract
The optimal management of monochorionic-triamniotic (MCTA) triplet pregnancies is not clearly established, and there is no literature to guide management of MCTA complicated with selective intrauterine growth restriction (sIUGR). This gap in knowledge and the concern for higher risk of severe complications have led some medical societies to recommend selective termination of nontrichorionic triplet pregnancies. We sought to report the favourable outcomes of two MCTA complicated by sIUGR expectantly managed at Sainte-Justine Hospital, Montreal, Canada. The first case is of a 42-year-old woman with spontaneous MCTA triplets diagnosed at 18 weeks with type II sIUGR who opted for expectant management. The second patient was a 22-year-old woman with a spontaneous MCTA triplet pregnancy diagnosed at 18 weeks with type III sIUGR. Our experience shows that close serial ultrasounds could potentially allow physicians to foresee fetal deterioration. In our opinion, expectant management should be considered as a management option for MCTA complicated by sIUGR.
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Jha P, Morgan TA, Kennedy A. US Evaluation of Twin Pregnancies: Importance of Chorionicity and Amnionicity. Radiographics 2020; 39:2146-2166. [PMID: 31697621 DOI: 10.1148/rg.2019190042] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The twin birth rate is increasing in the United States. Twin pregnancies can be dichorionic or monochorionic (MC). MC twins account for 20% of twin pregnancies but 30% of all-cause pregnancy-related complications. This article describes the imaging findings that establish chorionicity and amnionicity. Ideally, these are established in the first trimester when accuracy is high, but they can also be determined later in pregnancy. Complications unique to MC twin pregnancy include twin-twin transfusion syndrome, twin anemia polycythemia sequence, twin reversed arterial perfusion sequence, and selective fetal growth restriction. The US features, staging systems, and management of these complications are reviewed, and the consequences of MC twin demise are illustrated. Ongoing surveillance for these conditions starts at 16 weeks gestation. Monoamniotic (MA) twins are a small subset of MC twins. In addition to all of the MC complications, specific MA complications include cord entanglement and conjoined twinning. Radiologists must be able to determine chorionicity and amnionicity and should be aware of potential complications so that patients may be referred to appropriate regional specialized centers. A proposed algorithm for referral to specialized fetal treatment centers is outlined. Online supplemental material is available for this article. ©RSNA, 2019.
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Affiliation(s)
- Priyanka Jha
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., T.A.M.); and Department of Radiology and Imaging Sciences, University of Utah Medical Center, Salt Lake City, Utah (A.K.)
| | - Tara A Morgan
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., T.A.M.); and Department of Radiology and Imaging Sciences, University of Utah Medical Center, Salt Lake City, Utah (A.K.)
| | - Anne Kennedy
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., T.A.M.); and Department of Radiology and Imaging Sciences, University of Utah Medical Center, Salt Lake City, Utah (A.K.)
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11
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Delivery timing after laser surgery for twin-twin transfusion syndrome. J Perinatol 2020; 40:248-255. [PMID: 31611614 DOI: 10.1038/s41372-019-0532-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 08/12/2019] [Accepted: 08/19/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To compare outcomes of twin-twin transfusion syndrome (TTTS) patients who underwent early elective delivery vs. expectant management. STUDY DESIGN Retrospective study of monochorionic diamniotic twins who underwent laser surgery for TTTS and had dual survivors at 32 weeks. Patients who underwent elective delivery between 32 0/7 to 35 6/7 weeks ("early elective group") were compared with all patients who delivered ≥36 0/7 weeks ("expectant management group"). The primary outcome was a composite of fetal and neonatal morbidity. RESULTS The final study population was comprised of 15 early elective and 119 expectant management patients. Those in the early elective group were seven times more likely to experience the primary outcome (OR 7.38 [2.01-27.13], p = 0.0026). CONCLUSION Among patients who underwent laser surgery for TTTS who had dual survivors at 32 weeks, elective delivery prior to 36 weeks did not appear to be protective.
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12
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North American Fetal Therapy Network: Timing of and indications for delivery following laser ablation for twin-twin transfusion syndrome. Am J Obstet Gynecol MFM 2019; 1:74-81. [PMID: 32832884 DOI: 10.1016/j.ajogmf.2019.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background Despite improvements in fetal survival for pregnancies affected by twin-twin transfusion syndrome since the introduction of laser photocoagulation, prematurity remains a major source of neonatal morbidity and mortality. Objective To investigate the indications and factors influencing the timing of delivery following laser treatment, we collected delivery information regarding twin-twin transfusion syndrome cases in a large multicenter cohort. Study Design Eleven North American Fetal Therapy Network (NAFTNet) centers conducted a retrospective review of twin-twin transfusion syndrome patients who underwent laser photocoagulation. Clinical, demographic and ultrasound variables including twin-twin transfusion syndrome stage, and gestational age at treatment and delivery were recorded. Primary and secondary maternal and fetal indications for delivery were identified. Univariate analysis was used to select candidate variables with significant correlation with latency and GA at delivery. Multivariable Cox regression with competing risk analysis was utilized to determine the independent associations. Results A total of 847 pregnancies were analyzed. After laser, the average latency to delivery was 10.11 ± 4.8 weeks and the mean gestational age at delivery was 30.7 ± 4.5 weeks. Primary maternal indications for delivery comprised 79% of cases. The leading indications included spontaneous labor (46.8%), premature rupture of membranes (17.1%), and placental abruption (8.4%). Primary fetal indications accounted for 21% of cases and the most frequent indications included donor non-reassuring status (20.5%), abnormal donor Dopplers (15.1%), and donor growth restriction (14.5%). The most common secondary indications for delivery were premature rupture of membranes, spontaneous labor and donor growth restriction. Multivariate modeling found gestational age at diagnosis, stage, history of prior amnioreduction, cerclage, interwin membrane disruption, procedure complications and chorioamniotic membrane separation as predictors for both gestational age at delivery and latency. Conclusion Premature delivery after laser therapy for twin-twin transfusion syndrome is primarily due to spontaneous labor, preterm premature rupture of membranes and non-reassuring status of the donor fetus. Placental abruption was found to be a frequent complication resulting in early delivery. Future research should be directed toward the goal of prolonging gestation after laser photocoagulation to further reduce morbidity and mortality associated with twin-twin transfusion syndrome.
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13
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Sadda P, Imamoglu M, Dombrowski M, Papademetris X, Bahtiyar MO, Onofrey J. Deep-learned placental vessel segmentation for intraoperative video enhancement in fetoscopic surgery. Int J Comput Assist Radiol Surg 2018; 14:227-235. [PMID: 30484115 DOI: 10.1007/s11548-018-1886-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 11/06/2018] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Twin-to-twin transfusion syndrome (TTTS) is a potentially lethal condition that affects pregnancies in which twins share a single placenta. The definitive treatment for TTTS is fetoscopic laser photocoagulation, a procedure in which placental blood vessels are selectively cauterized. Challenges in this procedure include difficulty in quickly identifying placental blood vessels due to the many artifacts in the endoscopic video that the surgeon uses for navigation. We propose using deep-learned segmentations of blood vessels to create masks that can be recombined with the original fetoscopic video frame in such a way that the location of placental blood vessels is discernable at a glance. METHODS In a process approved by an institutional review board, intraoperative videos were acquired from ten fetoscopic laser photocoagulation surgeries performed at Yale New Haven Hospital. A total of 345 video frames were selected from these videos at regularly spaced time intervals. The video frames were segmented once by an expert human rater (a clinician) and once by a novice, but trained human rater (an undergraduate student). The segmentations were used to train a fully convolutional neural network of 25 layers. RESULTS The neural network was able to produce segmentations with a high similarity to ground truth segmentations produced by an expert human rater (sensitivity = 92.15% ± 10.69%) and produced segmentations that were significantly more accurate than those produced by a novice human rater (sensitivity = 56.87% ± 21.64%; p < 0.01). CONCLUSION A convolutional neural network can be trained to segment placental blood vessels with near-human accuracy and can exceed the accuracy of novice human raters. Recombining these segmentations with the original fetoscopic video frames can produced enhanced frames in which blood vessels are easily detectable. This has significant implications for aiding fetoscopic surgeons-especially trainees who are not yet at an expert level.
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Affiliation(s)
| | - Metehan Imamoglu
- Yale University School of Medicine, New Haven, USA.,Department of Obstetrics and Gynecology, Yale University School of Medicine, New Haven, USA.,Yale Fetal Care Center, New Haven, USA
| | - Michael Dombrowski
- Yale University School of Medicine, New Haven, USA.,Department of Obstetrics and Gynecology, Yale University School of Medicine, New Haven, USA.,Yale Fetal Care Center, New Haven, USA
| | - Xenophon Papademetris
- Yale University School of Medicine, New Haven, USA.,Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, USA.,Department of Biomedical Engineering, Yale University School of Medicine, New Haven, USA
| | - Mert O Bahtiyar
- Yale University School of Medicine, New Haven, USA.,Department of Obstetrics and Gynecology, Yale University School of Medicine, New Haven, USA.,Yale Fetal Care Center, New Haven, USA
| | - John Onofrey
- Yale University School of Medicine, New Haven, USA.,Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, USA
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14
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Sadda P, Onofrey J, Imamoglu M, Papademetris X, Qarni B, Bahtiyar MO. Real-time computerized video enhancement for minimally invasive fetoscopic surgery. ACTA ACUST UNITED AC 2018; 1:27-32. [PMID: 31080936 DOI: 10.1016/j.lers.2018.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background The only definitive treatment for twin-to-twin transfusion syndrome is minimally invasive fetoscopic surgery for the selective coagulation of placental blood vessels. Fetoscopic surgery is a technically challenging operation, mainly due to the poor visibility conditions in the uterine environment. We present the design of an algorithm for the computerized enhancement of fetoscopic video and show that the enhanced video increases the ability of human users to identify blood vessels within fetoscopic video rapidly and accurately. Methods A computer algorithm for the enhancement of fetoscopic video frames was created. First, optical fiber artifacts were removed via a modification of unsharp masking. Second, image contrast was increased via Contrast Limited Adaptive Histogram Equalization (CLAHE). Third, the effect of contrast enhancements on stationary features was removed by normalizing to a windowed mean of the video frames. Fourth, color information was reincorporated by combining the mean-normalized result with the unnormalized contrast enhanced image using the soft light blending algorithm. Medical trainees (n = 16) were recruited into a study to validate the algorithm. Subjects were shown enhanced or unenhanced fetoscopic video frames on a screen and were asked to identify whether a randomly placed marker fell on a blood vessel or on background. The accuracy of their responses was recorded. Results On the subset of images where subjects had the lowest mean accuracy in identifying the placement of the marker, subjects performed better when viewing video frames enhanced by the computer (accuracy 74.27%; SE 0.97) than when viewing unenhanced video frames (accuracy 63.78%; SE 2.79). This result was statistically significant (p < 0.01). Conclusion Real-time computerized enhancement of fetoscopic video has the potential to ease the readability of video in poor lighting conditions, thus providing a benefit to the surgeon intraoperatively.
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Affiliation(s)
- Praneeth Sadda
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
| | - John Onofrey
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA.,Department of Biomedical Engineering, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
| | - Metehan Imamoglu
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA.,Department of Obstetrics and Gynecology, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA.,Yale Fetal Care Center, Yale-New Haven Hospital, 1 Long Wharf Drive, New Haven, CT 06510, USA
| | - Xenophon Papademetris
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA.,Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA.,Department of Biomedical Engineering, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
| | - Bilal Qarni
- University of Western Ontario, 1151 Richmond Street, London, ON N6A 3K7, Canada
| | - Mert Ozan Bahtiyar
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA.,Department of Obstetrics and Gynecology, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA.,Yale Fetal Care Center, Yale-New Haven Hospital, 1 Long Wharf Drive, New Haven, CT 06510, USA
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15
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Glanc P, Nyberg DA, Khati NJ, Deshmukh SP, Dudiak KM, Henrichsen TL, Poder L, Shipp TD, Simpson L, Weber TM, Zelop CM. ACR Appropriateness Criteria ® Multiple Gestations. J Am Coll Radiol 2018; 14:S476-S489. [PMID: 29101986 DOI: 10.1016/j.jacr.2017.08.051] [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: 08/22/2017] [Accepted: 08/23/2017] [Indexed: 12/28/2022]
Abstract
Women with twin or higher-order pregnancies will typically have more ultrasound examinations than women with a singleton pregnancy. Most women will have at minimum a first trimester scan, a nuchal translucency evaluation scan, fetal anatomy scan at 18 to 22 weeks, and one or more scans in the third trimester to evaluate growth. Multiple gestations are at higher risk for preterm delivery, congenital anomalies, fetal growth restriction, placenta previa, vasa previa, and velamentous cord insertion. Chorionicity and amnionicity should be determined as early as possible when a twin pregnancy is identified to permit triage of the monochorionic group into a closer surveillance model. Screening for congenital heart disease is warranted in monochorionic twins because they have an increased rate of congenital cardiac anomalies. In addition, monochorionic twins have a higher risk of developing cardiac abnormalities in later gestation related to right ventricular outflow obstruction, in particular the subgroups with twin-twin transfusion syndrome or selective intrauterine growth restriction. Monochorionic twins have unique complications including twin-to-twin transfusion syndrome, twin embolization syndrome, and acardius, or twin-reversed arterial perfusion sequence. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Phyllis Glanc
- Principal Author and Specialty Chair, Sunnybrook Health Sciences Centre, Bayview Campus, Toronto, Ontario, Canada.
| | - David A Nyberg
- Co-Author, The Old Vicarage, Worcester Park, United Kingdom
| | - Nadia J Khati
- Panel Chair, George Washington University Hospital, Washington, District of Columbia
| | | | | | | | - Liina Poder
- University of California San Francisco, San Francisco, California
| | - Thomas D Shipp
- Brigham & Women's Hospital, Boston, Massachusetts; American College of Obstetrics and Gynecology
| | - Lynn Simpson
- Columbia University Medical Center, New York, New York; American College of Obstetrics and Gynecology
| | | | - Carolyn M Zelop
- Valley Hospital, Ridgewood, New Jersey and NYU School of Medicine, New York, New York; American College of Obstetrics and Gynecology
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Smith J, Treadwell MC, Berman DR. Role of ultrasonography in the management of twin gestation. Int J Gynaecol Obstet 2018. [PMID: 29536536 DOI: 10.1002/ijgo.12483] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Twins represent 1%-2% of all pregnancies, yet continue to account for a disproportionate share of neonatal adverse events including neonatal intensive care admission, morbidity, and mortality. Ultrasonography is central to the proper diagnosis of the type of twinning. Ideally, ultrasonography is performed before 14 weeks of gestation to determine chorionicity and amnionicity. Correct identification of the chorionicity in a twin pregnancy facilitates proper counseling and management of the gestation, including ultrasonography follow-up. Herein, the different types of twinning are reviewed, together with the implications for ultrasonography monitoring of each specific type of twin gestation.
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Affiliation(s)
- Jessica Smith
- Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Marjorie C Treadwell
- Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Deborah R Berman
- Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, MI, USA
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Bahtiyar M, Ekmekci E, Demirel E, Irani R, Copel J. In utero Partial Exchange Transfusion Combined with in utero Blood Transfusion for Prenatal Management of Twin Anemia-Polycythemia Sequence. Fetal Diagn Ther 2018. [DOI: 10.1159/000486198] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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18
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Chon AH, Korst LM, Assaf RD, Llanes A, Ouzounian JG, Chmait RH. Midtrimester isolated oligohydramnios in monochorionic diamniotic multiple gestations . J Matern Fetal Neonatal Med 2017; 32:590-596. [PMID: 28965437 DOI: 10.1080/14767058.2017.1387530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To describe the natural history and perinatal outcomes of monochorionic diamniotic twins with midtrimester isolated oligohydramnios (iOligo). MATERIALS AND METHODS We performed a retrospective study of iOligo patients who were initially referred for the management of evolving twin-twin transfusion syndrome (TTTS) or selective intrauterine growth restriction (sIUGR). iOligo was defined as a maximum vertical pocket of amniotic fluid of ≤2 cm in the iOligo twin's sac and normal fluid level (>2 and <8 cm) in the co-twin's sac. "Group A" patients did not subsequently develop TTTS or sIUGR Type II (umbilical artery persistent absent or reversed end-diastolic flow), and "Group B" patients did develop TTTS or sIUGR Type II. Results are reported as median (range). RESULTS Of the 828 patients with complicated monochorionic twin gestations referred for possible TTTS or sIUGR, 36 (4.3%) were initially diagnosed with iOligo. After initial consultation, two patients terminated and one was lost to follow-up, resulting in a final study population of 33. Group A had 10 patients (30.3%) and Group B had 23 patients (69.7%). In Group A, nine of the 10 were expectantly managed, resulting in a median gestational age (GA) at delivery of 34.7 (18.0-36.4) weeks, a 30-day perinatal survival of at-least-one twin of 88.9% (8/9), and dual 30-day survivors in 8/9 (88.9%). In Group B, 12 (52.2%) developed TTTS and 11 (47.8%) developed sIUGR Type II. Fifteen Group B patients had laser surgery, resulting in a median GA at delivery of 33.7 (26.4-37.1) weeks, a 30-day perinatal survival of at-least-one twin of 100% (15/15), and dual survivorship of 46.7% (7/15). CONCLUSIONS Our findings show that the majority of patients with midtrimester iOligo have fetal growth restriction of the affected twin and subsequently progress to TTTS or sIUGR Type II.
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Affiliation(s)
- Andrew H Chon
- a Department of Obstetrics and Gynecology , University of Southern California, Keck School of Medicine, Division of Maternal Fetal Medicine , Los Angeles , CA , USA
| | - Lisa M Korst
- b Childbirth Research Associates, LLC , Los Angeles , CA , USA
| | - Ryan D Assaf
- a Department of Obstetrics and Gynecology , University of Southern California, Keck School of Medicine, Division of Maternal Fetal Medicine , Los Angeles , CA , USA
| | - Arlyn Llanes
- a Department of Obstetrics and Gynecology , University of Southern California, Keck School of Medicine, Division of Maternal Fetal Medicine , Los Angeles , CA , USA
| | - Joseph G Ouzounian
- a Department of Obstetrics and Gynecology , University of Southern California, Keck School of Medicine, Division of Maternal Fetal Medicine , Los Angeles , CA , USA
| | - Ramen H Chmait
- a Department of Obstetrics and Gynecology , University of Southern California, Keck School of Medicine, Division of Maternal Fetal Medicine , Los Angeles , CA , USA
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Emery SP, Hasley SK, Catov JM, Miller RS, Moon-Grady AJ, Baschat AA, Johnson A, Lim FY, Gagnon AL, O'Shaughnessy RW, Ozcan T, Luks FI. North American Fetal Therapy Network: intervention vs expectant management for stage I twin-twin transfusion syndrome. Am J Obstet Gynecol 2016; 215:346.e1-7. [PMID: 27131587 DOI: 10.1016/j.ajog.2016.04.024] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Revised: 04/04/2016] [Accepted: 04/19/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Stage I twin-twin transfusion syndrome presents a management dilemma. Intervention may lead to procedure-related complications while expectant management risks deterioration. Insufficient data exist to inform decision-making. OBJECTIVE The aim of this retrospective observational study was to describe the natural history of stage I twin-twin transfusion syndrome, to assess for predictors of disease behavior, and to compare pregnancy outcomes after intervention at stage I vs expectant management. STUDY DESIGN Ten North American Fetal Therapy Network centers submitted well-documented cases of stage I twin-twin transfusion syndrome for analysis. Cases were retrospectively divided into 3 management strategies: those managed expectantly, those who underwent amnioreduction at stage I, and those who underwent laser therapy at stage I. Outcomes were categorized as no survivors, 1 survivor, 2 survivors, or at least 1 survivor to live birth, and good (twin live birth ≥30.0 weeks), mixed (single fetal demise or delivery between 26.0-29.9 weeks), and poor (double fetal demise or delivery <26.0 weeks) pregnancy outcomes. Outcomes were analyzed by initial management strategy. RESULTS A total of 124 cases of stage I twin-twin transfusion syndrome were studied. In all, 49 (40%) cases were managed expectantly while 30 (24%) underwent amnioreduction and 45 (36%) underwent laser therapy at stage I. The overall fetal mortality rate was 20.2% (50 of 248 fetuses). Of those managed expectantly, 11 patients regressed (22%), 4 remained stage I (8%), 29 advanced in stage (60%), and 5 experienced spontaneous previable preterm birth (10%) during observation. The mean number of days from diagnosis of stage I to a change in status (progression, regression, loss, or delivery) was 11.1 (SD 14.3) days. Intervention by amniocentesis or laser therapy was associated with a lower risk of fetal loss (P = .01) than expectant management. The unadjusted odds of poor outcome were 0.33 (95% confidence interval, 0.09-01.20), for amnioreduction and 0.26 (95% confidence interval, 0.09-0.77) for laser therapy vs expectant management. Adjusting for nulliparity, recipient maximum vertical pocket, gestational age at diagnosis, and placenta location had negligible effect. Both amnioreduction and laser therapy at stage I decreased the likelihood of no survivors (odds ratio, 0.11; 95% confidence interval, 0.02-0.68 and odds ratio, 0.07; 95% confidence interval, 0.01-0.37, respectively). Only laser therapy, however, was protective against poor outcome in our data (odds ratio, 0.29; 95% confidence interval, 0.07-1.30 for amnioreduction vs odds ratio, 0.12, 95% confidence interval, 0.03-0.44 for laser), although the estimate for amnioreduction suggests a protective effect. CONCLUSION Stage I twin-twin transfusion syndrome was associated with substantial fetal mortality. Spontaneous resolution was observed, although the majority of expectantly managed cases progressed. Progression was associated with a worse prognosis. Both amnioreduction and laser therapy decreased the chance of no survivors, and laser was particularly protective against poor outcome independent of multiple factors. Further studies are justified to corroborate these findings and to further define risk stratification and surveillance strategies for stage I disease.
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Affiliation(s)
- Stephen P Emery
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA.
| | - Steve K Hasley
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Janet M Catov
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Russell S Miller
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY
| | - Anita J Moon-Grady
- Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Ahmet A Baschat
- Department of Obstetrics and Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD
| | - Anthony Johnson
- Department of Obstetrics and Gynecology, University of Texas Health Science Center, Houston, TX
| | | | - Alain L Gagnon
- Division of Maternal-Fetal Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Richard W O'Shaughnessy
- Department of Obstetrics and Gynecology, Wexner Medical Center at the Ohio State University, Columbus, OH
| | - Tulin Ozcan
- Department of Obstetrics and Gynecology, University of Rochester, Rochester, NY
| | - Francois I Luks
- Division of Pediatric Surgery, Alpert Medical School of Brown University, Providence, RI
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Michelfelder E, Allen C, Urbinelli L. Evaluation and Management of Fetal Cardiac Function and Heart Failure. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2016; 18:55. [DOI: 10.1007/s11936-016-0477-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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22
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The North American Fetal Therapy Network Consensus Statement: Management of Complicated Monochorionic Gestations. Obstet Gynecol 2015; 126:575-584. [PMID: 26244534 DOI: 10.1097/aog.0000000000000994] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The North American Fetal Therapy Network is a consortium of 30 medical institutions in the United States and Canada with established expertise in fetal therapy and other forms of multidisciplinary care for complex fetal disorders. This publication is the third in a series of articles written by NAFTNet about monochorionic pregnancies. In this article, we provide the general obstetric practitioner with information regarding management options available for complications of monochorionic gestations. This information may be useful for a better understanding of the pathophysiology of the various conditions, for better patient counseling, for timely referral to a regional treatment center, and for ongoing comanagement after treatment.
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The North American Fetal Therapy Network Consensus Statement: prenatal management of uncomplicated monochorionic gestations. Obstet Gynecol 2015; 125:1236-1243. [PMID: 25932853 DOI: 10.1097/aog.0000000000000723] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Owing to vascular connections within a single placenta, monochorionic gestations present distinctive prenatal management challenges. Complications that can arise as a result of unbalanced hemodynamic exchange (twin-twin transfusion syndrome and twin anemia polycythemia sequence) and unequal placental sharing (selective fetal growth restriction) should be kept in mind while prenatal management is being planned. Because of unique monochorionic angioarchitecture, what happens to one twin can directly affect the other. Death of one twin can result in death or permanent disability of the co-twin. Early detection of these unique disease processes through frequent ultrasonographic surveillance may allow the opportunity for earlier referral, intervention, or both and potentially better outcomes. Therefore, monochorionic gestations should be managed differently than dichorionic gestations or singletons. The purpose of this document is to present in detail methods for monitoring and management of uncomplicated monochorionic gestations and to review the evidence for the roles of these methods for detection of complications in clinical practice. Finally, we present evidence-based and expert opinion-supported recommendations developed by the North American Fetal Therapy Network for the diagnosis, surveillance, and delivery of uncomplicated monochorionic gestations.
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