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Rahman RA, Mohammed Nawi A, Ishak S, Balaraman K, Abu MA, Abd Azman SH, Kalok AH, Mohamed Ismail NA, Mahdy ZA, Ahmad S. Second twin outcome at birth: retrospective analysis in a single tertiary centre in Malaysia. J Perinat Med 2024; 52:385-391. [PMID: 38511669 DOI: 10.1515/jpm-2023-0449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 01/15/2024] [Indexed: 03/22/2024]
Abstract
OBJECTIVES To investigate factors associated with outcome of second twin during labour. METHODS The study was a retrospective cohort study in a single tertiary centre in Malaysia from 2014 until 2018 involving all twin pregnancies delivered at or more than 24 weeks of gestation. RESULTS Total of 409 twin pregnancies were included. Dichorionic twin comprises of 54.5 % (n=223) and 45.5 % (n=186) are monochorionic. Women with dichorionic pregnancies are significantly older (p<0.001), have more pre-existing medical disorders (p=0.011) and fetal structural anomalies (p=0.009). Monochorionic pregnancies are significantly more amongst Malay (p=0.01) and conceived spontaneously (p<0.001). There are significantly more fetuses both in cephalic presentation (p=0.026), birthweight discrepancy more than 20 % (p=0.038) and shorter mean inter-twin delivery duration (p=0.048) in monochorionic pregnancies. Second twin delivered with Apgar score <7 is significantly more in dichorionic pregnancies (p=0.006). The second twin is associated with lower birthweight, small for gestational age and arterial cord pH<7.25. Within the group of women who delivered both fetuses vaginally, there was significantly more second twins with intertwin delivery duration less than 30 min who were delivered vaginally without instrumentation (p=0.018). There was significantly more second twin with intertwin delivery duration of 30 min and more with arterial cord pH<7.25 (p=0.045). Those who delivered spontaneously had inter-twin delivery duration within 15-29 min. The outcome of second twin is not influenced by type of twin, gestational age at delivery, inter-twin delivery duration, mode of delivery and presentation at birth. CONCLUSIONS The neonatal outcome for the second twin at birth is not influenced by type of twin, gestational age at delivery, inter-twin delivery duration, mode of delivery and presentation at birth in a cohort managed with non-active management of the second twin in Malaysia.
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Affiliation(s)
- Rahana Abd Rahman
- Department of Obstetrics & Gynaecology, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
- Hospital Canselor Tuanku Muhriz, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
| | - Azmawati Mohammed Nawi
- Hospital Canselor Tuanku Muhriz, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
- Department of Community Health, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
| | - Shareena Ishak
- Hospital Canselor Tuanku Muhriz, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
- Department of Paediatrics, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
| | - Kartik Balaraman
- Department of Obstetrics & Gynaecology, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
- Hospital Canselor Tuanku Muhriz, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
| | - Mohamad Azrai Abu
- Department of Obstetrics & Gynaecology, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
- Hospital Canselor Tuanku Muhriz, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
| | - Siti Hajar Abd Azman
- Department of Obstetrics & Gynaecology, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
- Hospital Canselor Tuanku Muhriz, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
| | - Aida Hani Kalok
- Department of Obstetrics & Gynaecology, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
- Hospital Canselor Tuanku Muhriz, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
| | - Nor Azlin Mohamed Ismail
- Department of Obstetrics & Gynaecology, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
- Hospital Canselor Tuanku Muhriz, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
| | - Zaleha Abdullah Mahdy
- Department of Obstetrics & Gynaecology, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
- Hospital Canselor Tuanku Muhriz, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
| | - Shuhaila Ahmad
- Department of Obstetrics & Gynaecology, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
- Hospital Canselor Tuanku Muhriz, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
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Moradi B, Badraqe N, Rahimi Sharbaf F, Firouznia K, Shirazi M, Kazemi MA, Rahimi R. Early detection of ischemic brain injuries by diffusion-weighted imaging after radiofrequency ablation for fetal reduction in monochorionic pregnancies. JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:1288-1296. [PMID: 35635295 DOI: 10.1002/jcu.23237] [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: 11/27/2021] [Revised: 03/22/2022] [Accepted: 03/26/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND This study aimed to investigate the additional advantages of magnetic resonance imaging (MRI), particularly diffusion-weighted imaging (DWI) over fetal ultrasound in the detection of acute ischemic cerebral injuries in complicated monochorionic (MC) pregnancies that underwent selective reduction by radiofrequency ablation (RFA). METHODS This prospective cohort study was conducted on 40 women with complicated MC pregnancies who were treated by RFA. Fetal brain imaging by DWI and conventional MRI was performed either in the early (within 10 days after RFA) or late phase (after 3-6 weeks) in the surviving fetuses to detect both acute and chronic ischemic injuries. The presence of anemia after RFA was also evaluated by Doppler ultrasound. RESULTS Overall, 13 of the total 43 fetuses (30.23%) demonstrated MRI abnormalities with normal brain ultrasound results including germinal matrix hemorrhage (GMH), extensive cerebral ischemia, and mild ventriculomegaly. Although seven fetuses with GMH eventually survived, fetuses that demonstrated ischemic lesions and ventriculomegaly on MRI died in the uterus. CONCLUSION The absence of abnormal cerebral lesions or anemia on ultrasound and Doppler exams does not necessarily rule out fetal brain ischemia. Performing early MRI, particularly DWI seems to be a reasonable option for detection of early intracranial ischemic changes and better management of complicated multiple pregnancies which were treated by RFA.
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Affiliation(s)
- Behnaz Moradi
- Department of Radiology, Yas Complex Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Department of radiology, Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Medical Imaging Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Narges Badraqe
- Department of radiology, Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Medical Imaging Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Rahimi Sharbaf
- Maternal, Fetal and Neonatal Research Center, Yas Complex Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Kavous Firouznia
- Department of radiology, Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Medical Imaging Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahboobeh Shirazi
- Maternal, Fetal and Neonatal Research Center, Yas Complex Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Ali Kazemi
- Department of radiology, Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Medical Imaging Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
- Department of Radiology, Amiralam Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Rahil Rahimi
- Department of radiology, Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Medical Imaging Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
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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: 1] [Impact Index Per Article: 0.5] [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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Anh ND, Hung HS, Sim NT, Ha NTT, Nguyen DL, Bac ND, Tong HV, Ville Y, Thuong PTH. Fetoscopic Laser Ablation for the Selective Fetal Reduction in Twin-Twin Transfusion Syndrome Stage II-IV: The Experience of a New Fetal Medicine Center. Int J Womens Health 2022; 14:555-563. [PMID: 35444472 PMCID: PMC9015043 DOI: 10.2147/ijwh.s350433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 03/18/2022] [Indexed: 11/23/2022] Open
Abstract
Objective To evaluate the surgery outcomes of fetoscopic laser ablation (FLA) for selective umbilical cord in treating twin-twin transfusion syndrome (TTTS) with special conditions and neonatal outcomes post-operation. Methods A prospective study, 21 monochorionic diamniotic (MCDA) twins diagnosed with TTTS stage II–IV according to Quintero classification from 16 to 26 weeks of gestation, among that, 12 cases of TTTS stage II with selective intrauterine growth restriction (sIUGR), 6 cases of TTTS stage II with proximate cord insertions, 3 cases of TTTS stage IV underwent fetoscopic laser ablation for the selective fetal reduction at Hanoi Obstetrics and Gynecology Hospital from September 2019 to July 2021. Complications and surgical outcomes were noted. Prenatal care was carried out every 2 weeks post operation until birth. Newborn neurologic complications were assessed at birth, three months, and six months after birth using Denver II test and magnetic resonance imaging (MRI). Results The mean gestational age at operation was 20.30 weeks. The average operation duration was 39.52 minutes. No complications of operation, such as bleeding or infection, were recorded. The mean gestational age at birth was 34.70 ± 4.33 weeks, with a mean duration of 12.97 ± 6.87 weeks between intervention and delivery. The survival rate of newborns after the operation was 90.48%. There were two stillbirths (9.52%) within seven days after the operation. No short-term neurological complications have been reported with follow-up of the newborn to 6 months after birth. Conclusion Our study showed that fetoscopic laser ablation of selected fetal reduction surgery for treatment of special conditions of TTTS had no complications of operation, high neonatal survival result (90.48%), no short-term neurological complications. This should be considered for TTTS in cases of indication.
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Affiliation(s)
- Nguyen Duy Anh
- Fetal Medicine Centre, Hanoi Obstetrics and Gynecology Hospital, Hanoi, Vietnam.,Hanoi Medical University, Hanoi, Vietnam
| | - Ho Sy Hung
- Hanoi Medical University, Hanoi, Vietnam
| | - Nguyen Thi Sim
- Fetal Medicine Centre, Hanoi Obstetrics and Gynecology Hospital, Hanoi, Vietnam
| | - Nguyen Thi Thu Ha
- Department of Assisted Reproductive and Andrology, Hanoi Obstetrics and Gynecology Hospital, Hanoi, Vietnam
| | | | - Nguyen Duy Bac
- Department of Education and Training, Vietnam Military Medical University, Hanoi, Vietnam
| | - Hoang Van Tong
- Biomedical and Pharmaceutical Applied Research Center, Vietnam Military Medical University, Hanoi, Vietnam
| | - Yves Ville
- Department of Obstetrics and Fetal Medicine at Necker-Enfants-Malades Hospital at the Paris Descartes University, Paris, France
| | - Phan Thi Huyen Thuong
- Hanoi Medical University, Hanoi, Vietnam.,Department of Delivery, Hanoi Obstetrics and Gynecology Hospital, Hanoi, Vietnam
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Brock CO, Johnson A. Twin reverse arterial perfusion: Timing of intervention. Best Pract Res Clin Obstet Gynaecol 2022; 84:127-142. [PMID: 35466064 DOI: 10.1016/j.bpobgyn.2022.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/13/2022] [Indexed: 11/24/2022]
Abstract
Twin reverse arterial perfusion (TRAP) sequence is a severe anomaly in monochorionic twins where one twin has profound corporeal underdevelopment and acardia. The normal "pump" co-twin provides blood flow to the acardiac twin through placental anastomoses which may lead to cardiac failure and pump twin demise as well as preterm delivery from severe polyhydramnios. Treatments include radiofrequency ablation, bipolar cord coagulation, and intrafetal laser with each aimed at occluding blood flow to the acardiac twin. However, none of these modalities has proven superior in terms of either pump twin survival or minimization of complications, including preterm premature rupture of membranes, preterm birth, or unexpected co-twin demise. The optimal timing of treatment is also unknown, without clear indications for intervention versus expectant management. Very early treatment of TRAP (i.e., <16 weeks) has been proposed to reduce first-trimester demise; however, this approach remains experimental. Further investigation is required to determine the best treatment and timing of intervention for TRAP.
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Affiliation(s)
- Clifton O Brock
- Department of Obstetrics, Gynecology and Reproductive Services, University of Texas Health Science Center at Houston, United States; The Fetal Center at Children's Memorial Hermann Hospital, United States
| | - Anthony Johnson
- Department of Obstetrics, Gynecology and Reproductive Services, University of Texas Health Science Center at Houston, United States; The Fetal Center at Children's Memorial Hermann Hospital, United States.
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Sam S, Tai-MacArthur S, Shangaris P, Sankaran S. Trends of Selective Fetal Reduction and Selective Termination in Multiple Pregnancy, in England and Wales: a Cross-Sectional Study. Reprod Sci 2021; 29:1020-1027. [PMID: 34902100 PMCID: PMC8863756 DOI: 10.1007/s43032-021-00819-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 12/01/2021] [Indexed: 12/01/2022]
Abstract
Selective abortion was shown to be increasingly common in England and Wales over a 9-year period, occurring most frequently as twin to singleton reductions in the 1st trimester. We analysed the trends in selective abortion (SA) in multiple pregnancies in England and Wales between 2009 and 2018. This is a cross-sectional study looking at 1143 women with multiple pregnancies in England and Wales undergoing SA. There were a total of 1143 cases of SA between 2009 and 2018 in England and Wales, representing 0.07% of total abortions. There has been a steady increase in cases, from 90 in 2009 to 131 in 2018, with 82.3% justified under ground E of The Abortion Act 1967. The majority of SAs were carried out at 13–19 weeks gestation, and intracardiac injection of potassium chloride was the most prevalent method (75%). Twin to singleton reductions accounted for 59%, the most common form of SAs. Over half of all cases (59%) were performed in women aged 30–39 years, and 84% of all women were of White ethnicity. SA has been an option available for couples diagnosed with multiple pregnancy, especially when there are discordant anomalies. Although SA may decrease multiple pregnancy-related complications, preventative methods must be championed.
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Affiliation(s)
- Sreya Sam
- GKT School of Biomedical Sciences, Kings College London, Guy's Campus, Great Maze Pond, London, SE1 1UL, UK
| | - Sarah Tai-MacArthur
- School of Bioscience Education, Kings College London, Guy's Campus, Great Maze Pond, London, SE1 1UL, UK
| | - Panicos Shangaris
- Department of Women and Children's Health, School of Life Course & Population Sciences, Faculty of Life Sciences and Medicine, Kings College London, London, 10th Floor North Wing St Thomas' Hospital, London, SE1 7EH, UK. .,Department of Women and Children, Guy's and St Thomas' NHS Foundation Trust, London, SE1 7EH, UK.
| | - Srividhya Sankaran
- Department of Women and Children, Guy's and St Thomas' NHS Foundation Trust, London, SE1 7EH, UK
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Wu T, Chen Z, Yin X, Shi H, Niu J, Xie J, Wei Y, Wang X. Perinatal outcomes after selective feticide via umbilical cord occlusion in complicated monochorionic pregnancies: A systematic review and meta-analysis. Prenat Diagn 2021; 42:37-48. [PMID: 34699084 DOI: 10.1002/pd.6064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 07/14/2021] [Accepted: 10/19/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE We aimed to compare perinatal outcomes between umbilical cord occlusion techniques in monochorionic pregnancies, including umbilical cord ligation, fetoscopic laser coagulation, interstitial laser coagulation, bipolar cord occlusion, radiofrequency ablation, and microwave ablation. METHODS This study was registered with PROSPERO (CRD42020158861). PubMed, Web of Science, Cochrane Library, and Embase were searched for studies published up to May 2020. The DerSimonian-Laird random-effects model was used for the meta-analysis. Subgroup analyses were performed to compare the outcomes among the six techniques. Meta-regression was used to adjust for confounders. RESULTS Thirty-four studies with 1646 participants were included. The overall survival was 76.5% after umbilical cord ligation, 78.8% after fetoscopic laser coagulation, 60.3% after interstitial laser coagulation, 79.2% after bipolar cord occlusion, 77.5% after radiofrequency ablation, and 75.0% after microwave ablation. Subgroup comparison showed the rates of overall survival and preterm premature rupture of membranes were not significant different among six techniques. However, rates of fetal loss, premature birth, live birth, and neonatal death differed significantly among the six groups. CONCLUSIONS The choice of umbilical cord occlusion techniques will affect perinatal outcomes. We suggested that the choice of umbilical cord occlusion techniques should fully consider these differences among techniques.
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Affiliation(s)
- Tianchen Wu
- Department of Maternal and Child Health, School of Public Health, Peking University, Beijing, China
| | - Ziyi Chen
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Xiaohan Yin
- Department of Maternal and Child Health, School of Public Health, Peking University, Beijing, China
| | - Huifeng Shi
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Jieqiong Niu
- Department of Maternal and Child Health, School of Public Health, Peking University, Beijing, China
| | - Jialei Xie
- 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
| | - Xiaoli Wang
- Department of Maternal and Child Health, School of Public Health, Peking University, Beijing, China.,Key Laboratory of Reproductive Health, National Health Commission, Beijing, China
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Dadhwal V, Sharma KA, Rana A, Sharma A, Singh L. Perinatal outcome in monochorionic twin pregnancies after selective fetal reduction using radiofrequency ablation. Int J Gynaecol Obstet 2021; 157:340-346. [PMID: 34118068 DOI: 10.1002/ijgo.13785] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 05/23/2021] [Accepted: 06/11/2021] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To study the perinatal outcomes in women with complicated monochorionic twin pregnancies undergoing selective fetal reduction using radiofrequency ablation (RFA). METHODS This retrospective study included 44 patients with monochorionic twin pregnancies, between 14 and 28 weeks of pregnancy, who underwent RFA for selective fetal reduction. Perinatal and maternal outcomes and procedure-related complications were analyzed. RESULTS The procedure was technically successful in all 44 cases. Indications for selective fetal reduction included twin-to-twin transfusion syndrome (52.3%), twin reversed arterial perfusion (20.5%), twins discordant for anomaly (15.9%), and selective fetal growth restriction (11.4%). Median gestational age at procedure was 222/7 weeks (range 14-266/7 ). Live birth rate was 77.3% with three neonatal deaths; so overall survival was 70.5%. Median procedure-to-delivery interval was 123/7 weeks (range 24/7 -23). There were eight losses before 24 weeks of pregnancy, which included two co-twin deaths. Median gestational age at delivery was 35 weeks (interquartile range 321/7 -37 weeks). The preterm delivery rate was 66.7% (24/36) and preterm prelabor rupture of membranes (PPROM) occurred in 22.7% (10/44) of patients. CONCLUSION Selective fetal reduction using RFA is safe and effective in complicated monochorionic pregnancies. However, the rates of PPROM and preterm delivery remain high.
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Affiliation(s)
- Vatsla Dadhwal
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, India
| | - K Aparna Sharma
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, India
| | - Anubhuti Rana
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, India
| | - Akash Sharma
- Division of Neonatology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Lakhwinder Singh
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, India
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Wang H, Zhou Q, Wang X, Song J, Chen P, Wang Y, Li L, Li H. Influence of indications on perinatal outcomes after radio frequency ablation in complicated monochorionic pregnancies: a retrospective cohort study. BMC Pregnancy Childbirth 2021; 21:41. [PMID: 33422050 PMCID: PMC7797138 DOI: 10.1186/s12884-020-03530-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 12/26/2020] [Indexed: 02/03/2023] Open
Abstract
Background Radiofrequency ablation (RFA) is recommended to prevent potential neurological injury or intrauterine foetal death (IUFD) of the co-twin(s) in complicated monochorionic (MC) pregnancies. However, the impacts of various indications on the pregnancy outcome following RFA remain unclear. This study aimed to determine how the indications influence the perinatal outcomes in complicated MC pregnancies undergoing radiofrequency ablation. Methods This was a retrospective cohort study performed in a single centre. All consecutive MC pregnancies treated with RFA between July 2011 and July 2019 were included. The adverse perinatal outcomes and the survival rate were analysed based on various indications. The continuous variables with and without normal distribution were compared between the groups using Student’s t-test and Mann–Whitney U test, respectively, and for categorical variables, Chi-square and Fisher’s exact tests were used. P < 0.05 indicated a significant difference. Results We performed 272 RFA procedures in 268 complicated MC pregnancies, including 60 selective intrauterine growth restriction (sIUGR), 64 twin–twin transfusion syndrome (TTTS), 12 twin reversed arterial perfusion sequence (TRAPs), 66 foetal anomaly and 66 elective foetal reduction (EFR) cases. The overall survival rate of the co-twin was 201/272 (73.9%). The overall technical successful rate was determined at 201/263 (76.7%). The IUFD rate in the co-twin was 20/272 (7.4%). The TTTS group had recorded the lowest survival rate (37/64, 57. 8%), and the survival rate was significantly correlated with Quintero stages (P = 0.029). Moreover, the sIUGR III subgroup had a lower survival rate compared with sIUGR II (55.6%, versus 84.3%). The subgroup of foetal anomaly of gastroschisis or exomphalos had the highest IUFD rate (4/10, 40%), followed by sIUGR III (2/9, 22.2%) and dichorionic triamniotic (DCTA) subgroup (8/46, 17.9%). In EFR group, eight IUFD cases were all coming from the DCTA subgroup and received RFA before 17 weeks. Conclusions The perinatal outcome of RFA was correlated with the indications, with the lowest survival rate in TTTS IV and the highest IUFD incidence in abdominal wall defect followed by sIUGR III. Elective RFA after 17 weeks may prevent IUFD in DCTA pregnancies.
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Affiliation(s)
- Hongmei Wang
- Department of Obstetrics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Qian Zhou
- Department of Obstetrics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Xietong Wang
- Department of Obstetrics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China.,Department of Obstetrics, Maternal Child Health Care Hospital of Shandong Province, Jinan, Shandong, China.,Key Laboratory of Birth Regulation and Control Technology of National Health Commission of China, Maternal Child Health Care Hospital of Shandong Province, Jinan, Shandong, China
| | - Jia Song
- Department of Neonatology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Pengzheng Chen
- Department of Obstetrics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Yanyun Wang
- Department of Obstetrics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Lei Li
- Department of Obstetrics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Hongyan Li
- Department of Obstetrics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China.
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10
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Chen Y, Sun L, Hua X, Li M, Yu S, Zhang J. Defining intertwin birth weight discordance and optimal delivery time in dichorionic twins: a retrospective cohort study. J Matern Fetal Neonatal Med 2020; 35:3915-3922. [PMID: 33249949 DOI: 10.1080/14767058.2020.1843627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND A high birth weight discordance (BWD) places twins at high risks of adverse perinatal outcomes; however, there is no commonly accepted definition of intertwin BWD. Given that gestational age (GA) is closely associated with both BWD and adverse neonatal outcomes, the aim of our study is to develop a measure that takes both BWD and GA into account to define BWD and explore the potentially optimal delivery time in dichorionic twins, with the balance against the risk of intrauterine demise and adverse neonatal outcomes. METHODS About 99,000 mixed gender twin pairs from the US matched multiple birth file from 1995 to 2000 were enrolled in our study. We set up a two-dimensional matrix model to select the BWD cutoff point related to outcomes. The optimal delivery time was identified based on the risks of adverse neonatal outcomes and fetal death by GA. RESULTS The combination of BWD and GA had a higher predictive performance for adverse neonatal outcomes than BWD alone (area under ROC curve (AUC): 0.816 vs. 0.523, p < .001). When GA was controlled for, the growth discordant cutoff point was BWD at the 40% level. The optimal delivery time suggested in dichorionic twins with BWD higher than 40% was identified at 33-34 gestational weeks. CONCLUSIONS The combination of BWD and GA was a better predictor for adverse neonatal outcomes than BWD alone. In dichorionic twins with BWD >40%, pregnancy may be continued till 33-34 gestation weeks if there is no indication for immediate delivery.
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Affiliation(s)
- Yan Chen
- Department of Neonatology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Luming Sun
- Department of Fetal Medicine, First Maternity and Infant Hospital Affiliated to Shanghai Tongji University, Shanghai, China
| | - Xiaolin Hua
- Department of Obstetrics, First Maternity and Infant Hospital Affiliated to Shanghai Tongji University, Shanghai, China
| | - Meng Li
- MOE-Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Stella Yu
- Center for Global Health and Health Policy, Global Health and Education Projects, Inc, Riverdale, MD, USA
| | - Jun Zhang
- MOE-Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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11
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Shinar S, Agrawal S, El-Chaâr D, Abbasi N, Beecroft R, Kachura J, Keunen J, Seaward G, Van Mieghem T, Windrim R, Ryan G. Selective fetal reduction in complicated monochorionic twin pregnancies: A comparison of techniques. Prenat Diagn 2020; 41:52-60. [PMID: 32939784 DOI: 10.1002/pd.5830] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 09/09/2020] [Accepted: 09/12/2020] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To compare perinatal outcomes associated with three methods of selective reduction in complicated monochorionic (MC) twin pregnancies: bipolar cord coagulation (BC), fetoscopic or ultrasound guided laser cord occlusion and radiofrequency ablation (RFA). METHODS Retrospective cohort study of complicated MC twin pregnancies undergoing selective fetal reduction at a tertiary fetal center over a 20-year period. Obstetric and perinatal outcomes were compared. RESULTS 105 procedures met inclusion criteria: 74 RFAs, 17 lasers and 14 BCs. Procedure duration was significantly shorter for RFA (27.4 ± 15.8 minutes) compared to BC (91.7 ± 38.7 minutes) and laser (83.4 ± 40.4 minutes), P < .0001). The incidence of preterm prelabor rupture of membranes (PPROM) and co-twin demise did not differ between groups, however preterm delivery <34 weeks occurred less frequently following RFA (29.7%), compared to laser (64.7%) or BC (42.9%) (P = .02); delivery <37 weeks was also less frequent following RFA (45.9%), compared to laser (76.5%) or BC (78.6%)(P = .01). The difference in preterm birth<34 weeks between RFA and laser was maintained after adjusting for cord occlusion indication and amnionicity (OR 3.96, 95% CI 1.27-12.31). CONCLUSIONS In our experience, RFA procedures were simpler, faster and associated with a lower risk of preterm delivery <34 and <37 weeks, compared to laser or BC.
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Affiliation(s)
- Shiri Shinar
- Ontario Fetal Centre, Fetal Medicine Unit, Dept. Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Swati Agrawal
- Ontario Fetal Centre, Fetal Medicine Unit, Dept. Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Darine El-Chaâr
- Ontario Fetal Centre, Fetal Medicine Unit, Dept. Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Nimrah Abbasi
- Ontario Fetal Centre, Fetal Medicine Unit, Dept. Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Robert Beecroft
- University of Toronto, Toronto, Ontario, Canada.,Dept. Medical Imaging, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - John Kachura
- University of Toronto, Toronto, Ontario, Canada.,Dept. Medical Imaging, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Johannes Keunen
- Ontario Fetal Centre, Fetal Medicine Unit, Dept. Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Gareth Seaward
- Ontario Fetal Centre, Fetal Medicine Unit, Dept. Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Tim Van Mieghem
- Ontario Fetal Centre, Fetal Medicine Unit, Dept. Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Rory Windrim
- Ontario Fetal Centre, Fetal Medicine Unit, Dept. Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Greg Ryan
- Ontario Fetal Centre, Fetal Medicine Unit, Dept. Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada.,Dept. Medical Imaging, Mount Sinai Hospital, Toronto, Ontario, Canada
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12
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Corroenne R, Al Ibrahim A, Stirnemann J, Zayed LH, Essaoui M, Russell NE, Chalouhi GE, Salomon LJ, Ville Y. Management of monochorionic twins discordant for structural fetal anomalies. Prenat Diagn 2020; 40:1375-1382. [PMID: 32394424 DOI: 10.1002/pd.5734] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 04/28/2020] [Accepted: 05/06/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To review the perinatal management and outcomes of monochorionic twin pregnancies (MC) discordant for congenital anomalies (DCA). METHODS Retrospective, study of all MC DCA cases referred to our tertiary referral center from 1997 to 2018. We excluded cases complicated with twin-to-twin transfusion syndrome, twin anemia-polycythemia sequence, twin reversed arterial perfusion sequence or selective intra-uterine growth restriction. Patients were counseled about the possibility of expectant (EM) or interventional management (selective feticide [SF] or termination of the entire pregnancy [TOP]). RESULTS One hundred eight of 4157 (2.6%) MC pregnancies were discordant for anomaly. Fifty two of 108 n(48.1%) underwent SF at a mean gestational age of 31.4 ± 5.9 weeks while 52/108(48.1%) opted for EM. Livebirth rate of the healthy co-twin was similar between the two groups (SF: 88.5% vs EM: 82.7%, P = .87). In the SF group, six healthy co-twins (6/52, 11.5%) died 5.3 ± 3.1 days after SF of the abnormal co-twin. In the EM group, in-utero demise of the abnormal twin occurred in 9 of 52 (17.3%) of the cases and was followed by the spontaneous demise of the healthy co-twin in 4 of 9 (44.4%) of these cases. CONCLUSION Selective feticide does not seem to significantly alter survival of the healthy co-twin compared to EM.
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Affiliation(s)
- Romain Corroenne
- Department of Obstetrics and Fetal Therapy, AP-HP, Necker-Enfants Malades Hospital, Paris, France
| | - Abdullah Al Ibrahim
- Department of Obstetrics and Fetal Therapy, AP-HP, Necker-Enfants Malades Hospital, Paris, France
| | - Julien Stirnemann
- Department of Obstetrics and Fetal Therapy, AP-HP, Necker-Enfants Malades Hospital, Paris, France
| | - Louay Hassan Zayed
- Department of Obstetrics and Fetal Therapy, AP-HP, Necker-Enfants Malades Hospital, Paris, France
| | - Mohamed Essaoui
- Department of Obstetrics and Fetal Therapy, AP-HP, Necker-Enfants Malades Hospital, Paris, France
| | - Noirin E Russell
- Department of Obstetrics and Fetal Therapy, AP-HP, Necker-Enfants Malades Hospital, Paris, France
| | - Gihad E Chalouhi
- Department of Obstetrics and Fetal Therapy, AP-HP, Necker-Enfants Malades Hospital, Paris, France
| | - Laurent J Salomon
- Department of Obstetrics and Fetal Therapy, AP-HP, Necker-Enfants Malades Hospital, Paris, France
| | - Yves Ville
- Department of Obstetrics and Fetal Therapy, AP-HP, Necker-Enfants Malades Hospital, Paris, France
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13
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Kim MS, Kang S, Kim Y, Kang JY, Moon MJ, Baek MJ. Transabdominal fetal reduction: a report of 124 cases. J OBSTET GYNAECOL 2020; 41:32-37. [PMID: 32705924 DOI: 10.1080/01443615.2019.1677577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
To prevent fetal loss, preterm delivery, and perinatal morbidity of multifetal pregnancies (MPs), fetal reduction (FR) is offered to some patients. We retrospectively analysed the data of 124 MPs that underwent transabdominal FR to twin (n = 63) and singleton (n = 61) pregnancies at a mean gestational age of 12 + 6 weeks between December 2006 and January 2018. FR was performed transabdominally with the injection of potassium chloride into the intracardiac or intrathoracic space of the fetus or fetuses after ultrasound screening for nuchal translucency and anatomical defects. The initial number of embryos were 48 twins, 63 triplets, 11 quadruplets, and 2 quintuplets. The procedure-related pregnancy loss rate was 0.8% (1/124), the overall pregnancy loss rate was 2.4% (3/124), the fetal loss rate was 1.6% (2/124), and the neonatal death rate was 0.8% (1/124). The baby take-home rates were 96% for twin pregnancies and 96.7% for singletons. This study shows that transabdominal FR is an effective and safe procedure with a pregnancy loss rate of 2.4%.Impact statementWhat is already known on this subject? The incidence of multifetal pregnancies has increased over the years. Because multifetal pregnancies increase perinatal morbidity and mortality due to prematurity, fetal reduction is offed to some patients.What the results of this study add? The results of this study add to the growing body of research on fetal reduction. The study showed that transabdominal fetal reduction is a safe procedure with a pregnancy loss rate of 2.4%.What the implications are of these findings for clinical practice and/or further research? The results of this study can be used in counselling couples with multifetal pregnancies who are considering fetal reduction. Further research is needed to confirm the current findings.
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Affiliation(s)
- Mi Sun Kim
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, Seongnam-si, Republic of Korea
| | - Sukho Kang
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, Seongnam-si, Republic of Korea
| | - Youngri Kim
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, Seongnam-si, Republic of Korea
| | - Ji Yeon Kang
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, Seongnam-si, Republic of Korea
| | - Myoung Jin Moon
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, Seongnam-si, Republic of Korea
| | - Min Jung Baek
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, Seongnam-si, Republic of Korea
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14
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Sacco A, Van der Veeken L, Bagshaw E, Ferguson C, Van Mieghem T, David AL, Deprest J. Maternal complications following open and fetoscopic fetal surgery: A systematic review and meta-analysis. Prenat Diagn 2019; 39:251-268. [PMID: 30703262 PMCID: PMC6492015 DOI: 10.1002/pd.5421] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 01/16/2019] [Accepted: 01/20/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To establish maternal complication rates for fetoscopic or open fetal surgery. METHODS We conducted a systematic literature review for studies of fetoscopic or open fetal surgery performed since 1990, recording maternal complications during fetal surgery, the remainder of pregnancy, delivery, and after the index pregnancy. RESULTS One hundred sixty-six studies were included, reporting outcomes for open fetal (n = 1193 patients) and fetoscopic surgery (n = 9403 patients). No maternal deaths were reported. The risk of any maternal complication in the index pregnancy was 20.9% (95%CI, 15.22-27.13) for open fetal and 6.2% (95%CI, 4.93-7.49) for fetoscopic surgery. For severe maternal complications (grades III to V Clavien-Dindo classification of surgical complications), the risk was 4.5% (95% CI 3.24-5.98) for open fetal and 1.7% (95% CI, 1.19-2.20) for fetoscopic surgery. In subsequent pregnancies, open fetal surgery increased the risk of preterm birth but not uterine dehiscence or rupture. Nearly one quarter of reviewed studies (n = 175, 23.3%) was excluded for failing to report the presence or absence of maternal complications. CONCLUSIONS Maternal complications occur in 6.2% fetoscopic and 20.9% open fetal surgeries, with serious maternal complications in 1.7% fetoscopic and 4.5% open procedures. Reporting of maternal complications is variable. To properly quantify maternal risks, outcomes should be reported consistently across all fetal surgery studies.
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Affiliation(s)
- Adalina Sacco
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Lennart Van der Veeken
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
| | - Emma Bagshaw
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Catherine Ferguson
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Tim Van Mieghem
- Department of Obstetrics and GynaecologyMount Sinai Hospital and University of TorontoTorontoOntarioCanada
| | - Anna L. David
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
- National Institute for Health ResearchUniversity College London Hospitals Biomedical Research CentreLondonUK
| | - Jan Deprest
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
- Clinical Department Obstetrics and GynaecologyUniversity Hospitals LeuvenLeuvenBelgium
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15
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Massively Parallel Sequencing (MPS) of Cell-Free Fetal DNA (cffDNA)
for Trisomies 21, 18, and 13 in Twin Pregnancies. Twin Res Hum Genet 2017; 20:242-249. [DOI: 10.1017/thg.2017.23] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Massively parallel sequencing (MPS) technology has become increasingly available
and has been widely used to screen for trisomies 21, 18, and 13 in singleton
pregnancies. This study assessed the performance of MPS testing of cell-free
fetal DNA (cffDNA) from maternal plasma for trisomies 21, 18, and 13 in twin
pregnancies. Ninety-two women with twin pregnancies were recruited. The results
were identified through karyotypes of amniocentesis or clinical examination and
follow-up of the neonates. Fluorescent in-situ hybridization was used to examine
the placentas postnatally in cases of false-positive results. The fetuses with
autosomal trisomy 21 (n = 2) and trisomy 15 (n
= 1) were successfully detected via MPS testing of cffDNA. There was one
false-positive for trisomy 13 (n = 1), and fluorescence in-situ
hybridization (FISH) identified confined placental mosaicism in this case. For
twin pregnancies undergoing second-trimester screening for trisomy, MPS testing
of cffDNA is feasible and can enhance the diagnostic spectrum of non-invasive
prenatal testing, which could effectively reduce invasive prenatal diagnostic
methods. In addition to screening for trisomy 21, 18, and 13 by cffDNA, MPS can
detect fetal additional autosomal trisomy. False-positive results cannot
completely exclude confined placental mosaicism.
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16
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Peng R, Xie HN, Lin MF, Yang JB, Zhou Y, Chen HQ, Zhu YX. Clinical Outcomes after Selective Fetal Reduction of Complicated Monochorionic Twins with Radiofrequency Ablation and Bipolar Cord Coagulation. Gynecol Obstet Invest 2016; 81:552-558. [PMID: 27035917 DOI: 10.1159/000445291] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 03/07/2016] [Indexed: 11/19/2022]
Abstract
AIMS To review pregnancy outcomes, complication rates and neonatal neural development of selective termination procedures for complicated monochorionic (MC) twins. METHODS This was a retrospective review of the pregnancies that underwent selective reduction with radiofrequency ablation (RFA) and bipolar cord coagulation (BCC) in our institution. RESULTS Forty-eight cases underwent selective reduction with BCC and the remaining 45 with RFA. Overall survival was not statistically different between the RFA and BCC groups (71.1 and 62.5%, p = 0.379). With regard to the indications, the survival rates were not significantly different for twin to twin transfusion syndrome, twin reversed arterial perfusion, discordant anomalies and selective intrauterine growth restriction. Preterm premature rupture of membrane was not statistically different between the BCC and RFA groups (47.9 and 33.3%, p = 0.153). Five foetuses presented with abnormal middle cerebral artery-peak systolic velocity in the BCC group and 4 in the RFA group (p = 0.829). In the BCC group, neurological injury was detected in 2 neonates, presenting with cerebral dysplasia on MR scanning. In the RFA group, intracranial haemorrhage Grade III was detected in one neonate with cranial ultrasound (p = 0.607). CONCLUSIONS Overall survival and complication rates following selective reduction in complicated MC twin pregnancies is similar irrespective of whether the reduction was performed using RFA or BCC. Key Message: It seems that selective reduction in MC pregnancies with RFA does not carry a significant decrease in the overall survival and complication rates than the cases with BCC. According to our data, neurodevelopmental impairment of the co-twins is relatively seldom after selective reduction.
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Affiliation(s)
- Ruan Peng
- Department of Ultrasonic Medicine, Fetal Medical Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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17
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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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18
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van de Mheen L, Everwijn SMP, Knapen MFCM, Haak MC, Engels MAJ, Manten GTR, Zondervan HA, Wirjosoekarto SAM, van Vugt JMG, Erwich JJHM, Bilardo CM, van Pampus MG, de Groot CJM, Mol BWJ, Pajkrt E. Pregnancy outcome after fetal reduction in women with a dichorionic twin pregnancy. Hum Reprod 2015; 30:1807-12. [PMID: 26093542 DOI: 10.1093/humrep/dev132] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 05/01/2015] [Indexed: 12/13/2022] Open
Abstract
STUDY QUESTION What are the pregnancy outcomes for women with a twin pregnancy that is reduced to a singleton pregnancy? SUMMARY ANSWER Fetal reduction of a twin pregnancy significantly improves gestational age at birth and neonatal birthweight, however at an increased risk of pregnancy loss and preterm delivery. WHAT IS KNOWN ALREADY Women with a multiple pregnancy are at increased risk for preterm delivery. Fetal reduction can be considered in these women. STUDY DESIGN, SIZE, AND DURATION Retrospective cohort study of 118 women with a twin pregnancy reduced to a singleton pregnancy between 2000 and 2010. PARTICIPANTS/MATERIALS, SETTING, AND METHODS We compared the outcome of pregnancy in consecutive women with a dichorionic twin pregnancy that was reduced to a singleton pregnancy to that of women with a dichorionic twin pregnancy that was managed expectantly and women with a primary singleton pregnancy. Reductions were performed between 10-23(6/7) weeks' gestation by intracardiac or intrathoracic injection of potassium chloride, mostly for congenital anomalies. We compared median gestational age, pregnancy loss <24 weeks, preterm delivery <32 weeks, neonatal birthweight and perinatal deaths. MAIN RESULTS AND THE ROLE OF CHANCE We studied 118 women with a twin pregnancy that was reduced to a singleton, 818 women with an ongoing dichorionic twin pregnancy and 611 women with a primary singleton pregnancy. Loss of the entire pregnancy <24 weeks and preterm delivery occurred significantly more in the reduction group compared with the ongoing twin group (11.9 versus 3.1% <24 weeks, P< 0.001 and 18.6 versus 11.5% <32 weeks, respectively, P < 0.001). In the reduction group, the percentage of women without any surviving child was significantly higher compared with the ongoing twin and primary singleton group (14.4, 3.4 and 0.7%, respectively, P < 0.001). Median gestational age was 38.9 weeks (interquartile range (IQR) 34.7-40.3) for reduced pregnancies, 37.1 weeks (IQR 35.3-38.1) for ongoing twin pregnancies and 40.1 (IQR 39.1-40.9) for primary singletons (P < 0.001 for all comparisons). LIMITATIONS, REASONS FOR CAUTION The main limitations of the study were its retrospective character, and the fact that indications for reduction were heterogeneous. WIDER IMPLICATIONS OF THE FINDINGS In women with a dichorionic twin pregnancy fetal reduction increases median gestational age only at considerable risk of complete early pregnancy loss. STUDY FUNDING/COMPETING INTERESTS The study was not funded. None of the authors has conflicts of interest.
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Affiliation(s)
- L van de Mheen
- Department of Obstetrics and Gynecology, VU University Medical Center, Amsterdam, The Netherlands
| | - S M P Everwijn
- Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam, The Netherlands
| | - M F C M Knapen
- Department of Obstetrics and Prenatal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - M C Haak
- Department of Obstetrics and Gynecology, Leiden University Medical Center, Leiden, The Netherlands
| | - M A J Engels
- Department of Obstetrics and Gynecology, VU University Medical Center, Amsterdam, The Netherlands
| | - G T R Manten
- Department of Obstetrics and Gynecology, University Medical Center, Utrecht, The Netherlands
| | - H A Zondervan
- Department of Obstetrics and Gynecology, Rijnstate Hospital, Arnhem, The Netherlands
| | - S A M Wirjosoekarto
- Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - J M G van Vugt
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J J H M Erwich
- Department of Obstetrics and Gynecology, University Medical Center, Groningen, The Netherlands
| | - C M Bilardo
- Department of Obstetrics and Gynecology, University Medical Center, Groningen, The Netherlands
| | - M G van Pampus
- Department of Obstetrics and Gynecology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - C J M de Groot
- Department of Obstetrics and Gynecology, VU University Medical Center, Amsterdam, The Netherlands
| | - B W J Mol
- The Robinson Institute, School of Reproductive Health and Paediatrics, University of Adelaide, Adelaide, Australia
| | - E Pajkrt
- Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam, The Netherlands
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Chmait RH, Kontopoulos EV, Jackson M, Horenstein J, Timor-Tritsch I, Quintero RA. Selective Reduction Using Intravascular Potassium Chloride Injection after Laser Surgery for Twin-Twin Transfusion Syndrome. Fetal Diagn Ther 2015; 39:306-10. [PMID: 26067899 DOI: 10.1159/000431255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Accepted: 05/05/2015] [Indexed: 11/19/2022]
Abstract
Selective reduction (SR) via intravascular potassium chloride (KCl) injection is contraindicated in monochorionic twins due to the presence of placental vascular communications, which may serve as a conduit for inter-twin passage of KCl or allow exsanguination of the living twin into the demised twin. After successful selective laser photocoagulation of communicating vessels (SLPCV) for twin-twin transfusion syndrome (TTTS), the twins' circulatory systems are rendered independent. Theoretically, intravascular KCl injection into one twin after successful SLPCV should not result in passage of the feticidal agent nor cause hemodynamic alterations in the co-twin. We describe 3 cases of 1,069 patients (0.3%) that underwent SLPCV for TTTS between 2003 and 2013 and subsequent SR. SLPCV was successfully completed at 180, 226, and 230 weeks' gestational age for Quintero stages III, IV, and III TTTS, respectively. SR via intravascular KCl injection was later performed at maternal request due to the risk of neurological compromise in one twin at 226, 254, and 236 weeks' gestational age. All co-twins survived after SR, and no neurological sequelae were suspected after birth. Further study is necessary before SR can be routinely considered after laser surgery for TTTS.
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Affiliation(s)
- Ramen H Chmait
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, Calif., USA
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Mahalingam S, Dighe M. Imaging concerns unique to twin pregnancy. Curr Probl Diagn Radiol 2014; 43:317-30. [PMID: 25239076 DOI: 10.1067/j.cpradiol.2014.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Accepted: 05/14/2014] [Indexed: 11/22/2022]
Abstract
The incidence of multiple gestations is increasing with rising maternal age and the utilization of artificial reproductive techniques. Twinning confers an increased risk to the pregnancy, with higher incidence of structural anomalies, preterm delivery, and perinatal morbidity and mortality. Certain conditions are unique to twin pregnancy, such as the twin-to-twin transfusion syndrome and the acardiac twin, secondary to vascular sharing between both the fetuses. Conjoined twinning is a phenomenon occurring because of late splitting of the zygote. Advances in imaging have increased our ability to manage multiple pregnancies with accurate prenatal diagnosis, better antenatal surveillance, and novel image-guided procedures. The purpose of this article is to provide an overview of the twinning process, including the pathophysiology, diagnostic pearls, and dilemmas and to briefly outline the outcomes and available treatment options to assist the radiologist in better management of multiple gestations.
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Affiliation(s)
| | - Manjiri Dighe
- Department of Radiology, University of Washington Medical Center, Seattle, WA
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Monni G, Iuculano A, Zoppi MA. Screening and Invasive Testing in Twins. J Clin Med 2014; 3:865-82. [PMID: 26237482 PMCID: PMC4449657 DOI: 10.3390/jcm3030865] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 06/26/2014] [Accepted: 06/27/2014] [Indexed: 11/16/2022] Open
Abstract
Prenatal screening and testing for trisomy 21 in twin pregnancies poses a number of challenges: the exact estimate of the a priori risk of trisomy 21, the choice of prenatal screening test and/or invasive techniques to employ for the diagnosis and the impact of the result on the options of treatment in case of discordant results within a twin pair or among multiples. These different aspects are discussed below while recognizing that many issues remain unresolved.
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Affiliation(s)
- Giovanni Monni
- Department of Obstetrics and Gynecology, Prenatal and Preimplantation Genetic Diagnosis, Fetal Therapy, Ospedale Microcitemico, via Jenner, 09121 Cagliari, Italy.
| | - Ambra Iuculano
- Department of Obstetrics and Gynecology, Prenatal and Preimplantation Genetic Diagnosis, Fetal Therapy, Ospedale Microcitemico, via Jenner, 09121 Cagliari, Italy.
| | - Maria Angelica Zoppi
- Department of Obstetrics and Gynecology, Prenatal and Preimplantation Genetic Diagnosis, Fetal Therapy, Ospedale Microcitemico, via Jenner, 09121 Cagliari, Italy.
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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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Abstract
The management of twin pregnancies discordant for trisomy 21 is dependent on the gestation at diagnosis, chorionicity, and parental preference. Our experience with the management of 15 cases in 1,839 twin pregnancies over a 12-year period is described. Selective termination is not always associated with a successful outcome for the normal co-twin. Two of the three monochorionic twin pregnancies affected by trisomy 21 were discordant. Amniocentesis should be strongly considered rather than chorionic villus sampling in monochorionic twin pregnancies. Pregnancies that continue with a trisomy 21 affected fetus are at risk of polyhydramnios and premature labor.
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Challis D, Gardener G, Dickinson JE. Regionalisation of fetal medicine in Australia and New Zealand. Aust N Z J Obstet Gynaecol 2013; 53:105-7. [DOI: 10.1111/ajo.12091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Daniel Challis
- NSW Pregnancy and Newborn Services Network; Westmead; New South Wales; Australia
| | - Glenn Gardener
- Mater Mothers' Hospital; Mater Health Services; South Brisbane; Queensland; Australia
| | - Jan E. Dickinson
- The School of Women's and Infants' Health; The University of Western Australia; Perth; Western Australia; Australia
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