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Chambon E, Hachem T, Salvador E, Rigourd V, Bellanger C, Stirnemann J, Kermorvant-Duchemin E, Tissieres P, Ville Y, Lapillonne A. Neonatal Hemodynamic Characteristics of the Recipient Twin of Twin-To-Twin Transfusion Syndrome Not Treated with Fetoscopic Laser Surgery. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9111766. [PMID: 36421215 PMCID: PMC9689049 DOI: 10.3390/children9111766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/10/2022] [Accepted: 11/14/2022] [Indexed: 11/19/2022]
Abstract
Background: This paper’s intent is to describe the neonatal hemodynamic characteristics of recipient twins of monochorionic pregnancies complicated with twin-to-twin transfusion syndrome (TTTS), born without prenatal fetoscopic selective laser coagulation (FSLC). Methods: Retrospective analysis of hemodynamic characteristics was performed during the first five days of life of recipient twins from untreated TTTS. Results: Forty-two recipient twins were included and divided into three groups: no hemodynamic impairment (NoHI) (n = 15, 36%), isolated high blood pressure (HighBP) (n = 12, 28%), and cardiac failure group (CF) (n = 15, 36%). Patients of both CF and HighBP groups had high systolic blood pressure during the first 12 h of life and ventricular hypertrophy at early echocardiography. Cardiac failure occurred at a median age of 14 h (IQR = 6−24) and was followed by a drop in systolic and diastolic blood pressure. Acute kidney injury was more frequent (93% vs. 25%, p < 0.001) and severe (p <0.001) in the CF group than in the HighBP group. The mortality rate in the CF group was 40%. Factors associated with CF were twin anemia-polycythemia sequence (p = 0.012), very preterm birth (p = 0.040), and polycythemia (p = 0.002). Conclusion: One-third of recipient twins born without prenatal FSLC developed life-threatening cardiac failure during the first 24 h of life.
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Affiliation(s)
- Edouard Chambon
- Neonatal Intensive Care Unit, APHP Necker-Enfants Malades University Hospital, 75015 Paris, France
| | - Taymme Hachem
- Neonatal Intensive Care Unit, APHP Necker-Enfants Malades University Hospital, 75015 Paris, France
| | - Elodie Salvador
- Neonatal Intensive Care Unit, APHP Necker-Enfants Malades University Hospital, 75015 Paris, France
| | - Virginie Rigourd
- Neonatal Intensive Care Unit, APHP Necker-Enfants Malades University Hospital, 75015 Paris, France
| | - Claire Bellanger
- Neonatal Intensive Care Unit, APHP Necker-Enfants Malades University Hospital, 75015 Paris, France
| | - Julien Stirnemann
- Department of Obstetrics and Fetal Medicine, APHP Necker-Enfants Malades University Hospital, 75015 Paris, France
- UFR de médecine, Université Paris Cité, Site Cordeliers, 75006 Paris, France
| | - Elsa Kermorvant-Duchemin
- Neonatal Intensive Care Unit, APHP Necker-Enfants Malades University Hospital, 75015 Paris, France
- UFR de médecine, Université Paris Cité, Site Cordeliers, 75006 Paris, France
| | - Pierre Tissieres
- Pediatric Intensive Care Unit, APHP Bicêtre University Hospital, 94270 Le Kremlin-Bicêtre, France
- UFR de médecine, Université de Paris Saclay, 94270 Le Kremlin-Bicêtre, France
| | - Yves Ville
- Department of Obstetrics and Fetal Medicine, APHP Necker-Enfants Malades University Hospital, 75015 Paris, France
- UFR de médecine, Université Paris Cité, Site Cordeliers, 75006 Paris, France
| | - Alexandre Lapillonne
- Neonatal Intensive Care Unit, APHP Necker-Enfants Malades University Hospital, 75015 Paris, France
- UFR de médecine, Université Paris Cité, Site Cordeliers, 75006 Paris, France
- Correspondence: ; Tel.: +33-1-71-19-61-74
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Molecular Mechanisms Underlying Twin-to-Twin Transfusion Syndrome. Cells 2022; 11:cells11203268. [PMID: 36291133 PMCID: PMC9600593 DOI: 10.3390/cells11203268] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 10/14/2022] [Accepted: 10/15/2022] [Indexed: 11/17/2022] Open
Abstract
Twin-to-twin transfusion syndrome is a unique disease and a serious complication occurring in 10–15% of monochorionic multiple pregnancies with various placental complications, including hypoxia, anemia, increased oxidative stress, and ischemia-reperfusion injury. Fetoscopic laser photocoagulation, a minimally invasive surgical procedure, seals the placental vascular anastomoses between twins and dramatically improves the survival rates in twin-to-twin transfusion syndrome. However, fetal demise still occurs, suggesting the presence of causes other than placental vascular anastomoses. Placental insufficiency is considered as the main cause of fetal demise in such cases; however, little is known about its underlying molecular mechanisms. Indeed, the further association of the pathogenic mechanisms involved in twin-to-twin transfusion syndrome placenta with several molecules and pathways, such as vascular endothelial growth factor and the renin–angiotensin system, makes it difficult to understand the underlying pathological conditions. Currently, there are no effective strategies focusing on these mechanisms in clinical practice. Certain types of cell death due to oxidative stress might be occurring in the placenta, and elucidation of the molecular mechanism underlying this cell death can help manage and prevent it. This review reports on the molecular mechanisms underlying the development of twin-to-twin transfusion syndrome for effective management and prevention of fetal demise after fetoscopic laser photocoagulation.
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Cruz-Martínez R, Villalobos-Gómez R, Gil-Pugliese S, Gámez-Varela A, López-Briones H, Martínez-Rodríguez M, Barrios-Prieto E. Management of atypical cases of twin-to-twin transfusion syndrome. Best Pract Res Clin Obstet Gynaecol 2022; 84:155-165. [PMID: 35490103 DOI: 10.1016/j.bpobgyn.2022.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 03/13/2022] [Indexed: 11/02/2022]
Abstract
Up to 20% of monochorionic diamniotic twin pregnancies can be complicated with twin-to-twin transfusion syndrome (TTTS). This complication is diagnosed by ultrasound demonstrating amniotic fluid discordance between both amniotic sacs, with polyhydramnios in the recipient's sac and oligohydramnios in the donor's, secondary to an imbalance in blood volume exchange between twins. Ultrasound evaluation of the amniotic fluid volume, bladder filling, and assessment of fetal Doppler parameters provide the basis for classification of TTTS, allowing severity assessment. The Quintero's staging system provides a standardized prenatal estimate on the risk of intrauterine fetal demise of one or both twins and the need for fetoscopic laser coagulation of placental vascular anastomoses or delivery depending on the gestational age. However, a proportion of TTTS cases may present without a linear progressive deterioration and no ultrasound signs of preceding staging, in rare situations, they arise even without amniotic fluid discordance. Thus, these unusual clinical presentations of TTTS have long been grouped into the category of atypical TTTS. In this review, we show the clues for diagnosis and management of different atypical cases of TTTS highlighting their underlying mechanism to improve the clinical understanding of such atypical situations, avoid misdiagnosis of TTTS, and allow a timely referral to a fetoscopic center.
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Affiliation(s)
- Rogelio Cruz-Martínez
- Fetal Medicine and Surgery Center, Medicina Fetal México, Guadalajara, Jalisco, Mexico; Department of Maternal-Fetal Medicine, Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Jalisco, Mexico; Fetal Medicine Center, Medicina Fetal México, Querétaro, Mexico.
| | - Rosa Villalobos-Gómez
- Fetal Medicine and Surgery Center, Medicina Fetal México, Guadalajara, Jalisco, Mexico; Department of Maternal-Fetal Medicine, Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Jalisco, Mexico; Fetal Medicine Center, Medicina Fetal México, Querétaro, Mexico
| | | | - Alma Gámez-Varela
- Fetal Medicine and Surgery Center, Medicina Fetal México, Guadalajara, Jalisco, Mexico
| | | | - Miguel Martínez-Rodríguez
- Fetal Medicine and Surgery Center, Medicina Fetal México, Guadalajara, Jalisco, Mexico; Department of Maternal-Fetal Medicine, Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Jalisco, Mexico
| | - Ernesto Barrios-Prieto
- Department of Maternal-Fetal Medicine, Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Jalisco, Mexico
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4
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The Amniotic Fluid Cell-Free Transcriptome Provides Novel Information about Fetal Development and Placental Cellular Dynamics. Int J Mol Sci 2021; 22:ijms22052612. [PMID: 33807645 PMCID: PMC7961801 DOI: 10.3390/ijms22052612] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 02/28/2021] [Accepted: 03/02/2021] [Indexed: 12/16/2022] Open
Abstract
The amniotic fluid (AF) is a complex biofluid that reflects fetal well-being during development. AF con be divided into two fractions, the supernatant and amniocytes. The supernatant contains cell-free components, including placenta-derived microparticles, protein, cell-free fetal DNA, and cell-free fetal RNA from the fetus. Cell-free mRNA (cfRNA) analysis holds a special position among high-throughput analyses, such as transcriptomics, proteomics, and metabolomics, owing to its ease of profiling. The AF cell-free transcriptome differs from the amniocyte transcriptome and alters with the progression of pregnancy and is often associated with the development of various organ systems including the fetal lung, skin, brain, pancreas, adrenal gland, gastrointestinal system, etc. The AF cell-free transcriptome is affected not only by normal physiologies, such as fetal sex, gestational age, and fetal maturity, but also by pathologic mechanisms such as maternal obesity, and genetic syndromes (Down, Edward, Turner, etc.), as well as pregnancy complications (preeclampsia, intrauterine growth restriction, preterm birth, etc.). cfRNA in the amniotic fluid originates from the placenta and fetal organs directly contacting the amniotic fluid as well as from the fetal plasma across the placenta. The AF transcriptome may reflect the fetal and placental development and therefore aid in the monitoring of normal and abnormal development.
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5
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Simpson L, Maturen KE, Feldstein VA, Oliver ER, Poder L, Strachowski LM, Sussman BL, Weber TM, Winter T, Zelop CM, Glanc P. ACR Appropriateness Criteria® Nuchal Translucency Evaluation at 11 to 14 Weeks of Gestation. J Am Coll Radiol 2020; 17:S447-S458. [PMID: 33153556 DOI: 10.1016/j.jacr.2020.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 09/01/2020] [Indexed: 11/20/2022]
Abstract
A fetus with an increased nuchal translucency at 11 to 14 weeks gestation is at risk for aneuploidy, genetic syndromes, structural anomalies, and intrauterine fetal demise in both single and twin gestations. In addition to referral to genetics for counseling and consideration of diagnostic genetic testing, a detailed anatomic survey and fetal echocardiogram are indicated in the second trimester to screen for congenital malformations and major heart defects. 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)
- Lynn Simpson
- Columbia University, New York, New York; American College of Obstetricians and Gynecologists.
| | | | | | - Edward R Oliver
- Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Liina Poder
- University of California San Francisco, San Francisco, California
| | | | - Betsy L Sussman
- The University of Vermont Medical Center, Burlington, Vermont
| | | | - Tom Winter
- University of Utah, Salt Lake City, Utah
| | - Carolyn M Zelop
- Valley Hospital, Ridgewood, New Jersey and NYU School of Medicine, New York, New York; American College of Obstetricians and Gynecologists
| | - Phyllis Glanc
- Specialty Chair, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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6
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Yoda H. Fetal and Neonatal Circulatory Disorders in Twin to Twin Transfusion Syndrome (The Secondary Publication). J NIPPON MED SCH 2020; 86:192-200. [PMID: 31484880 DOI: 10.1272/jnms.jnms.2019_86-301] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Twin to twin transfusion syndrome (TTTS) is a major complication of monochorionic diamniotic (MD) twins, and its onset is known to be associated with placental vascular anastomoses and blood flow imbalance. In a typical case of TTTS, the recipient develops polyhydramnios, weight gain, cardiomegaly and hydrops fetalis in the uterus. In contrast, the donor develops oligohydramnios and intrauterine growth restriction. Recently, the significance of the renin-angiotensin-aldosterone system (RAAS) that transfers from the donor to the recipient has attracted interest in the fetal circulation of TTTS. The donor has decreased renal blood flow due to decreased circulating blood volume. For this reason, the secretion of RAAS hormones is augmented in the fetal kidneys of the donor. In TTTS, these RAAS hormones from the donor transfer to the recipient through the anastomosed vessels. In addition to excess preload, the recipient heart is exposed to excess afterload due to systemic vasoconstriction through RAAS hormones. Commonly occurring complications in the recipient include myocardial hypertrophy, atrioventricular valve regurgitation, and pulmonary valve stenosis or pulmonary atresia. Fetoscopic laser photocoagulation (FLP) has been introduced recently because neither mortality nor neurological morbidity have been satisfactorily improved with conventional treatment. FLP is a curative method that may improve the prognosis of TTTS. In Japan, this procedure has been performed frequently, and positive neurological outcomes have been achieved.
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Affiliation(s)
- Hitoshi Yoda
- Department of Neonatology, Toho University, Faculty of Medicine
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7
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Prevalence of right ventricular outflow tract abnormalities among recipients in twin-twin transfusion syndrome after fetoscopic laser surgery in 90 consecutive cases. J Med Ultrason (2001) 2019; 47:117-121. [PMID: 31641903 DOI: 10.1007/s10396-019-00982-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 09/28/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE Right ventricular outflow tract obstruction (RVOTO) is a severe complication in recipients in twin-twin transfusion syndrome (TTTS). This study investigated the prevalence of RVOTO in TTTS after laser surgery and examined the risk factors for RVOTO. METHODS This retrospective study evaluated 90 patients who had undergone laser surgery and been followed for 6 months after birth. The diagnosis of RVOTO was made based on postnatal echocardiography findings. Ultrasound and clinical records, including maternal and neonatal data, were retrieved from our database. Risk factors for developing RVOTO were compared between recipients with and without RVOTO in a statistical analysis. RESULTS Six surviving recipients were diagnosed with RVOTO. Three recipients had developed severe pulmonary stenosis (PS) that required percutaneous transluminal pulmonary valvuloplasty or balloon pulmonary angioplasty. A total of 6.7% of recipients (6/90) had RVOTO, consisting of PS and tricuspid regurgitation (TR), and 3.3% of recipients (3/90) required invasive treatment. The characteristic factors did not differ significantly between recipients with and without RVOTO. CONCLUSION This study revealed that 6.7% of recipients with TTTS had PS, and 3.3% required invasive treatment for PS. However, no significant association was noted between RVOTO development in recipients and maternal clinical data and fetal ultrasound examination findings. It is difficult to predict RVOTO development in recipients using only preoperative ultrasound and clinical information.
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8
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Gijtenbeek M, Shirzada MR, Ten Harkel ADJ, Oepkes D, C Haak M. Congenital Heart Defects in Monochorionic Twins: A Systematic Review and Meta-Analysis. J Clin Med 2019; 8:E902. [PMID: 31238552 PMCID: PMC6617007 DOI: 10.3390/jcm8060902] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 06/14/2019] [Accepted: 06/18/2019] [Indexed: 12/19/2022] Open
Abstract
Monochorionic (MC) twins are at an increased risk of developing congenital heart defects (CHDs) compared to singletons and dichorionic twins. The development of acquired CHDs in this specific group of twins is associated with twin-twin transfusion syndrome (TTTS). We performed a systematic review and meta-analysis to provide an overview of the reported birth prevalence of CHDs in liveborn MC twins with and without TTTS. Twelve studies were included in this review. Compared to the reference population, MC twins were 6.3 times more likely to be born with a CHD (59.3 per 1000 liveborn twins; relative risk (RR) 6.3; 95% confidence interval (CI): 4.4-9.1), and TTTS twins had a 12-fold increased risk of having a CHD at birth (87.3 per 1000 live births; RR 12.4, 95% CI: 8.6-17.8). The increased incidence of CHDs can mainly be attributed to the risk of right ventricular outflow tract obstruction (35/1000 TTTS twin live births vs. 0.5/1000 singleton live births). We recommend an expert fetal echocardiogram in all MC twins, follow-up scans in the event of TTTS, and a postnatal cardiac evaluation in all TTTS survivors.
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Affiliation(s)
- Manon Gijtenbeek
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, PO Box 9600, NL-2300 RC Leiden, The Netherlands.
| | - Maryam R Shirzada
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, PO Box 9600, NL-2300 RC Leiden, The Netherlands.
| | - Arend D J Ten Harkel
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, PO Box 9600, NL-2300 RC Leiden, The Netherlands.
| | - Dick Oepkes
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, PO Box 9600, NL-2300 RC Leiden, The Netherlands.
| | - Monique C Haak
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, PO Box 9600, NL-2300 RC Leiden, The Netherlands.
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9
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Eschbach SJ, Ten Harkel ADJ, Middeldorp JM, Klumper FJCM, Oepkes D, Lopriore E, Haak MC. Acquired right ventricular outflow tract obstruction in twin-to-twin transfusion syndrome; a prospective longitudinal study. Prenat Diagn 2018; 38:1013-1019. [PMID: 30365169 DOI: 10.1002/pd.5378] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 10/07/2018] [Accepted: 10/12/2018] [Indexed: 01/11/2023]
Abstract
OBJECTIVE The pathophysiology of right ventricular outflow tract obstruction (RVOTO) in twin-to-twin transfusion syndrome (TTTS) recipients is incompletely understood. We aimed to investigate the development and spectrum of RVOTO in TTTS recipients. METHODS A prospective longitudinal cohort study was conducted between 2015 and 2017. Echocardiographic assessment was performed in recipients from TTTS diagnosis until the neonatal period. RESULTS Prenatal RVOTO, defined as abnormal flow velocity waveforms across the pulmonary valve (PV), was diagnosed in 12.9% (16/124) of recipients at TTTS diagnosis. Postnatal RVOTO was found in 6.7% (7/105) of surviving recipients. All recipients with severe postnatal RVOTO showed prenatal RVOTO at TTTS diagnosis. In 5.6% (6/108) of cases, prenatal RVOTO appeared only after laser therapy, and in 1.9% (2/108), this progressed to mild postnatal pulmonary stenosis. Elevated peak systolic PV velocities were more frequently associated with postnatal RVOTO compared with prenatal finding of functional pulmonary atresia. Postnatal RVOTO was associated with early manifestation of TTTS but was equally found in all Quintero stages. CONCLUSION In the spectrum of postnatal RVOTO, severe cases show prenatal RVOTO at TTTS diagnosis. However, RVOTO can develop after laser or even in the neonatal period and in all Quintero stages. A potential risk factor for postnatal RVOTO is early TTTS manifestation.
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Affiliation(s)
- Sanne J Eschbach
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, Netherlands
| | - Arend D J Ten Harkel
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Johanna M Middeldorp
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, Netherlands
| | - Frans J C M Klumper
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, Netherlands
| | - Dick Oepkes
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, Netherlands
| | - Enrico Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, Netherlands
| | - Monique C Haak
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, Netherlands
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10
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Perry H, Duffy JMN, Umadia O, Khalil A. Outcome reporting across randomized trials and observational studies evaluating treatments for twin-twin transfusion syndrome: systematic review. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 52:577-585. [PMID: 29607558 DOI: 10.1002/uog.19068] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 03/19/2018] [Accepted: 03/27/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE Twin-twin transfusion syndrome (TTTS) is associated with significant mortality and morbidity. Potential treatments for the condition require robust evaluation. The aim of this study was to evaluate outcome reporting across observational studies and randomized controlled trials assessing treatments for TTTS. METHODS Cochrane Central Register of Controlled Trials, EMBASE and MEDLINE were searched from inception to August 2016. Observational studies and randomized controlled trials reporting outcome following treatment for TTTS in monochorionic-diamniotic twin pregnancy and monochorionic-triamniotic or dichorionic-triamniotic triplet pregnancy were included. Outcome reporting was systematically extracted and categorized. RESULTS Six randomized trials and 94 observational studies were included, reporting data from 20 071 maternal participants and 3199 children. Six different treatments were evaluated. Included studies reported 62 different outcomes, including six fetal, seven offspring mortality, 25 neonatal, six early childhood and 18 maternal/operative outcomes. Outcomes were reported inconsistently across trials. For example, when considering offspring mortality, 31 (31%) studies reported live birth, 31 (31%) reported intrauterine death, 49 (49%) reported neonatal mortality and 17 (17%) reported perinatal mortality. Four (4%) studies reported respiratory distress syndrome. Only 19 (19%) studies were designed for long-term follow-up and 11 (11%) of these reported cerebral palsy. CONCLUSIONS Studies evaluating treatments for TTTS have often neglected to report clinically important outcomes, especially neonatal morbidity outcomes, and most are not designed for long-term follow-up. The development of a core outcome set could help standardize outcome collection and reporting in TTTS studies. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- H Perry
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - J M N Duffy
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford, UK
- Balliol College, University of Oxford, Oxford, UK
| | - O Umadia
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - A Khalil
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
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11
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Hecher K, Gardiner HM, Diemert A, Bartmann P. Long-term outcomes for monochorionic twins after laser therapy in twin-to-twin transfusion syndrome. THE LANCET CHILD & ADOLESCENT HEALTH 2018; 2:525-535. [PMID: 30169324 DOI: 10.1016/s2352-4642(18)30127-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 03/09/2018] [Accepted: 04/03/2018] [Indexed: 12/28/2022]
Abstract
Twin-to-twin transfusion syndrome typically occurs in the second trimester in 10-15% of monochorionic twin pregnancies. Vascular anastomoses of monochorionic placentae are the underlying cause of the development of the syndrome. If a blood flow imbalance occurs, one fetus becomes the so-called donor twin and the other the recipient. If untreated, perinatal mortality is 80-90%. Fetoscopic laser coagulation of the vascular anastomoses destroys the cause of the syndrome and leads to dual twin survival rates of around 70% and more than 90% of pregnancies with at least one survivor. However, unequal placental sharing, intrauterine death, and severe prematurity are still limiting factors for further improvement of survival rates and decreases in long-term morbidity. Prematurity and neurodevelopmental impairment affect the donor and recipient twins, whereas cardiovascular failure and obstruction of the right ventricular outflow tract are typical complications of recipients, which can lead to long-term morbidity. In this Review, we summarise the literature on follow-up data for survivors of twin-to-twin-transfusion syndrome after laser therapy, including neurodevelopmental outcomes, cardiovascular outcomes, growth, renal function, and ischaemic events, as well as the potential effects of intrauterine programming on later life.
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Affiliation(s)
- Kurt Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Helena M Gardiner
- Fetal Center at Children's Memorial Herman Hospital, McGovern Medical School at UTHealth, University of Texas Health Sciences Center, Houston, TX, USA
| | - Anke Diemert
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Bartmann
- Children's Hospital, University Hospital Bonn, Bonn, Germany
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12
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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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Pruetz JD, Votava-Smith JK, Chmait HR, Korst LM, Llanes A, Chmait RH. Recipient Twin Circular Shunt Physiology Before Fetal Laser Surgery: Survival and Risks for Postnatal Right Ventricular Outflow Tract Obstruction. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2017; 36:1595-1605. [PMID: 28370096 DOI: 10.7863/ultra.16.08038] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 11/07/2016] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To evaluate risk for congenital heart disease (CHD) in recipient twins with circular shunt physiology (CSP). METHODS This prospective study enrolled twin-twin transfusion syndrome (TTTS) cases from 2006 to 2015. Fetal echocardiography (FE) was performed before laser surgery when cardiac involvement was suspected. Diagnosis of recipient twin CSP required tricuspid and pulmonary regurgitation, right ventricular dysfunction, and flow reversal in the ductus arteriosus. Outcomes were assessed at 30 days after birth. RESULTS Of the 496 TTTS pregnancies, 20 (4%) met the criteria for CSP. Among those born alive, who had documented cardiac outcomes (n = 457), patients with CSP were more likely to have CHD, specifically right ventricular outflow tract obstruction (5 of 18 [27.8%] versus 22 of 439 [5.0%], odd ratio [OR] 7.29, 95% confidence interval [CI] 2.05-24.72, P = .0025). Of the recipient twins with preoperative FE (n = 259, 52%) who were born alive and had documented cardiac outcomes (n = 242), those with CSP were still more likely to have right ventricular outflow tract obstruction (5 of 18 [27.8%] versus 14 of 224 [6.3%], OR 5.77, CI 1.54-20.92, P = .0077). With both analyses, twins with CSP had higher Quintero stage, but similar patient characteristics and 30-day mortality compared with those without CSP. Subgroup analyses of the CSP cohort identified no differences in preoperative characteristics or FE findings predictive of CHD. CONCLUSIONS Recipient twins with preoperative CSP were at increased risk for postnatal right ventricular outflow tract obstruction, but appeared to have comparable survival after fetal laser surgery despite these dramatic pathophysiological prenatal findings. Preoperative FE in TTTS remains important for prediction of postnatal CHD.
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Affiliation(s)
- Jay D Pruetz
- Division of Pediatric Cardiology, Children's Hospital Los Angeles, University of Southern California, Los Angeles, California, USA
- Department of Obstetrics & Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Jodie K Votava-Smith
- Division of Pediatric Cardiology, Children's Hospital Los Angeles, University of Southern California, Los Angeles, California, USA
| | - Hikmat R Chmait
- Department of Obstetrics & Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Lisa M Korst
- Childbirth Research Associates, North Hollywood, California, USA
| | - Arlyn Llanes
- Department of Obstetrics & Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Ramen H Chmait
- Department of Obstetrics & Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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Eschbach SJ, Boons LSTM, Van Zwet E, Middeldorp JM, Klumper FJCM, Lopriore E, Teunissen AKK, Rijlaarsdam ME, Oepkes D, Ten Harkel ADJ, Haak MC. Right ventricular outflow tract obstruction in complicated monochorionic twin pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 49:737-743. [PMID: 27363529 DOI: 10.1002/uog.16008] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 06/16/2016] [Accepted: 06/17/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES Severe right ventricular outflow tract obstruction (RVOTO) is a potential complication in recipient twins of twin-to-twin transfusion syndrome (TTTS) that requires postnatal follow-up or treatment. We aimed to evaluate pregnancy characteristics of neonates with RVOTO from complicated monochorionic twin pregnancies, determine the incidence of RVOTO in TTTS cases and construct a prediction model for its development. METHODS This was an observational cohort study of all complicated monochorionic twin pregnancies with a postnatal diagnosis of RVOTO examined at our center. Cases were referred for evaluation of the need for fetal therapy or intervention because of TTTS, selective intrauterine growth restriction (sIUGR) or multiple congenital malformations in one of the twins. Ultrasound data were retrieved from our monochorionic twin database. Among liveborn TTTS recipients treated prenatally with laser therapy, those with RVOTO were compared with those without RVOTO (controls). We describe four additional cases with RVOTO that were not TTTS recipients. RESULTS A total of 485 twin pregnancies received laser therapy for TTTS during the study period. RVOTO was diagnosed in 3% (11/368) of liveborn TTTS recipients, of whom two showed mild Ebstein's anomaly. Before laser therapy, pericardial effusion was seen in 45% (5/11) of RVOTO cases (P < 0.01) and abnormal A-wave in the ductus venosus (DV) in 73% (8/11) (P = 0.03), significantly higher proportions than in controls. Mean gestational age at laser therapy was 17 + 3 weeks in RVOTO cases compared with 20 + 3 weeks in controls (P = 0.03). A prediction model for RVOTO was constructed incorporating these three significant variables. One TTTS donor had RVOTO after the development of transient hydrops following laser therapy. Three larger twins in pregnancies complicated by sIUGR developed RVOTO, the onset of which was detectable early in the second trimester. CONCLUSIONS RVOTO occurs in TTTS recipient twins but can also develop in TTTS donors and larger twins of pregnancies complicated by sIUGR. Abnormal flow in the DV, pericardial effusion and early gestational age at onset of TTTS are predictors of RVOTO in TTTS recipients, which suggests increased vulnerability to hemodynamic imbalances in the fetal heart in early pregnancy. These findings could guide diagnostic follow-up protocols after TTTS treatment. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- S J Eschbach
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - L S T M Boons
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - E Van Zwet
- Department of Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands
| | - J M Middeldorp
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - F J C M Klumper
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - E Lopriore
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - A K K Teunissen
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - M E Rijlaarsdam
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - D Oepkes
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - A D J Ten Harkel
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - M C Haak
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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Best KE, Rankin J. Increased risk of congenital heart disease in twins in the North of England between 1998 and 2010. Heart 2015; 101:1807-12. [PMID: 26412859 PMCID: PMC4680160 DOI: 10.1136/heartjnl-2015-307826] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 07/10/2015] [Indexed: 01/04/2023] Open
Abstract
Objective To examine the relative risk (RR) of congenital heart disease (CHD) in twins compared with singletons, according to chorionicity. Methods Twins and singletons with CHD notified to the Northern Congenital Abnormality Survey between 1998 and 2010 were included in this population-based study. Information on chorionicity was obtained from the Northern Survey of Twins and Multiple Pregnancy. Prevalence was calculated as the number of cases occurring in live births, late miscarriages (20–23 weeks), stillbirths (≥24 weeks) and terminations of pregnancy for fetal anomaly, per 10 000 total births. The risk of CHD in twins compared with singletons was estimated using Poisson regression. Results There were 399 414 singleton births of which 2984 (0.7%) had CHD. Among 11 871 twin births, 154 (1.3%) had CHD; one twin was affected by CHD in 2.5% of twin pregnancies. Of 8605 dichorionic (DC) births and 2317 monochorionic (MC) births, 96 (1.1%) and 47 (2.0%) were associated with CHD. Compared with singletons, twins were at significantly increased risk of CHD (RR=1.73, 95% CI 1.48 to 2.04; p<0.001). MC twins were at 82% significantly increased risk of CHD compared with DC twins (RR=1.82, 95% CI 1.29 to 2.57; p<0.001). The RR of severe and mild CHD was particularly high in MC twins compared with singletons (292% increased risk, RR=3.92, 95% CI 1.25 to 12.30, p=0.02 and 207% increased risk, RR=3.07, 95% CI 2.20 to 4.28; p<0.001). Conclusions Compared with singletons, twins were at increased risk of CHD, the risk being substantially higher among MC twins. This information is important for health professionals when counselling women with twin pregnancies.
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Affiliation(s)
- K E Best
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - J Rankin
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK PHE: Regional Maternity Survey Office, Newcastle upon Tyne, UK
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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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Herberg U, Bolay J, Graeve P, Hecher K, Bartmann P, Breuer J. Intertwin cardiac status at 10-year follow-up after intrauterine laser coagulation therapy of severe twin-twin transfusion syndrome: comparison of donor, recipient and normal values. Arch Dis Child Fetal Neonatal Ed 2014; 99:F380-5. [PMID: 24972991 DOI: 10.1136/archdischild-2013-305034] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND In twin-to-twin transfusion syndrome (TTTS), genetically identical twins are exposed to different haemodynamic conditions during fetal life, which are considered to be the cause of prenatal and postnatal cardiovascular differences between the donor and the recipient. OBJECTIVE To assess intertwin differences on childhood cardiac outcome after intrauterine laser coagulation therapy (LC) of severe TTTS. DESIGN AND PATIENTS Prospective, detailed, echocardiographic follow-up of 31 twin pairs aged 9.95±0.8 years (mean±SD) with severe TTTS treated by LC, and the comparison with reference values. RESULTS Cardiac function was normal and did not show intertwin differences in twins without structural heart disease. Discordant birth weight or birth weight <3rd centile for gestational age had no influence on blood pressure and cardiac indices. Pulmonary stenosis was more common (5/62; 8.1%) than in the general population (prevalence 0.066%, relative risk 134.4, 95% CI 42.1 to 428.8, p<0.0001) and affected both donor and recipient. Intertwin differences in late diastolic right ventricular filling (peak velocities: recipient 0.51±0.11 m/s vs donor 0.45±0.10 m/s, mean difference 0.74 m/s, 95% CI 0.23 to 1.24, p=0.009) and early septal relaxation (mean myocardial velocities: recipient -8.2±1.5 cm/s vs donor -8.9±1.2 cm/s, mean difference 0.7 cm/s, 95% CI 0.02 to 1.38, p=0.044) were found only when twins with right heart disease were included. CONCLUSIONS Despite severe prenatal cardiac involvement, childhood cardiac function is normal in the majority of surviving donors and recipients after successful LC of severe TTTS. This underlines the favourable impact of intrauterine LC on postnatal cardiovascular performance.
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Affiliation(s)
- Ulrike Herberg
- Division of Pediatric Cardiology, University of Bonn, Bonn, Germany
| | - Julian Bolay
- Division of Pediatric Cardiology, University of Bonn, Bonn, Germany
| | - Pauline Graeve
- Division of Neonatology, University of Bonn, Bonn, Germany
| | - Kurt Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Bartmann
- Division of Neonatology, University of Bonn, Bonn, Germany
| | - Johannes Breuer
- Division of Pediatric Cardiology, University of Bonn, Bonn, Germany
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Donofrio MT, Moon-Grady AJ, Hornberger LK, Copel JA, Sklansky MS, Abuhamad A, Cuneo BF, Huhta JC, Jonas RA, Krishnan A, Lacey S, Lee W, Michelfelder EC, Rempel GR, Silverman NH, Spray TL, Strasburger JF, Tworetzky W, Rychik J. Diagnosis and treatment of fetal cardiac disease: a scientific statement from the American Heart Association. Circulation 2014; 129:2183-242. [PMID: 24763516 DOI: 10.1161/01.cir.0000437597.44550.5d] [Citation(s) in RCA: 719] [Impact Index Per Article: 71.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND The goal of this statement is to review available literature and to put forth a scientific statement on the current practice of fetal cardiac medicine, including the diagnosis and management of fetal cardiovascular disease. METHODS AND RESULTS A writing group appointed by the American Heart Association reviewed the available literature pertaining to topics relevant to fetal cardiac medicine, including the diagnosis of congenital heart disease and arrhythmias, assessment of cardiac function and the cardiovascular system, and available treatment options. The American College of Cardiology/American Heart Association classification of recommendations and level of evidence for practice guidelines were applied to the current practice of fetal cardiac medicine. Recommendations relating to the specifics of fetal diagnosis, including the timing of referral for study, indications for referral, and experience suggested for performance and interpretation of studies, are presented. The components of a fetal echocardiogram are described in detail, including descriptions of the assessment of cardiac anatomy, cardiac function, and rhythm. Complementary modalities for fetal cardiac assessment are reviewed, including the use of advanced ultrasound techniques, fetal magnetic resonance imaging, and fetal magnetocardiography and electrocardiography for rhythm assessment. Models for parental counseling and a discussion of parental stress and depression assessments are reviewed. Available fetal therapies, including medical management for arrhythmias or heart failure and closed or open intervention for diseases affecting the cardiovascular system such as twin-twin transfusion syndrome, lung masses, and vascular tumors, are highlighted. Catheter-based intervention strategies to prevent the progression of disease in utero are also discussed. Recommendations for delivery planning strategies for fetuses with congenital heart disease including models based on classification of disease severity and delivery room treatment will be highlighted. Outcome assessment is reviewed to show the benefit of prenatal diagnosis and management as they affect outcome for babies with congenital heart disease. CONCLUSIONS Fetal cardiac medicine has evolved considerably over the past 2 decades, predominantly in response to advances in imaging technology and innovations in therapies. The diagnosis of cardiac disease in the fetus is mostly made with ultrasound; however, new technologies, including 3- and 4-dimensional echocardiography, magnetic resonance imaging, and fetal electrocardiography and magnetocardiography, are available. Medical and interventional treatments for select diseases and strategies for delivery room care enable stabilization of high-risk fetuses and contribute to improved outcomes. This statement highlights what is currently known and recommended on the basis of evidence and experience in the rapidly advancing and highly specialized field of fetal cardiac care.
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Hui L, Wick HC, Moise KJ, Johnson A, Luks F, Haeri S, Johnson KL, Bianchi DW. Global gene expression analysis of amniotic fluid cell-free RNA from recipient twins with twin-twin transfusion syndrome. Prenat Diagn 2013; 33:873-83. [PMID: 23640821 DOI: 10.1002/pd.4150] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2013] [Revised: 04/23/2013] [Accepted: 04/25/2013] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The objective of this study was to understand the biological pathways involved in twin-twin transfusion syndrome (TTTS) by performing global gene expression analysis of amniotic fluid (AF) cell-free RNA. METHODS A prospective whole transcriptome microarray study analyzing cell-free RNA in AF from TTTS recipient twins and singleton controls was carried out. Significantly differentially regulated genes in TTTS cases (N = 8) versus matched controls (N = 8) were identified and pathways analyses performed. Significant gene expression differences between stage II TTTS recipients (N = 5) and stage III TTTS recipients with abnormal Doppler measurements (N = 5) were also analyzed. RESULTS Analysis of paired data from TTTS cases and controls revealed differential expression of 801 genes, which were significantly enriched for neurological disease and cardiovascular system pathways. We also identified cardiovascular genes and pathways associated with the presence of critically abnormal Doppler measurements in stage III TTTS recipients. CONCLUSIONS This study provides the first transcriptome-wide data on the impact of TTTS on fetal development. Our results show that gene expression involving neurological and cardiovascular pathways are altered in recipient fetuses prior to surgical treatment. This has relevance for the origins of long-term complications seen in survivors and for the development of future fetal biomarkers.
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Affiliation(s)
- Lisa Hui
- Mother Infant Research Institute, Tufts Medical Center, Boston, MA, USA.
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Abstract
OBJECTIVE To determine the prevalence of congenital heart defects (CHDs) in a large, unselected cohort of monochorionic (MC) twins. STUDY DESIGN We completed a chart review of all MC twin pregnancies in the Kaiser Permanente Northern California population from 1996 to 2003. CHDs were identified by diagnostic codes and confirmed by postnatal echocardiograms. Follow-up was obtained through one year of age. RESULT A total of 926 liveborn MC twins met inclusion criteria. The prevalence of CHDs was 7.5%, 11.6 times the general population rate (CI 9.2 to 14.5). Septal defects were most common. 20% of infants with heart defects had twin-to-twin transfusion syndrome (TTTS) versus 8% of infants without defects (P<0.01); this association remained significant when controlling for potential confounders. CONCLUSION The prevalence of CHDs in this large cohort of MC twins was significantly higher than the general population rate, with TTTS an added risk factor.
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Abstract
OBJECTIVE We sought to review the natural history, pathophysiology, diagnosis, and treatment options for twin-twin transfusion syndrome (TTTS). METHODS A systematic review was performed using MEDLINE database, PubMed, EMBASE, and Cochrane Library. The search was restricted to English-language articles published from 1966 through July 2012. Priority was given to articles reporting original research, in particular randomized controlled trials, although review articles and commentaries also were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate for inclusion in this document. Evidence reports and guidelines published by organizations or institutions such as the National Institutes of Health, Agency for Health Research and Quality, American College of Obstetricians and Gynecologists, and Society for Maternal-Fetal Medicine were also reviewed, and additional studies were located by reviewing bibliographies of identified articles. Consistent with US Preventive Task Force guidelines, references were evaluated for quality based on the highest level of evidence, and recommendations were graded accordingly. RESULTS AND RECOMMENDATIONS TTTS is a serious condition that can complicate 8-10% of twin pregnancies with monochorionic diamniotic (MCDA) placentation. The diagnosis of TTTS requires 2 criteria: (1) the presence of a MCDA pregnancy; and (2) the presence of oligohydramnios (defined as a maximal vertical pocket of <2 cm) in one sac, and of polyhydramnios (a maximal vertical pocket of >8 cm) in the other sac. The Quintero staging system appears to be a useful tool for describing the severity of TTTS in a standardized fashion. Serial sonographic evaluation should be considered for all twins with MCDA placentation, usually beginning at around 16 weeks and continuing about every 2 weeks until delivery. Screening for congenital heart disease is warranted in all monochorionic twins, in particular those complicated by TTTS. Extensive counseling should be provided to patients with pregnancies complicated by TTTS including natural history of the disease, as well as management options and their risks and benefits. The natural history of stage I TTTS is that more than three-fourths of cases remain stable or regress without invasive intervention, with perinatal survival of about 86%. Therefore, many patients with stage I TTTS may often be managed expectantly. The natural history of advanced (eg, stage ≥III) TTTS is bleak, with a reported perinatal loss rate of 70-100%, particularly when it presents <26 weeks. Fetoscopic laser photocoagulation of placental anastomoses is considered by most experts to be the best available approach for stages II, III, and IV TTTS in continuing pregnancies at <26 weeks, but the metaanalysis data show no significant survival benefit, and the long-term neurologic outcomes in the Eurofetus trial were not different than in nonlaser-treated controls. Even laser-treated TTTS is associated with a perinatal mortality rate of 30-50%, and a 5-20% chance of long-term neurologic handicap. Steroids for fetal maturation should be considered at 24 0/7 to 33 6/7 weeks, particularly in pregnancies complicated by stage ≥III TTTS, and those undergoing invasive interventions.
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Right ventricular outflow tract obstruction in monochorionic twins with selective intrauterine growth restriction. Case Rep Pediatr 2012; 2012:426825. [PMID: 23050183 PMCID: PMC3462376 DOI: 10.1155/2012/426825] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Accepted: 08/23/2012] [Indexed: 11/18/2022] Open
Abstract
Monochorionic twin pregnancies are at increased risk of perinatal mortality and morbidity due to twin-twin transfusion syndrome (TTTS), selective intrauterine growth restriction (sIUGR), and higher incidence of congenital heart malformations. The incidence of right ventricular outflow tract obstruction (RVOTO) in recipients with TTTS is known to be higher than in the general population. There is limited data on the risk of RVOTO in monochorionic twins with sIUGR. We report a case of RVOTO in the larger twin in a monochorionic twin pregnancy with sIUGR, treated successfully with balloon dilatation after birth.
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Lopriore E, Oepkes D, Walther FJ. Neonatal morbidity in twin-twin transfusion syndrome. Early Hum Dev 2011; 87:595-9. [PMID: 21784588 DOI: 10.1016/j.earlhumdev.2011.07.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2011] [Accepted: 07/05/2011] [Indexed: 12/25/2022]
Abstract
Twin-twin transfusion syndrome (TTTS) is a severe complication of monochorionic twin pregnancies associated with high perinatal mortality and morbidity rates. Management in TTTS is a major challenge for obstetricians and neonatologists. Twins which are often born prematurely and may suffer from typical conditions associated with prematurity. In addition, surviving twins with TTTS are at increased risk for other complications including neurological, cardiovascular, renal and hematologic morbidity. Rare complications such as hypoxic-ischemic lesions to limbs or intestines and amniotic band syndrome have also been reported in TTTS survivors. This review focuses on the neonatal and pediatric mortality and morbidity in TTTS survivors, with special emphasis on the long-term neurodevelopmental outcome.
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Affiliation(s)
- Enrico Lopriore
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands.
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Pruetz JD, Sklansky M, Detterich J, Korst LM, Llanes A, Chmait RH. Twin-twin transfusion syndrome treated with laser surgery: postnatal prevalence of congenital heart disease in surviving recipients and donors. Prenat Diagn 2011; 31:973-7. [DOI: 10.1002/pd.2818] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Revised: 05/26/2011] [Accepted: 06/01/2011] [Indexed: 11/12/2022]
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Moon-Grady AJ, Rand L, Lemley B, Gosnell K, Hornberger LK, Lee H. Effect of selective fetoscopic laser photocoagulation therapy for twin-twin transfusion syndrome on pulmonary valve pathology in recipient twins. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2011; 37:27-33. [PMID: 20632308 DOI: 10.1002/uog.7748] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
OBJECTIVE To investigate the impact of selective fetoscopic laser photocoagulation (SFLP) on pre-existing pulmonary valve pathology in the recipient twin in twin-twin transfusion syndrome (TTTS). METHODS We evaluated preoperative echocardiograms of all pregnancies with TTTS treated with SFLP at our institution from 2001 to 2009 (n = 76). Sixteen (21%) recipients had an abnormal pulmonary valve (stenosis/dysplasia, insufficiency or functional atresia) before SFLP. Postoperative echocardiograms and medical records from these 16 recipients were reviewed. Changes in pulmonary valve structure and function, and overall cardiac function, were noted after SFLP. RESULTS The mean gestational age at SFLP was 21 (range, 18.7-24.3) weeks. Seven of sixteen (44%) recipients with abnormal pulmonary valve prior to SFLP survived. Six of the 16 (37.5%) recipient twins had documented absence of persistent pulmonary valve abnormalities at birth or at autopsy. Two (12.5%) of the 16 recipients (2.6% of the original cohort) had persistent pulmonary valve abnormalities at birth, requiring intervention. Systolic and diastolic function improved or normalized after SFLP in all patients undergoing longitudinal follow-up. There was a tendency for a better cardiovascular profile score (best = 10 points) at initial evaluation in pregnancies with survivors compared with those with no survivors (mean (SD): 5.6 (2.2) vs. 6.75 (1.28)), but this was not statistically significant. Severity of cardiac involvement did not predict persistence of valve pathology or survival. CONCLUSIONS SFLP can improve flow through the pulmonary valve of the recipient twin in TTTS, probably as a consequence of improvements in right ventricular systolic and diastolic function. However, pulmonary valve pathology may persist and require postnatal intervention.
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Affiliation(s)
- A J Moon-Grady
- Pediatric Cardiology, University of California San Francisco, San Francisco, CA, USA.
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Abstract
The risk of fetal loss is multiplied by 4 in monochorionic pregnancies by comparison with dichorionic one. The incidence of selective growth retardation (sIUGR) is between 12.5 to 25%. This variation is explained by the mixture between pure twin-to-twin transfusion syndrome (TTTS) and pregnancies without TTTS but with a pure sIUGR. The ability to diagnose prenatally sIUGR is low; the positive predictive value is only 37% (EL4). The umbilical flow velocity waveforms with absent diastolic flow (Type II) or with diastolic intermittent flow (Type III) is clearly a strong risk factor of mortality of the IUGR and also a risk factor of leucomalacia of the bigger fetus (EL3). The observed incidence of malformations in twins is 4.05% versus 2.38% for singletons (OR=1.7 [IC 95% 1.47-1.97]). Furthermore, the rate of fetal malformations is higher in monochorionic pregnancies by comparison with dichorionic one, 6.33% versus 3.43% (OR=1.8 [IC 95% 1.3-2.5]) (EL3). In the majority of the cases, the malformation is concerning only one fetus. The most frequent malformations are those of the central nervous system by comparison with singletons, those of the urinary tract and the cardiovascular malformations. Monozygotic pregnancies are not necessarily phenotypically and genetically identical. In situation of asymmetrical malformation, it is necessary to propose fetal karyotype of the malformed fetus. In case aneuploidy of the malformed fetus, secondarily it will be necessary to explore the other apparently normal one. Uniparental disomy should be suspected in such situation (EL3). In TRAP sequence, an intensive follow up should be organised with serial measurement of the respective size of the acardiac fetus and the normal one, Doppler exploration should be done to look for early sign of cardiac decompensation (expert viewpoint). In dichorionic pregnancies, when the malformation is threatening the whole pregnancy like anencephaly, a selective feticide allow a prolongation of the pregnancy, but with a risk of fetal loss of 8% and a risk of iatrogenic prematurity of 12%. In such situation, it could be wise to evaluate the evolution or to wait until the third trimester to undergo the procedure (EL3). In monochorionic pregnancies, in the same situation of anencephalic fetus the best option is bipolar cord coagulation. The result seems to be better after 18 weeks of gestation (EL4). There is a 20% risk of premature rupture of membrane. In the up to date analysis of the literature, there is no formal indication of selective feticide expect case of TRAP sequence with cardiac decompensation of the normal fetus. The very special situation of sIUGR is the object of a randomized trial. In all cases the active participation of the patients to the therapeutic option is mandatory (expert viewpoint).
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27
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Pulmonary diffuse arterial calcifications: a very rare complication in the recipient of a twin-to-twin transfusion syndrome. Cardiol Young 2009; 19:410-2. [PMID: 19450382 DOI: 10.1017/s1047951109004181] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The syndrome of twin-to-twin transfusion is known potentially to be associated with the development of right ventricular obstruction, albeit rarely at supravalvar levels, in the recipient twin. We report the case of a recipient twin with diffuse hypoplasia and calcification of the pulmonary arterial tree, confirmed by postnatal thoracic angioscan. When aged 2 years, the child was moderately symptomatic with mild cyanosis, in spite of suprasystemic right ventricular systolic pressure as revealed by follow-up echocardiography.
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28
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Pruetz JD, Chmait RH, Sklansky MS. Complete right heart flow reversal: pathognomonic recipient twin circular shunt in twin-twin transfusion syndrome. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2009; 28:1101-1106. [PMID: 19643796 DOI: 10.7863/jum.2009.28.8.1101] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Affiliation(s)
- Jay D Pruetz
- Department of Pediatrics, Division of Cardiology, Childrens Hospital Los Angeles, 4650 Sunset Blvd, Mail Stop 34, Los Angeles, CA 90027, USA.
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29
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Sekar P, Hornberger LK. The role of fetal echocardiography in fetal intervention: a symbiotic relationship. Clin Perinatol 2009; 36:301-27, ix. [PMID: 19559322 DOI: 10.1016/j.clp.2009.03.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
In this review, the authors explore the role of noninvasive and invasive fetal interventions in fetal cardiovascular disease guided by observations at fetal echocardiography. They first review fetal cardiac lesions that may be ameliorated by fetal intervention and then review noncardiac fetal pathologic findings for which fetal echocardiography can provide important insight into the pathophysiology and aid in patient selection for and timing of intervention and postintervention surveillance.
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Affiliation(s)
- Priya Sekar
- Department of Pediatrics, Division of Cardiology, Fetal and Neonatal Cardiology Program, WCMC 4C2 Stollery Children's Hospital, Alberta, Canada
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30
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Gray PH, Ward C, Chan FY. Cardiac outcomes of hydrops as a result of twin-twin transfusion syndrome treated with laser surgery. J Paediatr Child Health 2009; 45:48-52. [PMID: 19208066 DOI: 10.1111/j.1440-1754.2008.01425.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM To determine cardiac outcomes of foetal hydrops as a result of twin-twin transfusion syndrome treated with laser surgery. METHODS Hydrops identified in 16 recipient foetuses with twin-twin transfusion syndrome was treated with laser ablation surgery to anastomotic vessels. Prior to laser surgery, the foetuses were assessed by echocardiography for cardiac abnormalities and ventricular and valvular dysfunction. After delivery, echocardiography was performed on 15 of the 16 newborn infants. RESULTS Foetal echocardiography indicated impaired biventricular function in the 16 hydropic foetuses. Five foetuses had little or no forward flow through the pulmonary valve, while four had pulmonary regurgitation. Following laser surgery performed at a mean of 22.9 weeks gestation, hydrops resolved in all cases. Delivery occurred at a mean of 33.6 weeks gestation. Post-natal echocardiography revealed cardiac abnormalities in five neonates, of whom three had right ventricular outflow tract obstruction. One preterm infant with severe pulmonary stenosis died with intractable cardiac failure. CONCLUSION The majority of hydropic infants with twin-win transfusion syndrome have normal cardiac outcomes following intrauterine laser surgery. As up to one-third may have cardiac abnormalities, cardiological monitoring is recommended during the first year of life.
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Affiliation(s)
- Peter H Gray
- Department of Neonatology, University of Queensland, Mater Mothers' Hospital, Queensland, Australia.
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31
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Sueters M, Middeldorp JM, Lopriore E, Bökenkamp R, Oepkes D, Teunissen KA, Kanhai HHH, Le Cessie S, Vandenbussche FPHA. Fetal cardiac output in monochorionic twins. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2008; 32:807-812. [PMID: 18956438 DOI: 10.1002/uog.6230] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVES To compare fetal cardiac output (CO) in donor and recipient twins of twin-twin transfusion syndrome (TTTS) pregnancies after laser therapy with that of monochorionic twins without TTTS and normal singletons. METHODS In a longitudinal, prospective study, we sonographically assessed fetal CO in donors (n = 10) and recipients (n = 10) with TTTS after fetoscopic laser therapy, in monochorionic twins without TTTS (n = 20) and in normal singleton pregnancies (n = 20). The fetal CO of TTTS twins was determined 1 day and 1 week after laser treatment, and from then on every 2-4 weeks until birth. Twins without TTTS were examined biweekly until birth. Singletons were examined twice, with an 8-week interval, at different gestational ages between 17 and 35 weeks. RESULTS Absolute CO increased exponentially with advancing gestational age (P < 0.0001), and was significantly related to fetal weight in all groups (P < 0.0001). The median CO/kg in donors after laser therapy, recipients after laser therapy and non-TTTS monochorionic twins was significantly higher than that in singletons (all P < 0.001). Median CO/kg in donors after laser therapy, recipients after laser therapy, and non-TTTS monochorionic twins was not significantly different between groups. CONCLUSIONS Monochorionic twins with TTTS have higher CO after laser therapy than normal singletons.
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Affiliation(s)
- M Sueters
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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32
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Hidaka N, Tsukimori K, Chiba Y, Hara T, Wake N. Monochorionic twins in which at least one fetus has a congenital heart disease with or without twin-twin transfusion syndrome. J Perinat Med 2007; 35:425-30. [PMID: 17624935 DOI: 10.1515/jpm.2007.099] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIMS To review the course of monochorionic (MC) twin gestations in which one or both fetuses were diagnosed with congenital heart disease (CHD) and to identify clinical characteristics regarding the related intrauterine environmental factors particularly associated with non-twin-twin transfusion syndrome (TTTS). METHODS This study is a review of a two-center experience of MC twin pregnancies with CHD born between 2000 and 2006. RESULTS There were 87 MC twin pregnancies of which 11 were associated with fetal heart disease. We found concordance of CHD in 2 of the 11 twin sets. Among all of the discordant cases, the size of the affected twin was smaller. TTTS was observed in one case associated with CHD; in this case the donor twin had a coarctation of the aorta. Abnormal cord insertion was observed in 9 (69%) out of the 13 affected infants, and a significant relation was found between the presence of CHD and abnormal cord insertion. CONCLUSIONS Of the MC twins, the smaller seemed more likely to be affected by primary structural cardiac anomalies. CHD in MC twins is possibly related to an abnormal cord insertion. Further studies are warranted to determine whether a causal relationship exists.
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Affiliation(s)
- Nobuhiro Hidaka
- Department of Obstetrics and Gynecology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
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33
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Bahtiyar MO, Dulay AT, Weeks BP, Friedman AH, Copel JA. Prevalence of congenital heart defects in monochorionic/diamniotic twin gestations: a systematic literature review. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2007; 26:1491-1498. [PMID: 17957043 DOI: 10.7863/jum.2007.26.11.1491] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
OBJECTIVE Congenital heart defects (CHDs) affect approximately 0.5% of all neonates. Recent literature points to a possible increase in the CHD prevalence among monochorionic/diamniotic (MC/DA) twin gestations. We hypothesized that MC/DA twin pregnancy is a risk factor for CHD. METHODS A systematic review of all published English literature was conducted on MEDLINE (Ovid and PubMed) from January 2000 through April 2007 using the medical subject heading terms "congenital heart defect" and "monozygotic twins." Four observational studies were included in the final analysis. Published historical data were used for the population background risk of CHD. Relative risk (RR) estimates with 95% confidence intervals (CIs) were calculated by fixed and random effect models. RESULTS We included a total of 40 fetuses with CHDs among 830 fetuses from MC/DA twin gestations. Compared with the population, CHDs were significantly more prevalent in MC/DA twins regardless of the presence of twin-twin transfusion syndrome (TTTS) (RR, 9.18; 95% CI, 5.51-15.29; P < .001). Monochorionic/diamniotic twin gestations affected by TTTS were more likely to be complicated by CHDs than those that did not have TTTS (RR, 2.78; 95% CI, 1.03-7.52; P = .04). Ventricular septal defects were the most frequent heart defects. Pulmonary stenosis and atrial septal defects were significantly more prevalent in pregnancies complicated with TTTS. CONCLUSIONS Monochorionic/diamniotic twin gestation appears to be a risk factor for CHDs. Conditions that lead to abnormal placentation may also contribute to abnormal heart development, especially in MC/DA twin pregnancies complicated with TTTS. Fetal echocardiography may be considered for all MC/DA twin gestations because ventricular septal defects and pulmonary stenosis are the most common defects.
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Affiliation(s)
- Mert Ozan Bahtiyar
- Section of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT 06520, USA.
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