1
|
Nicolì P, Damiani GR, Gaetani M, Dellino M, Vitagliano A, Malvasi A, Cazzato G, Cascardi E, Marzullo A, Alfonso R, Cicinelli E, Vimercati A. "The Strange Case of Dr Pump and Mr Acardiac": The Twin Reversed Arterial Perfusion (TRAP) Sequence in Two Monochorionic Monoamniotic (MCMA) Twin Pregnancies-Diagnosis, Prognosis and Management: Review of Literature. Diagnostics (Basel) 2023; 13:3109. [PMID: 37835852 PMCID: PMC10572342 DOI: 10.3390/diagnostics13193109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/22/2023] [Accepted: 09/27/2023] [Indexed: 10/15/2023] Open
Abstract
The Twin Reversed Arterial Perfusion (TRAP) Sequence is an extremely rare complication of monochorionic twin pregnancies, with one severely malformed twin (the "acardiac") lacking autonomous placental blood supply and being perfused by the co-twin (the "pump"), through arterio-arterial (and sometimes also veno-venous) vascular anastomoses located on the placental surface. The prognosis is poor: mortality is 100% in the acardiac twin because of its severe malformations and about 50-55% in the pump twin, mainly due to heart failure and prematurity. So, the goal of perinatal management of the TRAP twin pregnancy is to deliver a healthy and near-term pump twin without heart failure or fetal hydrops. Intuitively, the earlier the diagnosis, the better the outcome. Herein, we report two cases of monochorionic monoamniotic (MCMA) twin pregnancies complicated by the TRAP Sequence, which are of interest since the objective of early diagnosis was achieved by means of transvaginal and 3D ultrasound, two techniques which revealed themselves as being useful to this purpose but are underused in the literature. The second aim of this study is to provide an overview of literature data about the diagnosis, prognosis establishment, and management of this rare condition, which are still debated and unclear due to negligible poor-quality evidence.
Collapse
Affiliation(s)
- Pierpaolo Nicolì
- Department of Interdisciplinary Medicine (DIM), Unit of Obstetrics and Gynecology, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Gianluca Raffaello Damiani
- Department of Interdisciplinary Medicine (DIM), Unit of Obstetrics and Gynecology, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Maria Gaetani
- Department of Interdisciplinary Medicine (DIM), Unit of Obstetrics and Gynecology, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Miriam Dellino
- Department of Interdisciplinary Medicine (DIM), Unit of Obstetrics and Gynecology, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Amerigo Vitagliano
- Department of Interdisciplinary Medicine (DIM), Unit of Obstetrics and Gynecology, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | | | - Gerardo Cazzato
- Department of Precision and Regenerative Medicine and Ionian Area, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Eliano Cascardi
- Department of Medical Sciences, University of Turin, 10124 Turin, Italy
- Pathology Unit, FPO-IRCCS Candiolo Cancer Institute, 10060 Candiolo, Italy
| | - Andrea Marzullo
- Department of Precision and Regenerative Medicine and Ionian Area, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Raffaello Alfonso
- Department of Interdisciplinary Medicine (DIM), Unit of Obstetrics and Gynecology, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Ettore Cicinelli
- Department of Interdisciplinary Medicine (DIM), Unit of Obstetrics and Gynecology, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Antonella Vimercati
- Department of Precision and Regenerative Medicine and Ionian Area, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| |
Collapse
|
2
|
Dhanju G, Breddam A. Twin reversed arterial perfusion (TRAP) sequence: A case report and a brief literature review. Radiol Case Rep 2022; 17:1682-1691. [PMID: 35342490 PMCID: PMC8942792 DOI: 10.1016/j.radcr.2022.02.057] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 02/19/2022] [Indexed: 11/24/2022] Open
Abstract
Twin reversed arterial perfusion (TRAP) sequence is rare in monochorionic twin pregnancies. TRAP sequence is distinct from other multifetal pregnancies in that one of the twins has normal anatomy while the other twin has a varied amount of characteristic abnormal features. In the literature, mortality is reported 100% in the abnormal twin. We report 1 case of TRAP sequence at our institution in which the diagnosis of TRAP sequence was missed in the first trimester at another hospital. The patient, a 33-year-old G1P0A0, did not have any follow-up after her first scan until the routine second-trimester ultrasound at our institution. Both the radiologist and the sonographer did not appreciate the differential diagnosis of TRAP sequence in their clinical decision-making. The TRAP diagnosis was established after the ultrasound performed at the fetal assessment unit in our hospital. Radiofrequency ablation (RFA) procedure was performed to give the normal twin a chance to survive, but unfortunately, the prognosis was poor in this case. We conclude that diagnosing a TRAP sequence is very important early in the pregnancy for a positive outcome in the normal twin. A robust collaboration among radiologists and obstetricians is vital for the best outcome of the normal twin.
Collapse
|
3
|
Arora S, Lohiya N, Singhal A, Prasad A, Katyal A. Acardius acephalus with spontaneous umbilical cord occlusion: Reporting a rare case. Radiol Case Rep 2022; 17:1573-1578. [PMID: 35282319 PMCID: PMC8914117 DOI: 10.1016/j.radcr.2022.02.023] [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: 12/02/2021] [Revised: 02/04/2022] [Accepted: 02/05/2022] [Indexed: 11/28/2022] Open
Abstract
Twin reversed arterial perfusion syndrome is a rare obstetric condition that occurs in monochorionic twin pregnancies, resulting in coexistence of a normal “pump” twin and an acardiac twin. The acardiac twin is dependent upon the normal twin to provide circulation by means of vascular anastomosis, thereby putting the pump fetus at risk of high output cardiac failure. Overall only 50% of pump twins survive. Mortality for acardiac twin is 100%. We present a case of 26-year-old primigravida female presenting with 8 months of amenorrhea with unsure LMP. Ultrasonography followed by fetal MRI was carried out which revealed acardius acephalus twin with absence of blood flow in umbilical vessels. Pump twin had multicystic dysplastic left kidney with single umbilical artery. Following delivery, the pump twin survived well and the deformed fetus showed features of twin reversed arterial perfusion syndrome.
Collapse
Affiliation(s)
- Suryansh Arora
- Department of Radiodiagnosis, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi 110001, India
| | - Nimisha Lohiya
- Department of Radiodiagnosis, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi 110001, India
| | - Annu Singhal
- Department of Radiodiagnosis, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi 110001, India
| | - Akhila Prasad
- Department of Radiodiagnosis, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi 110001, India
| | - Aparna Katyal
- Department of Radiodiagnosis, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi 110001, India
| |
Collapse
|
4
|
Sullivan A, Radford C, Steele J, Platek D, Brodsky D. Twin Reversed Arterial Perfusion Sequence. Neoreviews 2022; 23:e141-e150. [PMID: 35102389 DOI: 10.1542/neo.23-2-e141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Anne Sullivan
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | | | - Jasmine Steele
- Harvard Medical School, Boston, MA
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Deborah Platek
- Harvard Medical School, Boston, MA
- Harvard Vanguard Medical Associates, Atrius Health, Boston, MA
| | - Dara Brodsky
- Harvard Medical School, Boston, MA
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA
| |
Collapse
|
5
|
Abouie A, Rakhshankhah N, Younesi L, Safarpour Z, Roostaee A, Amjad G. Twin reversed arterial perfusion sequence in a monochorionic monoamniotic twin pregnancy: a very rare condition. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2020. [DOI: 10.1186/s43055-020-00350-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Twin reversed arterial perfusion sequence (TRAP) is a very rare congenital anomaly. We present sonographic findings of TRAP sequence in the case of a multiparous woman with a monochorionic monoamniotic twin pregnancy who was referred to our unit for blood sugar control.
Case presentation
The patient had a history of co-twin demise at 13 weeks of gestation without appropriate fetal surveillance afterwards. We found a monochorionic placentation with a normal appearing pump twin, an abnormal appearing co-twin without obvious cardiac activity and reversed arterial flow toward instead of away from the anomalous acardiac fetus. Therefore, the sonographic diagnosis of TRAP sequence was confirmed.
Conclusions
We recommend considering the potential rare complications of monochorionic twin pregnancy which necessitates proper surveillance and intervention to monitor suitable growth of pump twin.
Collapse
|