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Yamamoto R, Kuruma A, Moriuchi K, Shiro M, Wagata M, Yamamoto R, Kawaguchi H, Hayashi S, Ishii K. Re-evaluation of the predictive value of Quintero staging of twin-twin transfusion syndrome for fetal death after fetoscopic laser photocoagulation. Prenat Diagn 2021; 41:1560-1567. [PMID: 34586692 DOI: 10.1002/pd.6053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 09/07/2021] [Accepted: 09/09/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To elucidate the significance of sonographic indices, including Doppler waveforms, that constitute the Quintero classification for predicting death of the recipient or donor after fetoscopic laser photocoagulation (FLP) for twin-twin transfusion syndrome (TTTS). METHODS Prospectively collected data of twins who underwent FLP for TTTS were reviewed. Among the abnormal indices of ultrasound performed just before FLP, factors that were significantly associated with fetal and neonatal deaths in the log-rank test, including fetal demise of co-twins and preterm birth before 28 weeks of gestation, were introduced into the Cox proportional-hazards model to calculate risk ratio (RR). RESULTS We included 235 cases with a prevalence of recipient and donor deaths of 7% and 14%, respectively. In the proportional-hazards model, absent or reversed umbilical artery end-diastolic velocity (UA AREDV) of recipients (n = 7) was independently associated with recipient death (RR = 6.97). In recipients without UA AREDV, reversed ductus venosus (DV) a-wave of recipients (RR = 3.55) was independently associated with recipient death. In donors, UA AREDV with a visible bladder (stage III atypical donor) was independently associated with donor death (RR = 4.24). CONCLUSION Some individual components of the Quintero stage are associated with death of either recipient or donor twins following FLP.
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Affiliation(s)
- Ryo Yamamoto
- Department of Fetal Maternal Medicine, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Airi Kuruma
- Department of Fetal Maternal Medicine, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Kaori Moriuchi
- Department of Fetal Maternal Medicine, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Michihisa Shiro
- Department of Fetal Maternal Medicine, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Maiko Wagata
- Department of Fetal Maternal Medicine, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Rumiko Yamamoto
- Department of Fetal Maternal Medicine, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Haruna Kawaguchi
- Department of Fetal Maternal Medicine, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Shusaku Hayashi
- Department of Fetal Maternal Medicine, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Keisuke Ishii
- Department of Fetal Maternal Medicine, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
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Spruijt MS, Lopriore E, J Steggerda S, Slaghekke F, Van Klink JMM. Twin-twin transfusion syndrome in the era of fetoscopic laser surgery: antenatal management, neonatal outcome and beyond. Expert Rev Hematol 2020; 13:259-267. [PMID: 31971028 DOI: 10.1080/17474086.2020.1720643] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Introduction: Twin-twin transfusion syndrome (TTTS) is a devastating complication of monochorionic twin pregnancy and remains a major challenge for worldwide fetal medicine specialists. In TTTS, intertwin transfusion through vascular anastomoses in the shared placenta leads to severe hemodynamic imbalance. This review summarizes the current knowledge of TTTS.Areas covered: The most recent insights concerning the management of TTTS, as well as fetal and neonatal complications are described. Relevant articles were selected based on a Pubmed search using the keywords below. Understanding of the underlying pathophysiology has improved greatly as a result of placental injection studies. Advancements in antenatal management have led to increased perinatal survival and a decreased incidence of neonatal complications, including brain injury and neurodevelopmental impairment.Expert opinion: Further opportunities for improvement comprise technological innovations in laser procedures and the prevention of preterm rupture of membranes with subsequent prematurity. A noninvasive treatment such as high-intensity focused ultrasound (HIFU) seems to hold promise for the future treatment of TTTS. Fetal MRI studies are important to improve our understanding of fetal brain injury and should relate their findings to long-term neurodevelopment. International collaboration and centralization of care are of paramount importance to ensure the best care for our patients.
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Affiliation(s)
- Marjolijn S Spruijt
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Enrico Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Sylke J Steggerda
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Femke Slaghekke
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeanine M M Van Klink
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
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Emotional Effect of the Loss of One or Both Fetuses in a Monochorionic Twin Pregnancy. J Obstet Gynecol Neonatal Nurs 2018; 47:137-145. [DOI: 10.1016/j.jogn.2018.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/01/2018] [Indexed: 10/18/2022] Open
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Djaafri F, Stirnemann J, Mediouni I, Colmant C, Ville Y. Twin-twin transfusion syndrome - What we have learned from clinical trials. Semin Fetal Neonatal Med 2017; 22:367-375. [PMID: 29122542 DOI: 10.1016/j.siny.2017.08.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Monochorionic twin pregnancies are at increased risk for adverse outcome compared to dichorionic twin pregnancies and singletons. Monochorionic-specific complications include twin-twin transfusion syndrome (TTTS), twin anemia-polycythemia sequence, single intrauterine fetal demise and its consequences on the co-twin, and selective intrauterine growth restriction. Whereas the natural history of monochorionic-specific complications carries a high risk of fetal death or severe neurologic disability, a framework now exists, based on well-designed clinical trials, for optimal treatment of these entities. Fetoscopic selective laser coagulation of anastomotic vessels on the chorionic plate has been clearly demonstrated to improve survival and neurologic outcomes for Quintero stage ≥2 TTTS. However, many challenges remain unsolved, the most important of which is preterm premature rupture of membranes. Further improvement in the outcomes of monochorionic pregnancies will require improvements in the rate of premature delivery, and improved diagnosis and treatment strategies for early and late onset TTTS.
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Affiliation(s)
- Fatiha Djaafri
- Obstetrics and Maternal-Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France
| | - Julien Stirnemann
- Obstetrics and Maternal-Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France; EA7328, Faculté de Medicine Paris Descartes, Paris, France
| | - Imen Mediouni
- Obstetrics and Maternal-Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France
| | - Claire Colmant
- Obstetrics and Maternal-Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France
| | - Yves Ville
- Obstetrics and Maternal-Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France; EA7328, Faculté de Medicine Paris Descartes, Paris, France.
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Murata S, Takano M, Kagawa Y, Sumie M, Nakata M. The experience of modified sequential selective laser photocoagulation of communicating vessels technique for twin-twin transfusion syndrome. J Matern Fetal Neonatal Med 2017; 31:1137-1141. [DOI: 10.1080/14767058.2017.1311309] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Susumu Murata
- Department of Obstetrics and Gynecology, Kawasaki Medical School, Okayama, Japan
| | - Mayumi Takano
- Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - Yukiko Kagawa
- Department of Obstetrics and Gynecology, Kawasaki Medical School, Okayama, Japan
| | - Masahiro Sumie
- Department of Obstetrics, Fukuoka Children’s Hospital, Fukuoka, Japan
| | - Masahiko Nakata
- Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
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Slaghekke F, Zhao DP, Middeldorp JM, Klumper FJ, Haak MC, Oepkes D, Lopriore E. Antenatal management of twin-twin transfusion syndrome and twin anemia-polycythemia sequence. Expert Rev Hematol 2016; 9:815-20. [PMID: 27322562 DOI: 10.1080/17474086.2016.1200968] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Twin-twin transfusion syndrome (TTTS) and twin anemia polycythemia sequence (TAPS) are severe complications in monochorionic twin pregnancies associated with high mortality and morbidity risk if left untreated. Both diseases result from imbalanced inter-twin blood transfusion through placental vascular anastomoses. AREAS COVERED This review focuses on the differences in antenatal management between TTTS and TAPS. Expert commentary: The optimal management for TTTS is fetoscopic laser coagulation of the vascular anastomoses, preferably using the Solomon technique in which the whole vascular equator is coagulated. The Solomon technique is associated with a reduction of residual anastomosis and a reduction in post-operative complications. The optimal management for TAPS is not clear and includes expectant management, intra-uterine transfusion with or without partial exchange transfusion and fetoscopic laser surgery.
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Affiliation(s)
- Femke Slaghekke
- a Division of Fetal Medicine, Department of Obstetrics , Leiden University Medical Centre , Leiden , The Netherlands
| | - Depeng P Zhao
- b Division of Neonatology, Department of Pediatrics , Leiden University Medical Centre , Leiden , The Netherlands
| | - Johanna M Middeldorp
- a Division of Fetal Medicine, Department of Obstetrics , Leiden University Medical Centre , Leiden , The Netherlands
| | - Frans J Klumper
- a Division of Fetal Medicine, Department of Obstetrics , Leiden University Medical Centre , Leiden , The Netherlands
| | - Monique C Haak
- a Division of Fetal Medicine, Department of Obstetrics , Leiden University Medical Centre , Leiden , The Netherlands
| | - Dick Oepkes
- a Division of Fetal Medicine, Department of Obstetrics , Leiden University Medical Centre , Leiden , The Netherlands
| | - Enrico Lopriore
- b Division of Neonatology, Department of Pediatrics , Leiden University Medical Centre , Leiden , The Netherlands
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Beauquier-Maccotta B, Chalouhi GE, Picquet AL, Carrier A, Bussières L, Golse B, Ville Y. Impact of Monochorionicity and Twin to Twin Transfusion Syndrome on Prenatal Attachment, Post Traumatic Stress Disorder, Anxiety and Depressive Symptoms. PLoS One 2016; 11:e0145649. [PMID: 26751570 PMCID: PMC4709103 DOI: 10.1371/journal.pone.0145649] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 12/07/2015] [Indexed: 11/19/2022] Open
Abstract
Monochronioric (MC) twin pregnancies are considered as high-risk pregnancies with potential complications requiring in-utero interventions. We aimed to assess prenatal attachment, anxiety, post-traumatic stress disorder (PTSD) and depressive symptoms in MC pregnancies complicated with Twin-To-Twin-transfusion syndrome (TTTS) in comparison to uncomplicated monochorionic (UMC) and dichorionic pregnancies (DC). Auto-questionnaires were filled out at diagnosis of TTTS and at successive milestones. Prenatal attachment, PTSD, anxiety and perinatal depression were evaluated respectively by the Prenatal Attachment Inventory (PAI) completed for each twin, the Post-traumatic Checklist Scale (PCLS), the State-Trait Anxiety Inventory (STAI) and the Edinburgh Perinatal Depression Scale (EPDS). There was no significant difference in the PAI scores between the two twins. In the DC and UMC groups, PAI scores increased throughout pregnancy, whilst it didn't for TTTS group. TTTS and DC had a similar prenatal attachment while MC mothers expressed a significantly higher attachment to their fetuses and expressed it earlier. At the announcement of TTTS, 72% of the patients present a score over the threshold at the EPDS Scale, with a higher score for TTTS than for DC (p = 0.005), and UMC (p = 0.007) at the same GA. 30% of mothers in TTTS group have PTSD during pregnancy. 50% of TTTS- patients present an anxiety score over the threshold (STAI-Scale), with a score significantly higher in TTTS than in UMC (p<0.001) or DC (p<0.001). The proportion of subject with a STAI-State over the threshold is also significantly higher in TTTS than in DC at 20 GW (p = 0.01) and at 26 GW (p<0.05). The STAI-state scores in UMC and DC increase progressively during pregnancy while they decrease significantly in TTTS. TTTS announcement constitutes a traumatic event during a pregnancy with an important risk of PTSD, high level of anxiety and an alteration of the prenatal attachment. These results should guide the psychological support provided to these patients.
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Affiliation(s)
- Berengere Beauquier-Maccotta
- Department of Child and Adolescent Psychiatry, Necker-Enfants-Malades Hospital, APHP, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Gihad E. Chalouhi
- Obstetrics and Fetal Medicine Department, Necker-Enfants-Malades Hospital, APHP, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
- Rare Disease Center- TTTS, Necker-Enfants-Malades Hospital, APHP, Paris, France
| | - Anne-Laure Picquet
- Rare Disease Center- TTTS, Necker-Enfants-Malades Hospital, APHP, Paris, France
| | - Aude Carrier
- Obstetrics and Fetal Medicine Department, Necker-Enfants-Malades Hospital, APHP, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
- Rare Disease Center- TTTS, Necker-Enfants-Malades Hospital, APHP, Paris, France
| | - Laurence Bussières
- Rare Disease Center- TTTS, Necker-Enfants-Malades Hospital, APHP, Paris, France
| | - Bernard Golse
- Department of Child and Adolescent Psychiatry, Necker-Enfants-Malades Hospital, APHP, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Yves Ville
- Obstetrics and Fetal Medicine Department, Necker-Enfants-Malades Hospital, APHP, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
- Rare Disease Center- TTTS, Necker-Enfants-Malades Hospital, APHP, Paris, France
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Akkermans J, Peeters SH, Klumper FJ, Lopriore E, Middeldorp JM, Oepkes D. Twenty-Five Years of Fetoscopic Laser Coagulation in Twin-Twin Transfusion Syndrome: A Systematic Review. Fetal Diagn Ther 2015; 38:241-53. [DOI: 10.1159/000437053] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 06/17/2015] [Indexed: 11/19/2022]
Abstract
Objective: The aim of this study was to assess the perinatal outcome of pregnancies with twin-twin transfusion syndrome (TTTS) treated with laser therapy over the past 25 years, and in relation to different techniques used in this time period. Methods: A systematic review of studies reporting on perinatal outcome according to the Meta-Analysis of Observational Studies in Epidemiology (MOOSE) guidelines was conducted. The MEDLINE, Embase and Cochrane Library databases were systematically searched. Comparisons were made in respect to time period and laser technique and Quintero stages. Results: In total, 34 studies reporting on 3,868 monochorionic twin pregnancies were included. The mean survival of both twins increased from 35 to 65% (p = 0.012) and for at least one twin from 70 to 88% (p = 0.009) over the past 25 years. Mean gestational age at birth remained stable over the years at 32 weeks gestation. Also, we showed a significantly improved perinatal survival with the evolution of the laser technique from non-selective to selective, selective sequential and the Solomon technique (p = 0.010). Discussion: Since the introduction of laser therapy for TTTS more than two decades ago, perinatal survival improved significantly. Improved outcome is probably associated with several factors, including evolution of the laser technique, learning curve effect, better referral and improved early neonatal care.
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