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Fabrizio N, Pankey CL, Martin K, Baker M, Felty CC. Novel autopsy and genetic findings in an acardiac twin: case report and literature review. Autops Case Rep 2024; 14:e2024477. [PMID: 38487033 PMCID: PMC10939183 DOI: 10.4322/acr.2024.477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 02/05/2024] [Indexed: 03/17/2024]
Abstract
Twin reversed arterial perfusion (TRAP) sequence is a rare complication of monochorionic twinning whereby a donor twin perfuses an acardiac twin via aberrant vascular anastomoses. The resulting paradoxical retrograde blood flow supplying the acardiac twin is oxygen-poor, leading to some of the most severe malformations encountered in humans. Though the first descriptions of acardiac twins date back to at least the 16th century, the pathophysiologic processes which underpin the development of TRAP sequence are still being elucidated. Theories on the pathogenesis of TRAP sequence include deficiencies intrinsic to the embryo and primary abnormalities of the placental vasculature. Autopsy studies continue to provide clues to the underlying pathogenesis of TRAP sequence, and the characterization of the spectrum of manifestations that can be observed in acardiac twins. Herein, we present the clinical, autopsy, and molecular findings in a unique case of TRAP sequence. Novel findings include a primitive cloaca-like structure and chromosomal aberrations involving 6q11.1 and 15q25.1.
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Affiliation(s)
- Natalie Fabrizio
- West Virginia School of Osteopathic Medicine, Lewisburg, WV, United States
| | | | - Kathleen Martin
- West Virginia School of Osteopathic Medicine, Lewisburg, WV, United States
| | - Michael Baker
- Dartmouth-Hitchcock Medical Center, Department of Pathology and Laboratory Medicine, Lebanon, NH, United States
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Gobikrushanth M, Zachar EK, Singh N, Schumann F, Dadarwal D. Theriogenology Question of the Month. J Am Vet Med Assoc 2022; 260:170-173. [PMID: 34843438 DOI: 10.2460/javma.21.06.0285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Mohanathas Gobikrushanth
- Department of Large Animal Clinical Sciences, Western College of Veterinary Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Erin K Zachar
- Prairie Diagnostic Services Inc, University of Saskatchewan, Saskatoon, SK, Canada
| | - Navgeet Singh
- Department of Large Animal Clinical Sciences, Western College of Veterinary Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Fritz Schumann
- Department of Large Animal Clinical Sciences, Western College of Veterinary Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Dinesh Dadarwal
- Department of Large Animal Clinical Sciences, Western College of Veterinary Medicine, University of Saskatchewan, Saskatoon, SK, Canada
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Gemert MJC, Ross MG, Wijngaard JPHM, Nikkels PGJ. Hypothesized pathogenesis of acardius acephalus, acormus, amorphus, anceps, acardiac edema, single umbilical artery, and pump twin risk prediction. Birth Defects Res 2021; 114:149-164. [PMID: 34931489 PMCID: PMC9299632 DOI: 10.1002/bdr2.1976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 12/04/2021] [Indexed: 11/16/2022]
Abstract
Background Acardiac twinning complicates monochorionic twin pregnancies in ≈2.6%, in which arterioarterial (AA) and venovenous placental anastomoses cause a reverse circulation between prepump and preacardiac embryos and cessation of cardiac function in the preacardiac. Literature suggested four acardiac body morphologies in which select (groups of) organs fail to develop, deteriorate, or become abnormal: acephalus (≈64%, [almost] no head, part of body, legs), amorphus (≈22%, amorphous tissue lump), anceps (≈10%, cranial bones, well‐developed), and acormus (≈4%, head only). We sought to develop hypotheses that could explain acardiac pathogenesis, its progression, and develop methods for clinical testing. Methods We used qualitatively described pathophysiology during development, including twin‐specific AA and Hyrtl's anastomoses, the short umbilical cord syndrome, high capillary permeability, properties of spontaneous aborted embryos, and Pump/Acardiac umbilical venous diameter (UVD) ratios. Results We propose that each body morphology has a specific pathophysiologic pathway. An acephalus acardius may be larger than an anceps, verifiable from UVD ratio measurements. A single umbilical artery develops when one artery, unconnected to the AA, vanishes due to flow reduction by Hyrtl's anastomotic resistance. Acardiac edema may result from acardiac body hypoxemia combined with physiological high fetal capillary permeability, high interstitial compliance and low albumin synthesis. Morphological changes may occur after acardiac onset. Pump twin risk follows from UVD ratios. Conclusion Our suggested outcomes agree reasonably well with reported onset, incidence, and progression of acardiac morphologies. Guidance for clinical prediction and testing requires ultrasound anatomy/circulation study, from the first trimester onward.
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Affiliation(s)
- Martin J. C. Gemert
- Department of Biomedical Engineering & Physics Amsterdam UMC Amsterdam The Netherlands
| | - Michael G. Ross
- Department of Obstetrics and Gynecology Harbor UCLA Medical Center Torrance California USA
| | - Jeroen P. H. M. Wijngaard
- Department of Clinical Chemistry, Hematology and Immunology Diakonessenhuis Utrecht Zeist Doorn Utrecht The Netherlands
| | - Peter G. J. Nikkels
- Department of Pathology, Wilhelmina Children’s Hospital University Medical Center Utrecht The Netherlands
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Weber J, Rudolph N, Freick M. Facets of Clinical Appearance and Aetiology in an Unusual Bovine Amorphus Globosus. Anat Histol Embryol 2017; 46:502-506. [PMID: 28718952 DOI: 10.1111/ahe.12286] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 06/12/2017] [Indexed: 01/10/2023]
Abstract
Amorphus globosus is a rare entity, more common in the cow but also reported in mares, buffaloes and goats. In respect of both development and clinical presentation, this abnormity can be evolved very variably. Previously, it has been discussed whether it is a form of twin pregnancy or placental teratoma. This case report deals with morphology and genetic observations in an unusual bovine amorphus globosus exhibiting a rudimentary clitoris and vulva, gut-like structures and rudimentary bones. The amorphus globosus was shown to be dizygotic to the normal male twin using the BovineSNP50 v2 BeadChip and had a genetical female sex. Aspects of aetiology and pathogenesis as well as the possible impact of amorphus globosus in the emergence of freemartinism are discussed.
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Affiliation(s)
- J Weber
- Veterinary Practice Zettlitz, Straße der Jugend 68, 09306, Zettlitz, Germany
| | - N Rudolph
- Saxon State Laboratory of Health and Veterinary Affairs, Dresden, Germany
| | - M Freick
- Veterinary Practice Zettlitz, Straße der Jugend 68, 09306, Zettlitz, Germany
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Ruiz-Cordero R, Birusingh RJ, Pelaez L, Azouz M, Rodriguez MM. Twin Reversed Arterial Perfusion Sequence (TRAPS): An Illustrative Series of 13 Cases. Fetal Pediatr Pathol 2016; 35:63-80. [PMID: 26847661 DOI: 10.3109/15513815.2015.1131785] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Twin reversed-arterial-perfusion sequence (TRAPS) is a rare and severe complication of monochorionic twin pregnancies. It usually occurs in the setting of monochorionic placentation, when the heart of a normal appearing twin serves as the pump for one or more dysmorphic twins whose head, thoracic organs, and upper extremities do not fully develop or do not develop at all and thus lack cardiac activity. Anomalous vascular placental architecture causes a shift in arterial flow towards the acardiac twin(s). The exact physiopathologic mechanisms that lead to this devastating phenomenon are not well known. We reviewed the maternal history and the surgical pathology reports of the fetuses and placentas of 13 different cases of TRAPS that were collected in a 23-year study period at a single institution. Herein we summarize the characteristic findings and illustrate specific mechanical feto-placental circulation issues that appear to be instrumental in the development of TRAPS.
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Affiliation(s)
| | | | - Liset Pelaez
- a Pathology, University of Miami , Miami , Florida , USA
| | - Michel Azouz
- b Radiology, University of Miami , Miami , Florida , USA
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Rehder H, Schoner K, Kluge B, Louwen F, Schwinger E, Neesen J. Klinefelter twins presenting with discordant aneuploidies, acardia, forked umbilical cord and with different gonadal sex despite monozygosity. Prenat Diagn 2012; 32:173-9. [PMID: 22418962 DOI: 10.1002/pd.2928] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE A higher frequency of twin births in sibships of Klinefelter syndrome patients and also monozygotic or dizygotic twins, themselves being affected by Klinefelter syndrome have been noted repeatedly. To address this issue, we evaluated type and frequency of twinning among Klinefelter fetuses that we had received for autopsy within a 'Prenatal Diagnosis' program. METHOD We performed fetal autopsies, and genetic analyses on DNA extracted from stained histological slides. RESULTS Among 41 prenatal diagnoses of a 47, XXY karyotype we observed four twin pairs. One was dizygotic with discordant Klinefelter and Down syndrome. Three twin pairs were monozygotic as concluded from monochorial placentation. In two monozygotic pairs one twin partner was an acardiac monster and in one of these the acardiac twin showed a female gonadal sex and missing Y-chromosomal SRY-sequences as confirmed by polymerase chain reaction. CONCLUSIONS There is a high rate of twinning and twin reversed arterial perfusion sequence among our Klinefelter fetuses. Forked umbilical cords at the placental insertion site in one case allowed classification as conjoined twins in the sense of a 'funiculopagus'. Anaphase lagging or semidizygosity by second polar body twinning are proposed as explanations for the gonadal sex discordance and the excessive developmental disadvantage in the one acardiac. Problems may arise with regard to non-invasive prenatal diagnosis of aneuploidies in twin pregnancies.
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Affiliation(s)
- Helga Rehder
- Institute of Medical Genetics, Medical University Vienna, Austria.
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Botto LD, Feldkamp ML, Amar E, Carey JC, Castilla EE, Clementi M, Cocchi G, de Walle HE, Halliday J, Leoncini E, Li Z, Lowry RB, Marengo LK, Martínez-Frías ML, Merlob P, Morgan M, Muñoz LL, Rissmann A, Ritvanen A, Scarano G, Mastroiacovo P. Acardia: Epidemiologic findings and literature review from the International Clearinghouse for Birth Defects Surveillance and Research. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2011; 157C:262-73. [DOI: 10.1002/ajmg.c.30318] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2011] [Accepted: 08/28/2011] [Indexed: 11/09/2022]
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Martínez-Frías ML. Epidemiology of acephalus/acardius monozygotic twins: new insights into an epigenetic causal hypothesis. Am J Med Genet A 2009; 149A:640-9. [PMID: 19291778 DOI: 10.1002/ajmg.a.32741] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Apart from a series of 10 acephalus/acardius (Ac/Ac) cases described from a pathological point of view, and the analysis of a review of published cases, we have been unable to find any epidemiological studies on Ac/Ac. Using data from the Spanish Collaborative Study of Congenital Malformations (ECEMC), we present here what seems to be the first epidemiological analysis of a consecutive series of the Ac/Ac type of monozygotic twins (MZT). Among a total of 2,281,604 consecutive births, 11 cases of Ac/Ac MZT were detected, giving a frequency of 0.48 per 100,000 births. However, we consider the period 1980-1985 as the baseline for our data, as in this period voluntary termination of pregnancy was not possible in Spain, and the frequency of Ac/Ac MZT was 0.49 per 100,000 births. Nonetheless, this frequency should be considered as a minimal estimation. The characteristics of these Ac/Ac cases indicate that they are more frequent in males (sex ratio 2.67). In addition, gestational age in Ac/Ac cases was 2.41 and 3.12 weeks lower than in malformed and control twins, respectively. Similarly, their mothers are 4.54 and 4.68 years younger than mothers of separate malformed and control twins, respectively. To understand the biological basis behind the occurrence of MZT in the context of recent observations, we evaluate the hypothesis that the epigenetic processes involved in the early cleavage of the embryo, and in blastocyst formation during development, may be implicated in twinning.
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MESH Headings
- Abnormalities, Multiple/embryology
- Abnormalities, Multiple/epidemiology
- Abnormalities, Multiple/genetics
- Anencephaly/embryology
- Anencephaly/epidemiology
- Anencephaly/genetics
- Case-Control Studies
- Databases, Genetic
- Epigenesis, Genetic
- Female
- Heart Defects, Congenital/embryology
- Heart Defects, Congenital/epidemiology
- Heart Defects, Congenital/genetics
- Humans
- Infant, Newborn
- Male
- Models, Genetic
- Pregnancy
- Sex Ratio
- Spain/epidemiology
- Twins, Monozygotic
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Affiliation(s)
- María Luisa Martínez-Frías
- ECEMC, Centro de Investigación sobre Anomalías Congénitas, Instituto de Salud Carlos III, Madrid, Spain.
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Steffensen TS, Gilbert-Barness E, Spellacy W, Quintero RA. Placental pathology in trap sequence: clinical and pathogenetic implications. Fetal Pediatr Pathol 2008; 27:13-29. [PMID: 18568986 DOI: 10.1080/15513810801893389] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Twin reversed arterial perfusion sequence (TRAP) resulting in an acardiac twin is a rare occurrence. Acardia requires the presence of arterial-arterial anastomosis, with retrograde perfusion of poorly oxygenated blood from the normal twin to the acardiac twin, venous-venous anastomosis carrying blood back from the acardiac to the normal twin, and circulatory failure of the acardiac twin. Although vascular anastomoses in cases of TRAP have been well described, there is little published literature on the microscopic changes in the placenta in TRAP sequence. We report a case of monochorionic monozygotic twins with an acardiac twin, large arterial-arterial anastomosis, and direct continuity of the umbilical cord veins. The placenta showed villous immaturity, striking villous calcifications, and extensive fetal thrombotic vasculopathy of the umbilical vein of the donor twin and the chorionic plate vessels. Thrombi in the umbilical vessels of the acardiac twin have been reported, and trombi in donor twin organs have been seen after fetal demise in utero. But to our knowledge there is no previously reported thrombi in the donor twin umbilical vessels or the chorionic plate veins. This may have implications not only as a possible factor in the etiology of TRAP, but also and more important as a possible risk factor for thrombotic events in the donor twin. Further studies with clinico-pathological correlation are needed to explore this issue.
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Affiliation(s)
- Thora S Steffensen
- Department of Pathology, University of South Florida and Tampa General Hospital, Tampa, Florida, USA
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Current World Literature. Curr Opin Obstet Gynecol 2007; 19:596-605. [DOI: 10.1097/gco.0b013e3282f37e31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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