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Jha P, Feldstein VA, Poder L, Strachowski LM, Bulas DI, Burger I, Laifer-Narin SL, Oliver ER, Wang EY, Zelop CM, Kang SK. ACR Appropriateness Criteria® Multiple Gestations: 2024 Update. J Am Coll Radiol 2024; 21:S413-S432. [PMID: 39488352 DOI: 10.1016/j.jacr.2024.08.013] [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: 08/21/2024] [Accepted: 08/26/2024] [Indexed: 11/04/2024]
Abstract
The incidence of twin pregnancies has been rising, largely attributable to increasing use of artificial reproductive techniques. Ultrasound plays a critical role in establishing the chorionicity and amnionicity of multiple gestations, a key predictor of the expected risk and complications, along with guiding future clinical and imaging follow-up examinations and intervals. People carrying multiple gestations will typically undergo more ultrasound examinations (and occasionally fetal MRI) than those carrying singletons, at minimum including a first trimester dating scan, nuchal translucency scan at 11 to 14 weeks, an anatomy scan at 18 to 22 weeks, and other scans in the second and third trimesters for growth and surveillance. This document clarifies the most appropriate imaging guidelines for multiple gestations for seven clinical scenarios/variants, which range from initial imaging, follow-up imaging, growth and surveillance for uncomplicated multiple gestations, and those complicated by a known abnormality or discordance between fetuses. 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 process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
- Priyanka Jha
- Stanford University School of Medicine, Stanford, California.
| | | | - Liina Poder
- Panel Chair, University of California San Francisco, San Francisco, California
| | | | - Dorothy I Bulas
- Children's National Hospital and George Washington University, Washington, District of Columbia
| | | | | | - Edward R Oliver
- Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Eileen Y Wang
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; American College of Obstetricians and Gynecologists
| | - Carolyn M Zelop
- Valley Hospital, Ridgewood, New Jersey and NYU School of Medicine, New York, New York; American College of Obstetricians and Gynecologists
| | - Stella K Kang
- Specialty Chair, New York University Medical Center, New York, New York
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Guzys A, Reid SM, Bolch C, Reddihough DS, Teoh M, Palma-Dias R, Fung A, Cole S, Hodges R, Fahey M, Walker SP. Developmental outcomes for survivors of placental laser photocoagulation for the management of twin-to-twin transfusion syndrome. BMC Pregnancy Childbirth 2023; 23:699. [PMID: 37770827 PMCID: PMC10540356 DOI: 10.1186/s12884-023-05997-5] [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: 03/17/2023] [Accepted: 09/13/2023] [Indexed: 09/30/2023] Open
Abstract
BACKGROUND Fetoscopic laser coagulation of placental anastomoses reverses the pathological process in twin-to-twin transfusion syndrome, thereby increasing survival, but there are a paucity of studies addressing long-term neurodevelopmental outcome of survivors. This study aimed to ascertain the presence of neurodevelopmental disabilities in child survivors of monochorionic pregnancies managed by placental laser photocoagulation in the Australian state of Victoria. METHODS All pregnancies undergoing placental laser photocoagulation with the Victorian Fetal Therapy Service between 2006-2017 were included. Information on each surviving child, including demographics, perinatal course, and developmental progress was collected from parents, and consent was sought to complete the Child Behaviour Checklist. Interviewers evaluated whether this information was consistent with a diagnosis of any of 14 neurodevelopmental conditions. A three-tiered outcome measure was allocated for each child: (1) unimpaired or developmentally normal, (2) mild or moderate neurological impairment, or (3) severe neurological impairment. Clinical predictors for adverse outcome were identified. RESULTS Of 116 pregnancies (113 twin, 3 triplet), 96 (83%) resulted in 1 + surviving fetuses. 57/113 (50%) twin pregnancies resulted in 2 survivors, 36 (32%) in 1 survivor, and 20 (18%) in no survivors. Of the 235 fetuses, 154 (65.5%) survived to follow-up. Survival increased from 59% in 2006-2008 to 73% in 2015-2017. 90/154 (58%) survivors were followed up at a mean age of 7.5 [SD 3.0] years. Based on parental interview and Child Behaviour Checklist data, 28/90 (31%) participants were assessed as having neurodevelopmental impairment, 27 of mild-moderate severity and 1 severe. Speech/language disorders, attention deficit (hyperactivity) disorders, and fine motor impairment were most common. Neonatal length of stay conferred the highest risk of impairment. CONCLUSION Substantial variation exists between fetal therapy services in the type and length of neonatal follow-up following fetoscopic laser coagulation, contributing to a lack of data on long-term outcomes. The findings from this study support increasingly urgent calls to undertake systematic and sustained follow-up of fetoscopic laser coagulation survivors until school age. Information from this study may assist parents in their decision-making when offered fetal surgery. Importantly, it highlights a group for targeted surveillance and early intervention.
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Affiliation(s)
- Angela Guzys
- Neurodisability and Rehabilitation, Murdoch Children's Research Institute, Melbourne, Australia
| | - Susan M Reid
- Neurodisability and Rehabilitation, Murdoch Children's Research Institute, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
- Department of Neurodevelopment and Disability, The Royal Children's Hospital, Melbourne, Australia
| | - Christie Bolch
- Neurodisability and Rehabilitation, Murdoch Children's Research Institute, Melbourne, Australia
| | - Dinah S Reddihough
- Neurodisability and Rehabilitation, Murdoch Children's Research Institute, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
- Department of Neurodevelopment and Disability, The Royal Children's Hospital, Melbourne, Australia
| | - Mark Teoh
- Fetal Diagnostics Unit, Monash Health, Melbourne, Australia
- Victorian Fetal Therapy Service, Monash Health, Melbourne, Australia
| | - Ricardo Palma-Dias
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia
- Ultrasound Services, The Royal Women's Hospital, Melbourne, Australia
| | - Alison Fung
- Mercy Perinatal, Mercy Hospital for Women, Melbourne, Australia
| | - Stephen Cole
- Division of Maternity Services, The Royal Women's Hospital, Melbourne, Australia
| | - Ryan Hodges
- Women's and Newborn Program, Monash Health, Melbourne, Australia
| | - Michael Fahey
- Paediatric Neurology Unit, Monash Children's Hospital, Melbourne, Australia
- Department of Paediatrics, Monash University, Melbourne, Australia
| | - Susan P Walker
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia.
- Mercy Perinatal, Mercy Hospital for Women, Melbourne, Australia.
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da Silva Rocha J, Guedes-Martins L, Cunha A. Twin Anemia-Polycythemia Sequence (TAPS): From Basic Research to Clinical Practice. Curr Vasc Pharmacol 2023; 21:91-105. [PMID: 36718965 DOI: 10.2174/1570161121666230131112930] [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: 09/28/2022] [Revised: 12/30/2022] [Accepted: 12/30/2022] [Indexed: 02/01/2023]
Abstract
Twin pregnancy is associated with an increased risk of perinatal and maternal complications, and early establishment of the chorionicity type defines this risk. In monochorionic (MC) pregnancies, the fetuses share the same placental mass and exhibit vascular anastomoses crossing the intertwin membrane, and the combination and pattern of anastomoses determine the primary clinical picture and occurrence of future complications. Twin Anemia-Polycythemia Sequence (TAPS) was first described in 2006 after fetoscopic laser surgery in twin-to-twin transfusion syndrome (TTTS) twins, and in 2007, the first spontaneous cases were reported, recognizing TAPS as an individualized vascular identity in fetofetal transfusion syndromes. There are two types of TAPS: spontaneous (3-5%) and iatrogenic or postlaser (2-16%). TAPS consists of small diameter arteriovenous anastomoses (<1 mm) and low-rate, small-caliber AA anastomoses in the absence of amniotic fluid discordances. There are certain antenatal and postnatal diagnostic criteria, which have progressively evolved over time. New, additional secondary markers have been proposed, and their reliability is being studied. The best screening protocol for TAPS in MC twins is still a matter of debate. This review provides a survey of the relevant literature on the epidemiology, vascular pathophysiology, underlying hemodynamic factors that regulate mismatched vascular connections, and diagnostic criteria of this condition. The aim is to increase awareness and knowledge about this recently identified and frequently unrecognized and misdiagnosed pathology.
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Affiliation(s)
- Joana da Silva Rocha
- Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto 4050-313, Portugal
| | - Luís Guedes-Martins
- Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto 4050-313, Portugal
- Centro Hospitalar Universitário do Porto EPE, Centro Materno Infantil do Norte, Centro de Medicina Fetal, Serviço de Obstetrícia, Departamento da Mulher e da Medicina Reprodutiva, Largo Prof. Abel Salazar, Porto 4099-001, Portugal
- Unidade de Investigação e Formação - Centro Materno Infantil do Norte, Porto 4099-001, Portugal
- Instituto de Investigação e Inovação em Saúde, Universidade do Porto, 4200-319 Portugal
| | - Ana Cunha
- Centro Hospitalar Universitário do Porto EPE, Centro Materno Infantil do Norte, Centro de Medicina Fetal, Serviço de Obstetrícia, Departamento da Mulher e da Medicina Reprodutiva, Largo Prof. Abel Salazar, Porto 4099-001, Portugal
- Unidade de Investigação e Formação - Centro Materno Infantil do Norte, Porto 4099-001, Portugal
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Wang X, Li L, Yuan P, Zhao Y, Wei Y. Effect of fetoscopic laser surgery on the placental characteristics and birth-weight discordance of twins with twin-to-twin transfusion syndrome. Front Med (Lausanne) 2022; 9:942816. [PMID: 36250079 PMCID: PMC9556886 DOI: 10.3389/fmed.2022.942816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 08/31/2022] [Indexed: 11/30/2022] Open
Abstract
Objective This study explored the effect of fetoscopic laser surgery on the placental structure and birth-weight discordance of twin-to-twin transfusion syndrome (TTTS). Methods A retrospective cohort study was conducted in TTTS patients who were admitted to the Peking University Third Hospital between April 2014 and April 2020. The patients were divided into two groups: laser group and control group. Placentas with twin survival were injected, and pregnancy outcomes and placental characteristics of the two groups were compared. The correlation between the birth-weight discordance and placental characteristics in each group was analyzed. Results The gestational age at first diagnosis in the laser group was significantly smaller than that in the control group (21.6 ± 2.8 weeks vs. 27.7 ± 3.0 weeks, p < 0.001). The proportion of patients with TTTS stage-I in the laser group was significantly lower than the control group (9.4 vs. 64.0%, p < 0.001). The gestational age at delivery in the laser group was significantly larger than that in the control group (33.6 ± 2.1 weeks vs. 31.4 ± 2.5 weeks, p = 0.001). In the laser group, the birth-weight discordance ratio was positively correlated with the placental territory discordance ratio (Spearman coefficient = 0.556; p = 0.001). Conclusion The birth-weight discordance is positively correlated with placental territory discordance in TTTS patients after FLS.
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Affiliation(s)
| | | | | | | | - Yuan Wei
- *Correspondence: Yuan Wei, ; orcid.org/0000-0003-3387-7549
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Twin-to-Twin Transfusion Syndrome: Diagnostic Imaging and Its Role in Staving Off Malpractice Charges and Litigation. Diagnostics (Basel) 2021; 11:diagnostics11030445. [PMID: 33806678 PMCID: PMC8002196 DOI: 10.3390/diagnostics11030445] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 03/01/2021] [Indexed: 11/16/2022] Open
Abstract
The study aims to expound upon the imaging-based diagnostic methodologies aimed at identifying twin-to-twin transfusion syndrome (TTTS), a serious, somewhat rare prenatal condition that takes place in pregnancies where identical twins, or other multiples, share a placenta (monochorionic placenta), highlighting how medico-legal outcomes can be affected by provable compliance with consolidated diagnostic guidelines or best practices. It is of utmost importance to produce a prompt identification of TTTS instances; an early diagnosis is in fact critical in order to effectively treat and manage TTTS. By virtue of TTTS being a highly progressive condition, a delay in diagnosis can result in disastrous outcomes; just a few weeks delay in the diagnosis of TTTS can turn out fatal for one or both twins. Hence, most TTTS malpractice claims involve allegations of medical negligence, namely the failure to recognize the condition in a timely fashion, or to proceed with adequate diagnostic and therapeutic pathways. In that regard, case law databases have been pored over (Justia, Lexis, Leagle), and five significant court cases have been examined and discussed in an attempt to identify objective medico-legal standards and bring to the forefront relevant forensic dynamics. In fact, when health professionals are capable of proving adherence to guidelines or best practices, this can shield them from malpractice allegations and ensuing litigation.
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Rezende TMDES, Weihermann V, Fachin CG, Bruns RF, Dias AIBS. Twin-twin transfusion syndrome - a University Hospital experience with intrauterine treatment. Rev Col Bras Cir 2021; 48:e20202671. [PMID: 33503142 PMCID: PMC10846384 DOI: 10.1590/0100-6991e-20202671] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 08/27/2020] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION twin-to-twin transfusion syndrome (TTTS), defined by combination of polyhydramnios-oligohydramnios, is the most prevalent (5%-35%) of the abnormalities due to placental vascular anastomoses and the most lethal (80%-100% mortality) if untreated. Fetoscopic laser ablation of abnormal vasculature using the Solomon technique is the gold standard approach. It consists of interrupting the intertwin blood flow. OBJECTIVES to present our initial experience at the Fetal Surgery Service of the Hospital de Clinicas of the Federal University of Parana (HC-UFPR) and to compare our results with those reported in the literature. METHODS we conducted a retrospective analysis of pregnancies who had undergone laser ablation, assessing data on Quintero's staging, gestational age at diagnosis and at the time of the procedure, placental position, immediate post-procedure survival, and survival after the neonatal period. We then compared these data with the most recent data available in the literature. RESULTS we analyzed ten TTTS cases. The diagnosis was performed before the 26th week of pregnancy (median 20.8 weeks) and treatment occurred in a median of 9.5 days later. The distribution by the Quintero's staging was of three cases in stage II, five in stage III, and two in stage IV. In 50% of the gestations, at least one of the fetuses survived through the neonatal period. CONCLUSION the treatment of TTTS in the HC-UFPR had a positive impact in the survival of the affected fetuses, although the results were worse than the ones reported in the literature, probably due to the delay in referencing the patients to our service, leading to a prolonged interval between diagnosis and treatment.
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Affiliation(s)
| | - Viktoria Weihermann
- - Federal University of Paraná, Department of Pediatric Surgery - Curitiba - PR - Brazil
| | - Camila Girardi Fachin
- - Federal University of Paraná, Department of Pediatric Surgery - Curitiba - PR - Brazil
| | - Rafael Frederico Bruns
- - Federal University of Paraná, Department of Gynecology and Obstetrics - Curitiba - PR - Brazil
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Park KB, Chapman T, Aldinger KA, Mirzaa GM, Zeiger J, Beck A, Glass IA, Hevner RF, Jansen AC, Marshall DA, Oegema R, Parrini E, Saneto RP, Curry CJ, Hall JG, Guerrini R, Leventer RJ, Dobyns WB. The spectrum of brain malformations and disruptions in twins. Am J Med Genet A 2020; 185:2690-2718. [PMID: 33205886 DOI: 10.1002/ajmg.a.61972] [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] [Received: 06/22/2020] [Revised: 09/27/2020] [Accepted: 10/24/2020] [Indexed: 12/12/2022]
Abstract
Twins have an increased risk for congenital malformations and disruptions, including defects in brain morphogenesis. We analyzed data on brain imaging, zygosity, sex, and fetal demise in 56 proband twins and 7 less affected co-twins with abnormal brain imaging and compared them to population-based data and to a literature series. We separated our series into malformations of cortical development (MCD, N = 39), cerebellar malformations without MCD (N = 13), and brain disruptions (N = 11). The MCD group included 37/39 (95%) with polymicrogyria (PMG), 8/39 (21%) with pia-ependymal clefts (schizencephaly), and 15/39 (38%) with periventricular nodular heterotopia (PNH) including 2 with PNH but not PMG. Cerebellar malformations were found in 19 individuals including 13 with a cerebellar malformation only and another 6 with cerebellar malformation and MCD. The pattern varied from diffuse cerebellar hypoplasia to classic Dandy-Walker malformation. Brain disruptions were seen in 11 individuals with hydranencephaly, porencephaly, or white matter loss without cysts. Our series included an expected statistically significant excess of monozygotic (MZ) twin pairs (22/41 MZ, 54%) compared to population data (482/1448 MZ, 33.3%; p = .0110), and an unexpected statistically significant excess of dizygotic (DZ) twins (19/41, 46%) compared to the literature cohort (1/46 DZ, 2%; p < .0001. Recurrent association with twin-twin transfusion syndrome, intrauterine growth retardation, and other prenatal factors support disruption of vascular perfusion as the most likely unifying cause.
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Affiliation(s)
- Kaylee B Park
- University of Washington School of Medicine, Seattle, Washington, USA
| | - Teresa Chapman
- Department of Radiology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Kimberly A Aldinger
- Seattle Children's Research Institute, Center for Integrative Brain Research, Seattle, Washington, USA
| | - Ghayda M Mirzaa
- Seattle Children's Research Institute, Center for Integrative Brain Research, Seattle, Washington, USA.,Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA.,Brotman Baty Institute for Precision Medicine, Seattle, Washington, USA
| | - Jordan Zeiger
- Seattle Children's Research Institute, Center for Integrative Brain Research, Seattle, Washington, USA
| | - Anita Beck
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Ian A Glass
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Robert F Hevner
- Department of Pathology, University of California San Diego, La Jolla, California, USA
| | - Anna C Jansen
- Neurogenetics Research Group, Reproduction Genetics and Regenerative Medicine Research Cluster, Vrije Universiteit Brussel, Brussels, Belgium.,Pediatric Neurology Unit, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Desiree A Marshall
- Department of Anatomic Pathology and Neuropathology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Renske Oegema
- University Medical Center Utrecht, Department of Genetics, Utrecht, The Netherlands
| | - Elena Parrini
- Pediatric Neurology, Neurogenetics and Neurobiology Unit and Laboratories, Meyer Children's Hospital, University of Florence, Florence, Italy
| | - Russell P Saneto
- Department of Neurology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Cynthia J Curry
- Genetic Medicine, Department of Pediatrics, University of California San Francisco, Fresno, California, USA
| | - Judith G Hall
- Departments of Medical Genetics and Pediatrics, University of British Columbia and BC Children's Hospital, Vancouver, Canada
| | - Renzo Guerrini
- Pediatric Neurology, Neurogenetics and Neurobiology Unit and Laboratories, Meyer Children's Hospital, University of Florence, Florence, Italy
| | - Richard J Leventer
- Department of Neurology, Royal Children's Hospital, Murdoch Children's Research Institute and University of Melbourne Department of Pediatrics, Melbourne, Australia
| | - William B Dobyns
- Department of Pediatrics, Division of Genetics and Metabolism, University of Minnesota, Minneapolis, Minnesota, USA
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Wang X, Li L, Yuan P, Zhao Y, Wei Y. Comparison of placental characteristics of twin-twin transfusion syndrome with and without selective intrauterine growth restriction. J Matern Fetal Neonatal Med 2020; 35:4306-4311. [PMID: 33203261 DOI: 10.1080/14767058.2020.1849110] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To explore differences among placental anastomoses, territory discordance, and umbilical cord insertion of twin-to-twin transfusion syndrome (TTTS) with and without selective intrauterine growth restriction (sIUGR). METHODS This study retrospectively analyzed 57 patients with TTTS who received conservative treatment and finally delivered at the Department of Obstetrics and Gynecology of Peking University Third Hospital from April 2014 to April 2019. Nine of the patient's placentas were too broken to finish the perfusion, and 48 were kept for graph analysis after perfusion. Among the 48 placentas, there were 17 in the TTTS with sIUGR group and 31 in the TTTS without sIUGR group. Differences in the placentas were compared between groups. RESULTS The birth weight discordance ratio in the sIUGR group was significantly higher than that in the non-sIUGR group (0.41 ± 0.20 vs 0.24 ± 0.15, p = .001). The prevalence of thick artery-artery (AA) anastomoses in the sIUGR group was significantly higher than that in the non-sIUGR group (35.3% vs 6.5%, p = .017). The placental territory discordance ratio in the sIUGR group was significantly higher than that in the non-sIUGR group (0.40 [0.05, 0.86] vs 0.25 [0.02, 0.67], p = .024). The prevalence of velamentous cord insertion in the sIUGR group was significantly higher than that in the non sIUGR group (35.3% and 6.5%, p = .017). CONCLUSIONS Placental territory discordance and velamentous umbilical cord insertion may be causes of TTTS with sIUGR. Compared with TTTS without sIUGR, TTTS with sIUGR had a higher prevalence of protective AA anastomoses in the placenta.
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Affiliation(s)
- Xueju Wang
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Luyao Li
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Pengbo Yuan
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Yangyu Zhao
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Yuan Wei
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
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Starnes SE, Nardi F, Fitchev P, Plunkett BA, Thorpe C, Wang CH, Vogler C, Crawford SE. Influence of maternal obesity and metabolic and vascular mediators in twin-twin transfusion syndrome. Reprod Biol 2019; 19:165-172. [PMID: 31147266 DOI: 10.1016/j.repbio.2019.05.002] [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: 03/21/2019] [Revised: 05/10/2019] [Accepted: 05/16/2019] [Indexed: 10/26/2022]
Abstract
Obesity is a risk factor for complications in singleton and twin pregnancies; however, there are limited data regarding maternal body mass index (BMI) in the setting of twin-twin transfusion syndrome (TTTS). We hypothesized that increased BMI in TTTS is associated with adverse perinatal outcomes and vascular pathology. A retrospective study of twin reversed arterial perfusion (n = 4), selective intrauterine growth restriction (n = 10) and TTTS (n = 33) was conducted. Treatment included fetoscopic laser photocoagulation (FLP) (n = 35) or Solomon technique (n = 12). Ex vivo placental intravascular injections, immunohistochemistry, and perinatal outcomes were compared by maternal BMI. In pregnancy complicated by TTTS, 16/33 women were obese (BMI > 30 kg/m2) and 11/33 were overweight (BMI 25-29.9 kg/m2). Women who were overweight or obese had an increased rate of premature rupture of membranes (PPROM), cesarean delivery, and/or concomitant co-morbidities when compared to the normal weight group. Duration of neonatal intensive care unit (NICU) admission was longer in neonates of overweight/obese women versus normal weight. Placental examination of FLP sites in the obese group showed larger infarcts, increased adipose triglyceride lipase, and a proangiogenic phenotype. Increased BMI is common in our TTTS cohort and it is associated with higher rate of co-morbidity, PPROM, prolonged NICU stay, and an imbalance of placental metabolic and vascular mediators.
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Affiliation(s)
- Sarah E Starnes
- Department of Pathology, Saint Louis University School of Medicine, St. Louis, MO, 63103, United States
| | - Francesca Nardi
- Department of Surgery, NorthShore University Research Institute, Affiliate of University of Chicago Pritzker School of Medicine, Evanston, IL, 60201, United States
| | - Philip Fitchev
- Department of Surgery, NorthShore University Research Institute, Affiliate of University of Chicago Pritzker School of Medicine, Evanston, IL, 60201, United States
| | - Beth A Plunkett
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, NorthShore University, Evanston, IL, 60201, United States
| | - Constance Thorpe
- Department of Pathology, Saint Louis University School of Medicine, St. Louis, MO, 63103, United States
| | - Chi-Hsung Wang
- Center for Bioinformatics and Computational Biology, NorthShore University Research Institute, Evanston, IL, 60201, United States
| | - Carole Vogler
- Department of Pathology, Saint Louis University School of Medicine, St. Louis, MO, 63103, United States
| | - Susan E Crawford
- Department of Pathology, Saint Louis University School of Medicine, St. Louis, MO, 63103, United States; Department of Surgery, NorthShore University Research Institute, Affiliate of University of Chicago Pritzker School of Medicine, Evanston, IL, 60201, United States.
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10
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Melhem NZ, Ledermann S, Rees L. Chronic kidney disease following twin-to-twin transfusion syndrome-long-term outcomes. Pediatr Nephrol 2019; 34:883-888. [PMID: 30560449 DOI: 10.1007/s00467-018-4176-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 11/17/2018] [Accepted: 12/11/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND Amongst other sequelae, acute kidney injury (AKI) is a well-recognised post-natal complication of twin-to-twin transfusion syndrome (TTTS). Despite this, there has been a lack of data reporting long-term renal outcomes. Our aim was to report the long-term renal outcomes of infants born with TTTS. METHODS We performed a retrospective case note review of all infants referred to our centre between 1998 and 2018 with a primary diagnosis of TTTS. Subjects with confirmed TTTS were divided into a chronic kidney disease (CKD) group and a non-CKD group for comparison. RESULTS Twenty-six infants with TTTS were included for analysis. Eight (31%) subjects developed CKD. Within the CKD group, 50% went on to require long-term renal replacement therapy (RRT) of whom all underwent renal transplantation. For subjects who had neonatal AKI, cumulative survival rate before RRT at 5 and 10 years was 79% and 70%, respectively. Subjects with CKD had a significantly higher incidence of AKI in the neonatal period and were more likely to be the donor twin. Gestational age at birth, gender, antenatal interventions and comorbidities did not affect long-term renal outcome between the two groups. CONCLUSION This is the first long-term follow-up study demonstrating that CKD progressing to the need for RRT can develop after TTTS. Donor-twin status and neonatal AKI associated with adverse long-term outcomes warranting long-term surveillance in this group.
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Affiliation(s)
- Nabil Ziad Melhem
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK.
| | - Sarah Ledermann
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
| | - Lesley Rees
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
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Bolch C, Fahey M, Reddihough D, Williams K, Reid S, Guzys A, Cole S, Edwards A, Fung A, Hodges R, Palma-Dias R, Teoh M, Walker S. Twin-to-twin transfusion syndrome neurodevelopmental follow-up study (neurodevelopmental outcomes for children whose twin-to-twin transfusion syndrome was treated with placental laser photocoagulation). BMC Pediatr 2018; 18:256. [PMID: 30068295 PMCID: PMC6090765 DOI: 10.1186/s12887-018-1230-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Accepted: 07/19/2018] [Indexed: 11/10/2022] Open
Abstract
Background Twin-to-twin transfusion syndrome (TTTS) is a serious complication of 10–15% of twin or triplet pregnancies in which multiple fetuses share a single placenta. Communicating placental vessels allow one fetus (the donor) to pump blood to the other (the recipient). Mortality rates without intervention are high, approaching 100% in some series, with fetal deaths usually due to cardiac failure. Surgical correction using laser photocoagulation of communicating placental vessels was developed in the 1980s and refined in the 1990s. Since it was introduced in Victoria in 2006, laser surgery has been performed in approximately 120 pregnancies. Survival of one or more fetuses following laser surgery is currently > 90%, however the neurodevelopmental outcomes for survivors remain incompletely understood. Prior to laser therapy, at least one in five survivors of TTTS had serious adverse neurodevelopmental outcomes (usually cerebral palsy). Current estimates of neurological impairment among survivors following laser surgery vary from 4 to 31% and long-term follow-up data are limited. Methods This paper describes the methodology for a retrospective cohort study in which children aged 24 months and over (corrected for prematurity), who were treated with laser placental photocoagulation for TTTS at Monash Health in Victoria, Australia, will undergo comprehensive neurodevelopmental assessment by a multidisciplinary team. Evaluation will include parental completion of pre-assessment questionnaires of social and behavioural development, a standardised medical assessment by a developmental paediatrician or paediatric neurologist, and age-appropriate cognitive and academic, speech and fine and gross motor assessments by psychologists, speech and occupational therapists or physiotherapists. Assessments will be undertaken at the Murdoch Children’s Research Institute/Royal Children’s Hospital, at Monash Health or at another mutually agreed location. Results will be recorded in a secure online database which will facilitate future related research. Discussion This will be the first study to report and evaluate neurodevelopmental outcomes following laser surgery for twin-to-twin transfusion syndrome in Victoria, and will inform clinical practice regarding follow-up of children at risk of adverse outcomes. Electronic supplementary material The online version of this article (10.1186/s12887-018-1230-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Christie Bolch
- Developmental Disability and Rehabilitation Research, Murdoch Children's Research Institute, Melbourne, Australia. .,Neurodevelopment and Disability, The Royal Children's Hospital, Melbourne, Australia.
| | - Michael Fahey
- Department of Paediatrics, Monash Health, Clayton, Australia.,Department of Paediatrics, Monash University, Clayton, Australia
| | - Dinah Reddihough
- Developmental Disability and Rehabilitation Research, Murdoch Children's Research Institute, Melbourne, Australia.,Neurodevelopment and Disability, The Royal Children's Hospital, Melbourne, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Australia
| | - Katrina Williams
- Developmental Disability and Rehabilitation Research, Murdoch Children's Research Institute, Melbourne, Australia.,Neurodevelopment and Disability, The Royal Children's Hospital, Melbourne, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Australia
| | - Susan Reid
- Developmental Disability and Rehabilitation Research, Murdoch Children's Research Institute, Melbourne, Australia.,Neurodevelopment and Disability, The Royal Children's Hospital, Melbourne, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Australia
| | - Angela Guzys
- Developmental Disability and Rehabilitation Research, Murdoch Children's Research Institute, Melbourne, Australia
| | - Stephen Cole
- Department of Maternity Services, Royal Women's Hospital, Melbourne, Australia
| | - Andrew Edwards
- Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia
| | - Alison Fung
- Department of Perinatal Medicine, Mercy Hospital for Women, Heidelberg, VIC, Australia
| | - Ryan Hodges
- Women's & Newborn Program, Monash Health, Clayton, VIC, Australia.,The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia
| | - Ricardo Palma-Dias
- Ultrasound Services, Royal Women's Hospital, Parkville, VIC, Australia.,Pregnancy Research Centre, Department of Maternal-Fetal Medicine, Royal Women's Hospital, Parkville, VIC, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, Australia
| | - Mark Teoh
- Fetal Diagnostic Unit, Monash Health, Clayton, VIC, Australia
| | - Susan Walker
- Department of Obstetrics and Gynaecology, Mercy Hospital for Women, Heidelberg, Australia.,Maternal Fetal Medicine, The University of Melbourne, Melbourne, Australia
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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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13
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Wataganara T, Gosavi A, Nawapun K, Vijayakumar PD, Phithakwatchara N, Choolani M, Su LL, Biswas A, Mattar CNZ. Model Surgical Training: Skills Acquisition in Fetoscopic Laser Photocoagulation of Monochorionic Diamniotic Twin Placenta Using Realistic Simulators. J Vis Exp 2018. [PMID: 29630059 DOI: 10.3791/57328] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Fetoscopic laser coagulation of arterio-venous anastomoses (AVA) in a monochorionic placenta is the standard of care for twin-twin transfusion syndrome (TTTS), but is technically challenging and can lead to significant complications. Acquiring and maintaining the necessary surgical skills require consistent practice, a critical caseload, and time. Training on realistic surgical simulators can potentially shorten this steep learning curve and enables several proceduralists to acquire procedure-specific skills simultaneously. Here we describe realistic simulators designed to allow the user familiarity with the equipment and specific steps required in the surgical treatment of TTTS, including fetoscopic handling, approaches to anterior and posterior placenta, recognition of anastomoses, and efficient coagulation of vessels. We describe the skills that are especially important in conducting placental laser coagulation that the surgeon can practice on the model and apply in a clinical case. These models can be adapted easily depending on the availability of materials and require standard fetoscopy equipment. Such training systems are complementary to traditional surgical apprenticeships and can be useful aids for fetal medicine units that provide this clinical service.
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Affiliation(s)
- Tuangsit Wataganara
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine, Siriraj Hospital
| | - Arundhati Gosavi
- Department of Obstetrics and Gynaecology, National University Health Systems
| | - Katika Nawapun
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine, Siriraj Hospital
| | | | - Nisarat Phithakwatchara
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine, Siriraj Hospital
| | - Mahesh Choolani
- Department of Obstetrics and Gynaecology, National University Health Systems; Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore
| | - Lin Lin Su
- Department of Obstetrics and Gynaecology, National University Health Systems; Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore
| | - Arijit Biswas
- Department of Obstetrics and Gynaecology, National University Health Systems; Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore
| | - Citra N Z Mattar
- Department of Obstetrics and Gynaecology, National University Health Systems; Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore;
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14
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Nicholas L, Fischbein R, Falletta L, Baughman K. Twin-Twin Transfusion Syndrome and Maternal Symptomatology-An Exploratory Analysis of Patient Experiences When Reporting Complaints. J Patient Exp 2017; 5:134-139. [PMID: 29978030 PMCID: PMC6022942 DOI: 10.1177/2374373517736760] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objective: The aim of this study was to assess patient experiences when reporting symptoms of twin–twin transfusion syndrome (TTTS) to their health-care providers. Methodology: The study utilized an online, retrospective survey of women, over the age of 18, who were living in the United States at the time of their pregnancy and had completed a TTTS pregnancy. Results: Three hundred sixty-seven cases were included for analysis. Nearly half of the respondents (45.2%) reported experiencing maternal symptoms prior to TTTS diagnosis. The average number of symptoms experienced was 2.85. The average gestational week of symptom onset was 18.2. A total of 76.2% of respondents experiencing symptoms shared these concerns with their health-care provider; however, slightly more than half (51.2%) believed that the provider dismissed their complaints. Conclusions: Results suggest a disconnect between patients’ reporting TTTS symptoms and health-care providers responding attentively, as perceived by the patient. It would be advantageous for health-care providers to inform women pregnant with a monochorionic–diamniotic pregnancy to immediately report the presence of any symptom described in the present research, which may be associated with any number of twin pregnancy–related complications.
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Affiliation(s)
- Lauren Nicholas
- Department of Liberal Arts, D'Youville College, Buffalo, NY, USA
| | - Rebecca Fischbein
- Department of Family and Community Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Lynn Falletta
- College of Public Health, Kent State University, Kent, OH, USA
| | - Kristin Baughman
- Department of Family and Community Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
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15
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De Paepe ME, Gündoğan F, Mao Q, Chu S, Shapiro S. Redness discordance in monochorionic twin placentas: Correlation with clinical and placental findings. Placenta 2017; 60:54-60. [PMID: 29208240 DOI: 10.1016/j.placenta.2017.10.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 10/18/2017] [Accepted: 10/21/2017] [Indexed: 11/25/2022]
Abstract
INTRODUCTION/OBJECTIVES Recent studies suggest redness (color) discordance of the placental basal plate may be a marker for twin anemia-polycythemia sequence (TAPS), a recently described complication of diamniotic-monochorionic twinning characterized by marked intertwin hemoglobin (Hb) discordance in the absence of oligohydramnios-polyhydramnios. In this study, we determined the clinicoplacental and choriovascular correlates of basal plate color discordance in monochorionic twin placentas, and assessed its value as postnatal indicator of TAPS. METHODS We performed a clinicoplacental analysis of 100 consecutive non-TTTS diamniotic-monochorionic twin placentas with available photographic documentation of the basal plate. Basal plate redness was quantified by computer-assisted analysis of digital images and expressed as intertwin color difference ratio (CDR). RESULTS The CDR ranged between 1.00 and 3.58 (median CDR: 1.14; 90th %ile: 1.98). Compared to twins with low CDR (N = 90), twins with high CDR (≥2.0; N = 10) had significantly higher hemoglobin difference (11.25 g/dL versus 2.55 g/dL) and significantly fewer and smaller artery-to-artery (AA) and artery-to-vein (AV) anastomoses. Apgar scores and birth weights were equivalent in both groups. Among the 10 twin sets with high CDR, six (60%) qualified as TAPS, as defined by intertwin Hb difference >8 g/dL and absent or very small AA and AV anastomoses. Conversely, 6 of 8 (75%) twin sets with TAPS had a CDR ≥ 2.0. CONCLUSION Intertwin CDR correlates with intertwin hemoglobin difference and chorionic angioarchitecture. A CDR value ≥ 2.0 (the 90%ile value for CDR derived from the present cohort) has high specificity (96%), but relatively low positive predictive value (60%) as indicator of TAPS, as currently defined.
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Affiliation(s)
- Monique E De Paepe
- Department of Pathology, Women and Infants Hospital, Providence, RI, 02905, United States; Department of Pathology and Laboratory Medicine, Alpert Medical School of Brown University, Providence, RI, 02905, United States.
| | - Füsun Gündoğan
- Department of Pathology, Women and Infants Hospital, Providence, RI, 02905, United States; Department of Pathology and Laboratory Medicine, Alpert Medical School of Brown University, Providence, RI, 02905, United States
| | - Quanfu Mao
- Department of Pathology, Women and Infants Hospital, Providence, RI, 02905, United States
| | - Sharon Chu
- Department of Pathology, Women and Infants Hospital, Providence, RI, 02905, United States
| | - Svetlana Shapiro
- Department of Pathology, Women and Infants Hospital, Providence, RI, 02905, United States
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16
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Gosavi A, Vijayakumar PD, Ng BSW, Loh MH, Tan LG, Johana N, Tan YW, Sandikin D, Su LL, Wataganara T, Biswas A, Choolani MA, Mattar CNZ. Rapid initiation of fetal therapy services with a system of learner-centred training under proctorship: the National University Hospital (Singapore) experience. Singapore Med J 2017; 58:311-320. [PMID: 27439783 PMCID: PMC5474526 DOI: 10.11622/smedj.2016127] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Management of complicated monochorionic twins and certain intrauterine structural anomalies is a pressing challenge in communities that still lack advanced fetal therapy. We describe our efforts to rapidly initiate selective feticide using radiofrequency ablation (RFA) and selective fetoscopic laser photocoagulation (SFLP) for twin-to-twin transfusion syndrome (TTTS), and present the latter as a potential model for aspiring fetal therapy units. METHODS Five pregnancies with fetal complications were identified for RFA. Three pregnancies with Stage II TTTS were selected for SFLP. While RFA techniques utilising ultrasonography skills were quickly mastered, SFLP required stepwise technical learning with an overseas-based proctor, who provided real-time hands-off supervision. RESULTS All co-twins were live-born following selective feticide; one singleton pregnancy was lost. Fetoscopy techniques were learned in a stepwise manner and procedures were performed by a novice team of surgeons under proctorship. Dichorionisation was completed in only one patient. Five of six twins were live-born near term. One pregnancy developed twin anaemia-polycythaemia sequence, while another was complicated by co-twin demise. DISCUSSION Proctor-supervised directed learning facilitated the rapid provision of basic fetal therapy services by our unit. While traditional apprenticeship is important for building individual expertise, this system is complementary and may benefit other small units committed to providing these services.
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Affiliation(s)
- Arundhati Gosavi
- Department of Obstetrics and Gynaecology, National University Health System, Singapore
| | - Pradip D Vijayakumar
- Department of Obstetrics and Gynaecology, National University Health System, Singapore
| | - Bryan SW Ng
- Department of Anaesthesia, National University Health System, Singapore
| | - May-Han Loh
- Department of Anaesthesia, National University Health System, Singapore
| | - Lay Geok Tan
- Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Nuryanti Johana
- Department of Reproductive Medicine, KK Women’s and Children’s Hospital, Singapore
| | - Yi Wan Tan
- Department of Reproductive Medicine, KK Women’s and Children’s Hospital, Singapore
| | - Dedy Sandikin
- Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Lin Lin Su
- Department of Obstetrics and Gynaecology, National University Health System, Singapore
- Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Tuangsit Wataganara
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine, Siriraj Hospital, Bangkok, Thailand
| | - Arijit Biswas
- Department of Obstetrics and Gynaecology, National University Health System, Singapore
- Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Mahesh A Choolani
- Department of Obstetrics and Gynaecology, National University Health System, Singapore
- Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Citra NZ Mattar
- Department of Obstetrics and Gynaecology, National University Health System, Singapore
- Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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17
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Zhao D, Dang Q, Haak M, Middeldorp J, Klumper F, Oepkes D, Lopriore E. ‘Superficial’ anastomoses in monochorionic placentas are not always superficial. Placenta 2015; 36:1059-61. [DOI: 10.1016/j.placenta.2015.07.127] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 07/17/2015] [Accepted: 07/21/2015] [Indexed: 10/23/2022]
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18
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Kashireddy P, Larson A, Minturn L, Ernst L. Case Report of Autopsy and Placental Examination After Radiofrequency Ablation of an Acardiac Twin. Lab Med 2015. [DOI: 10.1309/lm4b4du7uimklnai] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Abstract
Twin birth rates have increased dramatically over the past three decades, and twins currently account for 3% of all pregnancies. Twin pregnancies of any type are at risk for prematurity. In addition, monochorionic twin pregnancies (25-30% of all twin pregnancies) are predisposed to a specific set of complications, including twin-to-twin transfusion syndrome (TTTS), twin reversed arterial perfusion syndrome (TRAP), malformations, and intertwin growth discordance. This article reviews the basic mechanisms underlying the twinning process, the relationship between zygosity and chorionicity, and the various types of twinning. We describe the major complications of monochorionic twinning in association with their reported placental characteristics (or lack thereof). Finally, a rational, evidence-based approach to examination of the twin placenta is presented. It is essential for the pathologist to understand the value, strengths, and limitations of examination of the twin placenta in order to provide a meaningful clinicopathological correlation in complicated (monochorionic) twin pregnancies.
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Affiliation(s)
- Monique E De Paepe
- Department of Pathology, Women and Infants Hospital, 101 Dudley St, Providence, RI 02905; Department of Pathology and Laboratory Medicine, Alpert Medical School of Brown University, Providence, RI.
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20
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Chon AH, Korst LM, Llanes A, Miller DA, Ouzounian JG, Chmait RH. Midtrimester isolated polyhydramnios in monochorionic diamniotic multiple gestations. Am J Obstet Gynecol 2014; 211:303.e1-5. [PMID: 24858201 DOI: 10.1016/j.ajog.2014.05.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Revised: 04/14/2014] [Accepted: 05/20/2014] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To identify risk factors for development of twin-twin transfusion syndrome (TTTS) in monochorionic diamniotic multiple gestations complicated by midtrimester isolated polyhydramnios (iPoly). STUDY DESIGN A retrospective study of patients referred for possible TTTS between 16 and 26 gestational weeks was performed. IPoly was defined as a maximum vertical pocket of ≥8 cm in the iPoly twin's sac and >2 and <8 cm in the co-twin's sac on the consultative ultrasound. RESULTS Of 628 consecutive patients referred for possible TTTS, 74 were diagnosed with iPoly. The majority of these patients (n = 52, 70.3%) were not subsequently diagnosed with TTTS, and of these, 40 were managed expectantly and 12 had amnioreductions because of symptomatic iPoly; 30-day perinatal survival of at-least-one twin in the non-TTTS group was 93.0% (40/43). TTTS developed in the 22 remaining patients, of which 63.6% were of advanced Quintero Stage. Nineteen underwent laser surgery; 30-day perinatal survival of at-least-one twin was 84.2% (16/19). In a multivariate logistic regression model, 2 characteristics were associated with the development of TTTS: (1) gestational age <20 weeks at the time of diagnosis of iPoly (odds ratio, 13.48; 95% confidence interval, 3.40-53.48; P = .0002); and (2) intrauterine growth restriction of the co-twin (odds ratio, 7.28; 95% confidence interval, 1.72-30.88; P = .0071). CONCLUSION Among referred patients with midtrimester iPoly, 29.7% subsequently developed TTTS. Early diagnosis (<20 weeks) and/or co-twin intrauterine growth restriction were significant risk factors for development of TTTS in these patients.
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Affiliation(s)
- Andrew H Chon
- Department of Obstetrics and Gynecology, Kaiser Permanente Los Angeles, Los Angeles, CA
| | - Lisa M Korst
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Arlyn Llanes
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - David A Miller
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Joseph G Ouzounian
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Ramen H Chmait
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA
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