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Moise KJ, Oepkes D, Lopriore E, Bredius RGM. Targeting neonatal Fc receptor: potential clinical applications in pregnancy. Ultrasound Obstet Gynecol 2022; 60:167-175. [PMID: 35229965 DOI: 10.1002/uog.24891] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/19/2022] [Accepted: 02/21/2022] [Indexed: 06/14/2023]
Abstract
The neonatal Fc receptor (FcRn) plays an important role in the transfer of the immunoglobulin G isotype (IgG) from the mother to the fetus. FcRn expressed on endothelial cells also binds to IgG and albumin, regulating the circulating half-lives of these proteins. Alloimmune and autoimmune IgG antibodies have been implicated in various perinatal immune-mediated diseases. FcRn-mediated placental transfer of pathogenic antibodies can result in cell and tissue injury in the fetus and neonate, with devastating outcomes. Thus, blockade of FcRn may be an effective treatment strategy in managing these conditions and could additionally reduce the concentration of pathogenic antibodies in the maternal circulation by preventing IgG recycling. In this review, we discuss the biology of FcRn, the rationale and considerations for development of FcRn-blocking agents, and their potential clinical applications in various perinatal immune-mediated diseases. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- K J Moise
- Department of Women's Health, Dell Medical School, University of Texas at Austin, Austin, TX, USA
| | - D Oepkes
- Department of Obstetrics and Fetal Therapy, Leiden University Medical Center, Leiden, The Netherlands
| | - E Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - R G M Bredius
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
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2
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Tedjawirja VN, van Klink JM, Haak MC, Klumper FJ, Middeldorp JM, Miller JL, Rosner M, Baschat AA, Lopriore E, Oepkes D. Questionable benefit of intrauterine transfusion following single fetal death in monochorionic twin pregnancy. Ultrasound Obstet Gynecol 2022; 59:824-825. [PMID: 35137996 DOI: 10.1002/uog.24876] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/29/2022] [Accepted: 02/01/2022] [Indexed: 06/14/2023]
Affiliation(s)
- V N Tedjawirja
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - J M van Klink
- Department of Medical Psychology, Leiden University Medical Center, Leiden, The Netherlands
| | - M C Haak
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - F J Klumper
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - J M Middeldorp
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - J L Miller
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Baltimore, MD, USA
| | - M Rosner
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Baltimore, MD, USA
| | - A A Baschat
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Baltimore, MD, USA
| | - E Lopriore
- Department of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - D Oepkes
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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Slootweg YM, Zwiers C, Koelewijn JM, van der Schoot E, Oepkes D, van Kamp IL, de Haas M. Risk factors for RhD immunisation in a high coverage prevention programme of antenatal and postnatal RhIg: a nationwide cohort study. BJOG 2022; 129:1721-1730. [PMID: 35133072 PMCID: PMC9543810 DOI: 10.1111/1471-0528.17118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 12/30/2021] [Accepted: 01/13/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate which risk factors for RhD immunisation remain, despite adequate routine antenatal and postnatal RhIg prophylaxis (1000 IU RhIg) and additional administration of RhIg. The second objective was assessment of the current prevalence of RhD immunisations. DESIGN Prospective cohort study. SETTING The Netherlands. POPULATION Two-year nationwide cohort of alloimmunised RhD-negative women. METHODS RhD-negative women in their first RhD immunised pregnancy were included for risk factor analysis. We compared risk factors for RhD immunisation, occurring either in the previous non-immunised pregnancy or in the index pregnancy, with national population data derived from the Dutch perinatal registration (Perined). RESULTS In the 2-year cohort, data from 193 women were eligible for analysis. Significant risk factors in women previously experiencing a pregnancy of an RhD-positive child (n = 113) were: caesarean section (CS) (OR 1.7, 95% CI 1.1-2.6), perinatal death (OR 3.5, 95% CI 1.1-10.9), gestational age >42 weeks (OR 6.1, 95% CI 2.2-16.6), postnatal bleeding (>1000 ml) (OR 2.0, 95% CI 1.1-3.6), manual removal of the placenta (MRP) (OR 4.3, 95% CI 2.0-9.3); these factors often occurred in combination. The miscarriage rate was significantly higher than in the Dutch population (35% versus 12.-5%, P < 0.001). CONCLUSION Complicated deliveries, including cases of major bleeding and surgical interventions (CS, MRP), must be recognised as a risk factor, requiring estimation of fetomaternal haemorrhage volume and adjustment of RhIg dosing. The higher miscarriage rate suggests that existing RhIg protocols need adjustment or better compliance.
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Affiliation(s)
- Y M Slootweg
- Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands.,Centre for Clinical Transfusion Research, Sanquin Research, Amsterdam, the Netherlands
| | - C Zwiers
- Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands.,Centre for Clinical Transfusion Research, Sanquin Research, Amsterdam, the Netherlands
| | - J M Koelewijn
- Centre for Clinical Transfusion Research, Sanquin Research, Amsterdam, the Netherlands.,Department of Immunohaematology Diagnostics, Sanquin Diagnostic Services, Amsterdam, the Netherlands
| | - E van der Schoot
- Centre for Clinical Transfusion Research, Sanquin Research, Amsterdam, the Netherlands.,Department of Immunohaematology Diagnostics, Sanquin Diagnostic Services, Amsterdam, the Netherlands
| | - D Oepkes
- Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands
| | - I L van Kamp
- Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands
| | - M de Haas
- Centre for Clinical Transfusion Research, Sanquin Research, Amsterdam, the Netherlands.,Department of Immunohaematology Diagnostics, Sanquin Diagnostic Services, Amsterdam, the Netherlands.,Department of Haematology, Leiden University Medical Center, Leiden, the Netherlands
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Zhang A, Stolk TT, Lopriore E, Sun L, Duan T, Oepkes D. Second-trimester abdominal circumference discordance and adverse perinatal outcomes in monochorionic twins. J Matern Fetal Neonatal Med 2021; 35:7316-7321. [PMID: 34219590 DOI: 10.1080/14767058.2021.1947227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The perinatal outcomes in second-trimester abdominal circumference (AC) discordant twins are yet to be established. The aim of this study was to ascertain perinatal risks associated with second-trimester AC discordance in monochorionic (MC) twins. METHOD We conducted a retrospective study of all MC twin pregnancies over a 7-year period. Intertwin AC discordance at 14-26 gestational weeks was analyzed in relation to Doppler abnormalities, obstetric complications, and perinatal adverse outcomes. RESULTS A total of 246 MC twin pregnancies were included in the analysis. The smaller twins of second-trimester AC discordant pairs were at increased prevalence of abnormal umbilical artery flow (50% versus 24%, p < .001) and low positive A wave of ductus venous flow (24% versus 9%, p = .002). The second-trimester AC discordant twins were at increased risk of oligohydramnios in smaller twin (OR = 2.44, 95% CI = 1.37-4.32, p < .01), cardiomegaly in larger twin (OR = 2.95, 95% CI = 1.01-8.60, p < .05), birth weight of either twin below the 10th percentile for gestational age (OR = 5.56, 95% CI = 2.67-11.59, p < .001), birth weight discordance > 25% (OR = 9.41, 95% CI = 4.46-19.87, p < .001), IUFD (OR = 3.26, 95% CI = 1.76-6.05, p < .001), and severe neonatal morbidity (OR = 1.83, 95% CI = 1.03-3.26, p < .05). The intact survival rate in discordant and concordant twin pairs was 70% and 89%, respectively (p < .001). CONCLUSIONS Early and increase fetal surveillance of the second-trimester AC discordant twins should be utilized to establish perinatal risks, thus allowing prenatal care to improve.
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Affiliation(s)
- A Zhang
- Qingdao Women and Children's Hospital, Qingdao University School of Medicine, Qingdao, PR China
| | - T T Stolk
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - E Lopriore
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - L Sun
- Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, PR China
| | - T Duan
- Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, PR China
| | - D Oepkes
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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Verweij EJ, van der Hout S, Lopriore E, Oepkes D, Dondorp WJ. [Maternal-fetal therapy: from saving the fetus towards a better life for the future child]. Ned Tijdschr Geneeskd 2021; 165:D5575. [PMID: 33914436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Maternal-fetal therapy (MFT) is special because treatment of the fetus is exclusively possible through the body of another person, the pregnant woman. MFT is a broad specialty with diverse interventions. In this manuscript several examples of innovations in MFT are discussed to illustrate the shift of lifesaving interventions to interventions aiming to improve morbidity of the future child. The broadening of the scope and shift towards prenatal treatments improving morbidity result in new ethical challenges. Particularly attention is needed for counseling and (the risk of) therapeutic misconception.
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Affiliation(s)
- E J Verweij
- LUMC, afd. Verloskunde, Leiden
- Contact: E. J. Verweij
| | - S van der Hout
- Universiteit Maastricht, Care and Public Health Research Institute (CAPHRI), Maastricht
| | | | | | - W J Dondorp
- Universiteit Maastricht, Care and Public Health Research Institute (CAPHRI), Maastricht
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6
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Tollenaar LSA, Slaghekke F, Lewi L, Ville Y, Lanna M, Weingertner A, Ryan G, Arévalo S, Khalil A, Brock CO, Klaritsch P, Hecher K, Gardener G, Bevilacqua E, Kostyukov KV, Bahtiyar M, Kilby M, Tiblad E, Oepkes D, Lopriore E. Treatment and outcome of 370 cases with spontaneous or post-laser twin anemia-polycythemia sequence managed in 17 fetal therapy centers. Ultrasound Obstet Gynecol 2020; 56:378-387. [PMID: 32291846 PMCID: PMC7497010 DOI: 10.1002/uog.22042] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 03/23/2020] [Accepted: 03/25/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To investigate the antenatal management and outcome in a large international cohort of monochorionic twin pregnancies with spontaneous or post-laser twin anemia-polycythemia sequence (TAPS). METHODS This study analyzed data of monochorionic twin pregnancies diagnosed antenatally with spontaneous or post-laser TAPS in 17 fetal therapy centers, recorded in the TAPS Registry between 2014 and 2019. Antenatal diagnosis of TAPS was based on fetal middle cerebral artery peak systolic velocity > 1.5 multiples of the median (MoM) in the TAPS donor and < 1.0 MoM in the TAPS recipient. The following antenatal management groups were defined: expectant management, delivery within 7 days after diagnosis, intrauterine transfusion (IUT) (with or without partial exchange transfusion (PET)), laser surgery and selective feticide. Cases were assigned to the management groups based on the first treatment that was received after diagnosis of TAPS. The primary outcomes were perinatal mortality and severe neonatal morbidity. The secondary outcome was diagnosis-to-birth interval. RESULTS In total, 370 monochorionic twin pregnancies were diagnosed antenatally with TAPS during the study period and included in the study. Of these, 31% (n = 113) were managed expectantly, 30% (n = 110) with laser surgery, 19% (n = 70) with IUT (± PET), 12% (n = 43) with delivery, 8% (n = 30) with selective feticide and 1% (n = 4) underwent termination of pregnancy. Perinatal mortality occurred in 17% (39/225) of pregnancies in the expectant-management group, 18% (38/215) in the laser group, 18% (25/140) in the IUT (± PET) group, 10% (9/86) in the delivery group and in 7% (2/30) of the cotwins in the selective-feticide group. The incidence of severe neonatal morbidity was 49% (41/84) in the delivery group, 46% (56/122) in the IUT (± PET) group, 31% (60/193) in the expectant-management group, 31% (57/182) in the laser-surgery group and 25% (7/28) in the selective-feticide group. Median diagnosis-to-birth interval was longest after selective feticide (10.5 (interquartile range (IQR), 4.2-14.9) weeks), followed by laser surgery (9.7 (IQR, 6.6-12.7) weeks), expectant management (7.8 (IQR, 3.8-14.4) weeks), IUT (± PET) (4.0 (IQR, 2.0-6.9) weeks) and delivery (0.3 (IQR, 0.0-0.5) weeks). Treatment choice for TAPS varied greatly within and between the 17 fetal therapy centers. CONCLUSIONS Antenatal treatment for TAPS differs considerably amongst fetal therapy centers. Perinatal mortality and morbidity were high in all management groups. Prolongation of pregnancy was best achieved by expectant management, treatment by laser surgery or selective feticide. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- L. S. A. Tollenaar
- Department of Obstetrics, Division of Fetal therapyLeiden University Medical CenterLeidenThe Netherlands
| | - F. Slaghekke
- Department of Obstetrics, Division of Fetal therapyLeiden University Medical CenterLeidenThe Netherlands
| | - L. Lewi
- Department of Obstetrics and GynecologyUniversity Hospitals LeuvenLeuvenBelgium
| | - Y. Ville
- Department of Obstetrics and Maternal‐Fetal MedicineHôpital Necker‐Enfants Malades, AP‐HPParisFrance
| | - M. Lanna
- Fetal Therapy Unit ‘U. Nicolini’, Vittore Buzzi Children's HospitalUniversity of MilanMilanItaly
| | - A. Weingertner
- Department of Obstetrics and GynecologyStrasbourg University HospitalStrasbourg CedexFrance
| | - G. Ryan
- Fetal Medicine Unit, Ontario Fetal Centre, Mount Sinai HospitalUniversity of TorontoTorontoCanada
| | - S. Arévalo
- Maternal Fetal Medicine Unit, Department of ObstetricsVall d'Hebron University HospitalBarcelonaSpain
| | - A. Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation TrustUniversity of LondonLondonUK
- Vascular Biology Research CentreMolecular and Clinical Sciences Research Institute, St George's University of LondonLondonUK
| | - C. O. Brock
- The Fetal Center, Department of Obstetrics, Children's Memorial Hermann Hospital, Gynecology and Reproductive Sciences, UT Health, McGovern Medical SchoolUniversity of TexasHoustonTXUSA
| | - P. Klaritsch
- Division of Obstetrics and Maternal Fetal Medicine, Department of Obstetrics and GynecologyMedical University of Graz, GrazAustria
| | - K. Hecher
- Department of Obstetrics and Fetal MedicineUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - G. Gardener
- Department of Maternal Fetal MedicineMater Mothers' HospitalSouth BrisbaneQueenslandAustralia
| | - E. Bevilacqua
- Department of Obstetrics and Gynecology, University Hospital BrugmannUniversité Libre de BruxellesBrusselsBelgium
| | - K. V. Kostyukov
- Acad. V. I. Kulakov Research Center of ObstetricsGynecology, and Perinatology, Ministry of Health of the Russian FederationMoscowRussia
| | - M. O. Bahtiyar
- Department of Obstetrics, Gynecology and Reproductive SciencesYale School of MedicineNew HavenCTUSA
| | - M. D. Kilby
- Fetal Medicine Centre, Birmingham Women's and Children's Foundation TrustUniversity of BirminghamBirminghamUK
| | - E. Tiblad
- Center for Fetal MedicineKarolinska University HospitalStockholmSweden
| | - D. Oepkes
- Department of Obstetrics, Division of Fetal therapyLeiden University Medical CenterLeidenThe Netherlands
| | - E. Lopriore
- Department of Pediatrics, Division of NeonatologyLeiden University Medical CenterLeidenThe Netherlands
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Khalil A, Gordijn S, Ganzevoort W, Thilaganathan B, Johnson A, Baschat AA, Hecher K, Reed K, Lewi L, Deprest J, Oepkes D, Lopriore E. Consensus diagnostic criteria and monitoring of twin anemia-polycythemia sequence: Delphi procedure. Ultrasound Obstet Gynecol 2020; 56:388-394. [PMID: 31605505 DOI: 10.1002/uog.21882] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 09/22/2019] [Accepted: 09/24/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Twin anemia-polycythemia sequence (TAPS) is associated with increased perinatal morbidity and mortality. Inconsistencies in the diagnostic criteria for TAPS exist, which hinder the ability to establish robust evidence-based management or monitoring protocols. The main aim of this study was to determine, by expert consensus using a Delphi procedure, the key diagnostic features and optimal monitoring approach for TAPS. METHODS A Delphi process was conducted among an international panel of experts on TAPS. Panel members were provided with a list of literature-based parameters for diagnosing and monitoring TAPS. They were asked to rate the importance of the parameters on a five-point Likert scale. Consensus was sought to determine the cut-off values for accepted parameters, as well as parameters used in the monitoring of and assessment of outcome in twin pregnancy complicated by TAPS. RESULTS A total of 132 experts were approached. Fifty experts joined the first round, of whom 33 (66%) completed all three rounds. There was agreement that the monitoring interval for the development of TAPS should be every 2 weeks and that the severity should be assessed antenatally using a classification system based on middle cerebral artery (MCA) peak systolic velocity (PSV), but there was no agreement on the gestational age at which to start monitoring. Once the diagnosis of TAPS is made, monitoring should be scheduled weekly. For the antenatal diagnosis of TAPS, the combination of MCA-PSV ≥ 1.5 MoM in the anemic twin and ≤ 0.8 MoM in the polycythemic twin was agreed. Alternatively, MCA-PSV discordance ≥ 1 MoM can be used to diagnose TAPS. Postnatally, hemoglobin difference ≥ 8 g/dL and intertwin reticulocyte ratio ≥ 1.7 were agreed criteria for diagnosis of TAPS. There was no agreement on the cut-off of MCA-PSV or its discordance for prenatal intervention. The panel agreed on prioritizing perinatal and long-term survival outcomes in follow-up studies. CONCLUSIONS Consensus-based diagnostic features of TAPS, as well as cut-off values for the parameters involved, were agreed upon by a panel of experts. Future studies are needed to validate these diagnostic features before they can be used in clinical trials of interventions. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Twins Trust Centre for Research and Clinical Excellence, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - S Gordijn
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - W Ganzevoort
- Department of Obstetrics and Gynecology, Academic Medical Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
| | - B Thilaganathan
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - A Johnson
- Departments of Obstetrics/Gynecology & Pediatric Surgery, The University of Texas Health Science Center, The Fetal Center, Children's Memorial Hermann Hospital, Houston, TX, USA
| | - A A Baschat
- The Johns Hopkins Center for Fetal Therapy, Baltimore, MD, USA
| | - K Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - K Reed
- Twins Trust, Aldershot, UK
| | - L Lewi
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - J Deprest
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - D Oepkes
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - E Lopriore
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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Tollenaar LSA, Lopriore E, Middeldorp JM, Klumper FJCM, Haak MC, Oepkes D, Slaghekke F. Prevalence of placental dichotomy, fetal cardiomegaly and starry-sky liver in twin anemia-polycythemia sequence. Ultrasound Obstet Gynecol 2020; 56:395-399. [PMID: 31856326 PMCID: PMC7496878 DOI: 10.1002/uog.21948] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 11/12/2019] [Accepted: 12/04/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To investigate the prevalence of three additional ultrasound markers, placental dichotomy, cardiomegaly and 'starry-sky' liver, in monochorionic twin pregnancy with twin anemia-polycythemia sequence (TAPS). METHODS All monochorionic twin pregnancies, diagnosed antenatally with TAPS at our center between 2006 and 2019, were reviewed retrospectively for the presence of placental dichotomy, cardiomegaly in the donor twin and a starry-sky liver in the recipient twin. TAPS was diagnosed based on delta middle cerebral artery (MCA) peak systolic velocity (PSV) > 0.5 multiples of the median. The primary outcome was the prevalence of placental dichotomy, cardiomegaly, starry-sky liver and at least one of these markers in both spontaneous and post-laser TAPS. The secondary outcome was the prevalence of these ultrasound markers according to the antenatal stage of TAPS. RESULTS A total of 91 monochorionic twin pregnancies with TAPS were eligible for analysis. Placental dichotomy was observed in 44% (40/91) of TAPS cases. A total of 70% (64/91) of the TAPS donors developed cardiomegaly and a starry-sky liver was identified in 66% (53/80) of the TAPS recipients. The prevalence of cardiomegaly and starry-sky liver was roughly comparable between spontaneous and post-laser TAPS (69% (33/48) vs 72% (31/43) and 64% (25/39) vs 68% (28/41), respectively). Pregnancies with spontaneous TAPS showed a higher prevalence of placental dichotomy compared with post-laser TAPS (63% (30/48) vs 23% (10/43)). At least one of the three ultrasound markers was detected in 86% (78/91) of TAPS cases, meaning that 14% (13/91) of cases presented solely with discordant MCA-PSV values. There was a trend towards increased prevalence of all three ultrasound markers with increasing antenatal TAPS stage. CONCLUSIONS Placental dichotomy, fetal cardiomegaly and a starry-sky liver are commonly found in TAPS pregnancy. Investigating the presence of these ultrasound markers can be of additional help in improving antenatal detection of TAPS in monochorionic twin pregnancy. © 2019 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- L. S. A. Tollenaar
- Division of Fetal Medicine, Department of ObstetricsLeiden University Medical CenterLeidenThe Netherlands
| | - E. Lopriore
- Division of Neonatology, Department of PediatricsLeiden University Medical CenterLeidenThe Netherlands
| | - J. M. Middeldorp
- Division of Fetal Medicine, Department of ObstetricsLeiden University Medical CenterLeidenThe Netherlands
| | - F. J. C. M. Klumper
- Division of Fetal Medicine, Department of ObstetricsLeiden University Medical CenterLeidenThe Netherlands
| | - M. C. Haak
- Division of Fetal Medicine, Department of ObstetricsLeiden University Medical CenterLeidenThe Netherlands
| | - D. Oepkes
- Division of Fetal Medicine, Department of ObstetricsLeiden University Medical CenterLeidenThe Netherlands
| | - F. Slaghekke
- Division of Fetal Medicine, Department of ObstetricsLeiden University Medical CenterLeidenThe Netherlands
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9
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Townsend R, Duffy JMN, Sileo F, Perry H, Ganzevoort W, Reed K, Baschat AA, Deprest J, Gratacos E, Hecher K, Lewi L, Lopriore E, Oepkes D, Papageorghiou A, Gordijn SJ, Khalil A. Core outcome set for studies investigating management of selective fetal growth restriction in twins. Ultrasound Obstet Gynecol 2020; 55:652-660. [PMID: 31273879 DOI: 10.1002/uog.20388] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 06/07/2019] [Accepted: 06/21/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Selective fetal growth restriction (sFGR) occurs in monochorionic twin pregnancies when unequal placental sharing leads to restriction in the growth of just one twin. Management options include laser separation of the fetal circulations, selective reduction or expectant management, but what constitutes the best treatment is not yet known. New trials in this area are urgently needed but, in this rare and complex group, maximizing the relevance and utility of clinical research design and outputs is paramount. A core outcome set ensures standardized outcome collection and reporting in future research. The objective of this study was to develop a core outcome set for studies evaluating treatments for sFGR in monochorionic twins. METHODS An international steering group of clinicians, researchers and patients with experience of sFGR was established to oversee the process of development of a core outcome set for studies investigating the management of sFGR. Outcomes reported in the literature were identified through a systematic review and informed the design of a three-round Delphi survey. Clinicians, researchers, and patients and family representatives participated in the survey. Outcomes were scored on a Likert scale from 1 (limited importance for making a decision) to 9 (critical for making a decision). Consensus was defined a priori as a Likert score of ≥ 8 in the third round of the Delphi survey. Participants were then invited to take part in an international meeting of stakeholders in which the modified nominal group technique was used to consider the consensus outcomes and agree on a final core outcome set. RESULTS Ninety-six outcomes were identified from 39 studies in the systematic review. One hundred and three participants from 23 countries completed the first round of the Delphi survey, of whom 88 completed all three rounds. Twenty-nine outcomes met the a priori criteria for consensus and, along with six additional outcomes, were prioritized in a consensus development meeting, using the modified nominal group technique. Twenty-five stakeholders participated in this meeting, including researchers (n = 3), fetal medicine specialists (n = 3), obstetricians (n = 2), neonatologists (n = 3), midwives (n = 4), parents and family members (n = 6), patient group representatives (n = 3), and a sonographer. Eleven core outcomes were agreed upon. These were live birth, gestational age at birth, birth weight, intertwin birth-weight discordance, death of surviving twin after death of cotwin, loss during pregnancy or before final hospital discharge, parental stress, procedure-related adverse maternal outcome, length of neonatal stay in hospital, neurological abnormality on postnatal imaging and childhood disability. CONCLUSIONS This core outcome set for studies investigating the management of sFGR represents the consensus of a large and diverse group of international collaborators. Use of these outcomes in future trials should help to increase the clinical relevance of research on this condition. Consensus agreement on core outcome definitions and measures is now required. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- R Townsend
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - J M N Duffy
- Balliol College, University of Oxford, Oxford, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - F Sileo
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - H Perry
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - W Ganzevoort
- Department of Obstetrics and Gynecology, Academic Medical Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
| | - K Reed
- Twin and Multiple Births Association (TAMBA), Aldershot, UK
| | - A A Baschat
- The Johns Hopkins Center for Fetal Therapy, Baltimore, MD, USA
| | - J Deprest
- Department of Obstetrics and Gynecology, University Hospitals of KU Leuven, Leuven, Belgium
| | - E Gratacos
- Barcelona Center for Maternal-Fetal and Neonatal Medicine, Hospital Clínic and Hospital Sant Joan de Deu, Universitat de Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - K Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - L Lewi
- Department of Obstetrics and Gynecology, University Hospitals of KU Leuven, Leuven, Belgium
| | - E Lopriore
- Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - D Oepkes
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - A Papageorghiou
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - S J Gordijn
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - A Khalil
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
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10
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de Ruigh AA, Simons NE, van 't Hooft J, van Teeffelen AS, Duijnhoven RG, van Wassenaer-Leemhuis AG, Aarnoudse-Moens C, van de Beek C, Oepkes D, Haak MC, Woiski M, Porath MM, Derks JB, van Kempen L, Roseboom TJ, Mol BW, Pajkrt E. Child outcomes after amnioinfusion compared with no intervention in women with second-trimester rupture of membranes: a long-term follow-up study of the PROMEXIL-III trial. BJOG 2020; 128:292-301. [PMID: 31984652 PMCID: PMC7818451 DOI: 10.1111/1471-0528.16115] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To assess the effect of transabdominal amnioinfusion or no intervention on long-term outcomes in children born after second-trimester prelabour rupture of the membranes (PROM between 16+0/7 -24+0/7 weeks) and oligohydramnios. POPULATION Follow up of infants of women who participated in the randomised controlled trial: PPROMEXIL-III (NTR3492). METHODS Surviving infants were invited for neurodevelopmental assessment up to 5 years of corrected age using a Bayley Scales of Infant and Toddler Development or a Wechsler Preschool and Primary Scale of Intelligence. Parents were asked to complete several questionnaires. MAIN OUTCOME MEASURES Neurodevelopmental outcomes were measured. Mild delay was defined as -1 standard deviation (SD), severe delay as -2 SD. Healthy long-term survival was defined as survival without neurodevelopmental delay or respiratory problems. RESULTS In the amnioinfusion group, 18/28 children (64%) died versus 21/28 (75%) in the no intervention group (relative risk 0.86; 95% confidence interval [CI] 0.60-1.22). Follow-up data were obtained from 14/17 (82%) children (10 amnioinfusion, 4 no intervention). In both groups, 2/28 (7.1%) had a mild neurodevelopmental delay. No severe delay was seen. Healthy long-term survival occurred in 5/28 children (17.9%) after amnioinfusion versus 2/28 (7.1%) after no intervention (odds ratio 2.50; 95% CI 0.53-11.83). When analysing data for all assessed survivors, 10/14 (71.4%) survived without mild neurodevelopmental delay and 7/14 (50%) were classified healthy long-term survivor. CONCLUSIONS In this small sample of women suffering second-trimester PROM and oligohydramnios, amnioinfusion did not improve long-term outcomes. Overall, 71% of survivors had no neurodevelopmental delay. TWEETABLE ABSTRACT Healthy long-term survival was comparable for children born after second-trimester PROM and treatment with amnioinfusion or no intervention.
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Affiliation(s)
- A A de Ruigh
- Department of Obstetrics and Gynaecology, Academic Medical Centre (AMC), Amsterdam, The Netherlands
| | - N E Simons
- Department of Obstetrics and Gynaecology, Academic Medical Centre (AMC), Amsterdam, The Netherlands
| | - J van 't Hooft
- Department of Obstetrics and Gynaecology, Academic Medical Centre (AMC), Amsterdam, The Netherlands
| | - A S van Teeffelen
- Department of Obstetrics and Gynaecology, Grow, School for Oncology and Developmental Biology, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
| | - R G Duijnhoven
- Department of Obstetrics and Gynaecology, Academic Medical Centre (AMC), Amsterdam, The Netherlands
| | - A G van Wassenaer-Leemhuis
- Department of Neonatology, Emma Children's Hospital Academic Medical Centre (AMC), Amsterdam, The Netherlands
| | - C Aarnoudse-Moens
- Department of Neonatology, Emma Children's Hospital Academic Medical Centre (AMC), Amsterdam, The Netherlands
| | - C van de Beek
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction and Development Research Institute, Academic Medical Centre (AMC), Amsterdam, The Netherlands
| | - D Oepkes
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre (LUMC), Leiden, The Netherlands
| | - M C Haak
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre (LUMC), Leiden, The Netherlands
| | - M Woiski
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre (Radboudumc), Nijmegen, The Netherlands
| | - M M Porath
- Department of Obstetrics and Gynaecology, Maxima Medical Centre (MMC), Veldhoven, The Netherlands
| | - J B Derks
- Department of Obstetrics and Gynaecology, University Medical Centre Utrecht (UMCU), Utrecht, The Netherlands
| | - Lem van Kempen
- Department of Obstetrics and Gynaecology, Academic Medical Centre (AMC), Amsterdam, The Netherlands
| | - T J Roseboom
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction and Development Research Institute, Academic Medical Centre (AMC), Amsterdam, The Netherlands
| | - B W Mol
- Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - E Pajkrt
- Department of Obstetrics and Gynaecology, Academic Medical Centre (AMC), Amsterdam, The Netherlands
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11
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Murgano D, Khalil A, Prefumo F, Mieghem TV, Rizzo G, Heyborne KD, Melchiorre K, Peeters S, Lewi L, Familiari A, Lopriore E, Oepkes D, Murata M, Anselem O, Buca D, Liberati M, Hack K, Nappi L, Baxi LV, Scambia G, Acharya G, D'antonio F. Outcome of twin-to-twin transfusion syndrome in monochorionic monoamniotic twin pregnancy: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2020; 55:310-317. [PMID: 31595578 DOI: 10.1002/uog.21889] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 08/15/2019] [Accepted: 09/18/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To explore the outcome of monochorionic monoamniotic (MCMA) twin pregnancies affected by twin-to-twin transfusion syndrome (TTTS). METHODS MEDLINE and EMBASE databases were searched for studies reporting the outcome of MCMA twin pregnancies complicated by TTTS. The primary outcome was intrauterine death (IUD); secondary outcomes were miscarriage, single IUD, double IUD, neonatal death (NND), perinatal death (PND), survival of at least one twin, survival of both twins and preterm birth (PTB) before 32 weeks' gestation. Outcomes were assessed in MCMA twins affected by TTTS not undergoing intervention and in those treated with amniodrainage, laser therapy or cord occlusion. Subgroup analysis was performed including cases diagnosed before 24 weeks. Random-effects meta-analysis of proportions was used to analyze the data. RESULTS Fifteen cohort studies, including 888 MCMA twin pregnancies, of which 44 were affected by TTTS, were included in the review. There was no randomized trial comparing the different management options in MCMA twin pregnancies complicated by TTTS. In cases not undergoing intervention, miscarriage occurred in 11.0% of fetuses, while the incidence of IUD, NND and PND was 25.2%, 12.2% and 31.2%, respectively. PTB complicated 50.5% of these pregnancies. In cases treated by laser surgery, the incidence of miscarriage, IUD, NND and PND was 19.6%, 27.4%, 7.4% and 35.9%, respectively, and the incidence of PTB before 32 weeks' gestation was 64.9%. In cases treated with amniodrainage, the incidence of IUD, NND and PND was 31.3%, 13.5% and 45.7% respectively, and PTB complicated 76.2% of these pregnancies. Analysis of cases undergoing cord occlusion was affected by the very small number of included cases. Miscarriage occurred in 19.2%, while there was no case of IUD or NND of the surviving twin. PTB before 32 weeks occurred in 50.0% of these cases. CONCLUSIONS MCMA twin pregnancies complicated by TTTS are at high risk of perinatal mortality and PTB. Further studies are needed in order to elucidate the optimal type of prenatal treatment in these pregnancies. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- D Murgano
- Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK; and Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - F Prefumo
- Department of Obstetrics and Gynecology, Spedali Riunit, Brescia, Italy
| | - T Van Mieghem
- Department of Obstetrics and Gynecology, Mount Sinai Hospital and University of Toronto, Toronto, Canada
| | - G Rizzo
- Division of Maternal and Fetal Medicine, Ospedale Cristo Re, University of Rome Tor Vergata, Rome, Italy
| | - K D Heyborne
- Department of Obstetrics and Gynecology, Denver Health and Hospital Authority, Denver, CO, USA; Department of Obstetrics and Gynecology, University of Colorado Denver, Aurora, CO, USA
| | - K Melchiorre
- Department of Obstetrics and Gynecology, 'Spirito Santo' Hospital, Pescara, Italy
| | - S Peeters
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - L Lewi
- Department of Obstetrics and Gynecology, University Hospitals of KU Leuven, Leuven, Belgium
| | - A Familiari
- Department of Obstetrics and Gynecology, Fondazione IRCCS, Ca Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - E Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - D Oepkes
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - M Murata
- Center for Maternal, Fetal and Neonatal Medicine, Fukuoka University Hospital, Fukuoka, Japan
| | - O Anselem
- Maternité Port-Royal, Groupe Hospitalier Cochin-Broca-Hôtel-Dieu, Université Paris Descartes, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - D Buca
- Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - M Liberati
- Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - K Hack
- Department of Obstetrics and Gynecology, Gelre Hospitals, Apeldoorn, The Netherlands
| | - L Nappi
- Department of Obstetrics and Gynecology, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - L V Baxi
- School of Medicine, Columbia University, New York, USA
| | - G Scambia
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Fondazione Policlinico A. Gemelli, Rome, Italy
| | - G Acharya
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Center for Fetal Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - F D'antonio
- Department of Obstetrics and Gynecology, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
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Tollenaar LSA, Lopriore E, Slaghekke F, Oepkes D, Middeldorp JM, Haak MC, Klumper FJCM, Tan RNGB, Rijken M, Van Klink JMM. High risk of long-term neurodevelopmental impairment in donor twins with spontaneous twin anemia-polycythemia sequence. Ultrasound Obstet Gynecol 2020; 55:39-46. [PMID: 31432580 DOI: 10.1002/uog.20846] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 08/03/2019] [Accepted: 08/09/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To evaluate the long-term neurodevelopmental and behavioral outcomes in surviving infants of pregnancies with spontaneous twin anemia-polycythemia sequence (TAPS), to compare outcome between donors and recipients, and to investigate potential risk factors for neurodevelopmental impairment (NDI). METHODS This was a retrospective study of a consecutive cohort of spontaneous-TAPS survivors delivered between 2005 and 2017 at the Leiden University Medical Center, The Netherlands. Neurological, motor, cognitive and behavioral development were assessed at a median age of 4 years. The primary outcome was NDI, which was a composite outcome of cerebral palsy, deafness, blindness and motor and/or cognitive delay. NDI was subdivided into two grades of severity: mild-to-moderate and severe NDI. Outcome was compared between surviving donor and recipient twins. Logistic regression analysis was used to assess risk factors for NDI. RESULTS Forty-nine twin pregnancies complicated by spontaneous TAPS were eligible for inclusion. The perinatal survival rate was 83% (81/98) of twins. Neurodevelopmental assessment was performed in 91% (74/81) of surviving twins. NDI occurred in 30% (22/74) of TAPS survivors, and was found more often in donors (44%; 15/34) than in recipients (18%; 7/40) (odds ratio (OR), 4.1; 95% CI, 1.8-9.1; P = 0.001). Severe NDI was detected in 9% (7/74) of survivors and was higher in donors compared with recipients (18% (6/34) vs 3% (1/40)), although the difference did not reach statistical significance; P = 0.056). Donors demonstrated lower cognitive scores compared with recipients (P = 0.011). Bilateral deafness was identified in 15% (5/34) of donors compared with 0% (0/40) of recipients (P = 0.056). Parental concern regarding development was reported more often for donor than for recipient twins (P = 0.001). On multivariate analysis, independent risk factors for NDI were gestational age at delivery (OR, 0.7; 95% CI, 0.5-0.9; P = 0.003) and severe anemia (OR, 6.4; 95% CI, 2.4-17.0; P < 0.001). CONCLUSION Surviving donor twins of pregnancies complicated by spontaneous TAPS have four-fold higher odds of NDI compared with recipient cotwins, are at increased risk of cognitive delay and have a high rate of deafness. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- L S A Tollenaar
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - E Lopriore
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - F Slaghekke
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - D Oepkes
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - J M Middeldorp
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - M C Haak
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - F J C M Klumper
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - R N G B Tan
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - M Rijken
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - J M M Van Klink
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
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13
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Perry H, Duffy JMN, Reed K, Baschat A, Deprest J, Hecher K, Lewi L, Lopriore E, Oepkes D, Khalil A. Core outcome set for research studies evaluating treatments for twin-twin transfusion syndrome. Ultrasound Obstet Gynecol 2019; 54:255-261. [PMID: 30520170 DOI: 10.1002/uog.20183] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 11/04/2018] [Accepted: 11/16/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To develop, using a Delphi procedure and a nominal group technique, a core outcome set (COS) for studies evaluating treatments for twin-twin transfusion syndrome (TTTS), which should assist in standardizing outcome selection, collection and reporting in future research studies. METHODS An international steering group comprising healthcare professionals, researchers and patients with experience of TTTS guided the development of this COS. Potential core outcomes, identified through a comprehensive literature review and supplemented by outcomes suggested by the steering group, were entered into a three-round Delphi survey. Healthcare professionals, researchers, and patients or relatives of patients who had experienced TTTS were invited to participate. Consensus was defined a priori using the 15%/70% definition of the Core Outcome Measures in Effectiveness Trials (COMET) initiative. The modified nominal group technique was used to evaluate the consensus outcomes in a face-to-face consultation meeting and identify the final COS. RESULTS One hundred and three participants, from 29 countries, participated in the three-round Delphi survey. Of those, 88 completed all three rounds. Twenty-two consensus outcomes were identified through the Delphi procedure and entered into the modified nominal group technique. The consensus meeting was attended by 11 healthcare professionals, two researchers and three patients; 12 core outcomes were prioritized for inclusion in the COS. Fetal core outcomes included live birth, pregnancy loss (including miscarriage, stillbirth, termination of pregnancy and neonatal mortality), subsequent death of a cotwin following single-twin demise at the time of treatment, recurrence of TTTS, twin anemia-polycythemia sequence and amniotic band syndrome. Neonatal core outcomes included gestational age at delivery, birth weight, brain injury syndromes and ischemic limb injury. Maternal core outcomes included maternal mortality and admission to Level-2 or -3 care setting. One aspirational outcome, neurodevelopment at 18-24 months of age, was also prioritized. CONCLUSIONS Implementing the COS for TTTS within future research studies could make a substantial contribution to advancing the usefulness of research in TTTS. Standardized definitions and measurement instruments are now required for individual core outcomes. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- H Perry
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - J M N Duffy
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Balliol College, University of Oxford, Oxford, UK
| | - K Reed
- Twin and Multiple Births Association (TAMBA), Aldershot, UK
| | - A Baschat
- The Johns Hopkins Center for Fetal Therapy, Baltimore, MD, USA
| | - J Deprest
- Department of Obstetrics and Gynecology, University Hospitals of KU Leuven, Leuven, Belgium
- Institute for Women's Health, University College London, London, UK
| | - K Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Neues Klinikum, Hamburg, Germany
| | - L Lewi
- Department of Obstetrics and Gynecology, University Hospitals of KU Leuven, Leuven, Belgium
| | - E Lopriore
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - D Oepkes
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - A Khalil
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
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Fontanella F, Maggio L, Verheij JBGM, Duin LK, Adama Van Scheltema PN, Cohen‐Overbeek TE, Pajkrt E, Bekker M, Willekes C, Bax CJ, Gracchi V, Oepkes D, Bilardo CM. Fetal megacystis: a lot more than LUTO. Ultrasound Obstet Gynecol 2019; 53:779-787. [PMID: 30043466 PMCID: PMC6593717 DOI: 10.1002/uog.19182] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Revised: 05/29/2018] [Accepted: 07/09/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE Fetal megacystis presents a challenge in terms of counseling and management because of its varied etiology and evolution. The aim of this study was to present a comprehensive overview of the underlying etiologies and structural anomalies associated with fetal megacystis. METHODS This was a retrospective multicenter study of cases referred to the fetal medicine unit of one of the eight academic hospitals in The Netherlands with a diagnosis of fetal megacystis. For each case, data on and measurements of fetal urinary tract and associated structural anomalies were collected. All available postmortem examinations and postnatal investigations were reviewed in order to establish the final diagnosis. In the first trimester, fetal megacystis was defined as longitudinal bladder diameter (LBD) ≥ 7 mm, and in the second and third trimesters as an enlarged bladder failing to empty during an extended ultrasound examination lasting at least 40 min. RESULTS Of the 541 pregnancies with fetal megacystis, it was isolated (or solely accompanied by other signs of lower urinary tract obstruction (LUTO)) in 360 (67%) cases and associated with other abnormal ultrasound findings in 181 (33%) cases. The most common associated ultrasound anomaly was an increased nuchal translucency thickness (22%), followed by single umbilical artery (10%) and cardiac defect (10%). A final diagnosis was established in 418 cases, including 222 (53%) cases with isolated LUTO and 60 (14%) infants with normal micturition or minor isolated urological anomalies. In the remaining 136 (33%) cases, concomitant developmental or chromosomal abnormality or genetic syndrome was diagnosed. Overall, 40 chromosomal abnormalities were diagnosed, including trisomy 18 (n = 24), trisomy 21 (n = 5), Turner syndrome (n = 5), trisomy 13 (n = 3) and 22q11 deletion (n = 3). Thirty-two cases presented with anorectal malformations involving the anus, rectum and urogenital tract. In cases with confirmed urethral and anal atresia, megacystis occurred early in pregnancy and the bladder appeared severely distended (the LBD (in mm) was equal to or greater than twice the gestational age (in weeks)). Fetal macrosomia was detected in six cases and an overgrowth syndrome was detected in four cases, comprising two infants with Beckwith-Wiedemann syndrome and two with Sotos syndrome. Megacystis-microcolon-intestinal hypoperistalsis syndrome was diagnosed in five (1%) cases and prenatally suspected only in one case. CONCLUSIONS Although the main cause of fetal megacystis is LUTO, an enlarged fetal bladder can also be present as a concomitant finding of miscellaneous genetic syndromes, developmental disturbances and chromosomal abnormalities. We provide an overview of the structural anomalies and congenital disorders associated with fetal megacystis and propose a practical guide for the differential diagnosis of genetic syndromes and chromosomal and developmental abnormalities in pregnancies presenting with fetal megacystis, focusing on the morphological examination of the fetus. © 2018 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- F. Fontanella
- Department of Obstetrics, Gynaecology and Prenatal DiagnosisUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - L. Maggio
- Department of Obstetrics, Gynaecology and Prenatal DiagnosisUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - J. B. G. M. Verheij
- Department of GeneticsUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - L. K. Duin
- Department of Obstetrics, Gynaecology and Prenatal DiagnosisUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - P. N. Adama Van Scheltema
- Department of Obstetrics, Gynaecology and Prenatal DiagnosisLeiden University Medical CenterLeidenThe Netherlands
| | - T. E. Cohen‐Overbeek
- Division of Obstetrics and Prenatal Medicine, Department of Obstetrics and Gynecology, Erasmus MCUniversity Medical Center RotterdamRotterdamThe Netherlands
| | - E. Pajkrt
- Department of ObstetricsAcademic Medical Center AmsterdamAmsterdamThe Netherlands
| | - M. Bekker
- Department of Obstetrics, Gynaecology and Prenatal DiagnosisRadboud University Medical CenterNijmegenThe Netherlands
- Department of Obstetrics, Gynaecology and Prenatal DiagnosisUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - C. Willekes
- Department of Obstetrics, Gynaecology and Prenatal DiagnosisMaastricht University Medical Center, Grow School for Oncology and Medical BiologyMaastrichtThe Netherlands
| | - C. J. Bax
- Department of Obstetrics, Gynaecology and Prenatal DiagnosisVU University Medical CenterAmsterdamThe Netherlands
| | - V. Gracchi
- Department of PediatricsUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - D. Oepkes
- Department of Obstetrics, Gynaecology and Prenatal DiagnosisLeiden University Medical CenterLeidenThe Netherlands
| | - C. M. Bilardo
- Department of Obstetrics, Gynaecology and Prenatal DiagnosisUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
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Tollenaar LSA, Lopriore E, Middeldorp JM, Haak MC, Klumper FJ, Oepkes D, Slaghekke F. Improved prediction of twin anemia-polycythemia sequence by delta middle cerebral artery peak systolic velocity: new antenatal classification system. Ultrasound Obstet Gynecol 2019; 53:788-793. [PMID: 30125414 PMCID: PMC6593803 DOI: 10.1002/uog.20096] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 07/27/2018] [Accepted: 08/08/2018] [Indexed: 06/01/2023]
Abstract
OBJECTIVES To investigate the diagnostic accuracy of delta middle cerebral artery peak systolic velocity (MCA-PSV) > 0.5 multiples of the median (MoM) and compare its predictive value with that of the current MCA-PSV cut-off values of > 1.5 MoM in the donor and < 1.0 MoM in the recipient, for the diagnosis of twin anemia-polycythemia sequence (TAPS) in monochorionic twin pregnancy. METHODS This was a retrospective consecutive cohort study comprising all uncomplicated monochorionic twin pregnancies and twin pregnancies with a postnatal diagnosis of TAPS managed between 2003 and 2017 in the Dutch national referral center for fetal therapy. Cases with incomplete MCA-PSV Doppler measurements 1 week prior to delivery or with incomplete hemoglobin measurements within 1 day after birth were excluded. The postnatal diagnosis of TAPS was based on an intertwin hemoglobin difference > 8 g/dL and at least one of the following: reticulocyte count ratio > 1.7 or presence of minuscule anastomoses on the placental surface. We compared the predictive accuracy of the current diagnostic method using MCA-PSV cut-off values of > 1.5 MoM in the donor and < 1.0 MoM in the recipient with that of a new method based on intertwin difference in MCA-PSV > 0.5 MoM for prediction of TAPS. RESULTS In total, 45 uncomplicated and 35 TAPS monochorionic twin pregnancies were analyzed. The sensitivity and specificity of the cut-off MCA-PSV values (donor > 1.5 MoM, recipient < 1.0 MoM) to predict TAPS was 46% (95% CI, 30-62%) and 100% (95% CI, 92-100%), respectively; positive predictive value was 100% (95% CI, 81-100%) and negative predictive value 70% (95% CI, 58-80%). Delta MCA-PSV showed a sensitivity of 83% (95% CI, 67-92%) and a specificity of 100% (95% CI, 92-100%); the positive and negative predictive values were 100% (95% CI, 88-100%) and 88% (95% CI, 77-94%), respectively. Of the 35 cases with TAPS diagnosed postnatally, 13 twin pairs showed a delta MCA-PSV > 0.5 MoM but did not fulfill the cut-off MCA-PSV criteria. Of these 13 TAPS twins, nine donors and four recipients had normal MCA-PSV values. There was a high correlation between delta MCA-PSV and intertwin difference in hemoglobin level (R = 0.725, P < 0.01). CONCLUSION Delta MCA-PSV > 0.5 MoM has a greater diagnostic accuracy for predicting TAPS compared to the current MCA-PSV cut-off criteria. We therefore propose a new antenatal classification system for TAPS. In monochorionic twin pregnancies with delta MCA-PSV > 0.5 MoM on Doppler ultrasound, but normal MCA-PSV values in the donor or recipient, obstetricians should be aware of the therapeutic implications and neonatal morbidities associated with TAPS. © 2018 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- L. S. A. Tollenaar
- Division of Fetal Medicine, Department of ObstetricsLeiden University Medical CenterLeidenThe Netherlands
| | - E. Lopriore
- Division of Neonatology, Department of PediatricsLeiden University Medical CenterLeidenThe Netherlands
| | - J. M. Middeldorp
- Division of Fetal Medicine, Department of ObstetricsLeiden University Medical CenterLeidenThe Netherlands
| | - M. C. Haak
- Division of Fetal Medicine, Department of ObstetricsLeiden University Medical CenterLeidenThe Netherlands
| | - F. J. Klumper
- Division of Fetal Medicine, Department of ObstetricsLeiden University Medical CenterLeidenThe Netherlands
| | - D. Oepkes
- Division of Fetal Medicine, Department of ObstetricsLeiden University Medical CenterLeidenThe Netherlands
| | - F. Slaghekke
- Division of Fetal Medicine, Department of ObstetricsLeiden University Medical CenterLeidenThe Netherlands
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Fontanella F, van Scheltema PNA, Duin L, Cohen-Overbeek TE, Pajkrt E, Bekker MN, Willekes C, Oepkes D, Bilardo CM. Antenatal staging of congenital lower urinary tract obstruction. Ultrasound Obstet Gynecol 2019; 53:520-524. [PMID: 29978555 DOI: 10.1002/uog.19172] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 06/10/2018] [Accepted: 06/11/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To propose a staging system for congenital lower urinary tract obstruction (LUTO) capable of predicting the severity of the condition and its prognosis. METHODS This was a national retrospective study carried out at the eight Academic Hospitals in The Netherlands. We collected prenatal and postnatal data of fetuses at high risk of isolated LUTO that were managed conservatively. Postnatal renal function was assessed by the estimated glomerular filtration rate (eGFR), calculated using the Schwartz formula, considering the length of the infant and the creatinine nadir in the first year after birth. Receiver-operating characteristics (ROC) curve analysis, univariate analysis and multivariate logistic regression analysis with stepwise backward elimination were performed in order to identify the best antenatal predictors of perinatal mortality and postnatal renal function. RESULTS In total, 261 fetuses suspected of having LUTO and managed conservatively were included in the study. The pregnancy was terminated in 110 cases and perinatal death occurred in 35 cases. Gestational age at appearance of oligohydramnios showed excellent accuracy in predicting the risk of perinatal mortality with an area under the ROC curve of 0.95 (P < 0.001) and an optimal cut-off at 26 weeks' gestation. Fetuses with normal amniotic fluid (AF) volume at 26 weeks' gestation presented with low risk of poor outcome and were therefore defined as cases with mild LUTO. In fetuses referred before the 26th week of gestation, the urinary bladder volume (BV) was the best unique predictor of perinatal mortality. ROC curve analysis identified a BV of 5.4 cm3 and appearance of oligohydramnios at 20 weeks as the best threshold for predicting an adverse outcome. LUTO cases with a BV ≥ 5.4 cm3 or abnormal AF volume before 20 weeks' gestation were defined as severe and those with BV < 5.4 cm3 and normal AF volume at the 20 weeks' scan were defined as moderate. Risk of perinatal mortality significantly increased according to the stage of severity, from mild to moderate to severe stage, from 9% to 26% to 55%, respectively. Similarly, risk of severely impaired renal function increased from 11% to 31% to 44%, for mild, moderate and severe LUTO, respectively. CONCLUSIONS Gestational age at appearance of oligo- or anhydramnios and BV at diagnosis can accurately predict mortality and morbidity in fetuses with LUTO. Our proposed staging system can triage reliably fetuses with LUTO and predict the severity of the condition and its prognosis. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- F Fontanella
- Department of Obstetrics, Gynecology and Prenatal Diagnosis, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - L Duin
- Department of Obstetrics, Gynecology and Prenatal Diagnosis, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - T E Cohen-Overbeek
- Department of Obstetrics and Gynecology, Division of Obstetrics and Prenatal Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - E Pajkrt
- Department of Obstetrics and Gynecology, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - M N Bekker
- Department of Obstetrics, Gynecology and Prenatal Diagnosis, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Obstetrics, Gynecology and Prenatal Diagnosis, University Medical Center Utrecht, Utrecht, The Netherlands
| | - C Willekes
- Department of Obstetrics, Gynecology and Prenatal Diagnosis, University Medical Center, Grow School for Oncology and Medical Biology, Maastricht, The Netherlands
| | - D Oepkes
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - C M Bilardo
- Department of Obstetrics, Gynecology and Prenatal Diagnosis, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Obstetrics, Gynecology and Prenatal Diagnosis, VU University Medical Center, Amsterdam, The Netherlands
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17
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Zhao DP, Verbeek L, Tollenaar LSA, Te Pas AB, Oepkes D, Lopriore E. Inter-twin hemoglobin difference at birth in uncomplicated monochorionic twins in relation to the size of the placental anastomoses. Placenta 2019; 74:28-31. [PMID: 30630614 DOI: 10.1016/j.placenta.2019.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 12/22/2018] [Accepted: 01/01/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To evaluate the relation between Hb levels and the size of the placental anastomoses. METHODS We performed a retrospective review of all uncomplicated MC twins delivered vaginally at our center from 2002 to 2017. Hb levels at birth and on day 2 were retrieved. All MC placentas were routinely injected with colored dye and high-resolution pictures were taken for computer-based analysis. We measured the size of arterio-arterial (AA) and veno-venous (VV) anastomoses as well as the total venous size, defined as the sum of the diameter of first generation of placental veins within 5 cm of each cord insertion. We assessed the relation between Hb levels and placental angioarchitecture. RESULTS A total of 170 MC twin pairs were analyzed. Median Hb level in twin 1 was significantly lower than that in twin 2 both at birth (16.0 versus 17.4 g/dl, P = 0.02) and on day 2 (14.6 versus 18.1 g/dl, P = 0.000000188). Inter-twin Hb difference on day 2 was positively correlated with the size of AA anastomoses (Spearman r = 0.25, 95% CI 0.04-0.43, P = 0.0161). The diameter of AA anastomoses was positively related to the total size of veins connecting to AA anastomoses in the placental territory of twin 2 (Spearman r = 0.55, 95% CI 0.41-0.66, P = 0.0001). DISCUSSION MC twins with larger AA anastomoses have higher Hb differences at birth. Higher Hb levels in second born twins may partly be due to increased placento-fetal transfusion through larger placental vessels.
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Affiliation(s)
- D P Zhao
- Department of Reproductive Medicine, Shenzhen Maternity and Child Healthcare Hospital, Southern Medical University, Shenzhen, China; Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands.
| | - L Verbeek
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - L S A Tollenaar
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands
| | - A B Te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - D Oepkes
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands
| | - E Lopriore
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands
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18
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Khalil A, Beune I, Hecher K, Wynia K, Ganzevoort W, Reed K, Lewi L, Oepkes D, Gratacos E, Thilaganathan B, Gordijn SJ. Consensus definition and essential reporting parameters of selective fetal growth restriction in twin pregnancy: a Delphi procedure. Ultrasound Obstet Gynecol 2019; 53:47-54. [PMID: 29363848 DOI: 10.1002/uog.19013] [Citation(s) in RCA: 114] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Revised: 01/01/2018] [Accepted: 01/08/2018] [Indexed: 05/27/2023]
Abstract
OBJECTIVES Twin pregnancy complicated by selective fetal growth restriction (sFGR) is associated with increased perinatal mortality and morbidity. Inconsistencies in the diagnostic criteria for sFGR employed in existing studies hinder the ability to compare or combine their findings. It is therefore challenging to establish robust evidence-based management or monitoring pathways for these pregnancies. The main aim of this study was to determine, by expert consensus using a Delphi procedure, the key diagnostic features of and the essential reporting parameters in sFGR. METHODS A Delphi process was conducted among an international panel of experts in sFGR in twin pregnancy. Panel members were provided with a list of literature-based parameters for diagnosing sFGR and were asked to rate their importance on a five-point Likert scale. Parameters were described as solitary (sufficient to diagnose sFGR, even if all other parameters are normal) or contributory (those that require other abnormal parameter(s) to be present for the diagnosis of sFGR). Consensus was sought to determine the cut-off values for accepted parameters, as well as parameters used in the monitoring, management and assessment of outcome of twin pregnancy complicated by sFGR. The questions were presented in two separate categories according to chorionicity. RESULTS A total of 72 experts were approached, of whom 60 agreed to participate and entered the first round; 48 (80%) completed all four rounds. For the definition of sFGR irrespective of chorionicity, one solitary parameter (estimated fetal weight (EFW) of one twin < 3rd centile) was agreed. For monochorionic twin pregnancy, at least two out of four contributory parameters (EFW of one twin < 10th centile, abdominal circumference of one twin < 10th centile, EFW discordance of ≥ 25%, and umbilical artery pulsatility index of the smaller twin > 95th centile) were agreed. For sFGR in dichorionic twin pregnancy, at least two out of three contributory parameters (EFW of one twin < 10th centile, EFW discordance of ≥ 25%, and umbilical artery pulsatility index of the smaller twin > 95th centile) were agreed. CONCLUSIONS Consensus-based diagnostic features of sFGR in both monochorionic and dichorionic twin pregnancies, as well as cut-off values for the parameters involved, were agreed upon by a panel of experts. Future studies are needed to validate these diagnostic features before they can be used in clinical trials of interventions. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - I Beune
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - K Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - K Wynia
- Department of Health Sciences, Community and Occupational Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - W Ganzevoort
- Department of Obstetrics and Gynecology, Academic Medical Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
| | - K Reed
- Twin and Multiple Births Association (TAMBA), UK
| | - L Lewi
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, KU, Leuven, Belgium
- Department of Development and Regeneration, KU, Leuven, Belgium
| | - D Oepkes
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - E Gratacos
- Fetal Medicine Unit and Department of Obstetrics, Hospital Clinic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - B Thilaganathan
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - S J Gordijn
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Donepudi R, Akkermans J, Mann L, Klumper FJ, Middeldorp JM, Lopriore E, Moise KJ, Bebbington M, Johnson A, Oepkes D, Papanna R. Impact of cannula size on recurrent twin-twin transfusion syndrome and twin anemia-polycythemia sequence after fetoscopic laser surgery. Ultrasound Obstet Gynecol 2018; 52:744-749. [PMID: 28925589 DOI: 10.1002/uog.18904] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Revised: 07/28/2017] [Accepted: 09/08/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE The optimal outcome after fetoscopic laser surgery (FLS) for twin-twin transfusion syndrome (TTTS) depends on the successful ablation of all placental anastomoses. The objective of this study was to determine the incidence of and risk factors for recurrent TTTS (rTTTS) or twin anemia-polycythemia sequence (TAPS) after FLS, focusing on the impact of cannula diameter. METHODS This was a secondary analysis of data collected prospectively at two centers from 666 consecutive patients undergoing FLS for TTTS. The main outcomes were rTTTS and TAPS following FLS. Variables assessed included gestational age at intervention, stage of disease, recipient maximum vertical pocket, anterior placenta, number of anastomoses ablated, cannula diameter/operative scopes and use of the Solomon technique. Cannula diameter and corresponding scopes used were as follows: 8 Fr and 1.3 mm/0°; 9 Fr and 2.7 mm/0°; 10 Fr and 3 mm/0°; or 12 Fr and 3.3-3.7 mm/30-70°. Cannula diameter was used as a surrogate for scopes during analysis. Multivariate logistic regression analysis was performed to identify risk factors associated with rTTTS or TAPS after FLS; 'center' was considered an independent variable to account for variations in practice. In a nested cohort of pregnancies in which both fetuses survived, placental dye injection was performed in 315 placentae. Multivariate logistic regression analysis was performed to evaluate variables associated with the presence of residual anastomoses. RESULTS rTTTS or TAPS occurred in 61 (9%) cases following FLS (rTTTS in eight (1%) and TAPS in 53 (8%)). Factors associated significantly with the risk of rTTTS/TAPS on multivariate analysis were cannula diameter (when an 8-Fr, 9-Fr, 10-Fr or 12-Fr cannula was used, there was rTTTS/TAPS in 24%, 13%, 2% or 0.8% of cases, respectively (P < 0.001)) and use of the Solomon technique (rTTTS/TAPS occurred in 4.2% of those in which it was used vs 18.1% in those in which it was not (P < 0.001)). Only use of the Solomon technique was associated significantly with no residual anastomoses found after delivery. CONCLUSIONS Following FLS for TTTS, a lower incidence of rTTTS/TAPS was seen when the Solomon technique was used, as well as when a 10-Fr or 12-Fr cannula was used. A lower complication rate may be due to the use of a scope with better optics during placental mapping. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- R Donepudi
- The Fetal Center, Children's Memorial Hermann Hospital, Department of Obstetrics and Gynecology, McGovern Medical School, University of Texas Health Science Center at Houston, TX, USA
| | - J Akkermans
- Department of Obstetrics, Division of Fetal Therapy, Leiden University Medical Center, Leiden, The Netherlands
| | - L Mann
- The Fetal Center, Children's Memorial Hermann Hospital, Department of Obstetrics and Gynecology, McGovern Medical School, University of Texas Health Science Center at Houston, TX, USA
| | - F J Klumper
- Department of Obstetrics, Division of Fetal Therapy, Leiden University Medical Center, Leiden, The Netherlands
| | - J M Middeldorp
- Department of Obstetrics, Division of Fetal Therapy, Leiden University Medical Center, Leiden, The Netherlands
| | - E Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - K J Moise
- The Fetal Center, Children's Memorial Hermann Hospital, Department of Obstetrics and Gynecology, McGovern Medical School, University of Texas Health Science Center at Houston, TX, USA
| | - M Bebbington
- The Fetal Center, Children's Memorial Hermann Hospital, Department of Obstetrics and Gynecology, McGovern Medical School, University of Texas Health Science Center at Houston, TX, USA
| | - A Johnson
- The Fetal Center, Children's Memorial Hermann Hospital, Department of Obstetrics and Gynecology, McGovern Medical School, University of Texas Health Science Center at Houston, TX, USA
| | - D Oepkes
- Department of Obstetrics, Division of Fetal Therapy, Leiden University Medical Center, Leiden, The Netherlands
| | - R Papanna
- The Fetal Center, Children's Memorial Hermann Hospital, Department of Obstetrics and Gynecology, McGovern Medical School, University of Texas Health Science Center at Houston, TX, USA
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Fontanella F, Duin LK, Adama van Scheltema PN, Cohen‐Overbeek TE, Pajkrt E, Bekker M, Willekes C, Bax CJ, Gracchi V, Oepkes D, Bilardo CM. Prenatal diagnosis of LUTO: improving diagnostic accuracy. Ultrasound Obstet Gynecol 2018; 52:739-743. [PMID: 29266464 PMCID: PMC6587765 DOI: 10.1002/uog.18990] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Revised: 11/13/2017] [Accepted: 12/08/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To propose a clinical score for the optimal antenatal diagnosis of fetal lower urinary tract obstruction (LUTO) in the second and third trimesters of pregnancy, as an alternative to the commonly used ultrasound triad of megacystis, keyhole sign and hydronephrosis. METHODS This was a national retrospective study carried out at the eight tertiary fetal medicine units (FMUs) in The Netherlands. Only cases referred for megacystis from the second trimester onwards and with a clear postnatal diagnosis were included in the study. At referral, data were collected on amniotic fluid volume, renal cortical appearance, bladder volume, hydronephrosis, fetal ascites, ureteral size, keyhole sign, fetal sex and gestational age. Multivariate analysis was performed, starting by including all antenatal variables, and then excluding the weakest predictors using the backward stepwise strategy. RESULTS Over a 7-year period, 312 fetuses with a diagnosis of megacystis were referred to the eight Dutch tertiary FMUs. A final diagnosis was achieved in 143 cases, including 124 of LUTO and 19 reclassified after birth as non-obstructive megacystis. The optimal bladder volume cut-off for prediction of LUTO was 35 cm3 (area under the curve (AUC) = 0.7, P = 0.03). The clinical score formulated on the basis of the multivariate analysis included fetal sex, degree of bladder distension, ureteral size, oligo- or anhydramnios and gestational age at referral. The combination of these five variables demonstrated good accuracy in discriminating LUTO from non-obstructive megacystis (AUC = 0.84, P < 0.001), compared with the poor performance of the ultrasound triad (AUC = 0.63, P = 0.07). CONCLUSIONS We propose a clinical score that combines five antenatal variables for the prospective diagnosis of congenital LUTO. This score showed good discriminative capacity in predicting LUTO, and better diagnostic accuracy compared with that of the classic ultrasound triad. Future studies to validate these results should be carried out in order to refine antenatal management of LUTO and prevent inappropriate fetal interventions. © 2017 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- F. Fontanella
- Department of Obstetrics, Gynaecology and Prenatal Diagnosis, University Medical Center GroningenUniversity of GroningenThe Netherlands
| | - L. K. Duin
- Department of Obstetrics, Gynaecology and Prenatal Diagnosis, University Medical Center GroningenUniversity of GroningenThe Netherlands
| | - P. N. Adama van Scheltema
- Department of Obstetrics, Gynaecology and Prenatal DiagnosisLeiden University Medical CenterLeidenThe Netherlands
| | - T. E. Cohen‐Overbeek
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Prenatal MedicineErasmus MC University Medical CenterRotterdamThe Netherlands
| | - E. Pajkrt
- Department of ObstetricsAcademic Medical Center AmsterdamAmsterdamThe Netherlands
| | - M. Bekker
- Department of Obstetrics, Gynaecology and Prenatal DiagnosisRadboud University Medical CenterNijmegenThe Netherlands
- Department of Obstetrics, Gynaecology and Prenatal DiagnosisUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - C. Willekes
- Department of Obstetrics, Gynaecology and Prenatal Diagnosis, University Medical CenterGrow School for Oncology and Medical BiologyMaastrichtThe Netherlands
| | - C. J. Bax
- Department of Obstetrics, Gynaecology and Prenatal DiagnosisVU University Medical CenterAmsterdamThe Netherlands
| | - V. Gracchi
- Department of PediatricsUniversity Medical Center Groningen, University of GroningenThe Netherlands
| | - D. Oepkes
- Department of Obstetrics, Gynaecology and Prenatal DiagnosisLeiden University Medical CenterLeidenThe Netherlands
| | - C. M. Bilardo
- Department of Obstetrics, Gynaecology and Prenatal Diagnosis, University Medical Center GroningenUniversity of GroningenThe Netherlands
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Groene SG, Tollenaar LSA, Slaghekke F, Middeldorp JM, Haak M, Oepkes D, Lopriore E. Placental characteristics in monochorionic twins with selective intrauterine growth restriction in relation to the umbilical artery Doppler classification. Placenta 2018; 71:1-5. [PMID: 30415741 DOI: 10.1016/j.placenta.2018.09.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 08/23/2018] [Accepted: 09/17/2018] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The objective of this study was to evaluate the placental characteristics of monochorionic twin pregnancies with selective intrauterine growth restriction (sIUGR) classified according to the Gratacós classification based on umbilical artery Doppler measurements. METHODS All consecutive placentas from monochorionic twin pregnancies with sIUGR, (defined as a birthweight discordance > 25% and/or an estimated fetal weight in one twin <10th centile) examined between May 2002 and February 2018 were included in the study. Each placenta was injected with colored dye to study the angioarchitecture. Primary outcomes were placental share discordance and diameter of the arterio-arterial anastomoses in relation to the umbilical artery Doppler types of sIUGR (Gratacós classification). RESULTS Of the 83 sIUGR twins included, 27 were classified as Gratacós type I, 24 as type II and 32 as type III. The median gestational age at delivery was 34.3 weeks for type I, compared to 31.2 weeks and 31.6 weeks for type II and type III respectively. A trend towards a higher placental share discordance in type III sIUGR was observed. The median arterio-arterial diameter was 1.7 mm (0.8-2.6) in type I, 1.7 mm (1.2-2.2) in type II and 2.8 (2.0-3.5) mm in type III (p < 0.01). DISCUSSION Type III sIUGR placentas appear to be characterized by a larger diameter of the arterio-arterial anastomoses and a larger placental share discordance compared to type I and II sIUGR. The insights in the placental architecture of sIUGR placentas may offer new views on the pathophysiology of the disease.
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Affiliation(s)
- S G Groene
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, the Netherlands.
| | - L S A Tollenaar
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, the Netherlands
| | - F Slaghekke
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, the Netherlands
| | - J M Middeldorp
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, the Netherlands
| | - M Haak
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, the Netherlands
| | - D Oepkes
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, the Netherlands
| | - E Lopriore
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, the Netherlands
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Knijnenburg P, Slaghekke F, Tollenaar L, van Klink J, Zhao D, Middeldorp J, Haak M, Klumper F, Oepkes D, Lopriore E. Incidence of and Risk Factors for Residual Anastomoses in Twin-Twin Transfusion Syndrome Treated with Laser Surgery: A 15-Year Single-Center Experience. Fetal Diagn Ther 2018; 45:13-20. [DOI: 10.1159/000485932] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 11/29/2017] [Indexed: 01/14/2023]
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Zwiers C, Lindenburg ITM, Klumper FJ, de Haas M, Oepkes D, Van Kamp IL. Complications of intrauterine intravascular blood transfusion: lessons learned after 1678 procedures. Ultrasound Obstet Gynecol 2017; 50:180-186. [PMID: 27706858 PMCID: PMC5601196 DOI: 10.1002/uog.17319] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 08/19/2016] [Accepted: 09/22/2016] [Indexed: 05/14/2023]
Abstract
OBJECTIVE Maternal alloimmunization to fetal red-blood-cell antigens is a major cause of fetal anemia, which can lead to hydrops and perinatal death if untreated. The cornerstone of management during pregnancy is intrauterine intravascular blood transfusion (IUT). Although this procedure is considered relatively safe, complications continue to occur. The aim of this study was to evaluate rates of procedure-related complications and perinatal loss following IUT, and their change over time, in order to identify factors leading to improved outcome. METHODS This was a retrospective analysis of all IUTs for red-cell alloimmunization performed at the national referral center for fetal therapy in The Netherlands, from 1988 to 2015. Differences in complication rates and their associations with alterations in transfusion technique after 2001 were assessed. RESULTS Between 1988 and 2015, 1678 IUTs were performed in 589 fetuses. For IUTs performed in 2001 and onwards, there was significant improvement in survival (88.6% vs 97.0%, P < 0.001) and a decline in procedure-related complications per fetus (9.8% vs 3.3%, P = 0.001) and per procedure (3.4% vs 1.2%, P = 0.003) compared with those performed before 2001. Procedure-related perinatal loss declined from 4.7% to 1.8% per fetus (P = 0.053). Beneficial changes in transfusion technique were routine use of fetal paralysis, increased use of intrahepatic transfusion and avoidance of arterial puncture. CONCLUSIONS IUT has become an increasingly safe procedure in recent years when performed by experienced hands. The chosen technique should be fine-tuned according to the patient's individual situation. The declining complication rates are most likely related to center volume: this rare procedure is best performed in experienced fetal therapy centers. © 2016 Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- C. Zwiers
- Department of ObstetricsLeiden University Medical CenterLeidenThe Netherlands
| | - I. T. M. Lindenburg
- Department of ObstetricsLeiden University Medical CenterLeidenThe Netherlands
| | - F. J. Klumper
- Department of ObstetricsLeiden University Medical CenterLeidenThe Netherlands
| | - M. de Haas
- Department of Red Blood Cell Serology, Sanquin DiagnosticsAmsterdamThe Netherlands
- Department of Immunohematology and Blood TransfusionLeiden University Medical CenterLeidenThe Netherlands
| | - D. Oepkes
- Department of ObstetricsLeiden University Medical CenterLeidenThe Netherlands
| | - I. L. Van Kamp
- Department of ObstetricsLeiden University Medical CenterLeidenThe Netherlands
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24
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Wolf H, Arabin B, Lees CC, Oepkes D, Prefumo F, Thilaganathan B, Todros T, Visser GHA, Bilardo CM, Derks JB, Diemert A, Duvekot JJ, Ferrazzi E, Frusca T, Hecher K, Marlow N, Martinelli P, Ostermayer E, Papageorghiou AT, Scheepers HCJ, Schlembach D, Schneider KTM, Valcamonico A, van Wassenaer-Leemhuis A, Ganzevoort W. Longitudinal study of computerized cardiotocography in early fetal growth restriction. Ultrasound Obstet Gynecol 2017; 50:71-78. [PMID: 27484356 DOI: 10.1002/uog.17215] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 07/03/2016] [Accepted: 07/08/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To explore whether, in early fetal growth restriction (FGR), the longitudinal pattern of fetal heart rate (FHR) short-term variation (STV) can be used to identify imminent fetal distress and whether abnormalities of FHR recordings are associated with 2-year infant outcome. METHODS The original TRUFFLE study assessed whether, in early FGR, delivery based on ductus venosus (DV) Doppler pulsatility index (PI), in combination with safety-net criteria of very low STV on cardiotocography (CTG) and/or recurrent FHR decelerations, could improve 2-year infant survival without neurological impairment in comparison with delivery based on CTG monitoring only. This was a secondary analysis of women who delivered before 32 weeks and had consecutive STV data recorded > 3 days before delivery and known infant outcome at 2 years of age. Women who received corticosteroids within 3 days of delivery were excluded. Individual regression line algorithms of all STV values, except the last one before delivery, were calculated. Life tables and Cox regression analysis were used to calculate the daily risk for low STV or very low STV and/or FHR decelerations (below DV group safety-net criteria) and to assess which parameters were associated with this risk. Furthermore, it was assessed whether STV pattern, last STV value or recurrent FHR decelerations were associated with 2-year infant outcome. RESULTS One hundred and forty-nine women from the original TRUFFLE study met the inclusion criteria. Using the individual STV regression lines, prediction of a last STV below the cut-off used by the CTG monitoring group had sensitivity of 42% and specificity of 91%. For each day after study inclusion, the median risk for low STV (CTG group cut-off) was 4% (interquartile range (IQR), 2-7%) and for very low STV and/or recurrent FHR decelerations (below DV group safety-net criteria) was 5% (IQR, 4-7%). Measures of STV pattern, fetal Doppler (arterial or venous), birth-weight multiples of the median and gestational age did not usefully improve daily risk prediction. There was no association of STV regression coefficients, a low last STV and/or recurrent FHR decelerations with short- or long-term infant outcomes. CONCLUSION The TRUFFLE study showed that a strategy of DV monitoring with safety-net criteria of very low STV and/or recurrent FHR decelerations for delivery indication could increase 2-year infant survival without neurological impairment. This post-hoc analysis demonstrates that, in early FGR, the daily risk of abnormal CTG, as defined by the DV group safety-net criteria, is 5%, and that prediction is not possible. This supports the rationale for CTG monitoring more often than daily in these high-risk fetuses. Low STV and/or recurrent FHR decelerations were not associated with adverse infant outcome and it appears safe to delay intervention until such abnormalities occur, as long as DV-PI is within normal range. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- H Wolf
- Department of Obstetrics and Gynecology, Academic Medical Centre, Amsterdam, The Netherlands
| | - B Arabin
- Center for Mother and Child of the Phillips University, Marburg, Germany
| | - C C Lees
- Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - D Oepkes
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - F Prefumo
- Maternal-Fetal Medicine Unit, University of Brescia, Brescia, Italy
| | - B Thilaganathan
- Fetal Medicine Unit, St George's, University of London and St George's University Hospitals NHS Foundation Trust, Molecular and Clinical Sciences Research Institute, London, UK
| | - T Todros
- Department of Obstetrics and Gynaecology, University of Turin, Turin, Italy
| | - G H A Visser
- Department of Perinatal Medicine, University Medical Center, Utrecht, The Netherlands
| | - C M Bilardo
- Department of Obstetrics and Gynaecology, University Medical Center, University of Groningen, Groningen, The Netherlands
| | - J B Derks
- Department of Perinatal Medicine, University Medical Center, Utrecht, The Netherlands
| | - A Diemert
- Department of Obstetrics and Fetal Medicine, University Medical Center, Hamburg, Eppendorf, Germany
| | - J J Duvekot
- Department of Obstetrics and Gynaecology, Erasmus MC, Rotterdam, The Netherlands
| | - E Ferrazzi
- Department of Woman, Mother and Neonate, Buzzi Children's Hospital, University of Milan, Milan, Italy
| | - T Frusca
- Department of Obstetrics and Gynecology, Maggiore Hospital, University of Parma, Parma, Italy
| | - K Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center, Hamburg, Eppendorf, Germany
| | - N Marlow
- Department of Neonatology, Institute for Women's Health, University College Hospitals London, London, UK
| | - P Martinelli
- Department of Neuroscience, Dentistry and Reproductive Sciences, University of Naples Federico II, Naples, Italy
| | - E Ostermayer
- Division of Perinatal Medicine, Department of Obstetrics and Gynecology, Technical University, Munich, Germany
| | - A T Papageorghiou
- Fetal Medicine Unit, St George's, University of London and St George's University Hospitals NHS Foundation Trust, Molecular and Clinical Sciences Research Institute, London, UK
| | - H C J Scheepers
- Department of Obstetrics, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - D Schlembach
- Department of Obstetrics, Vivantes Clinic Neukölln, Berlin, Germany
| | - K T M Schneider
- Division of Perinatal Medicine, Department of Obstetrics and Gynecology, Technical University, Munich, Germany
| | - A Valcamonico
- Maternal-Fetal Medicine Unit, University of Brescia, Brescia, Italy
| | - A van Wassenaer-Leemhuis
- Department of Neonatology, Emma Children's Hospital Academic Medical Centre, Amsterdam, The Netherlands
| | - W Ganzevoort
- Department of Obstetrics and Gynecology, Academic Medical Centre, Amsterdam, The Netherlands
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Eschbach SJ, Boons LSTM, Van Zwet E, Middeldorp JM, Klumper FJCM, Lopriore E, Teunissen AKK, Rijlaarsdam ME, Oepkes D, Ten Harkel ADJ, Haak MC. Right ventricular outflow tract obstruction in complicated monochorionic twin pregnancy. Ultrasound Obstet Gynecol 2017; 49:737-743. [PMID: 27363529 DOI: 10.1002/uog.16008] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 06/16/2016] [Accepted: 06/17/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES Severe right ventricular outflow tract obstruction (RVOTO) is a potential complication in recipient twins of twin-to-twin transfusion syndrome (TTTS) that requires postnatal follow-up or treatment. We aimed to evaluate pregnancy characteristics of neonates with RVOTO from complicated monochorionic twin pregnancies, determine the incidence of RVOTO in TTTS cases and construct a prediction model for its development. METHODS This was an observational cohort study of all complicated monochorionic twin pregnancies with a postnatal diagnosis of RVOTO examined at our center. Cases were referred for evaluation of the need for fetal therapy or intervention because of TTTS, selective intrauterine growth restriction (sIUGR) or multiple congenital malformations in one of the twins. Ultrasound data were retrieved from our monochorionic twin database. Among liveborn TTTS recipients treated prenatally with laser therapy, those with RVOTO were compared with those without RVOTO (controls). We describe four additional cases with RVOTO that were not TTTS recipients. RESULTS A total of 485 twin pregnancies received laser therapy for TTTS during the study period. RVOTO was diagnosed in 3% (11/368) of liveborn TTTS recipients, of whom two showed mild Ebstein's anomaly. Before laser therapy, pericardial effusion was seen in 45% (5/11) of RVOTO cases (P < 0.01) and abnormal A-wave in the ductus venosus (DV) in 73% (8/11) (P = 0.03), significantly higher proportions than in controls. Mean gestational age at laser therapy was 17 + 3 weeks in RVOTO cases compared with 20 + 3 weeks in controls (P = 0.03). A prediction model for RVOTO was constructed incorporating these three significant variables. One TTTS donor had RVOTO after the development of transient hydrops following laser therapy. Three larger twins in pregnancies complicated by sIUGR developed RVOTO, the onset of which was detectable early in the second trimester. CONCLUSIONS RVOTO occurs in TTTS recipient twins but can also develop in TTTS donors and larger twins of pregnancies complicated by sIUGR. Abnormal flow in the DV, pericardial effusion and early gestational age at onset of TTTS are predictors of RVOTO in TTTS recipients, which suggests increased vulnerability to hemodynamic imbalances in the fetal heart in early pregnancy. These findings could guide diagnostic follow-up protocols after TTTS treatment. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- S J Eschbach
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - L S T M Boons
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - E Van Zwet
- Department of Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands
| | - J M Middeldorp
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - F J C M Klumper
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - E Lopriore
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - A K K Teunissen
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - M E Rijlaarsdam
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - D Oepkes
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - A D J Ten Harkel
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - M C Haak
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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Stampalija T, Arabin B, Wolf H, Bilardo CM, Lees C, Brezinka C, Derks J, Diemert A, Duvekot J, Ferrazzi E, Frusca T, Ganzevoort W, Hecher K, Kingdom J, Marlow N, Marsal K, Martinelli P, Ostermayer E, Papageorghiou A, Schlembach D, Schneider K, Thilaganathan B, Thornton J, Todros T, Valcamonico A, Valensise H, van Wassenaer-Leemhuis A, Visser G, Aktas A, Borgione S, Chaoui R, Cornette J, Diehl T, van Eyck J, Fratelli N, van Haastert I, Lobmaier S, Lopriore E, Missfelder-Lobos H, Mansi G, Martelli P, Maso G, Maurer-Fellbaum U, Mensing van Charante N, Mulder-de Tollenaer S, Napolitano R, Oberto M, Oepkes D, Ogge G, van der Post J, Prefumo F, Preston L, Raimondi F, Reiss I, Scheepers L, Skabar A, Spaanderman M, Weisglas-Kuperus N, Zimmermann A. Is middle cerebral artery Doppler related to neonatal and 2-year infant outcome in early fetal growth restriction? Am J Obstet Gynecol 2017; 216:521.e1-521.e13. [PMID: 28087423 DOI: 10.1016/j.ajog.2017.01.001] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 12/20/2016] [Accepted: 01/03/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND Reduced fetal middle cerebral artery Doppler impedance is associated with hypoxemia in fetal growth restriction. It remains unclear as to whether this finding could be useful in timing delivery, especially in the third trimester. In this regard there is a paucity of evidence from prospective studies. OBJECTIVES The aim of this study was to determine whether there is an association between middle cerebral artery Doppler impedance and its ratio with the umbilical artery in relation to neonatal and 2 year infant outcome in early fetal growth restriction (26+0-31+6 weeks of gestation). Additionally we sought to explore which ratio is more informative for clinical use. STUDY DESIGN This is a secondary analysis from the Trial of Randomized Umbilical and Fetal Flow in Europe, a prospective, multicenter, randomized management study on different antenatal monitoring strategies (ductus venosus Doppler changes and computerized cardiotocography short-term variation) in fetal growth restriction diagnosed between 26+0 and 31+6 weeks. We analyzed women with middle cerebral artery Doppler measurement at study entry and within 1 week before delivery and with complete postnatal follow-up (374 of 503). The primary outcome was survival without neurodevelopmental impairment at 2 years corrected for prematurity. Neonatal outcome was defined as survival until first discharge home without severe neonatal morbidity. Z-scores were calculated for middle cerebral artery pulsatility index and both umbilicocerebral and cerebroplacental ratios. Odds ratios of Doppler parameter Z-scores for neonatal and 2 year infant outcome were calculated by multivariable logistic regression analysis adjusted for gestational age and birthweight p50 ratio. RESULTS Higher middle cerebral artery pulsatility index at inclusion but not within 1 week before delivery was associated with neonatal survival without severe morbidity (odds ratio, 1.24; 95% confidence interval, 1.02-1.52). Middle cerebral artery pulsatility index Z-score and umbilicocerebral ratio Z-score at inclusion were associated with 2 year survival with normal neurodevelopmental outcome (odds ratio, 1.33; 95% confidence interval, 1.03-1.72, and odds ratio, 0.88; 95% confidence interval, 0.78-0.99, respectively) as were gestation at delivery and birthweight p50 ratio (odds ratio, 1.41; 95% confidence interval, 1.20-1.66, and odds ratio, 1.86; 95% confidence interval, 1.33-2.60, respectively). When comparing cerebroplacental ratio against umbilicocerebral ratio, the incremental range of the cerebroplacental ratio tended toward zero, whereas the umbilicocerebral ratio tended toward infinity as the values became more abnormal. CONCLUSION In a monitoring protocol based on ductus venosus and cardiotocography in early fetal growth restriction (26+0-31+6 weeks of gestation), the impact of middle cerebral artery Doppler and its ratios on outcome is modest and less marked than birthweight and delivery gestation. It is unlikely that middle cerebral artery Doppler and its ratios are informative in optimizing the timing of delivery in fetal growth restriction before 32 weeks of gestation. The umbilicocerebral ratio allows for a better differentiation in the abnormal range than the cerebroplacental ratio.
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Gottschalk I, Chitty LS, Oepkes D, David A, Westgren M, Götherström C. BOOSTB4 – eine klinische Studie zur prä- und/oder postnatalen Stammzelltherapie zur Behandlung der Osteogenesis imperfecta. Geburtshilfe Frauenheilkd 2016. [DOI: 10.1055/s-0036-1593180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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28
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Araujo Júnior E, Eggink AJ, van den Dobbelsteen J, Martins WP, Oepkes D. Procedure-related complications of open vs endoscopic fetal surgery for treatment of spina bifida in an era of intrauterine myelomeningocele repair: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2016; 48:151-160. [PMID: 26612040 DOI: 10.1002/uog.15830] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 10/19/2015] [Accepted: 11/20/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To assess and compare the rate of procedure-related complications after intrauterine treatment of spina bifida by endoscopic surgery and by open fetal surgery. METHODS Systematic literature searches in PubMed and SCOPUS databases were performed on 20 September 2015 to identify randomized controlled trials and observational studies on treatment of human spina bifida by endoscopic or open fetal surgery techniques. Only studies with ≥ 10 cases that were published in or after 2000 were included in the meta-analysis in order to reduce the risk of bias. Primary outcomes (complete dehiscence, focal dehiscence and/or markedly thin hysterotomy scar; preterm delivery < 34 weeks; mean gestational age at delivery) and secondary outcomes (oligohydramnios, prelabor rupture of membranes, placental abruption, chorioamnionitis and perinatal death) were assessed for both techniques. Precision of the estimated proportions was evaluated with 95% CIs. Inconsistency was assessed using the I(2) statistic. RESULTS The search identified 1080 records that were examined based on title and abstract, of which 28 full-text articles were examined completely for eligibility. Nine records were excluded because cases were also described in other studies, leaving 19 records for analysis. When comparing endoscopic vs open fetal surgery, the rate of complete dehiscence, focal dehiscence and/or markedly thin hysterotomy scar was, respectively, 1% (95% CI, 0-4%) vs 26% (95% CI, 12-42%); preterm delivery < 34 weeks was 80% (95% CI, 41-100%) vs 45% (95% CI, 38-53%); oligohydramnios was 39% (95% CI, 9-75%) vs 14% (95% CI, 7-24%); prelabor rupture of membranes was 67% (95% CI, 12-100%) vs 38% (95% CI, 26-50%); and perinatal death was 14% (95% CI, 1-38%) vs 5% (95% CI, 3-8%). CONCLUSION Open fetal surgery for spina bifida seems to show lower rates of procedure-related complications than does endoscopic surgery, but the rate of hysterotomy scar complications is high after open surgery. Because of the low quality of evidence, the conclusions should be interpreted with caution. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- E Araujo Júnior
- Department of Obstetrics and Fetal Therapy, Leiden University Medical Center, Leiden, The Netherlands
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo, São Paulo, SP, Brazil
| | - A J Eggink
- Department of Obstetrics and Gynecology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - J van den Dobbelsteen
- Department of Biomechanical Engineering, Delft University of Technology, Delft, The Netherlands
| | - W P Martins
- Department of Obstetrics and Gynecology, Ribeirão Preto School of Medicine, São Paulo University, Ribeirão Preto, SP, Brazil
| | - D Oepkes
- Department of Obstetrics and Fetal Therapy, Leiden University Medical Center, Leiden, The Netherlands
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Oepkes D, Bartha JL, Schmid M, Yaron Y. Benefits of contingent screening vs primary screening by cell-free DNA testing: think again. Ultrasound Obstet Gynecol 2016; 47:542-545. [PMID: 26415101 DOI: 10.1002/uog.15758] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 09/15/2015] [Accepted: 09/18/2015] [Indexed: 06/05/2023]
Affiliation(s)
- D Oepkes
- Leiden University Medical Centre, Department of Obstetrics, Leiden, The Netherlands
| | - J L Bartha
- University Hospital La Paz, Madrid, Spain
| | - M Schmid
- Medical University of Vienna, Vienna, Austria
| | - Y Yaron
- Genetic Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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Eschbach SJ, Boons LSTM, Wolterbeek R, Middeldorp JM, Klumper FJCM, Lopriore E, Oepkes D, Haak MC. Prediction of single fetal demise after laser therapy for twin-twin transfusion syndrome. Ultrasound Obstet Gynecol 2016; 47:356-362. [PMID: 26395988 DOI: 10.1002/uog.15753] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 07/16/2015] [Accepted: 09/02/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE Single fetal demise (SFD) occurs in up to 20% of monochorionic pregnancies treated with laser coagulation for twin-twin transfusion syndrome (TTTS). We aimed to determine the independent factors associated with SFD to improve outcome in the care of TTTS pregnancies in the future. METHODS This was a case-control study on twin pregnancies treated for TTTS between 2007 and 2013. Data on ultrasound, laser surgery and outcome were retrieved from our monochorionic twin database. We analyzed separately cases of SFD in donor and recipient twins, and compared them with treated pregnancies that resulted in two live births. RESULTS Of the 273 TTTS pregnancies treated with laser coagulation, SFD occurred in 30 donors (11.0%) and 27 recipients (9.9%). In 67% of pregnancies with SFD, the death occurred within 1 week after laser treatment. For SFD in donors, absent/reversed end-diastolic flow in the umbilical artery was the strongest predictor (odds ratio (OR), 3.0 (95% CI, 1.1-8.0); P = 0.01), followed by the presence of an arterioarterial anastomosis (OR, 4.2 (95% CI, 1.4-13.1); P = 0.03) and discordance in estimated fetal weight (OR, 1.0 (95% CI, 1.0-1.1); P = 0.04). For SFD in recipients, independent predictors were absent/reversed A-wave in the ductus venosus (OR, 3.6 (95% CI, 1.2-10.5); P = 0.02) and the absence of recipient-to-donor arteriovenous anastomoses (OR, 10.6 (95% CI, 1.8-62.0); P < 0.01). CONCLUSIONS Our findings confirm earlier reports that suggest that abnormal blood flow is associated with SFD after laser treatment for TTTS. The association of SFD with the type of anastomoses is a new finding. We speculate that the type of anastomoses present determines the degree of hemodynamic change during laser therapy. Future strategies should aim at stabilizing fetal circulation before laser therapy to decrease the vulnerability to acute preload and afterload changes. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- S J Eschbach
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - L S T M Boons
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - R Wolterbeek
- Department of Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands
| | - J M Middeldorp
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - F J C M Klumper
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - E Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - D Oepkes
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - M C Haak
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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31
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Peeters SHP, Akkermans J, Bustraan J, Middeldorp JM, Lopriore E, Devlieger R, Lewi L, Deprest J, Oepkes D. Operator competence in fetoscopic laser surgery for twin-twin transfusion syndrome: validation of a procedure-specific evaluation tool. Ultrasound Obstet Gynecol 2016; 47:350-355. [PMID: 26307171 DOI: 10.1002/uog.15734] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 07/29/2015] [Accepted: 08/14/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVES Fetoscopic laser surgery for twin-twin transfusion syndrome is a procedure for which no objective tools exist to assess technical skills. To ensure that future fetal surgeons reach competence prior to performing the procedure unsupervised, we developed a performance assessment tool. The aim of this study was to validate this assessment tool for reliability and construct validity. METHODS We made use of a procedure-specific evaluation instrument containing all essential steps of the fetoscopic laser procedure, which was previously created using Delphi methodology. Eleven experts and 13 novices from three fetal medicine centers performed the procedure on the same simulator. Two independent observers assessed each surgery using the instrument (maximum score: 52). Interobserver reliability was assessed using Spearman correlation. We compared the performance of novices and experts to assess construct validity. RESULTS The interobserver reliability was high (Rs = 0.974, P < 0.001). Checklist scores for experts and novices were significantly different; the median score for novices was 28/52 (54%), whereas that for experts was 47.5/52 (91%) (P < 0.001). The procedure time and fetoscopy time were significantly shorter (P < 0.001) for experts. Residual anastomoses were found in 1/11 (9%) procedures performed by experts and in 9/13 (69%) procedures performed by novices (P = 0.005). Multivariable analysis showed that the checklist score, independent of age and gender, predicted competence. CONCLUSIONS The procedure-specific assessment tool for fetoscopic laser surgery shows good interobserver reliability and discriminates experts from novices. This instrument may therefore be a useful tool in the training curriculum for fetal surgeons. Further intervention studies with reassessment before and after training may increase the construct validity of the tool. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- S H P Peeters
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, The Netherlands
| | - J Akkermans
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, The Netherlands
| | - J Bustraan
- PLATO, Center for Research and Development in Education and Training, Faculty of Social Sciences, Leiden, The Netherlands
| | - J M Middeldorp
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, The Netherlands
| | - E Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, The Netherlands
| | - R Devlieger
- Department of Obstetrics, Division of Fetal Medicine, University Hospitals Leuven, Department of Development and Regeneration, KU Leuven, Belgium
| | - L Lewi
- Department of Obstetrics, Division of Fetal Medicine, University Hospitals Leuven, Department of Development and Regeneration, KU Leuven, Belgium
| | - J Deprest
- Department of Obstetrics, Division of Fetal Medicine, University Hospitals Leuven, Department of Development and Regeneration, KU Leuven, Belgium
| | - D Oepkes
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, The Netherlands
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Khalil A, Rodgers M, Baschat A, Bhide A, Gratacos E, Hecher K, Kilby MD, Lewi L, Nicolaides KH, Oepkes D, Raine-Fenning N, Reed K, Salomon LJ, Sotiriadis A, Thilaganathan B, Ville Y. ISUOG Practice Guidelines: role of ultrasound in twin pregnancy. Ultrasound Obstet Gynecol 2016; 47:247-63. [PMID: 26577371 DOI: 10.1002/uog.15821] [Citation(s) in RCA: 325] [Impact Index Per Article: 40.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 11/16/2015] [Indexed: 05/27/2023]
Affiliation(s)
- A Khalil
- Fetal Medicine Unit, St George’s Hospital, St George’s University of London, London, UK
| | - M Rodgers
- The Johns Hopkins Center for Fetal Therapy, Baltimore, MD, USA
| | - A Baschat
- The Johns Hopkins Center for Fetal Therapy, Baltimore, MD, USA
| | - A Bhide
- Fetal Medicine Unit, St George’s Hospital, St George’s University of London, London, UK
| | - E Gratacos
- Fetal Medicine Units and Departments of Obstetrics, Hospital Clinic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - K Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germaniy
| | - M D Kilby
- Centre for Women’s and Children's Health, University of Birmingham and Fetal Medicine Centre, Birmingham Women’s Foundation Trust, Birmingham, UK
| | - L Lewi
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - K H Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, King’s College Hospital, London, UK
| | - D Oepkes
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - N Raine-Fenning
- Division of Child Health, Obstetrics and Gynaecology, School of Medicine, University of Nottingham, Nottingham, UK
| | - K Reed
- Twin and Multiple Births Association (TAMBA)
| | - L J Salomon
- Hopital Necker-Enfants Malades, AP-HP, Universit´e Paris Descartes, Paris, France
| | - A Sotiriadis
- Department of Obstetrics and Gynaecology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - B Thilaganathan
- Fetal Medicine Unit, St George’s Hospital, St George’s University of London, London, UK
| | - Y Ville
- Hospital Necker-Enfants Malades, AP-HP, Université Paris Descartes, Paris, France
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Slootweg YM, Koelewijn JM, van Kamp IL, van der Bom JG, Oepkes D, de Haas M. Third trimester screening for alloimmunisation in Rhc-negative pregnant women: evaluation of the Dutch national screening programme. BJOG 2015; 123:955-63. [DOI: 10.1111/1471-0528.13816] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2015] [Indexed: 11/28/2022]
Affiliation(s)
- YM Slootweg
- Department of Obstetrics; Leiden University Medical Centre; Leiden the Netherlands
| | - JM Koelewijn
- Department of Obstetrics and Gynaecology; Academic Medical Centre; University of Amsterdam; Amsterdam the Netherlands
- Department of Experimental Immunohaematology; Sanquin Research; Amsterdam the Netherlands
- Department of General Practice; University Medical Centre; Groningen the Netherlands
| | - IL van Kamp
- Department of Obstetrics; Leiden University Medical Centre; Leiden the Netherlands
| | - JG van der Bom
- Centre for Clinical Transfusion Research, Sanquin Research; Department of Clinical Epidemiology; Leiden University Medical Centre; Leiden the Netherlands
| | - D Oepkes
- Department of Obstetrics; Leiden University Medical Centre; Leiden the Netherlands
| | - M de Haas
- Department of Experimental Immunohaematology; Sanquin Research; Amsterdam the Netherlands
- Leiden University Medical Centre; Department of Translational Immunohematology; Leiden the Netherlands
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Slaghekke F, Pasman S, Veujoz M, Middeldorp JM, Lewi L, Devlieger R, Favre R, Lopriore E, Oepkes D. Middle cerebral artery peak systolic velocity to predict fetal hemoglobin levels in twin anemia-polycythemia sequence. Ultrasound Obstet Gynecol 2015; 46:432-436. [PMID: 26094734 DOI: 10.1002/uog.14925] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Revised: 06/02/2015] [Accepted: 06/05/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To evaluate the diagnostic accuracy of middle cerebral artery peak systolic velocity (MCA-PSV) Doppler measurements in prediction of hemoglobin levels in twin anemia-polycythemia sequence (TAPS). METHODS This study involved a consecutive cohort comprising monochorionic twin pregnancies complicated by TAPS managed at three European fetal medicine centers between 2005 and 2013. The accuracy of MCA-PSV, measured immediately prior to fetal hemoglobin (Hb) measurement by fetal or cord blood sampling, for prediction of anemia and polycythemia was assessed using 2 × 2 tables. RESULTS A total of 116 measurements (74 recorded in donors and 42 in recipients) from 43 twin pregnancies complicated by TAPS were available for analysis. MCA-PSV multiples of the median (MoM) values correlated well with Hb levels (r = - 0.86; P < 0.001). The sensitivity of MCA-PSV ≥ 1.5 MoM to predict severe anemia (Hb deficit > 5 SD below the mean) in TAPS donors was 94% (95% CI, 85-98%); specificity was 74% (95% CI, 62-83%); positive and negative predictive values were 76% (95% CI, 65-85%) and 94% (95% CI, 83-98%), respectively. The sensitivity of MCA-PSV ≤ 1.0 MoM to predict polycythemia (Hb level > 5 SD above the mean) in TAPS recipients was 97% (95% CI, 87-99%); specificity was 96% (95% CI, 89-99%); positive and negative predictive values were 93% (95% CI, 81-97%) and 99% (95% CI, 93-100%), respectively. CONCLUSION MCA-PSV measurement has high diagnostic accuracy for predicting abnormal Hb levels in fetuses with TAPS.
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Affiliation(s)
- F Slaghekke
- Department of Obstetrics, Leiden University Medical Centre, Leiden, The Netherlands
| | - S Pasman
- Department of Obstetrics and Gynecology, University Hospitals KU Leuven, Leuven, Belgium
| | - M Veujoz
- Department of Obstetrics, University Hospital CMCO-HUS, Strasbourg, France
| | - J M Middeldorp
- Department of Obstetrics, Leiden University Medical Centre, Leiden, The Netherlands
| | - L Lewi
- Department of Obstetrics and Gynecology, University Hospitals KU Leuven, Leuven, Belgium
| | - R Devlieger
- Department of Obstetrics and Gynecology, University Hospitals KU Leuven, Leuven, Belgium
| | - R Favre
- Department of Obstetrics, University Hospital CMCO-HUS, Strasbourg, France
| | - E Lopriore
- Department of Neonatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - D Oepkes
- Department of Obstetrics, Leiden University Medical Centre, Leiden, The Netherlands
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van Steenis A, Zhao DP, Steggerda SJ, Kist WJ, Haak MC, Oepkes D, Lopriore E. Double fatal outcome after ruptured vasa previa in monochorionic twins: case report and review of the literature. J Matern Fetal Neonatal Med 2015; 29:2523-6. [PMID: 26366672 DOI: 10.3109/14767058.2015.1092957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Vasa previa is a condition in which one or more fetal blood vessels run through the amniotic membranes and cross or run near the external orifice of the uterus. Rupture of membranes can lead to tearing of these vessels and cause acute fetal exsanguination. In monochorionic twin (MC) pregnancies, acute exsanguination in one twin can lead to severe complications in the co-twin due to the presence of inter-twin placental vascular connections. We report a MC pair with severe perinatal asphyxia due to acute exsanguination after prenatally undetected ruptured vasa previa. This resulted in severe hemorrhagic shock in both twins with double fatal outcome. Antenatal detection of vasa previa is of paramount importance to prevent severe morbidity and mortality, especially in MCs. A review of the literature is presented.
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Affiliation(s)
- A van Steenis
- a Division of Neonatology , Department of Pediatrics, Leiden University Medical Center , Leiden , the Netherlands and
| | - D P Zhao
- a Division of Neonatology , Department of Pediatrics, Leiden University Medical Center , Leiden , the Netherlands and
| | - S J Steggerda
- a Division of Neonatology , Department of Pediatrics, Leiden University Medical Center , Leiden , the Netherlands and
| | - W J Kist
- b Division of Fetal Medicine , Department of Obstetrics, Leiden University Medical Center , Leiden , the Netherlands
| | - M C Haak
- b Division of Fetal Medicine , Department of Obstetrics, Leiden University Medical Center , Leiden , the Netherlands
| | - D Oepkes
- b Division of Fetal Medicine , Department of Obstetrics, Leiden University Medical Center , Leiden , the Netherlands
| | - Enrico Lopriore
- a Division of Neonatology , Department of Pediatrics, Leiden University Medical Center , Leiden , the Netherlands and
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Peeters SHP, Akkermans J, Slaghekke F, Bustraan J, Lopriore E, Haak MC, Middeldorp JM, Klumper FJ, Lewi L, Devlieger R, De Catte L, Deprest J, Ek S, Kublickas M, Lindgren P, Tiblad E, Oepkes D. Simulator training in fetoscopic laser surgery for twin-twin transfusion syndrome: a pilot randomized controlled trial. Ultrasound Obstet Gynecol 2015; 46:319-326. [PMID: 26036333 DOI: 10.1002/uog.14916] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Revised: 05/17/2015] [Accepted: 05/22/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To evaluate the effect of a newly developed training curriculum on the performance of fetoscopic laser surgery for twin-twin transfusion syndrome (TTTS) using an advanced high-fidelity simulator model. METHODS Ten novices were randomized to receive verbal instructions and either skills training using the simulator (study group; n = 5) or no training (control group; n = 5). Both groups were evaluated with a pre-training and post-training test on the simulator. Performance was assessed by two independent observers and comprised a 52-item checklist for surgical performance (SP) score, measurement of procedure time and number of anastomoses missed. Eleven experts set the benchmark level of performance. Face validity and educational value of the simulator were assessed using a questionnaire. RESULTS Both groups showed an improvement in SP score at the post-training test compared with the pre-training test. The simulator-trained group significantly outperformed the control group, with a median SP score of 28 (54%) in the pre-test and 46 (88%) in the post-test vs 25 (48%) and 36 (69%), respectively (P = 0.008). Procedure time decreased by 11 min (from 44 to 33 min) in the study group vs 1 min (from 39 to 38 min) in the control group (P = 0.69). There was no significant difference in the number of missed anastomoses at the post-training test between the two groups (1 vs 0). Subsequent feedback provided by the participants indicated that training on the simulator was perceived as a useful educational activity. CONCLUSIONS Proficiency-based simulator training improves performance, indicated by SP score, for fetoscopic laser therapy. Despite the small sample size of this study, practice on a simulator is recommended before trainees carry out laser therapy for TTTS in pregnant women.
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Affiliation(s)
- S H P Peeters
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - J Akkermans
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - F Slaghekke
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - J Bustraan
- PLATO, Center for Research and Development in Education and Training, Faculty of Social Sciences, Leiden, The Netherlands
| | - E Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - M C Haak
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - J M Middeldorp
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - F J Klumper
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - L Lewi
- Department of Obstetrics and Gynecology, Division of Fetal Medicine, University Hospitals KU Leuven, Leuven, Belgium
| | - R Devlieger
- Department of Obstetrics and Gynecology, Division of Fetal Medicine, University Hospitals KU Leuven, Leuven, Belgium
| | - L De Catte
- Department of Obstetrics and Gynecology, Division of Fetal Medicine, University Hospitals KU Leuven, Leuven, Belgium
| | - J Deprest
- Department of Obstetrics and Gynecology, Division of Fetal Medicine, University Hospitals KU Leuven, Leuven, Belgium
| | - S Ek
- Center for Fetal Medicine, Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
| | - M Kublickas
- Center for Fetal Medicine, Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
| | - P Lindgren
- Center for Fetal Medicine, Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
| | - E Tiblad
- Center for Fetal Medicine, Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
| | - D Oepkes
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
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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] [What about the content of this article? (0)] [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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Zhao D, Cambiaso O, Otaño L, Lewi L, Deprest J, Sun L, Duan T, Oepkes D, Shapiro S, De Paepe M, Lopriore E. Veno–venous anastomoses in twin–twin transfusion syndrome: A multicenter study. Placenta 2015; 36:911-4. [DOI: 10.1016/j.placenta.2015.05.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Revised: 05/15/2015] [Accepted: 05/19/2015] [Indexed: 11/26/2022]
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van Klink J, Koopman HM, Middeldorp JM, Klumper FJ, Rijken M, Oepkes D, Lopriore E. Long-term neurodevelopmental outcome after selective feticide in monochorionic pregnancies. BJOG 2015; 122:1517-24. [PMID: 26147116 DOI: 10.1111/1471-0528.13490] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To assess the incidence of and risk factors for adverse long-term neurodevelopmental outcome in complicated monochorionic pregnancies treated with selective feticide at our centre between 2000 and 2011. DESIGN Observational cohort study. SETTING National referral centre for fetal therapy (Leiden University Medical Centre, the Netherlands). POPULATION Neurodevelopmental outcome was assessed in 74 long-term survivors. METHODS Children, at least 2 years of age, underwent an assessment of neurologic, motor and cognitive development using standardised psychometric tests and the parents completed a behavioural questionnaire. MAIN OUTCOME MEASURES A composite outcome termed neurodevelopmental impairment including cerebral palsy (GMFCS II-V), cognitive and/or motor test score of <70, bilateral blindness or bilateral deafness requiring amplification. RESULTS A total of 131 monochorionic pregnancies were treated with selective feticide at the Leiden University Medical Centre. Overall survival rate was 88/131 (67%). Long-term outcome was assessed in 74/88 (84%). Neurodevelopmental impairment was detected in 5/74 [6.8%, 95% confidence interval (CI), 1.1-12.5] of survivors. Overall adverse outcome, including perinatal mortality or neurodevelopmental impairment was 48/131 (36.6%). In multivariate analysis, parental educational level was associated with cognitive test scores (regression coefficient B 3.9, 95% CI 1.8-6.0). Behavioural problems were reported in 10/69 (14.5%). CONCLUSIONS Adverse long-term outcome in survivor twins of complicated monochorionic pregnancies treated with selective feticide appears to be more prevalent than in the general population. Cognitive test scores were associated with parental educational level. TWEETABLE ABSTRACT Neurodevelopmental impairment after selective feticide was detected in 5/74 (6.8%, 95% CI 1.1-12.5) of survivors.
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Affiliation(s)
- Jmm van Klink
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Centre, Leiden, the Netherlands
| | - H M Koopman
- Clinical Psychology, Faculty of Social Sciences, Leiden University, Leiden, the Netherlands
| | - J M Middeldorp
- Division of Fetal Therapy, Department of Obstetrics, Leiden University Medical Centre, Leiden, the Netherlands
| | - F J Klumper
- Division of Fetal Therapy, Department of Obstetrics, Leiden University Medical Centre, Leiden, the Netherlands
| | - M Rijken
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Centre, Leiden, the Netherlands
| | - D Oepkes
- Division of Fetal Therapy, Department of Obstetrics, Leiden University Medical Centre, Leiden, the Netherlands
| | - E Lopriore
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Centre, Leiden, the Netherlands
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Peeters SHP, Akkermans J, Westra M, Lopriore E, Middeldorp JM, Klumper FJ, Lewi L, Devlieger R, Deprest J, Kontopoulos EV, Quintero R, Chmait RH, Smoleniec JS, Otaño L, Oepkes D. Identification of essential steps in laser procedure for twin-twin transfusion syndrome using the Delphi methodology: SILICONE study. Ultrasound Obstet Gynecol 2015; 45:439-446. [PMID: 25504904 DOI: 10.1002/uog.14761] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 11/27/2014] [Accepted: 12/04/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To determine, by expert consensus, the essential substeps of fetoscopic laser surgery (FLS) for twin-twin transfusion syndrome (TTTS) that could be used to create an authority-based curriculum for training in this procedure among fetal medicine specialists. METHODS A Delphi survey was conducted among an international panel of experts (n = 98) in FLS. Experts rated the substeps of FLS on a five-point Likert-type scale to indicate whether they considered them to be essential, and were able to comment on each substep, using a dedicated online platform accessed by the invited tertiary care facilities that specialize in fetal therapy. Responses were returned to the panel until consensus was reached (Cronbach's α ≥ 0.80). All substeps that were rated ≥ 4 by 80% of the experts were included in the evaluation instrument. RESULTS After the first iteration of the Delphi procedure, a response rate of 74% (73/98) was reached, and in the second and third iterations response rates of 90% (66/73) and 81% (59/73) were reached, respectively. Among a total of 81 substeps rated in the first round, 21 substeps had to be re-rated in the second round. Finally, from the initial list of substeps, 55 were agreed by experts to be essential. In the third round, the 18 categorized substeps were ranked in order of importance, with 'coagulation of all anastomoses that cross the equator' and 'determination of fetoscope insertion site' as the most important. CONCLUSIONS A total of 55 substeps of FLS for TTTS were defined by a panel of experts to be essential in the procedure. This list is the first authority-based evidence to be used in the development of a final training model for future fetal surgeons.
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Affiliation(s)
- S H P Peeters
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
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van Klink JMM, van Steenis A, Steggerda SJ, Genova L, Sueters M, Oepkes D, Lopriore E. Single fetal demise in monochorionic pregnancies: incidence and patterns of cerebral injury. Ultrasound Obstet Gynecol 2015; 45:294-300. [PMID: 25377504 DOI: 10.1002/uog.14722] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 10/20/2014] [Accepted: 10/27/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To evaluate the incidence, type and severity of cerebral injury in the surviving monochorionic (MC) cotwin after single fetal demise in twin pregnancies. METHODS All MC pregnancies with single fetal demise that were evaluated at the Leiden University Medical Center between 2002 and 2013 were included. Perinatal characteristics, neonatal outcome and the presence of cerebral injury, observed on neuroimaging, were recorded for all cotwin survivors. RESULTS A total of 49 MC pregnancies with single fetal demise, including one MC triplet, were included in the study (n = 50 cotwins). Median gestational age at occurrence of single fetal demise was 25 weeks and median interval between single fetal demise and live birth was 61 days, with a median gestational age at birth of 36 weeks. Severe cerebral injury was diagnosed in 13 (26%) of the 50 cotwins and was detected antenatally in 4/50 (8%) and postnatally in 9/50 (18%) cases. Cerebral injury was mostly due to hypoxic-ischemic injury resulting in cystic periventricular leukomalacia, middle cerebral artery infarction or injury to basal ganglia, thalamus and/or cortex. Risk factors associated with severe cerebral injury were advanced gestational age at the occurrence of single fetal demise (odds ratio (OR), 1.14 (95% CI, 1.01-1.29) for each week of gestation; P = 0.03), twin-twin transfusion syndrome developing prior to single fetal demise (OR, 5.0 (95% CI, 1.30-19.13); P = 0.02) and a lower gestational age at birth (OR, 0.83 (95% CI, 0.69-0.99) for each week of gestation; P = 0.04). CONCLUSIONS Single fetal demise in MC pregnancies is associated with severe cerebral injury occurring in 1 in 4 surviving cotwins. Routine antenatal and postnatal neuroimaging, followed by standardized long-term follow-up, is mandatory.
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MESH Headings
- Basal Ganglia/embryology
- Basal Ganglia/injuries
- Basal Ganglia/pathology
- Diagnostic Techniques, Neurological
- Female
- Fetal Death/etiology
- Fetofetal Transfusion/embryology
- Fetofetal Transfusion/mortality
- Fetofetal Transfusion/pathology
- Gestational Age
- Humans
- Hypoxia-Ischemia, Brain/complications
- Hypoxia-Ischemia, Brain/embryology
- Hypoxia-Ischemia, Brain/mortality
- Hypoxia-Ischemia, Brain/pathology
- Incidence
- Leukomalacia, Periventricular/embryology
- Leukomalacia, Periventricular/etiology
- Leukomalacia, Periventricular/mortality
- Leukomalacia, Periventricular/pathology
- Perinatal Mortality
- Pregnancy
- Pregnancy Outcome
- Retrospective Studies
- Risk Factors
- Severity of Illness Index
- Twins, Monozygotic
- Ultrasonography, Prenatal
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Affiliation(s)
- J M M van Klink
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
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Akkermans J, Peeters SHP, Middeldorp JM, Klumper FJ, Lopriore E, Ryan G, Oepkes D. A worldwide survey of laser surgery for twin-twin transfusion syndrome. Ultrasound Obstet Gynecol 2015; 45:168-174. [PMID: 25251913 DOI: 10.1002/uog.14670] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 09/01/2014] [Accepted: 09/04/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVES To evaluate differences between international fetal centers in their treatment of twin-twin transfusion syndrome (TTTS) by fetoscopic placental laser coagulation. METHODS Fetal therapy centers worldwide were sent a web-based questionnaire. Participants were identified through networks and through scientific presentations and papers. Questions included physician and center demographics, treatment criteria, operative technique and instrumentation. Laser treatment was compared between low-volume (< 20 procedures/year) and high-volume (≥ 20 procedures/year) centers. Data were analyzed using descriptive statistics. RESULTS Of 106 fetal therapy specialists approached, 76 (72%) from 64 centers in 25 countries responded. Of these, 48% (31/64) of centers and 63% (48/76) of operators performed fewer than 20 laser procedures annually. Comparison of low- and high-volume centers showed differences in technique, gestational age limits for treatment and geography. High-volume centers more often used the Solomon technique and applied wider gestational age limits for treatment. Europe and Asia had more high-volume centers, whereas South America, the Middle East and Australia had mainly low-volume centers. CONCLUSION This survey revealed significant differences between fetal centers in several aspects of fetoscopic placental laser therapy for TTTS. Increasing awareness of TTTS, and of laser coagulation as its preferred treatment, will lead to an increase in centers offering this modality, especially in Asia, Africa, South America and the Middle East. Considering the rarity of TTTS and the relative complexity of the procedure, developing international guidelines for techniques, instrumentation and suggested minimum volumes per center may aid in optimizing perinatal outcome.
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Affiliation(s)
- J Akkermans
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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Zhao D, Slaghekke F, Middeldorp J, Duan T, Oepkes D, Lopriore E. Placental share and hemoglobin level in relation to birth weight in twin anemia-polycythemia sequence. Placenta 2014; 35:1070-4. [DOI: 10.1016/j.placenta.2014.09.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 09/25/2014] [Accepted: 09/29/2014] [Indexed: 11/15/2022]
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Peeters SHP, Stolk TT, Slaghekke F, Middeldorp JM, Klumper FJ, Lopriore E, Oepkes D. Iatrogenic perforation of intertwin membrane after laser surgery for twin-to-twin transfusion syndrome. Ultrasound Obstet Gynecol 2014; 44:550-556. [PMID: 24961923 DOI: 10.1002/uog.13445] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 06/02/2014] [Accepted: 06/09/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To evaluate management and outcome of iatrogenic monoamniotic twins (iMAT) compared with twins with intact intertwin dividing membranes after laser surgery for twin-to-twin transfusion syndrome (TTTS). METHODS This was a retrospective analysis of twins with and without iatrogenic rupture of the intertwin membranes that had been treated for TTTS with laser surgery at our center between 2004 and 2012. Primary outcomes were perinatal survival and severe neonatal morbidity. Secondary outcomes were mode of delivery, gestational age at birth and cord entanglement. RESULTS In total, 338 pregnancies were included. In 67/338 (20%) pregnancies, iMAT was suspected antenatally. In 47 of these 67 (70%), a preterm Cesarean section was performed for monoamnionicity. Perinatal survival was 108/134 (81%) vs 396/542 (73%) in twins with intact intertwin membranes (P = 0.13). Mean gestational age at birth in iMAT was 31 completed weeks, compared to 33 weeks in twins with intact membranes (P < 0.01). At birth, cord entanglement was present in 8/67 (12%) iMAT pregnancies. Severe neonatal morbidity was assessed in 106/110 (96%) in iMAT cases and 392/416 (94%) in controls. The incidence of severe neonatal morbidity was 28/106 (26%) in iMAT vs 72/392 (18%) in controls (P = 0.25). Severe cerebral injury was significantly increased in the iMAT group as compared with controls, at 16/106 (15%) vs 18/392 (5%) (P < 0.01). CONCLUSIONS Iatrogenic rupture of intertwin membranes was suspected in 20% of pregnancies treated with laser therapy for TTTS and was associated with a lower gestational age at birth and increased neonatal morbidity.
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Affiliation(s)
- S H P Peeters
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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Slaghekke F, van Klink JMM, Koopman HM, Middeldorp JM, Oepkes D, Lopriore E. Neurodevelopmental outcome in twin anemia-polycythemia sequence after laser surgery for twin-twin transfusion syndrome. Ultrasound Obstet Gynecol 2014; 44:316-321. [PMID: 24753027 DOI: 10.1002/uog.13387] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Revised: 04/10/2014] [Accepted: 04/11/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To evaluate the long-term neurodevelopmental outcome in children who developed twin anemia-polycythemia sequence (TAPS) after fetoscopic laser surgery for twin-twin transfusion syndrome (TTTS). METHODS Neurological, motor and cognitive development was assessed in a consecutive cohort of TTTS survivors treated with laser surgery between 2004 and 2011 and complicated by post-laser TAPS. Primary outcome was neurodevelopmental impairment, a composite outcome including any of the following: cerebral palsy, bilateral deafness, blindness, severe motor and/or cognitive developmental delay (>2 SD below the mean). A risk analysis on cognitive outcome was performed. RESULTS During the study period, 33/306 (11%) monochorionic twin pairs developed TAPS after laser surgery for TTTS. Survival was 53/66 (80%). Long-term outcome was assessed in 47/53 (89%) children. The incidence of neurodevelopmental impairment was 4/47 (9%), occurring in one donor (1/20; 5%) and three recipients (3/27; 11%) (P=0.63). Mild-to-moderate cognitive delay, i.e. scores below 85, was detected in 8/47 (17%) children. Risk factors for low cognitive scores were low gestational age at birth (P=0.02) and low birth weight (P<0.01). The lowest cognitive scores were detected in the subgroup of TAPS survivors treated with intrauterine transfusion (median score, 82.5). CONCLUSIONS Neurodevelopmental impairment and cognitive delay were found in almost one in five children surviving post-laser TAPS. Better treatment and, ideally, prevention of this complication after laser treatment for TTTS is urgently needed.
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Affiliation(s)
- F Slaghekke
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden University, Leiden, The Netherlands
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Slaghekke F, Favre R, Peeters SHP, Middeldorp JM, Weingertner AS, van Zwet EW, Klumper FJ, Oepkes D, Lopriore E. Laser surgery as a management option for twin anemia-polycythemia sequence. Ultrasound Obstet Gynecol 2014; 44:304-310. [PMID: 24706478 DOI: 10.1002/uog.13382] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 03/27/2014] [Accepted: 03/27/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To evaluate the effectiveness of laser treatment for antenatally detected twin anemia-polycythemia sequence (TAPS) compared with intrauterine transfusion or expectant management. METHODS All monochorionic twin pregnancies with TAPS managed between 2005 and 2013 in two European fetal therapy centers were evaluated. The outcomes of TAPS cases treated primarily with laser surgery were compared with the outcomes of cases managed expectantly or treated with intrauterine transfusion. RESULTS In this retrospective study 52 cases of TAPS were detected antenatally and were managed with either laser surgery (n=8; 15%) or intrauterine blood transfusion (n=17; 33%) or expectantly (n=27; 52%). Perinatal survival in the laser group was 94% (15/16) vs 85% (29/34) in the intrauterine-transfusion group and 83% (45/54) in the expectant-management group (P=0.30). The rates of severe neonatal morbidity in liveborn neonates in the laser, intrauterine-transfusion and expectant-management groups were 7% (1/15), 38% (12/32) and 24% (12/50), respectively (P=0.17). There was a significant reduction in respiratory distress syndrome in cases treated by laser. No severe postnatal hematological complications were detected in the laser group compared with 72% (23/32) in the intrauterine-transfusion group and 52% (26/50) in the expectant-management group (P<0.01). Median time between diagnosis and birth was 11 weeks in the laser group compared to 5 weeks after intrauterine transfusion and 8 weeks after expectant management (P<0.01). After injection of colored dye no residual anastomoses were found in the laser group. CONCLUSIONS Laser surgery for TAPS appears to improve perinatal outcome by prolonging pregnancy and reducing respiratory distress syndrome. Larger, adequately controlled studies are needed to reach firm conclusions on the optimal management of TAPS.
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Affiliation(s)
- F Slaghekke
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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Verweij EJ, de Boer MA, Oepkes D. Non-invasive prenatal testing for trisomy 13: more harm than good? Ultrasound Obstet Gynecol 2014; 44:112-114. [PMID: 24753041 DOI: 10.1002/uog.13388] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 04/07/2014] [Accepted: 04/11/2014] [Indexed: 06/03/2023]
Abstract
A 35-year-old primigravida, pregnant after in-vitro fertilization, was seen because of a trisomy 13/trisomy 18 (T13/T18) risk of 1:55, based on the result of her first-trimester combined test. She elected for non-invasive prenatal testing (NIPT) at 14 + 5 weeks' gestation, which was positive for T13. After counseling, the patient elected to undergo amniocentesis. Quantitative fluorescence polymerase chain reaction (QF-PCR) showed no signs of trisomy, and full karyotyping confirmed a normal 46,XY result. Analysis of the published literature on NIPT for T13 gives an overall detection rate of 91.6%, with a false-positive rate of 0.097%. Based on this detection rate, hypothetical calculations show that the positive predictive value is highly dependent on the prevalence of the disease, resulting in an unfavorable balance between benefit and harm in a general population.
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Affiliation(s)
- E J Verweij
- Leiden University Medical Center, Department of Obstetrics, Leiden, The Netherlands
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Oepkes D, Yaron Y, Kozlowski P, Rego de Sousa MJ, Bartha JL, van den Akker ES, Dornan SM, Krampl-Bettelheim E, Schmid M, Wielgos M, Cirigliano V, Di Renzo GC, Cameron A, Calda P, Tabor A. Counseling for non-invasive prenatal testing (NIPT): what pregnant women may want to know. Ultrasound Obstet Gynecol 2014; 44:1-5. [PMID: 24984969 DOI: 10.1002/uog.13394] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Affiliation(s)
- D Oepkes
- Leiden University Medical Center, Department of Obstetrics, K-06-35, P.O.Box 9600, 2300, RC, Leiden, The Netherlands
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Zhao D, Cohen D, Middeldorp J, Klumper F, Haak M, Oepkes D, Lopriore E. The role of veno-venous anastomoses in twin–twin transfusion syndrome. Placenta 2014; 35:334-6. [DOI: 10.1016/j.placenta.2014.03.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Revised: 03/01/2014] [Accepted: 03/05/2014] [Indexed: 11/30/2022]
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van Steenis A, Kromhout HE, Steggerda SJ, Sueters M, Rijken M, Oepkes D, Lopriore E. Perinatal asphyxia in monochorionic versus dichorionic twins: incidence, risk factors and outcome. Fetal Diagn Ther 2014; 35:87-91. [PMID: 24457466 DOI: 10.1159/000356433] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Accepted: 10/13/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To estimate the incidence, risk factors, severity and outcome after perinatal asphyxia in monochorionic (MC) versus dichorionic (DC) twins. METHODS We included all consecutive near-term MC and DC twins with perinatal asphyxia admitted to our neonatal ward between 2004 and 2013 and compared the perinatal characteristics and neonatal outcome between both groups. RESULTS The incidence of perinatal asphyxia in MC and DC twin infants was 4.0 (11/272) and 4.0% (8/200; p = 1.00). In contrast to DC twins, asphyxia in MC twins was strongly associated with acute exsanguination and anemia at birth; 64% (7/11) in MC twins and 0% (0/8) in DC twins (p < 0.01). Median hemoglobin level at birth in the MC and DC groups was 11.5 and 18.6 g/dl, respectively (p < 0.01). CONCLUSIONS Perinatal asphyxia in MC twins is often associated with severe anemia at birth due to acute hemorrhage through the placental vascular anastomoses.
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Affiliation(s)
- A van Steenis
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
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