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Heeger LE, Houben NAM, Caram-Deelder C, Fustolo-Gunnink SF, van der Bom JG, Lopriore E. Impact of restrictive platelet transfusion strategies on transfusion rates: A cohort study in very preterm infants. Transfusion 2024. [PMID: 38660945 DOI: 10.1111/trf.17844] [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] [Received: 11/21/2023] [Revised: 03/18/2024] [Accepted: 04/01/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Evidence supports a restrictive platelet transfusion threshold in preterm neonates. We aimed to describe the effect of implementing this threshold on transfusion rates. STUDY DESIGN AND METHODS This retrospective observational cohort study included all very preterm infants (born <32 weeks' gestation) admitted to a neonatal intensive care unit between 2004 and 2022, divided into three epochs. Platelet transfusion thresholds changed from 30 × 109/L for stable neonates and 50 × 109/L for unstable neonates (January 2004 to December 2009) to 20 × 109/L for stable neonates and 50 × 109/L for unstable neonates (January 2010 to June 2019) to 25 × 109/L for non-bleeding neonates and 50 × 109/L for neonates with major bleeding (July 2019 to July 2022). The primary outcome was the percentage of transfused neonates in each epoch. Secondary outcomes included the median number of transfusions per neonate, the percentage of transfusions given above 25 or 50 × 109/L, and major bleeding and mortality rates. RESULTS The percentage of neonates transfused was 12.2% (115/939), 5.8% (96/1660), and 4.8% (25/525) in Epoch I, II, and III, respectively (p < .001), a relative reduction of 61%. The median number of transfusions per transfused neonate was 2.0 (interquartile range [IQR]: 1.0-3.0) in Epoch I, and 1.0 (IQR: 1.0-2.0) in subsequent Epochs (p = .04). The percentage of infants receiving at least one transfusion above 50 × 109/L in Epoch I, II, and III was 51.3% (59/115), 17.7% (17/96), and 20.0% (5/25; p < .001). Mortality and bleeding rates did not significantly differ between epochs. DISCUSSION Implementation of restrictive platelet guidelines led to reduction of the rate and number of platelet transfusions.
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Affiliation(s)
- L E Heeger
- Willem-Alexander Children's Hospital, Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
- Sanquin Blood Supply Foundation, Clinical Center for Transfusion Research, Amsterdam, The Netherlands
| | - N A M Houben
- Willem-Alexander Children's Hospital, Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
- Sanquin Blood Supply Foundation, Clinical Center for Transfusion Research, Amsterdam, The Netherlands
| | - C Caram-Deelder
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - S F Fustolo-Gunnink
- Sanquin Blood Supply Foundation, Clinical Center for Transfusion Research, Amsterdam, The Netherlands
| | - J G van der Bom
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - E Lopriore
- Willem-Alexander Children's Hospital, Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
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Jansen SJ, Broer SDL, Hemels MAC, Visser DH, Antonius TAJ, Heijting IE, Bergman KA, Termote JUM, Hütten MC, van der Sluijs JPF, d'Haens EJ, Kornelisse RF, Lopriore E, Bekker V. Central-line-associated bloodstream infection burden among Dutch neonatal intensive care units. J Hosp Infect 2024; 144:20-27. [PMID: 38103692 DOI: 10.1016/j.jhin.2023.11.020] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 11/18/2023] [Accepted: 11/25/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND The establishment of an epidemiological overview provides valuable insights needed for the (future) dissemination of infection-prevention initiatives. AIM To describe the nationwide epidemiology of central-line-associated bloodstream infections (CLABSI) among Dutch Neonatal Intensive Care Units (NICUs). METHODS Data from 2935 neonates born at <32 weeks' gestation and/or with a birth weight <1500 g admitted to all nine Dutch NICUs over a two-year surveillance period (2019-2020) were analysed. Variations in baseline characteristics, CLABSI incidence per 1000 central-line days, pathogen distribution and CLABSI care bundles were evaluated. Multi-variable logistic mixed-modelling was used to identify significant predictors for CLABSI. RESULTS A total of 1699 (58%) neonates received a central line, in which 160 CLABSI episodes were recorded. Coagulase-negative staphylococci were the most common infecting organisms of all CLABSI episodes (N=100, 63%). An almost six-fold difference in the CLABSI incidence between participating units was found (2.91-16.14 per 1000 line-days). Logistic mixed-modelling revealed longer central line dwell-time (adjusted odds ratio (aOR):1.08, P<0.001), umbilical lines (aOR:1.85, P=0.03) and single rooms (aOR:3.63, P=0.02) to be significant predictors of CLABSI. Variations in bundle elements included intravenous tubing care and antibiotic prophylaxis. CONCLUSIONS CLABSI remains a common problem in preterm infants in The Netherlands, with substantial variation in incidence between centres. Being the largest collection of data on the burden of neonatal CLABSI in The Netherlands, this epidemiological overview provides a solid foundation for the development of a collaborative platform for continuous surveillance, ideally leading to refinement of national evidence-based guidelines. Future efforts should focus on ensuring availability and extraction of routine patient data in aggregated formats.
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Affiliation(s)
- S J Jansen
- Willem-Alexander Children's Hospital, Department of Paediatrics, Division of Neonatology, Leiden University Medical Centre, The Netherlands.
| | - S D L Broer
- Willem-Alexander Children's Hospital, Department of Paediatrics, Division of Neonatology, Leiden University Medical Centre, The Netherlands
| | - M A C Hemels
- Department of Neonatology, Isala, Zwolle, The Netherlands
| | - D H Visser
- Emma Children's Hospital, Department of Paediatrics, Division of Neonatology, Amsterdam University Medical Centre (AUMC), Location AMC, Amsterdam, The Netherlands
| | - T A J Antonius
- Amalia Children's Hospital, Department of Paediatrics, Division of Neonatology, Radboud University Medical Centre (Radboud UMC), Nijmegen, The Netherlands
| | - I E Heijting
- Amalia Children's Hospital, Department of Paediatrics, Division of Neonatology, Radboud University Medical Centre (Radboud UMC), Nijmegen, The Netherlands
| | - K A Bergman
- Beatrix Children's Hospital, Department of Paediatrics, Division of Neonatology, University Medical Centre Groningen (UMCG), Groningen, The Netherlands
| | - J U M Termote
- Wilhelmina Children's Hospital, Department of Neonatology, Division of Mother and Child, University Medical Centre Utrecht (UMCU), Utrecht, The Netherlands
| | - M C Hütten
- Department of Paediatrics, Division of Neonatology, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
| | - J P F van der Sluijs
- Department Paediatrics, Division of Neonatology, Máxima Medical Centre (MMC), Veldhoven, The Netherlands
| | - E J d'Haens
- Department of Neonatology, Isala, Zwolle, The Netherlands
| | - R F Kornelisse
- Erasmus MC - Sophia Children's Hospital, Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - E Lopriore
- Willem-Alexander Children's Hospital, Department of Paediatrics, Division of Neonatology, Leiden University Medical Centre, The Netherlands
| | - V Bekker
- Willem-Alexander Children's Hospital, Department of Paediatrics, Division of Neonatology, Leiden University Medical Centre, The Netherlands
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Noll ATR, Lof FC, Groene SG, Haak MC, Lopriore E, Russo FM, Slaghekke F, Tollenaar LSA, Van der Merwe J, Verweij EJT, Lewi L. Artery-to-vein anastomoses in unequally divided placentas and their association with birthweight discordance. Placenta 2024; 146:58-63. [PMID: 38181521 DOI: 10.1016/j.placenta.2023.12.023] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 12/20/2023] [Accepted: 12/27/2023] [Indexed: 01/07/2024]
Abstract
INTRODUCTION This study investigated the impact of the shared intertwin circulation in unequally divided monochorionic (MC) placentas on fetal growth. METHODS This retrospective analysis included color-dyed, unequally shared placentas from two tertiary centers. Exclusions included twin-twin transfusion syndrome, twin anemia polycythemia sequence, and lethal anomalies. Measurement of the external diameters and areas of the artery-to-artery (AA), artery-to-vein (AV), and vein-to-vein (VV) anastomoses was performed. The ratio of the shared circulation (AV ratio) was determined by comparing the areas of the summed venous components of shared AV anastomoses to those in the individual AV anastomoses of the smaller placental part. The birth weight ratio/placental ratio (BWR/PR), total AV size areas and net AV transfusion were calculated. Univariable and multivariable linear regressions were performed to assess the relationship between BWR/PR, the AV ratio, the areas of the different anastomoses and cord insertion discordance. RESULTS Among 352 placentas, 97 % (340) had intertwin AV anastomoses, and 50 % (176) were from pregnancies with selective growth restriction. The AV ratio, AA, VV, total AV areas, and cord insertion discordance negatively correlated with BWR/PR. Multivariable linear regression confirmed the independent negative association between BWR/PR and the AV ratio, suggesting that a larger shared circulation benefits the twin with the smaller placental part. Type III sFGR placentas exhibited the highest AV ratio, resulting in the lowest BWR/PR. DISCUSSION A larger shared circulation mitigates the impact of an unequally divided placenta on fetal growth. This effect surpasses the influence of AA and VV diameters and is most prominent in Type III sFGR placentas.
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Affiliation(s)
- A T R Noll
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, the Netherlands; Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - F C Lof
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, the Netherlands
| | - S G Groene
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, the Netherlands
| | - M C Haak
- 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
| | - F M Russo
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - F Slaghekke
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, the Netherlands
| | - L S A Tollenaar
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, the Netherlands
| | - J Van der Merwe
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - E J T Verweij
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, the Netherlands
| | - L Lewi
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium.
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Spruijt MS, van Klink JMM, de Vries LS, Slaghekke F, Middeldorp JM, Lopriore E, Tan RNGB, Toirkens JP, Steggerda SJ. Fetal and neonatal neuroimaging in twin-twin transfusion syndrome. Ultrasound Obstet Gynecol 2024. [PMID: 38214436 DOI: 10.1002/uog.27583] [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] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 11/17/2023] [Accepted: 01/07/2024] [Indexed: 01/13/2024]
Abstract
OBJECTIVES To describe the types of brain injury and subsequent neurodevelopmental outcome, to determine risk factors for brain injury and to review the use of neuroimaging modalities in fetuses and neonates with twin-twin transfusion syndrome (TTTS). METHODS Retrospective cohort study of consecutive TTTS pregnancies treated with laser surgery in a single fetal therapy center between January 2010 and January 2020. Primary outcome was the incidence of brain injury, divided into predefined groups. Secondary outcomes included adverse outcome (perinatal mortality or neurodevelopmental impairment (NDI)), risk factors for brain injury and the numbers of magnetic resonance imaging (MRI) scans. RESULTS Fetal and neonatal brain ultrasound was performed in all 466 TTTS pregnancies and 685/749 (91%) liveborn neonates. MRI was performed in 3% of pregnancies and 4% of neonates. Brain injury was diagnosed in 16/935 (2%) fetuses and 37/685 (5%) neonates and all predefined injury groups were represented. Four fetal and four neonatal cases of cerebellar hemorrhage were detected. In the group with brain injury, perinatal mortality occurred in 11/16 (69%) fetuses and 8/37 (22%) neonates. Follow-up was available for 29/34 (85%) long-term survivors with brain injury and mean age at follow-up was 46 months. NDI was present in 9/29 (31%) survivors with brain injury. Adverse outcome occurred in 28/53 (53%) TTTS individuals with brain injury. The risk of brain injury was increased after recurrent TTTS/post-laser twin anemia polycythemia sequence (TAPS) (OR 3.095, 95%-CI 1.581 - 6.059, p = .001) and lower gestational age (GA) at birth (OR 1.381 for each week less, 95%-CI 1.238 - 1.541, p < .001). CONCLUSIONS Based on dedicated neurosonography and limited use of MRI, brain injury was diagnosed in 2% of fetuses and 5% of neonates with TTTS. Adverse outcome was seen in over half of cases with brain injury. Brain injury was related to recurrent TTTS/post-laser TAPS and a lower GA at birth. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- M S Spruijt
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Pediatrics, Division of Perinatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J M M van Klink
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - L S de Vries
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - F Slaghekke
- 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
| | - R N G B Tan
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - J P Toirkens
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - S J Steggerda
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
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Sileo FG, Accurti V, Baschat A, Binder J, Carreras E, Chianchiano N, Cruz-Martinez R, D'Antonio F, Gielchinsky Y, Hecher K, Johnson A, Lopriore E, Massoud M, Nørgaard LN, Papaioannou G, Prefumo F, Salsi G, Simões T, Umstad M, Vavilala S, Yinon Y, Khalil A. Perinatal outcome of monochorionic triamniotic triplet pregnancy: multicenter cohort study. Ultrasound Obstet Gynecol 2023; 62:540-551. [PMID: 37204929 DOI: 10.1002/uog.26256] [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] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 05/08/2023] [Accepted: 05/09/2023] [Indexed: 05/21/2023]
Abstract
OBJECTIVE Monochorionic (MC) triplet pregnancies are extremely rare and information on these pregnancies and their complications is limited. We aimed to investigate the risk of early and late pregnancy complications, perinatal outcome and the timing and methods of fetal intervention in these pregnancies. METHODS This was a multicenter retrospective cohort study of MC triamniotic (TA) triplet pregnancies managed in 21 participating centers around the world from 2007 onwards. Data on maternal age, mode of conception, diagnosis of major fetal structural anomalies or aneuploidy, gestational age (GA) at diagnosis of anomalies, twin-to-twin transfusion syndrome (TTTS), twin anemia-polycythemia sequence (TAPS), twin reversed arterial perfusion (TRAP) sequence and or selective fetal growth restriction (sFGR) were retrieved from patient records. Data on antenatal interventions were collected, including data on selective fetal reduction (three to two or three to one), laser surgery and any other active fetal intervention (including amniodrainage). Data on perinatal outcome were collected, including numbers of live birth, intrauterine demise, neonatal death, perinatal death and termination of fetus or pregnancy (TOP). Neonatal data such as GA at birth, birth weight, admission to neonatal intensive care unit and neonatal morbidity were also collected. Perinatal outcomes were assessed according to whether the pregnancy was managed expectantly or underwent fetal intervention. RESULTS Of an initial cohort of 174 MCTA triplet pregnancies, 11 underwent early TOP, three had an early miscarriage, six were lost to follow-up and one was ongoing at the time of writing. Thus, the study cohort included 153 pregnancies, of which the majority (92.8%) were managed expectantly. The incidence of pregnancy affected by one or more fetal structural abnormality was 13.7% (21/153) and that of TRAP sequence was 5.2% (8/153). The most common antenatal complication related to chorionicity was TTTS, which affected just over one quarter (27.6%; 42/152, after removing a pregnancy with TOP < 24 weeks for fetal anomalies) of the pregnancies, followed by sFGR (16.4%; 25/152), while TAPS (spontaneous or post TTTS with or without laser treatment) occurred in only 4.6% (7/152) of pregnancies. No monochorionicity-related antenatal complication was recorded in 49.3% (75/152) of pregnancies. Survival was apparently associated largely with the development of these complications: there was at least one survivor beyond the neonatal period in 85.1% (57/67) of pregnancies without antenatal complications, in 100% (25/25) of those complicated by sFGR and in 47.6% (20/42) of those complicated by TTTS. The overall rate of preterm birth prior to 28 weeks was 14.5% (18/124) and that prior to 32 weeks' gestation was 49.2% (61/124). CONCLUSION Monochorionicity-related complications, which can impact adversely perinatal outcome, occur in almost half of MCTA triplet pregnancies, creating a challenge with regard to counseling, surveillance and management. © 2023 The 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)
- F G Sileo
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Prenatal Medicine Unit, Obstetrics and Gynecology Unit, Department of Medical and Surgical Sciences for Mother, Child and Adult, University of Modena and Reggio Emilia, Modena, Italy
- Department of Biomedical, Metabolic and Neural Sciences, International Doctorate School in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - V Accurti
- Fetal Medicine and Surgery Service, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - A Baschat
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, MD, USA
| | - J Binder
- Department of Obstetrics and Feto-Maternal Medicine, Medical University of Vienna, Vienna, Austria
| | - E Carreras
- Maternal-Fetal Medicine Unit, Department of Obstetrics and Reproductive Medicine, Grup de Recerca en Medicina Materna I Fetal, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - N Chianchiano
- Fetal Medicine Unit, Bucchieri La Ferla-Fatebenefratelli Hospital, Palermo, Italy
| | - R Cruz-Martinez
- Fetal Surgery Center, Instituto Medicina Fetal México, Queretaro/Guadalajara, Jalisco, Mexico
| | - F D'Antonio
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University 'G. d'Annunzio' of Chieti-Pescara, Chieti, Italy
| | - Y Gielchinsky
- Fetal Medicine Center, Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikvah, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - K Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - A Johnson
- Department of Obstetrics and Gynecology, The Fetal Center at Children's Memorial Hermann Hospital, University of Texas Health Science Center, McGovern Medical School, Houston, TX, USA
| | - E Lopriore
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - M Massoud
- Department of Obstetrics and Fetal Medicine, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - L N Nørgaard
- Center of Fetal Medicine and Pregnancy, Department of Obstetrics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - G Papaioannou
- Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Athens, Greece
| | - F Prefumo
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - G Salsi
- Obstetric Unit, Department of Medical and Surgical Sciences, University of Bologna and IRCCS Azienda Ospedaliero-Universitaria S.Orsola-Malpighi, Bologna, Italy
| | - T Simões
- Department of Maternal-Fetal Medicine and Maternity Dr. Alfredo da Costa, Nova Medica School, Lisbon, Portugal
| | - M Umstad
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
| | - S Vavilala
- Department of Fetal Medicine, Fernandez Hospital, Hyderabad, Telangana, India
| | - Y Yinon
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel Hashomer, Israel
| | - 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
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van Hoek MJC, van Klink JMM, Verweij EJT, Middeldorp JM, Haak MC, Lopriore E, Slaghekke F. Perinatal outcome after selective fetal reduction in monochorionic twin pregnancies: A comparison of techniques over a 20-year period. Prenat Diagn 2023. [PMID: 37170409 DOI: 10.1002/pd.6385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/22/2023] [Accepted: 05/07/2023] [Indexed: 05/13/2023]
Abstract
OBJECTIVE To assess perinatal outcome after fetal reduction in complicated monochorionic (MC) twin pregnancies comparing different techniques. METHODS A retrospective cohort study at a national referral center, comparing data between four techniques: interstitial laser coagulation (ILC), radiofrequency ablation (RFA), fetoscopic laser coagulation (FLC) and bipolar cord coagulation (BCC). The primary outcome was mortality of the co-twin. Secondary outcomes were preterm pre-labor rupture of membranes (PPROM), gestational age at delivery and neonatal morbidity. RESULTS 259 MC twin pregnancies underwent selective fetal reduction: 29 IL, 64 RFA, 85 FLC and 81 BCC. Perinatal mortality rate was 29% and fetal demise of the co-twin occurred in 19%. The lowest mortality rate was seen after BCC (17%, P=0.012). PPROM occurred in 18% without significant differences between techniques. Mean gestational age at delivery in liveborn children was 35 weeks and did not differ between techniques. Severe cerebral injury and neonatal morbidity were reported in 4% and 14% respectively, without significant differences between techniques. CONCLUSIONS Selective fetal reductions in MC twins are precarious procedures with an increased risk of perinatal mortality of the co-twin. Our results show the lowest mortality rates after BCC. However, high PPROM rates were seen irrespective of the technique. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- M J C van Hoek
- Department of Obstetrics, Leiden University Medical Center, Fetal Therapy, Leiden, the Netherlands
| | - J M M van Klink
- Willem-Alexander Children's Hospital, Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, the Netherlands
| | - E J T Verweij
- Department of Obstetrics, Leiden University Medical Center, Fetal Therapy, Leiden, the Netherlands
| | - J M Middeldorp
- Department of Obstetrics, Leiden University Medical Center, Fetal Therapy, Leiden, the Netherlands
| | - M C Haak
- Department of Obstetrics, Leiden University Medical Center, Fetal Therapy, Leiden, the Netherlands
| | - E Lopriore
- Willem-Alexander Children's Hospital, Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, the Netherlands
| | - F Slaghekke
- Department of Obstetrics, Leiden University Medical Center, Fetal Therapy, Leiden, the Netherlands
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Tollenaar LSA, Slaghekke F, Middeldorp JM, Lopriore E. Fetal anemia in monochorionic twins: a review on diagnosis, management, and outcome. Expert Rev Hematol 2023; 16:9-16. [PMID: 36609186 DOI: 10.1080/17474086.2023.2166921] [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: 01/09/2023]
Abstract
INTRODUCTION Monochorionic twins may develop fetal anemia when blood is unequally distributed via the placental vascular anastomoses. This review focuses on the causes of fetal anemia in complicated monochorionic twins and highlights the differences in management and outcome. AREAS COVERED Fetal anemia can occur in the context of twin anemia polycythemia sequence (TAPS), chronic twin-twin transfusion syndrome (TTTS) and acute peripartum TTTS, and in cotwins after single fetal demise. Diagnosis of fetal anemia is based on abnormal Doppler ultrasound measurements. Management options include fetoscopic laser surgery, intrauterine blood transfusion, or expectant management, depending on the type of complication and the severity of the disease. In all complications, fetal anemia may lead to perinatal mortality, neonatal morbidity, severe cerebral injury, and long-term neurodevelopmental impairment. In TAPS specifically, anemic donors may also show bilateral deafness. EXPERT OPINION Knowledge on the diagnosis and optimal treatment in TTTS is nowadays widespread, but caregivers often fail to distinguish TAPS from acute peripartum TTTS at birth. A full blood count including reticulocyte count is required, and placental dye injection is extremely helpful to reach the correct diagnosis and establish the optimal management.
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Affiliation(s)
- L S A Tollenaar
- Department of Obstetrics, Division of Fetal therapy, Leiden University Medical Center, Leiden, The Netherlands
| | - F Slaghekke
- 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
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Lopriore E, de Vries W, van der Meeren L, Lopriore E, van Zanten H. Large variations between NICU nurses in predicting nasogastric tube insertion length in a mannequin study. Int J Nurs Stud Adv 2022; 4:100055. [PMID: 38745629 PMCID: PMC11080333 DOI: 10.1016/j.ijnsa.2021.100055] [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] [Received: 10/30/2021] [Revised: 11/22/2021] [Accepted: 11/24/2021] [Indexed: 10/19/2022] Open
Abstract
Aim To evaluate the inter- and intraindividual variation of predicted nasogastric tube insertion lengths by nurses working in two neonatal intensive care units in the Netherlands, using a mannequin model. Methods A total of 110 nurses (55 nurses from Center A and 55 from Center B) were asked to predict the nasogastric tube insertion length on a neonatal mannequin. We evaluated the length and prediction method used by the nurses. We also estimated the number of tubes that would have correctly been placed in the stomach of a neonate according to the seize of the mannequin. Results The mean predicted insertion length of the nasogastric tube was 30.0 cm with an interindividual variation of 12 cm (range 24-36 cm). The mean intraindividual variation was 0.75 cm. The two centers used two different prediction methods in their local guidelines, but overall at least 6 different methods were used by the nurses. We estimated that 77% (85/110) of the tubes would have ended in the body of the mannequins stomach, while 10% (11/110) would have ended in the esophagus and 13% (14/110) would have ended against the stomach lining or in the duodenum. Conclusion Nurses in two neonatal intensive care units used many different methods which lead to a large interindividual variation in predicted insertion lengths of the nasogastric tubes. Regular evaluations using this mannequin model could lead to more uniformity and reduce the risk of tube misplacement in neonates.
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Affiliation(s)
- E.A. Lopriore
- Department of Neonatology, Division Women & Baby, University Medical Center Utrecht, Utrecht, the Netherlands
| | - W.B. de Vries
- Department of Neonatology, Division Women & Baby, University Medical Center Utrecht, Utrecht, the Netherlands
| | - L.E. van der Meeren
- Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherland
- Department of Pathology, Leiden University Medical Center, Leiden, the Netherland
| | - E. Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, the Netherland
| | - H.A. van Zanten
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, the Netherland
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9
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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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10
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van de Sande MJA, Lopriore E, Verweij EJT, de Bruin C, Slaghekke F, Tollenaar LSA. Lactate acidosis and hypoglycaemia in twin anaemia polycythemia sequence donors. Arch Dis Child Fetal Neonatal Ed 2022; 108:320-321. [PMID: 35788032 DOI: 10.1136/archdischild-2022-323964] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2022] [Indexed: 11/04/2022]
Affiliation(s)
- M J A van de Sande
- 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
| | - E J T Verweij
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - C de Bruin
- Division of Pediatric Endocrinology, 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
| | - L S A Tollenaar
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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11
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Van Mieghem T, Lewi L, Slaghekke F, Lopriore E, Yinon Y, Raio L, Baud D, Dekoninck P, Melamed N, Huszti E, Sun L, Shinar S. Prediction of fetal death in monochorionic twin pregnancies complicated by Type-III selective fetal growth restriction. Ultrasound Obstet Gynecol 2022; 59:756-762. [PMID: 35258125 DOI: 10.1002/uog.24896] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 12/31/2021] [Revised: 02/02/2022] [Accepted: 02/15/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVE Monochorionic diamniotic twin pregnancies complicated by Type-III selective fetal growth restriction (sFGR) are at high risk of fetal death. The aim of this study was to identify predictors of fetal death in these pregnancies. METHODS This was an international multicenter retrospective cohort study. Type-III sFGR was defined as fetal estimated fetal weight (EFW) of one twin below the 10th percentile and intertwin EFW discordance of ≥ 25% in combination with intermittent absent or reversed end-diastolic flow in the umbilical artery of the smaller fetus. Predictors of fetal death were recorded longitudinally throughout gestation and assessed in univariable and multivariable logistic regression models. The classification and regression trees (CART) method was used to construct a prediction model of fetal death using significant predictors derived from the univariable analysis. RESULTS A total of 308 twin pregnancies (616 fetuses) were included in the analysis. In 273 (88.6%) pregnancies, both twins were liveborn, whereas 35 pregnancies had single (n = 19 (6.2%)) or double (n = 16 (5.2%)) fetal death. On univariable analysis, earlier gestational age at diagnosis of Type-III sFGR, oligohydramnios in the smaller twin and deterioration in umbilical artery Doppler flow were associated with an increased risk of fetal death, as was larger fetal EFW discordance, particularly between 24 and 32 weeks' gestation. None of the parameters identified on univariable analysis maintained statistical significance on multivariable analysis. The CART model allowed us to identify three risk groups: a low-risk group (6.8% risk of fetal death), in which umbilical artery Doppler did not deteriorate; an intermediate-risk group (16.3% risk of fetal death), in which umbilical artery Doppler deteriorated but the diagnosis of sFGR was made at or after 16 + 5 weeks' gestation; and a high-risk group (58.3% risk of fetal death), in which umbilical artery Doppler deteriorated and gestational age at diagnosis was < 16 + 5 weeks' gestation. CONCLUSIONS Type-III sFGR is associated with a high risk of fetal death. A prediction algorithm can help to identify the highest-risk group, which is characterized by Doppler deterioration and early referral. Further studies should investigate the potential benefit of fetal surveillance and intervention in this cohort. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- T Van Mieghem
- Ontario Fetal Centre, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - L Lewi
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - F Slaghekke
- Department of Gynecology, Leiden University Medical Center, Leiden, The Netherlands
| | - E Lopriore
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Y Yinon
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel Hashomer, Tel Aviv University, Tel Aviv, Israel
| | - L Raio
- Department of Obstetrics and Gynecology, Inselspital, University of Bern, Bern, Switzerland
| | - D Baud
- Department Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
| | - P Dekoninck
- Department of Obstetrics and Gynecology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - N Melamed
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - E Huszti
- Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | - L Sun
- Fetal Medicine Unit & Prenatal Diagnosis Center, Shanghai First Maternity and Infant Hospital of Tongji University, Shanghai, China
| | - S Shinar
- Ontario Fetal Centre, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
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12
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Groene SG, de Vries LS, Slaghekke F, Haak MC, Heijmans BT, de Bruin C, Roest AAW, Lopriore E, van Klink JMM, Steggerda SJ. Changes in structural brain development after selective fetal growth restriction in monochorionic twins. Ultrasound Obstet Gynecol 2022; 59:747-755. [PMID: 34931729 PMCID: PMC9415097 DOI: 10.1002/uog.24832] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 11/19/2021] [Accepted: 12/05/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Fetal growth restriction (FGR) may alter brain development permanently, resulting in lifelong structural and functional changes. However, in studies addressing this research question, FGR singletons have been compared primarily to matched appropriately grown singletons, a design which is inherently biased by differences in genetic and maternal factors. To overcome these limitations, we conducted a within-pair comparison of neonatal structural cerebral ultrasound measurements in monochorionic twin pairs with selective FGR (sFGR). METHODS Structural cerebral measurements on neonatal cerebral ultrasound were compared between the smaller and larger twins of monochorionic twin pairs with sFGR, defined as a birth-weight discordance (BWD) ≥ 20%, born in our center between 2010 and 2020. Measurements from each twin pair were also compared with those of an appropriately grown singleton, matched according to sex and gestational age at birth. RESULTS Included were 58 twin pairs with sFGR, with a median gestational age at birth of 31.7 (interquartile range, 29.9-33.8) weeks and a median birth weight of 1155 g for the smaller twin and 1725 g for the larger twin (median BWD, 32%). Compared with both the larger twin and the singleton, the smaller twin had significantly smaller cerebral structures (corpus callosum, vermis, cerebellum), less white/deep gray matter and smaller intracranial surface area and volume. Intracranial-volume discordance and BWD correlated significantly (R2 = 0.228, P < 0.0001). The median intracranial-volume discordance was smaller than the median BWD (19% vs 32%, P < 0.0001). After correction for intracranial volume, only one of the observed differences (biparietal diameter) remained significant for the smaller twin vs both the larger twin and the singleton. CONCLUSIONS In monochorionic twins with sFGR, neonatal cerebral ultrasound reveals an overall, proportional restriction in brain growth, with smaller cerebral structures, less white/deep gray matter and smaller overall brain-size parameters in the smaller twin. There was a positive linear relationship between BWD and intracranial-volume discordance, with intracranial-volume discordance being smaller than BWD. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- S. G. Groene
- Neonatology, Willem‐Alexander Children's Hospital, Department of PediatricsLeiden University Medical CenterLeidenThe Netherlands
- Molecular Epidemiology, Department of Biomedical Data SciencesLeiden University Medical CenterLeidenThe Netherlands
| | - L. S. de Vries
- Neonatology, Willem‐Alexander Children's Hospital, Department of PediatricsLeiden University Medical CenterLeidenThe Netherlands
| | - F. Slaghekke
- Fetal Therapy, Department of ObstetricsLeiden University Medical CenterLeidenThe Netherlands
| | - M. C. Haak
- Fetal Therapy, Department of ObstetricsLeiden University Medical CenterLeidenThe Netherlands
| | - B. T. Heijmans
- Molecular Epidemiology, Department of Biomedical Data SciencesLeiden University Medical CenterLeidenThe Netherlands
| | - C. de Bruin
- Pediatric Endocrinology, Willem‐Alexander Children's Hospital, Department of PediatricsLeiden University Medical CenterLeidenThe Netherlands
| | - A. A. W. Roest
- Pediatric Cardiology, Willem‐Alexander Children's Hospital, Department of PediatricsLeiden University Medical CenterLeidenThe Netherlands
| | - E. Lopriore
- Neonatology, Willem‐Alexander Children's Hospital, Department of PediatricsLeiden University Medical CenterLeidenThe Netherlands
| | - J. M. M. van Klink
- Neonatology, Willem‐Alexander Children's Hospital, Department of PediatricsLeiden University Medical CenterLeidenThe Netherlands
| | - S. J. Steggerda
- Neonatology, Willem‐Alexander Children's Hospital, Department of PediatricsLeiden University Medical CenterLeidenThe Netherlands
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13
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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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14
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van Vonderen JJ, Keus JMH, van Schaik J, Smiers FJ, Ten Harkel DJ, Lopriore E. A neonate with spontaneous arterial limb ischemia and an aneurysm of the oval foramen: a case report. J Med Case Rep 2021; 15:536. [PMID: 34696819 PMCID: PMC8543854 DOI: 10.1186/s13256-021-03078-9] [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: 05/27/2020] [Accepted: 08/25/2021] [Indexed: 11/10/2022] Open
Abstract
Background In this case report, we describe a very rare case of severe limb ischemia due to an arterial embolus caused by an aneurysm of the oval foramen in a term-born infant that occurred in the first few hours after birth. Case presentation A newborn male Caucasian patient presented on the maternity ward with ischemia of the right foot. Ischemia was treated with nitroglycerin spray and low-molecular-weight heparin in therapeutic dosage. An aneurysm of the oval foramen was found during postnatal echocardiography screening. This was thought to be the source of an embolus causing limb ischemia. At birth and upon follow-up, no clotting disorders were found. A large part of the right forefoot was ischemic, leading to loss of digits 1, 2, and 3. No significant loss of function was found in the first year of life. Conclusion Severe limb ischemia can be caused by an embolus arising from an aneurysm of the oval foramen and can be treated with heparin.
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Affiliation(s)
- J J van Vonderen
- Division of Neonatology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands.
| | - J M H Keus
- Division of Neonatology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - J van Schaik
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - F J Smiers
- Division of Hematology and Stem Cell Transplantation Program, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - D J Ten Harkel
- Division of Cardiology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - E Lopriore
- Division of Neonatology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
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15
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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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16
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Khalil A, Townsend R, Reed K, Lopriore E. Call to action: long-term neurodevelopment in monochorionic twins. Ultrasound Obstet Gynecol 2021; 58:5-10. [PMID: 33438253 DOI: 10.1002/uog.23591] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 12/26/2020] [Accepted: 12/30/2020] [Indexed: 06/12/2023]
Affiliation(s)
- A Khalil
- TwinsTrust Centre for Research and Clinical Excellence, 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
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - R Townsend
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - K Reed
- Twins Trust, Aldershot, UK
| | - E Lopriore
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Centre, Leiden, The Netherlands
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17
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Ree IMC, van 't Oever RM, Jansen L, Lopriore E, de Haas M, van Klink JMM. School performance and behavioral functioning in children after intrauterine transfusions for hemolytic disease of the fetus and newborn. Early Hum Dev 2021; 157:105381. [PMID: 33962361 DOI: 10.1016/j.earlhumdev.2021.105381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 04/05/2021] [Accepted: 04/27/2021] [Indexed: 11/16/2022]
Abstract
AIM To investigate the school performance and behavioral difficulties in children with hemolytic disease of the fetus and newborn (HDFN) treated with intrauterine transfusion (IUT) compared to Dutch norm data. STUDY DESIGN Cros-sectional cohort study. SUBJECTS Children who received one or multiple IUTs for severe Rh- or K (Kell)-mediated HDFN between January 2008 and January 2015 at the LUMC. OUTCOME MEASURES School performance reports were assessed as well as behavioral difficulties as assessed with the Dutch child behavioral checklist (CBCL) by parents and caregivers and the Teacher Report Form (TRF) completed by teachers. RESULTS A response rate of 56% (70 children, aged 5-12 years) was obtained. Grade repetition occurred in 13 cases (19%), 16 children (23%) received some form of additional help, most often support by a speech therapist (n = 8), but also support for dyslexia (n = 4), physical therapy (n = 2) and social-emotional support (n = 2). None of the children in our study group attended special-needs education. School performance levels for reading comprehension, spelling and mathematics according to the Dutch National Pupil Monitoring System were similar for the study population and Dutch norm data. The incidence of behavioral problems as reported by parents was similar to the Dutch norm data, teachers reported less behavioral difficulties in the study group. CONCLUSION This study shows favorable and reassuring school development in children treated with IUT in an experienced fetal-therapy center. A normal distribution in school and behavioral development is to be expected for children with HDFN treated with IUTs.
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Affiliation(s)
- I M C Ree
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands; Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, the Netherlands.
| | - R M van 't Oever
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, the Netherlands
| | - L Jansen
- Department of Medical Psychology, Leiden University Medical Center, the Netherlands
| | - E Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, the Netherlands
| | - M de Haas
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands; Department of Hematology, Leiden University Medical Center, Leiden, the Netherlands; Department of Immunohematology Diagnostics, Sanquin, Amsterdam, the Netherlands
| | - J M M van Klink
- Department of Medical Psychology, Leiden University Medical Center, the Netherlands
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18
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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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19
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Shinar S, Xing W, Pruthi V, Jianping C, Slaghekke F, Groene S, Lopriore E, Lewi L, Couck I, Yinon Y, Batsry L, Raio L, Amylidi-Mohr S, Baud D, Kneuss F, Dekoninck P, Moscou J, Barrett J, Melamed N, Ryan G, Sun L, Van Mieghem T. Outcome of monochorionic twin pregnancy complicated by Type-III selective intrauterine growth restriction. Ultrasound Obstet Gynecol 2021; 57:126-133. [PMID: 33073883 DOI: 10.1002/uog.23515] [Citation(s) in RCA: 8] [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] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 09/15/2020] [Accepted: 10/05/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE Type-III selective intrauterine growth restriction (sIUGR) is associated with a high and unpredictable risk of fetal death and fetal brain injury. The objective of this study was to describe the prospective risk of fetal death and the risk of adverse neonatal outcome in a cohort of twin pregnancies complicated by Type-III sIUGR and treated according to up-to-date guidelines. METHODS We reviewed retrospectively all monochorionic diamniotic twin pregnancies complicated by Type-III sIUGR managed at nine fetal centers over a 12-year period. Higher-order multiple gestations and pregnancies with major fetal anomalies or other monochorionicity-related complications at initial presentation were excluded. Data on fetal and neonatal outcomes were collected and management strategies reviewed. Composite adverse neonatal outcome was defined as neonatal death, invasive ventilation beyond the resuscitation period, culture-proven sepsis, necrotizing enterocolitis requiring treatment, intraventricular hemorrhage Grade > I, retinopathy of prematurity Stage > II or cystic periventricular leukomalacia. The prospective risk of intrauterine death (IUD) and the risk of neonatal complications according to gestational age were evaluated. RESULTS We collected data on 328 pregnancies (656 fetuses). After exclusion of pregnancies that underwent selective reduction (n = 18 (5.5%)), there were 51/620 (8.2%) non-iatrogenic IUDs in 35/310 (11.3%) pregnancies. Single IUD occurred in 19/328 (5.8%) pregnancies and double IUD in 16/328 (4.9%). The prospective risk of non-iatrogenic IUD per fetus declined from 8.1% (95% CI, 5.95-10.26%) at 16 weeks, to less than 2% (95% CI, 0.59-2.79%) after 28.4 weeks and to less than 1% (95% CI, -0.30 to 1.89%) beyond 32.6 weeks. In otherwise uncomplicated pregnancies with Type-III sIUGR, delivery was generally planned at 32 weeks, at which time the risk of composite adverse neonatal outcome was 29.0% (31/107 neonates). In twin pregnancies that continued to 34 weeks, there was a very low risk of IUD (0.7%) and a low risk of composite adverse neonatal outcome (11%). CONCLUSIONS In this cohort of twin pregnancies complicated by Type-III sIUGR and treated at several tertiary fetal centers, the risk of fetal death was lower than that reported previously. Further efforts should be directed at identifying predictors of fetal death and optimal antenatal surveillance strategies to select a cohort of pregnancies that can continue safely beyond 33 weeks' gestation. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- S Shinar
- Ontario Fetal Centre, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - W Xing
- Fetal Medicine Unit &Prenatal Diagnosis Center, Shanghai 1st Maternity and Infant Hospital of Tongji University, Shanghai, China
| | - V Pruthi
- Ontario Fetal Centre, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - C Jianping
- Fetal Medicine Unit &Prenatal Diagnosis Center, Shanghai 1st Maternity and Infant Hospital of Tongji University, Shanghai, China
| | - F Slaghekke
- Department of Gynecology, Leiden University Medical Center, Leiden, The Netherlands
| | - S Groene
- Department of Gynecology, Leiden University Medical Center, Leiden, The Netherlands
| | - E Lopriore
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - L Lewi
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - I Couck
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - Y Yinon
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel Hashomer, Tel Aviv University, Tel Aviv, Israel
| | - L Batsry
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel Hashomer, Tel Aviv University, Tel Aviv, Israel
| | - L Raio
- Department of Obstetrics and Gynecology, Inselspital, University of Bern, Bern, Switzerland
| | - S Amylidi-Mohr
- Department of Obstetrics and Gynecology, Inselspital, University of Bern, Bern, Switzerland
| | - D Baud
- Department of Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
| | - F Kneuss
- Department of Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
| | - P Dekoninck
- Department of Obstetrics and Gynaecology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - J Moscou
- Department of Obstetrics and Gynaecology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - J Barrett
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - N Melamed
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - G Ryan
- Ontario Fetal Centre, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - L Sun
- Fetal Medicine Unit &Prenatal Diagnosis Center, Shanghai 1st Maternity and Infant Hospital of Tongji University, Shanghai, China
| | - T Van Mieghem
- Ontario Fetal Centre, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
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Konstantinovski MM, Bekker V, Kraakman MEM, Bruijning ML, van der Zwan CJ, Lopriore E, Veldkamp KE. Borderline oxacillin-resistant Staphylococcus aureus carriage among healthcare workers at neonatal intensive care unit and paediatric ward. J Hosp Infect 2020; 108:104-108. [PMID: 33245996 DOI: 10.1016/j.jhin.2020.11.017] [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] [Received: 07/23/2020] [Revised: 11/19/2020] [Accepted: 11/20/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND During a meticillin-resistant Staphylococcus aureus contact tracing and screening investigation, two borderline oxacillin-resistant Staphylococcus aureus (BORSA)-positive screening cultures were encountered among neonatal intensive care unit (NICU) healthcare workers (HCWs). This finding led to further investigations. AIM To assess the likelihood of an outbreak with direct transmission among HCWs. METHODS An infection control team was initiated after the discovery. The team initiated additional infection control measures and evaluated new findings. All NICUs and paediatric ward HCWs were screened for BORSA carriage, and a prospective BORSA seven-week monitoring period for patients was observed. To assess the likelihood of an outbreak with direct transmission among HCWs, the BORSA isolates were analysed using augmented fragment length polymorphism and whole-genome sequencing (WGS). FINDINGS Positive HCWs were prohibited from clinical work while awaiting the results from the screening programme. In all, 127 NICU and 77 general paediatric ward HCWs were screened for BORSA carriage; five HCWs were BORSA positive. Seventy-two patients were screened during the seven-week period yielding a total of 138 cultures, ranging from one to nine cultures per patient. No spread from HCWs to patients occurred, and the BORSA screening programme was discontinued. WGS analysis with core genome multi-locus sequence typing of all five BORSA strains showed relatedness between two NICU strains. CONCLUSION During a seven-week period, no transmission from BORSA-positive HCWs to neonates was observed in either screening or clinical cultures. More vigilance and experience is needed to design adequate evidence-based interventions in the future for this vulnerable population.
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Affiliation(s)
| | - V Bekker
- Leiden University Medical Center, Leiden, The Netherlands
| | - M E M Kraakman
- Leiden University Medical Center, Leiden, The Netherlands
| | - M L Bruijning
- Leiden University Medical Center, Leiden, The Netherlands
| | | | - E Lopriore
- Leiden University Medical Center, Leiden, The Netherlands
| | - K E Veldkamp
- Leiden University Medical Center, Leiden, The Netherlands
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21
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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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22
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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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23
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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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24
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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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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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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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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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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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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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31
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Fustolo-Gunnink SF, Huisman EJ, van der Bom JG, van Hout FMA, Makineli S, Lopriore E, Fijnvandraat K. Are thrombocytopenia and platelet transfusions associated with major bleeding in preterm neonates? A systematic review. Blood Rev 2018; 36:1-9. [PMID: 30318111 DOI: 10.1016/j.blre.2018.10.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 10/07/2018] [Indexed: 11/16/2022]
Abstract
Over 75% of severely thrombocytopenic preterm neonates receive platelet transfusions to prevent bleeding, but transfusion guidelines are based mainly on expert opinion. The aim of this review was to investigate whether platelet counts, platelet transfusions or platelet indices are associated with major bleeding in preterm neonates. We performed a systematic search of the EMBASE and MEDLINE databases until December 2017. We included randomized trials, cohort and case control studies. (Prospero: CRD42015013399). We screened 8734 abstracts and 1225 fulltexts, identifying 36 eligible studies. In 30, timing of the platelet counts or transfusions in relation to the bleeding was unclear. Of the remaining six studies, two showed that thrombocytopenia was associated with increased risk of bleeding, two showed no such assocation, and three showed lack of an association between platelet transfusions and bleeding risk. No studies assessing platelet indices were found. The study results suggest that prophylactic platelet transfusions may not reduce bleeding risk in preterm neonates.
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Affiliation(s)
- S F Fustolo-Gunnink
- Sanquin blood supply foundation, Department of clinical transfusion medicine, Plesmanlaan 1A, 2333 BZ Leiden, the Netherlands; Amsterdam University Medical Center, Emma Children's Hospital, Department of pediatric hematology, Meibergdreef 9, 1105 AZ Amsterdam-Zuidoost, the Netherlands; Leiden University Medical Center, Department of Clinical Epidemiology, Albinusdreef 2, 2333 ZA Leiden, the Netherlands.
| | - E J Huisman
- Erasmus Medical Center, Sophia Children's hospital, Department of pediatric hematology, Wytemaweg 80, 3015 CN Rotterdam, the Netherlands.
| | - J G van der Bom
- Sanquin blood supply foundation, Department of clinical transfusion medicine, Plesmanlaan 1A, 2333 BZ Leiden, the Netherlands; Leiden University Medical Center, Department of Clinical Epidemiology, Albinusdreef 2, 2333 ZA Leiden, the Netherlands.
| | - F M A van Hout
- Sanquin blood supply foundation, Department of clinical transfusion medicine, Plesmanlaan 1A, 2333 BZ Leiden, the Netherlands.
| | - S Makineli
- Amsterdam University Medical Center, Emma Children's Hospital, Department of pediatric hematology, Meibergdreef 9, 1105 AZ Amsterdam-Zuidoost, the Netherlands.
| | - E Lopriore
- Leiden University Medical Center, Willem Alexander Children's hospital, Department of neonatology, Albinusdreef 2, 2333 ZA Leiden, the Netherlands.
| | - K Fijnvandraat
- Amsterdam University Medical Center, Emma Children's Hospital, Department of pediatric hematology, Meibergdreef 9, 1105 AZ Amsterdam-Zuidoost, the 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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Lopriore E. Re: Outcome of monochorionic twin pregnancy with selective intrauterine growth restriction according to umbilical artery Doppler flow pattern of smaller twin: systematic review and meta-analysis. D.Buca, G.Pagani, G.Rizzo, A.Familiari, M. E.Flacco, L.Manzoli, M.Liberati, F.Fanfani, G.Scambia and F.D'Antonio. Ultrasound Obstet Gynecol 2017; 50: 559-568. Ultrasound Obstet Gynecol 2017; 50:557. [PMID: 29105215 DOI: 10.1002/uog.18910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- E Lopriore
- Department of Neonatology, Leiden University Medical Center, 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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Aziz NA, Peeters-Scholte CM, de Bruine FT, Klumper FJ, Adama van Scheltema PN, Lopriore E, Steggerda SJ. Fetal cerebellar hemorrhage: three cases with postnatal follow-up. Ultrasound Obstet Gynecol 2016; 47:785-786. [PMID: 26426778 DOI: 10.1002/uog.15772] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 09/14/2015] [Accepted: 09/26/2015] [Indexed: 06/05/2023]
Affiliation(s)
- N A Aziz
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
| | - C M Peeters-Scholte
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
| | - F T de Bruine
- Department of Neuroradiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - F J Klumper
- Department of Obstetrics and Fetal Medicine, Leiden University Medical Centre, Leiden, The Netherlands
| | - P N Adama van Scheltema
- Department of Obstetrics and Fetal Medicine, Leiden University Medical Centre, Leiden, The Netherlands
| | - E Lopriore
- Department of Neonatology, Leiden University Medical Centre, Albinusdreef 2, 2333 AZ, Leiden, The Netherlands
| | - S J Steggerda
- Department of Neonatology, Leiden University Medical Centre, Albinusdreef 2, 2333 AZ, Leiden, The Netherlands
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Fustolo-Gunnink SF, Vlug RD, Smits-Wintjens VEHJ, Heckman EJ, te Pas AB, Fijnvandraat K, Lopriore E. Early-Onset Thrombocytopenia in Small-For-Gestational-Age Neonates: A Retrospective Cohort Study. PLoS One 2016; 11:e0154853. [PMID: 27177157 PMCID: PMC4866768 DOI: 10.1371/journal.pone.0154853] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 04/20/2016] [Indexed: 11/18/2022] Open
Abstract
Thrombocytopenia is a common finding in small for gestational age (SGA) neonates and is thought to result from a unique pathophysiologic mechanism related to chronic intrauterine hypoxia. Our objective was to estimate the incidence and severity of early-onset thrombocytopenia in SGA neonates, and to identify risk factors for thrombocytopenia. We performed a retrospective cohort study of all consecutive SGA neonates admitted to our ward and a control group of appropriate for gestational age (AGA) neonates matched for gestational age at birth. Main outcome measures were incidence and severity of thrombocytopenia, hematological and clinical risk factors for thrombocytopenia, and bleeding. A total of 330 SGA and 330 AGA neonates were included, with a mean gestational age at birth of 32.9 ± 4 weeks. Thrombocytopenia (<150x109/L) was found in 53% (176/329) of SGA neonates and 20% (66/330) of AGA neonates (relative risk (RR) 2.7, 95% confidence interval (CI) [2.1, 3.4]). Severe thrombocytopenia (21-50x109/L) occurred in 25 neonates (8%) in the SGA and 2 neonates (1%) in the AGA group (RR 12.5, 95% CI [3.0, 52.5]). Platelet counts <20x109/L were not recorded. Within the SGA group, lower gestational age at birth (p = <0.01) and erythroblastosis (p<0.01) were independently associated with a decrease in platelet count. Platelet count was positively correlated with birth weight centiles. In conclusion, early-onset thrombocytopenia is present in over 50% of SGA neonates and occurs 2.7 times as often as in AGA neonates. Thrombocytopenia is seldom severe and is independently associated with lower gestational age at birth and erythroblastosis.
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Affiliation(s)
- S. F. Fustolo-Gunnink
- Sanquin Blood Supply, Clinical Transfusion Research, Leiden, Zuid-Holland, The Netherlands
- Academic Medical Center, Pediatric hematology, Amsterdam, Noord-Holland, The Netherlands
- * E-mail:
| | - R. D. Vlug
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - V. E. H. J. Smits-Wintjens
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - E. J. Heckman
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - A. B. te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - K. Fijnvandraat
- Academic Medical Center, Pediatric hematology, Amsterdam, Noord-Holland, The Netherlands
| | - E. Lopriore
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
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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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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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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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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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43
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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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44
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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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45
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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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46
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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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50
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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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