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Götherström C, Chan J, O'Donoghue K, Fisk NM. Identification of candidate surface antigens for non-invasive prenatal diagnosis by comparative global gene expression on human fetal mesenchymal stem cells. Mol Hum Reprod 2017; 23:210. [PMID: 28122823 DOI: 10.1093/molehr/gax001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- C Götherström
- Experimental Fetal Medicine Group, Institute of Reproductive and Developmental Biology, Imperial College London, Hammersmith Campus, London, UK.,Karolinska Institutet, Division of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital Huddinge, SE-141 86 Stockholm, Sweden
| | - J Chan
- Experimental Fetal Medicine Group, Institute of Reproductive and Developmental Biology, Imperial College London, Hammersmith Campus, London, UK.,Department of Reproductive Medicine, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore 229899, Singapore
| | - K O'Donoghue
- Experimental Fetal Medicine Group, Institute of Reproductive and Developmental Biology, Imperial College London, Hammersmith Campus, London, UK.,Department of Obstetrics and Gynaecology, University College Cork and Cork University Maternity Hospital, Cork, Ireland
| | - N M Fisk
- Experimental Fetal Medicine Group, Institute of Reproductive and Developmental Biology, Imperial College London, Hammersmith Campus, London, UK.,UQ Centre for Clinical Research, University of Queensland, Brisbane, Australia
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Patel J, Shafiee A, Wang W, Fisk NM, Khosrotehrani K. Novel isolation strategy to deliver pure fetal-origin and maternal-origin mesenchymal stem cell (MSC) populations from human term placenta. Placenta 2014; 35:969-71. [PMID: 25239220 DOI: 10.1016/j.placenta.2014.09.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Revised: 08/26/2014] [Accepted: 09/02/2014] [Indexed: 12/22/2022]
Abstract
The placenta is an abundant source of mesenchymal stem/stromal cells (MSC). Although presumed of translationally-advantageous fetal origin, the literature instead suggests a high incidence of either contaminating or pure maternal MSC. Despite definitional criteria that MSC are CD34-, increasing evidence suggests that fetal MSC may be CD34 positive in vivo. We flow sorted term placental digests based on CD34+ expression and exploited differential culture media to isolate separately pure fetal and maternal MSC populations. This method has considerable translational implications, in particular to clinical trials underway with "placental" MSC of uncertain or decidual origin.
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Affiliation(s)
- J Patel
- The University of Queensland, UQ Centre for Clinical Research, Herston, QLD, 4029, Australia.
| | - A Shafiee
- The University of Queensland, UQ Centre for Clinical Research, Herston, QLD, 4029, Australia
| | - W Wang
- The University of Queensland, UQ Centre for Clinical Research, Herston, QLD, 4029, Australia
| | - N M Fisk
- The University of Queensland, UQ Centre for Clinical Research, Herston, QLD, 4029, Australia; Centre for Advanced Prenatal Care, Women's & Newborn Services, Royal Brisbane & Women's Hospital, Herston, QLD, 4029, Australia
| | - K Khosrotehrani
- The University of Queensland, UQ Centre for Clinical Research, Herston, QLD, 4029, Australia; The University of Queensland, UQ Diamantina Institute, Translational Research Institute, Woolloongabba, QLD, 4102, Australia.
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Seppanen E, Fisk NM, Khosrotehrani K. Pregnancy-acquired fetal progenitor cells. J Reprod Immunol 2013; 97:27-35. [PMID: 23432869 DOI: 10.1016/j.jri.2012.08.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Revised: 08/23/2012] [Accepted: 08/23/2012] [Indexed: 12/11/2022]
Abstract
The transfer and persistence of fetal progenitor cells into the mother throughout pregnancy has sparked considerable interest as a trafficking stem cell and immunological phenomenon. Indeed, the intriguing longevity of semi-allogeneic fetal microchimeric cells (FMC) in parous women raises questions over their potential clinical implications. FMC have been associated with both immune-modulatory roles and participation in maternal tissue repair. Although their influence on maternal health is as yet unresolved, FMC selectively home to damaged maternal tissues and often integrate, adopting site-appropriate phenotypes. FMC features, such as plasticity and persistence in their maternal host, suggest that they likely include pluripotent, or various multipotent and committed stem and progenitor cells. Recent efforts to determine what cell types are involved have established that FMC include cells of ectodermal, endodermal, mesodermal, and perhaps trophectodermal lineages. This review details FMC phenotypes and discusses how FMC themselves may be considered a naturally occurring stem cell therapy.
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Affiliation(s)
- E Seppanen
- UQ Centre for Clinical Research, Herston Campus, University of Queensland, Brisbane, Qld. 4029, Australia
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Morganstein DL, Wu P, Mane MR, Fisk NM, White R, Parker MG. Human fetal mesenchymal stem cells differentiate into brown and white adipocytes: a role for ERRalpha in human UCP1 expression. Cell Res 2010; 20:434-44. [PMID: 20101261 PMCID: PMC2848839 DOI: 10.1038/cr.2010.11] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
We investigated the ability of fetal mesenchymal stem cells (fMSCs) to differentiate into brown and white adipocytes and compared the expression of a number of marker genes and key regulatory factors. We showed that the expression of key adipocyte regulators and markers during differentiation is similar to that in other human and murine adipocyte models, including induction of PPARgamma2 and FABP4. Notably, we found that the preadipocyte marker, Pref-1, is induced early in differentiation and then declines markedly as the process continues, suggesting that fMSCs first acquire preadipocyte characteristics as they commit to the adipogenic lineage, prior to their differentiation into mature adipocytes. After adipogenic induction, some stem cell isolates differentiated into cells resembling brown adipocytes and others into white adipocytes. Detailed investigation of one isolate showed that the novel brown fat-determining factor PRDM16 is expressed both before and after differentiation. Importantly, these cells exhibited elevated basal UCP-1 expression, which was dependent on the activity of the orphan nuclear receptor ERRalpha, highlighting a novel role for ERRalpha in human brown fat. Thus fMSCs represent a useful in vitro model for human adipogenesis, and provide opportunities to study the stages prior to commitment to the adipocyte lineage. They also offer invaluable insights into the characteristics of human brown fat.
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Affiliation(s)
- DL Morganstein
- Molecular Endocrinology, Institution of Reproductive and Developmental Biology, Imperial College London, London, UK
| | - P Wu
- Experimental Fetal Medicine, Institution of Reproductive and Developmental Biology, Imperial College London, London, UK
| | - M Rosell Mane
- Molecular Endocrinology, Institution of Reproductive and Developmental Biology, Imperial College London, London, UK
| | - NM Fisk
- Experimental Fetal Medicine, Institution of Reproductive and Developmental Biology, Imperial College London, London, UK
| | - R White
- Molecular Endocrinology, Institution of Reproductive and Developmental Biology, Imperial College London, London, UK
| | - MG Parker
- Molecular Endocrinology, Institution of Reproductive and Developmental Biology, Imperial College London, London, UK
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Gotherstrom C, Chan J, O'Donoghue K, Fisk NM. Identification of candidate surface antigens for non-invasive prenatal diagnosis by comparative global gene expression on human fetal mesenchymal stem cells. Mol Hum Reprod 2010; 16:472-80. [DOI: 10.1093/molehr/gaq020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Gonzalez P, Nicolini U, Rahman F, Fisk NM, Rodeck CH. Does oligohydramnios cause fetal club foot? J OBSTET GYNAECOL 2009. [DOI: 10.3109/01443619109013495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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O’Donoghue K, Rutherford MA, Engineer N, Wimalasundera RC, Cowan FM, Fisk NM. Transfusional fetal complications after single intrauterine death in monochorionic multiple pregnancy are reduced but not prevented by vascular occlusion. BJOG 2009; 116:804-12. [DOI: 10.1111/j.1471-0528.2009.02128.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
BACKGROUND Little published evidence supports the widely held contention that research in pregnancy is underfunded compared with other disease areas. OBJECTIVES To assess absolute and relative government and charitable funding for maternal and perinatal research in the UK and internationally. SEARCH STRATEGY, SELECTION CRITERIA, DATA COLLECTION, AND ANALYSIS: Major research funding bodies and alliances were identified from an Internet search and discussions with opinion leaders/senior investigators. Websites and annual reports were reviewed for details of strategy, research spend, grants awarded, and allocation to maternal and/or perinatal disease using generic and disease-specific search terms. MAIN RESULTS Within the imprecision in the data sets, < or =1% of health research spend in the UK was on maternal/perinatal health. Other countries fared better with 1-4% investment, although nonexclusive categorisation may render this an overestimate. In low-resource settings, government funders focused on infectious disease but not maternal and perinatal health despite high relative disease burden, while global philanthropy concentrated on service provision rather than research. Although research expenditure has been deemed as appropriate for 'reproductive health' disease burden in the UK, there are no data on the equity of maternal/perinatal research spend against disease burden, which globally may justify a manyfold increase. AUTHOR'S CONCLUSIONS This systematic review of research expenditure and priorities from national and international funding bodies suggests relative underinvestment in maternal/perinatal health. Contributing factors include the low political priority given to women's health, the challenging nature of clinical research in pregnancy, and research capacity dearth as a consequence of chronic underinvestment.
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Affiliation(s)
- N M Fisk
- Institute of Reproductive and Developmental Biology, Imperial College London, London, UK.
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Abstract
Although much effort has gone into promoting early skin-to-skin contact and parental involvement at vaginal birth, caesarean birth remains entrenched in surgical and resuscitative rituals, which delay parental contact, impair maternal satisfaction and reduce breastfeeding. We describe a ‘natural’ approach that mimics the situation at vaginal birth by allowing (i) the parents to watch the birth of their child as active participants (ii) slow delivery with physiological autoresuscitation and (iii) the baby to be transferred directly onto the mother's chest for early skin-to-skin. Studies are required into methods of reforming caesarean section, the most common operation worldwide. Please cite this paper as: Smith J, Plaat F, Fisk N. The natural caesarean: a woman-centred technique. BJOG 2008;115:1037–1042.
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Affiliation(s)
- J Smith
- Division of Maternity, Directorate of Women's and Children's Services, Queen Charlotte's and Chelsea Hospital, London, UK
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Guillot PV, Cook HT, Pusey CD, Fisk NM, Harten S, Moss J, Shore I, Bou-Gharios G. Transplantation of human fetal mesenchymal stem cells improves glomerulopathy in a collagen type I alpha 2-deficient mouse. J Pathol 2008; 214:627-36. [PMID: 18266309 DOI: 10.1002/path.2325] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Fetal mesenchymal stem cell (fetal MSC) therapy has potential to treat genetic diseases with early onset, including those affecting the kidney and urinary tract. A collagen type I alpha 2-deficient mouse has a deletion in the alpha2 chain of the procollagen type I gene, resulting in the synthesis of abnormal alpha1(I)(3) homotrimers, which replace normal alpha 1(I)2 alpha 2(I)1 heterotrimers and a glomerulopathy. We first confirmed that col1 alpha 2-deficient homozygous mice show abnormal collagen deposition in the glomeruli, which increases in frequency and severity with postnatal age. Intrauterine transplantation of human MSCs from first trimester fetal blood led postnatally to a reduction of abnormal homotrimeric collagen type I deposition in the glomeruli of 4-12 week-old col1 alpha 2-deficient mice. Using bioluminescence imaging, in situ hybridization and immunohistochemistry in transplanted col1 alpha 2-deficient mice, we showed that the damaged kidneys preferentially recruited donor cells in glomeruli, around mesangial cells. Real-time RT-PCR demonstrated that this effect was seen at an engraftment level of 1% of total cells in the kidney, albeit higher in glomeruli. We conclude that intrauterine transplantation of human fetal MSCs improves renal glomerulopathy in a collagen type I-deficient mouse model. These data support the feasibility of prenatal treatment for hereditary renal diseases.
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Affiliation(s)
- P V Guillot
- Experimental Fetal Medicine Group, Institute of Reproductive and Developmental Biology, Imperial College London, Hammersmith Campus, London, UK.
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O'Donoghue K, Cartwright E, Galea P, Fisk NM. Stage I twin-twin transfusion syndrome: rates of progression and regression in relation to outcome. Ultrasound Obstet Gynecol 2007; 30:958-964. [PMID: 18008316 DOI: 10.1002/uog.5189] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
OBJECTIVES Twin-twin transfusion syndrome (TTTS) results in high rates of perinatal mortality and neurological morbidity. Fetoscopic laser ablation of placental anastomoses is now established as the treatment of choice for advanced disease. However, there remains controversy about its use in early-stage TTTS, in which laser-related fetal losses need to be balanced against relatively favorable outcomes with more conservative approaches. We investigated rates of progression and regression in Stage I TTTS and determined factors influencing the course of the disease. METHODS We undertook a retrospective observational study of all TTTS cases referred to our tertiary referral fetal medicine service from 2000 to 2006. In patients presenting with Stage I TTTS, the following variables were evaluated for their ability to predict the course and progression of the disease: gestational age (GA) at presentation, amniotic fluid index, recipient and donor deepest vertical pool, presence of artery-artery anastomoses, small-sized bladder compared to normal donor bladder and fetal size discordance. Study end-points were disease regression or progression, and neonatal survival at 28 days. RESULTS Among 132 consecutive cases of TTTS, 46 women presented with Stage I disease. In the majority (69.6%), disease remained stable (28.3%) or regressed (41.3%). Of cases that progressed, 79% did so within 2 weeks and 93% progressed to at least Stage III. No factor was significantly linked with progression or regression, although there was a trend towards the absence of an artery-artery anastomosis (P = 0.10) and the presence of a small rather than normal donor bladder (P = 0.10) influencing progression, and later GA at presentation (P = 0.07) influencing regression. At least one infant survived in 83% of cases and there was double survival in 59%. Perinatal outcome was significantly better in cases that regressed (the rates of at least one survivor and double survival being 89% and 89%, respectively) or remained Stage I (77% and 61%, respectively), compared with those cases that progressed (79% and 14%, respectively). Treatment with amnioreduction at first presentation did not influence progression or regression. CONCLUSIONS This study demonstrates that a high percentage of Stage I TTTS cases regress or remain early stage. Identification of factors predicting progression would facilitate the selection of patients for definitive therapy, while avoiding treatment-related morbidities in mild or transient disease.
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Affiliation(s)
- K O'Donoghue
- Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital, London, UK.
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Abstract
INTRODUCTION Foetal exposure to testosterone is increasingly implicated in the programming of future reproductive and non-reproductive behaviour. Some outcomes associated with prenatal exposure to testosterone may be predicted from exposure to prenatal stress, suggesting a link between them. The peak serum levels of testosterone in the foetus are thought to be around 14-18 weeks' gestation, and we explored testosterone levels at different gestations. Although best investigated in foetal plasma, this is now difficult because of the decline in frequency of foetal blood sampling; in this study, we used amniotic fluid as a biomarker to investigate foetal exposure. AIMS To investigate the relationship between amniotic fluid testosterone, amniotic fluid cortisol, foetal gender, and gestational age. METHODS Paired amniotic fluid and maternal plasma samples were collected from 264 pregnant women undergoing amniocentesis between 15 and 37 weeks' gestation (median 17 weeks [119 days]). Total testosterone and cortisol in amniotic fluid, and total plasma testosterone (maternal) were measured by radioimmunoassay. RESULTS Amniotic fluid testosterone levels were higher in male than in female foetuses, with a median (interquartile range) of 0.85 nmol/l (0.60-1.17 nmol/l) and 0.28 nmol/l (0.175-0.45 nmol/l), respectively. No relationship between amniotic fluid testosterone and gestational age was detected in either sex. Amniotic fluid testosterone correlated positively with amniotic fluid cortisol in both sexes (r = 0.30 male foetuses, r = 0.33 female foetuses, P < 0.001 for both), and remained significant in multivariate analysis. CONCLUSION Testosterone in amniotic fluid did not change with gestation in the second and third trimester, raising questions about the timing of the reported early peak in the male foetus. The positive correlation between cortisol and testosterone in amniotic fluid suggests that increased foetal exposure to cortisol may also be associated with increased exposure to testosterone.
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Affiliation(s)
- P Sarkar
- Institute of Reproductive and Developmental Biology, Imperial College London, Hammersmith Campus, London, UK.
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Abstract
OBJECTIVE There is increasing evidence that antenatal stress has long-lasting effects on child development, but there is less accord on the mechanisms and the gestational window of susceptibility. One possible mechanism is by foetal exposure to maternal cortisol. To explore this, we investigated the relationship between cortisol in maternal plasma and amniotic fluid, and any moderating influence of gestational age. PATIENTS AND MEASUREMENTS Two hundred and sixty-seven women awaiting amniocentesis for karyotyping were studied. Samples were collected between 0900 and 1730 h. Gestational age was determined to the nearest day by ultrasound biometry and time of collection noted to the nearest 15 min. Total cortisol was measured by radioimmunoassay in paired amniotic fluid and maternal blood samples (n = 267) [gestation range 15-37 weeks, median 17 weeks (119 days)]. RESULTS Both maternal and amniotic fluid cortisol levels increased with gestation (r = 0.25, P < 0.001; r = 0.33 P < 0.001, respectively). Amniotic fluid cortisol was positively correlated with time of collection (r = 0.22, P < 0.001) and negatively with maternal age (r =-0.24, P < 0.001). There was a positive correlation between amniotic fluid cortisol with maternal plasma levels (r = 0.32, P < 0.001), which persisted after multivariate analysis controlling for gestation, time of collection and maternal age. The association appeared to be dependent on gestational age, being nonsignificant at 15-16 weeks' gestation and increasing in strength thereafter. CONCLUSION This study shows a positive correlation between maternal and amniotic fluid cortisol levels, which becomes robust from 17 to 18 weeks onwards. The results provide support for the hypothesis that alterations in maternal cortisol may be reflected in amniotic fluid levels from this gestation.
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Affiliation(s)
- P Sarkar
- Institute of Reproductive and Developmental Biology, Imperial College London, London, UK.
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Choolani M, Ho SSY, Razvi K, Ponnusamy S, Baig S, Fisk NM, Biswas A. FastFISH: technique for ultrarapid fluorescence in situ hybridization on uncultured amniocytes yielding results within 2 h of amniocentesis. ACTA ACUST UNITED AC 2007; 13:355-9. [PMID: 17430982 DOI: 10.1093/molehr/gam016] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Rapid aneuploidy detection methods allow prenatal diagnosis results to be released within 48 h, but not on the same day as the invasive test. We aimed to develop a rapid fluorescence in situ hybridization (FISH) method (FastFISH) that releases accurate results on the same day as amniocentesis. FastFISH was optimized to be completed within 2 h of sample collection using CEP and LSI probes for chromosomes 13, 18, 21, X, Y and DiGeorge syndrome (DGS). The technique was tested on 100 consecutive amniotic fluid samples in a blinded study. It was also validated as a 1-day molecular genetic test on three representative fetal tissue samples: chorionic villus, amniotic fluid and fetal blood. In the blinded study, FastFISH results were ready within 2 h of sample collection. Of the 100 amniotic fluid samples, 49 male and 50 female fetuses were identified. One fetus was 47, XXY (Klinefelter syndrome). Three fetuses had trisomy 21. One fetus suspected of DGS by ultrasound was identified as normal. Results of FastFISH analyses in all 100 cases were concordant with their karyotypes (100% accuracy; lower 95% CI, 97.05%). In the 1-day test validation, all results were released on the same day and were concordant with their respective karyotypes. FastFISH allows results to be released on the same day as amniocentesis. It represents the necessary development for a 1-day prenatal diagnosis service.
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Affiliation(s)
- M Choolani
- Diagnostic Biomarker Discovery Laboratory, Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, 5 Lower Kent Ridge Road, 119074 Singapore.
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Pasquini L, Wimalasundera RC, Fichera A, Barigye O, Chappell L, Fisk NM. High perinatal survival in monoamniotic twins managed by prophylactic sulindac, intensive ultrasound surveillance, and Cesarean delivery at 32 weeks' gestation. Ultrasound Obstet Gynecol 2006; 28:681-7. [PMID: 17001748 DOI: 10.1002/uog.3811] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
OBJECTIVES Increased perinatal mortality in monoamniotic twin pregnancies is attributed to cord accidents in utero and at delivery. We evaluated the following parameters in monoamniotic pregnancies: (1) the incidence of cord entanglement; (2) the effect of sulindac on amniotic fluid volume and stability of fetal lie; and (3) the perinatal outcome with our current management paradigm. METHODS This is a retrospective review of monoamniotic pregnancies of >or=20 weeks' gestation managed with serial ultrasound surveillance, medical amnioreduction and elective Cesarean delivery at 32 weeks' gestation. Mean amniotic fluid index (AFI) and change in AFI in monoamniotic pregnancies managed with oral sulindac was compared with 40 gestation-matched monochorionic-diamniotic controls. RESULTS Among 44 monoamniotic pregnancies, 20 with two live structurally normal twins at 20 weeks' gestation satisfied the inclusion criteria. All fetuses survived to 28 days postnatally despite early prenatal cord entanglement in all but one case. Whereas AFI remained stable throughout gestation in the controls, the AFI fell in those patients on sulindac from a mean value of 21.0 cm (95% CI, 18.5-23.6 cm) at 20 weeks to a mean of 12.4 cm (95% CI, 10.1-14.6 cm) at 32 weeks (ANOVA P across gestation = 0.001) but mainly remained within normal limits. Fetal lie was stabilized in 11/20 cases in the monoamniotic group compared with 13/40 in the control group (P < 0.0001). CONCLUSIONS Cord entanglement appears unpreventable, as it typically occurs in early pregnancy. Sulindac therapy reduces AFI, leads to more stable fetal lie, and may prevent intrauterine death by diminishing the risk of constricting cords that are already entangled. Perinatal survival in monoamniotic pregnancies managed by a regime of sulindac from 20 weeks' gestation, close ultrasound surveillance and elective abdominal delivery at 32 weeks' gestation seems empirically higher than that in the literature.
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Affiliation(s)
- L Pasquini
- Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital, London, UK.
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Abstract
OBJECTIVES To assess whether anticipation of amniocentesis is linked with maternal anxiety, and whether this anxiety is associated with increased maternal plasma cortisol. METHODS Two hundred and fifty-four women awaiting a morning amniocentesis for karyotyping (gestation range 15-37 weeks, median 17 weeks) completed Spielberger state and trait anxiety inventory (STAI) questionnaires, and provided blood samples immediately before the procedure for cortisol assay. Six hundred and five women at mean gestation of 20 weeks, attending the same hospital for routine ultrasound but not for amniocentesis, also completed Spielberger STAI questionnaires and served as a comparison group for the anxiety ratings. RESULTS Mean state and trait anxiety scores (+/- SD) in the comparison group of 605 women at mean gestation of 20 weeks were 36.1 +/- 10.2 (range 20-70) and 35.6 +/- 8.9 (range 20-73), respectively. The mean state anxiety score (+/-SD) of 49.8 +/- 14.0 (range 20-77) of the amniocentesis group was considerably higher than the comparison group (p < 0.001), although the mean trait anxiety score in the amniocentesis group was similar at 36.4 +/- 8.6 (range 21-60). The state, but not trait, anxiety correlated with plasma cortisol (r = 0.176, p = 0.005). Maternal cortisol in the amniocentesis group increased with gestational age (r = 0.310, p < 0.001), whereas state anxiety scores showed no significant change with increase in gestational age (r = - 0.042, ns). Multivariate analysis demonstrated that maternal state anxiety was positively correlated with plasma cortisol independent of gestation and time of collection. CONCLUSION Women awaiting amniocentesis experience a high state anxiety associated with modestly increased plasma cortisol.
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Affiliation(s)
- P Sarkar
- Institute of Reproductive and Developmental Biology, Imperial College London, Hammersmith Campus, UK.
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Kennea NL, Stratou C, Naparus A, Fisk NM, Mehmet H. Functional intrinsic and extrinsic apoptotic pathways in human fetal mesenchymal stem cells. Cell Death Differ 2005; 12:1439-41. [PMID: 15962008 DOI: 10.1038/sj.cdd.4401641] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Wee LY, Sebire NJ, Bhundia J, Sullivan M, Fisk NM. Histomorphometric characterisation of shared and non-shared cotyledonary villus territories of monochorionic placentae in relation to pregnancy complications. Placenta 2005; 27:475-82. [PMID: 16023205 DOI: 10.1016/j.placenta.2005.02.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2005] [Revised: 02/05/2005] [Accepted: 02/05/2005] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Theoretical estimates and physiological inferences suggest that the structure of a shared cotyledon differs from a non-shared cotyledon. The aim of this study was to characterise the histomorphometry of terminal villi in shared and non-shared cotyledons in monochorionic placentae, both from uncomplicated twins and from those with twin-twin transfusion syndrome (TTTS) or discordant growth restriction (DeltaIUGR). METHODS Forty-one monochorionic placentae from Caucasian non-smokers were obtained at caesarean section. Their vascular anatomy and placental territories were ascertained by dye injection. After fixation, full thickness histological blocks were obtained by systematic random sampling from each twin's territory and the shared cotyledons. Fifty randomly selected terminal villi were assessed for: (i) median villus diameter (ii) median villus capillary diameter (iii) median fetomaternal diffusion distance (iv) median no. of capillaries/villus (v) degree of vascularization (median percentage cross-sectional area of terminal villi occupied by capillaries) using a stage micrometer and image analysis programme. The histomorphometric findings were then correlated with birthweight discordance, placental territory discordance and DeltaAVAs (no. of AVAs from smaller twin (donor) to larger twin (recipient) minus no. of AVAs from larger to smaller twin). RESULTS Histomorphometric variables were similar in shared and non-shared cotyledons of uncomplicated MCDA twins. However, the median diameter of terminal villi in shared cotyledons in DeltaIUGR and TTTS placentae was significantly smaller [51.2 microm (48.2-58.3), p<0.001 and 52.6 microm (53.1-50.4), p<0.001], and had a similar number of smaller capillaries, larger fetomaternal diffusion distance and reduced vascularization compared to non-shared IUGR and TTTS placentae. However, Deltadiameter (defined as the difference between median diameters of terminal villi in large minus small twins' territories) rose with increasing birthweight discordance (Pearson correlation coefficient=0.82, p<0.001). Multiple linear regression analysis revealed that Deltadiameter was influenced by placental territory discordance (p<0.001) and birthweight discordance (p<0.01): log10 Deltadiameter=1.38+(0.01 x birthweight discordance)+(0.56 x log10 placental territory discordance) (R2=0.82, p<0.001), but there was no significant relationship with DeltaAVA and AAA. In the TTTS group, Deltadiameter correlated significantly with DeltaAVA only: log10Deltadiameter=1.44+(0.02 x DeltaAVA) (R2=0.3, p<0.001). CONCLUSIONS This is the first study to characterise the histomorphometry of shared and non-shared cotyledons in MC twins. The findings suggest that abnormal placentation, rather than placental vascular anatomy may be responsible for DeltaIUGR in MC twins, whereas TTTS arises from imbalance in interfetal transfusion with resultant differing terminal villus histomorphometric features in donor, recipient and shared cotyledons.
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Affiliation(s)
- L Y Wee
- Institute of Reproductive & Developmental Biology, Imperial College London, Hammersmith Campus, London, UK.
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Welsh AW, Rubin JM, Fowlkes JB, Fisk NM. Standardization of power Doppler quantification of blood flow in the human fetus using the aorta and inferior vena cava. Ultrasound Obstet Gynecol 2005; 26:33-43. [PMID: 15971284 DOI: 10.1002/uog.1924] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
OBJECTIVE This study aimed to test the applicability to the fetus of mathematical techniques developed to standardize power Doppler indices of adult regional perfusion. METHOD Fetal power Doppler imaging was performed on 14 fetuses (25-37 weeks' gestation) using a standardized parasagittal plane, examining renal and aortic blood flow, and additionally inferior vena caval (IVC) flow in one fetus. Images were stored and transferred for off-line computer analysis using purpose-designed software. We first tested the need for techniques to remove the effects of red blood cell clumping on power Doppler amplitude, then performed further analyses to: (1) investigate cardiac cycle effects on aortic amplitude; (2) determine the spatial consistency of, and influence of angle of insonation on, maximal pixel value; (3) quantify temporal consistency; and (4) compare peak pixel values in the fetal aorta and IVC. RESULTS No rouleaux effect on the vascular profile was detectable, in contrast to that identified in the adult. Within each fetus a consistent value was seen in the center of the aorta corresponding to 100% vascular amplitude, which was unaltered by the phase of the cardiac cycle, with a coefficient of variation of 28.9% at 89 degrees and 6.5% at 73 degrees . This value was constant in the aorta and IVC. CONCLUSION Fetal blood does not appear to form rouleaux to any significant degree, so there is no artificially elevated maximal value for power Doppler amplitude as seen in the adult. We propose that the value representing 100% amplitude may be consistently measured in the center of large fetal vessels such as the aorta, allowing the direct measurement of fractional moving blood volumes in the human fetus.
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Affiliation(s)
- A W Welsh
- Department of Obstetrics, Royal Prince Alfred Hospital, Camperdown, Australia.
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21
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Abstract
OBJECTIVE To investigate (A) the determinants of infant stress response at delivery and (B) test the hypothesis that stress at birth, as reflected by cord arterial cortisol, influences cortisol response to vaccination at two months. DESIGN Prospective observational study. SETTING Tertiary referral maternity hospital. POPULATION One hundred and seventy-two primiparous women with uncomplicated singleton pregnancies. METHODS Women were recruited antenatally. At birth, cord arterial blood and obstetric data were collected. Saliva was collected from infants immediately before and after vaccination at two months. Cortisol was analysed from cord blood and saliva by radio-immunoassay. MAIN OUTCOME MEASURES Stress response at birth, as demonstrated by cord arterial cortisol; association with saliva cortisol response to vaccination at two months. RESULTS Cord arterial cortisol varied with mode of delivery, combined spinal/epidural use and pH. Salivary cortisol response at two months correlated with cord arterial cortisol (r= 0.24, P < 0.05). Infants with the highest and lowest cord arterial cortisol had markedly different cortisol responses at two months (P= 0.017). These groups had different modes of delivery with caesarean rates of <8% in the high cortisol response group and 83% in the low cortisol response group (P < 0.0001). CONCLUSION Babies born vaginally mount greater cortisol responses at birth than those delivered by caesarean section. Stress at delivery may influence the infant HPA axis response for up to two months.
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Affiliation(s)
- N M Miller
- Wolfson and Weston Research Centre for Family Health, Institute of Reproductive and Developmental Biology, Imperial College London, UK
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22
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Vanderheyden TM, Fichera A, Pasquini L, Tan TYT, Wee LY, Frusca T, Fisk NM. Increased latency of absent end-diastolic flow in the umbilical artery of monochorionic twin fetuses. Ultrasound Obstet Gynecol 2005; 26:44-9. [PMID: 15971285 DOI: 10.1002/uog.1900] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
OBJECTIVE To determine if absent end-diastolic flow (AEDF) in the umbilical artery (UA) has a longer latency in monochorionic (MC) twin fetuses compared to singleton or dichorionic twin (DC) fetuses. METHODS One hundred and eight pregnancies with a fetus with AEDF were reviewed: 47 MC and 17 DC twin pregnancies and 44 singletons. Because twin-twin transfusion syndrome (TTTS) is a potential confounder when determining latency, subgroup analysis was also performed on the 21 MC affected pregnancies without TTTS. Latency of AEDF (in days) was defined as the difference between the gestational age at diagnosis of AEDF and gestational age at delivery or intrauterine death. RESULTS Latency was similar in MC twins (median, 39 days) and DC twins (30 days) but longer compared to singletons (11 days; P = 0.0001). After excluding pregnancies with TTTS, latency in non-TTTS MC twins (54 days) was longer than in both singletons and DC twins. This was due to an earlier gestational age at AEDF in non-TTTS MC twins of 20 weeks compared to 27 weeks in both singleton and DC twins because median gestational age at delivery was similar in MC twins, DC twins and singletons. CONCLUSIONS The latency period of UA AEDF is longer in MC twins than in singletons. Our data suggest that in MC twin fetuses without TTTS, AEDF begins earlier and lasts about twice as long as in DC twin fetuses, which is consistent with placental insufficiency not being the sole factor mediating abnormal UA waveforms in MC placentation. This observation is important in counseling and managing twin pregnancies discordant for AEDF.
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Affiliation(s)
- T M Vanderheyden
- Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital, and Institute of Reproductive and Developmental Biology, Imperial College London, Hammersmith Campus, London, UK.
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Abstract
BACKGROUND Fetal exposure to testosterone has been implicated in programming childhood behaviour, but little is known about the determinants of fetal testosterone concentrations. AIMS To investigate the relation between fetal testosterone and maternal and fetal cortisol. METHODS Clinically indicated blood samples taken from 44 human fetuses (mean gestational age 27 weeks, range 15-38), together with paired maternal samples, were analysed for testosterone and cortisol concentrations. RESULTS Male fetuses had significantly higher concentrations of testosterone than females. Female but not male fetal concentrations rose significantly with gestational age. Fetal testosterone correlated positively with both fetal cortisol and maternal testosterone concentrations. Multiple regression showed that maternal testosterone and fetal cortisol were independently correlated with fetal plasma testosterone in both sexes. CONCLUSION Unlike the norm in the adult, where testosterone production is often inhibited by cortisol, in the fetus there is a positive link between the two.
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Affiliation(s)
- R Gitau
- Wolfson and Weston Research Centre for Family Health, Institute of Reproductive and Developmental Biology, Imperial College London, Du Cane Road, London W12 0NN, UK
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Wee LY, Taylor M, Watkins N, Franke V, Parker K, Fisk NM. Characterisation of deep arterio-venous anastomoses within monochorionic placentae by vascular casting. Placenta 2005; 26:19-24. [PMID: 15664407 DOI: 10.1016/j.placenta.2004.04.007] [Citation(s) in RCA: 38] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/19/2004] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To characterise arterio-venous anastomoses (AVA) in monochorionic (MC) placentae and determine (i) whether shared cotyledons lie beneath the co-termination of an artery from one twin and a vein to the contralateral twin and (ii) whether all AVA can be detected by visual inspection of the chorionic plate. METHODS Vascular casts were made of 15 MC placentae. The number of typical AVAs suspected visually before digestion was compared with the number of AVAs identified after acid digestion. RESULTS Thirty-three of 67 (49%) suspected typical AVAs were confirmed as typical after casting. There were five false positives and no false negatives. The remainder were classified as atypical AVAs, found in > or =90% of MC placentae. Type I (small vascular connections between two apparently normal cotyledons not seen before casting) and Type II (shared cotyledons arising within larger apparently normal cotyledons) atypical AVAs were found in 53% and 73% of placentae, respectively. CONCLUSIONS Only half the shared cotyledons in MC placentae are characterised by co-termination of an artery and vein on the chorionic plate. We report the existence of deep anastomoses beneath the chorionic plate that cannot be visualised by chorionic plate inspection. These findings have implications for laser treatment of twin-twin transfusion syndrome.
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Affiliation(s)
- L Y Wee
- Centre for Fetal Care, Queen Charlotte's & Chelsea Hospital, United Kingdom.
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25
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Abstract
Prednisolone is widely used to treat medical conditions in pregnancy, despite the lack of long-term safety studies on infants. Animal studies have shown that antenatal glucocorticoid treatment can cause in utero growth restriction and up-regulation of the offsprings' hypathalamic-pituitary-adrenal axis. We recruited women treated antenatally with prednisolone, and followed 12 of the infants up to four months, using routine infant vaccinations as a stressor. Birthweights were similar to controls (n = 289, uncomplicated, singleton term pregnancies), as were infants' baseline and stress-induced cortisol levels. Mothers rated their infants as less difficult and more adaptable than controls. This study provides initial reassurance about the safety of prednisolone in pregnancy.
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Affiliation(s)
- N M Miller
- Wolfson and Weston Research Centre for Family Health, Institute of Reproductive and Developmental Biology, Faculty of Medicine, Imperial College London, UK
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26
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Taylor MJO, Wee LY, Denbow ML, Fisk NM. Re: Intra-amniotic Doppler measurement of blood flow in placental vascular anastomoses in twin-twin transfusion syndrome. Ultrasound Obstet Gynecol 2004; 24:479-481. [PMID: 15343610 DOI: 10.1002/uog.1725] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
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Abstract
OBJECTIVE It has recently been claimed that fetoscopic recognition of a haemodynamic equator within an arterio-arterial anastomosis (AAA) suggests minimal net intertwin flow. This was based on blood from one fetus being dark and from the other bright red, the boundary between them reciprocating with the fetal heart beats. However, bright red indicates that the blood had passed through a cotyledon and been freshly oxygenated, which should be impossible in an AAA. We applied a computer model of chorionic vessels to determine a configuration that reproduced this phenomenon. METHODS A previously published TTTS model was extended to provide placental detail in a segment containing four cotyledons of each placenta supplied by three generations of placental arteries and veins. RESULTS Reciprocating flow is not unique to AAAs. It also occurs in the chorionic arteries of any cotyledon deprived of its venous outflow, in a similar manner to that in which reverse end-diastolic flow occurs in umbilical arteries when whole placental resistance is high. If venous return from the common chorionic vein in the recipient (draining the venous end of an AVA) is blocked as might happen after laser, there can be bidirectional flow from one umbilical artery insertion, through two cotyledons to the other insertion. We define this phenomenon as a pseudo-AAA (PAAA). The inclusion of two cotyledons in this path means that its resistance cannot match the low flow resistance of a true AAA, and transmission of the contralateral pulsatile pattern is absorbed in the cotyledons. Thus, PAAA Doppler patterns differ from true AAA patterns in that two sets of systolic peaks, one forward and one reverse, can be discerned in true AAAs but only one in PAAAs. CONCLUSIONS We demonstrate how venous occlusion of an arterio-venous anastomosis may produce a pseudo-AAA colour equator at endoscopy. However, visual observation of reciprocating flow is not sufficient to define a vessel as a true AAA which instead requires ultrasonical identification of two systolic patterns.
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Affiliation(s)
- M J O Taylor
- Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital and Institute of Reproductive and Developmental Biology, Imperial College, London, UK.
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Denbow ML, Taylor M, Cox P, Fisk NM. Derivation of rate of arterio-arterial anastomotic transfusion between monochorionic twin fetuses by Doppler waveform analysis. Placenta 2004; 25:664-70. [PMID: 15193874 DOI: 10.1016/j.placenta.2004.01.027] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/30/2004] [Indexed: 11/24/2022]
Abstract
We aimed to determine rates of interfetal transfusion along arterio-arterial (AA) anastomoses in monochorionic twins in vivo from analysis of Doppler waveform patterns. Twenty-one monochorionic twin pregnancies in which an AA anastomosis was identified antenatally underwent serial Doppler velocimetry. Unidirectional AA anastomotic flow rates increased with increasing gestational age (log y = 8 x 10(-9)x - 5 x 10(-8); p = 0.0002). The mean net rate of flow through an AA anastomosis at 28 weeks gestation was 7.6 x 10(-8) l/s (SD = 4.9 x 10(-8) l/s). This flow was significantly related to the distribution of arterio-venous (AV) anastomoses (p = 0.009) and birthweight discordancy (p = 0.006). We derived estimates of flow along individual AV anastomoses by assuming that net AA countertransfusion is shared equally among uncompensated AV anastomoses, and speculate that the median AV flow rate at 28 weeks is in the order of 6 x 10(-8) l/s. In conclusion, this study demonstrates that flow rates along AA anastomoses can be quantified antenatally. These are the first estimates of flow rates in vivo along placental anastomoses. Although AA net flows are modest, chronic unbalanced counterflow of this magnitude in the absence of compensatory superficial anastomoses could lead to significant haemodynamic compromise.
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Affiliation(s)
- M L Denbow
- Institute of Reproductive and Developmental Biology, Imperial College London, Hammersmith Campus, London, United Kingdom.
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29
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Abstract
Monochorionic (MC) twins have a 3-10-fold higher perinatal mortality and morbidity than dichorionic twins. This is largely attributable to their common vascular architecture and the high rate of discordant fetal growth, growth restriction and congenital abnormalities. In the event of a single intrauterine death (IUD), intertwin agonal transfusion results in up to a 38% risk of death and a 46% risk of neurological injury to the co-twin. This chapter addresses the management of complications unique to MC twins. The primary aim of management is to prevent single IUD or, if inevitable, prevent agonal transfusion occurring by vascular occlusive selective feticide. Older fetoscopic techniques have been replaced by the simpler ultrasound-guided techniques of interstitial laser and bipolar cord occlusion. Their application in twin reversed-arterial perfusion sequence has been associated with a 50% reduction of perinatal mortality in the pump twin. Moreover, prophylactic interstitial laser therapy in early pregnancy might obviate the technical and clinical difficulties in the presence of fetal decompensation in later pregnancy. Recent strategies to reduce the high perinatal mortality due to cord entanglement in antenatally diagnosed monoamniotic twins including medical amnioreduction and elective caesarean delivery at 32 weeks, are also discussed.
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Affiliation(s)
- L Pasquini
- Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital, Du Cane Road, Hammaersmith, W12 0HS London, UK.
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Fisk NM, Fysh J, Child AG. Is C-reactive protein really useful in preterm premature rupture of the membranes? Int J Gynaecol Obstet 2004. [DOI: 10.1016/0020-7292(88)90172-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Tan TYT, Denbow ML, Cox PM, Talbert D, Fisk NM. Occlusion of Arterio-Arterial Anastomosis Manifesting as Acute Twin–Twin Transfusion Syndrome. Placenta 2004; 25:238-42. [PMID: 14972456 DOI: 10.1016/j.placenta.2003.08.018] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2003] [Revised: 08/08/2003] [Accepted: 08/11/2003] [Indexed: 11/25/2022]
Abstract
In vivo, ex vivo and modelling studies suggest that arterio-arterial anastomoses (AAAs) protect against haemodynamic imbalance in monochorionic twins and thus the development of TTTS. We report the acute onset of severe TTTS at 34 weeks' gestation in a patient with an antenatally visualized AAA which was shown at injection studies to have been obliterated, presumably by thrombosis. Computer modelling with the relevant clinical data confirmed that occlusion of the AAA alone was sufficient to reproduce the clinical manifestations. A study of the vascular configuration of AAA in the fixed placenta suggested that its small diameter and turbulent flow may have contributed to its occlusion. This case report shows that the unmasking of unbalanced AVA configurations by occlusion of a protective AAA can manifest as TTTS.
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Affiliation(s)
- T Y T Tan
- Institute of Reproductive and Developmental Biology, Imperial College, Hammersmith Campus, London, UK
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32
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Abstract
OBJECTIVES To study the effect of acute stress, caused by intrauterine needling at the intrahepatic vein (IHV), on fetal plasma concentrations of corticotrophin releasing hormone (CRH), and to compare paired fetal and maternal samples for CRH concentration to determine the extent of their joint control. DESIGN Venous blood samples were obtained from fetuses (gestational age 17-38 weeks) undergoing fetal blood sampling (n = 29) or intrauterine transfusion (n = 17) through either the IHV or the placental cord insertion (PCI). SETTING The Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital, London, UK. PATIENTS Pregnant women undergoing clinically indicated fetal blood sampling or intrauterine blood/platelet transfusion. RESULTS Fetal plasma cortisol increased with intrahepatic vein transfusion (mean (SD) cortisol response Delta64.7 (54.5) nmol/l; p < 0.0001, n = 11), and fetal corticotrophin concentrations were higher after IHV (n = 7) than PCI needling (n = 6). Neither fetal nor maternal plasma CRH increased after IHV transfusion. Fetal CRH levels did not rise with gestation, whereas maternal CRH levels did (r = 0.58; n = 36; p < 0.0001). There was a modest correlation between paired maternal and fetal values (r = 0.36; n = 36; p = 0.03). CONCLUSIONS Acute fetal stress, caused by IHV needling of the fetal abdomen, resulted in hypothalamic-pituitary-adrenal axis activation, as shown by a rise in fetal cortisol and corticotrophin. However, it did not result in measurable CRH release into fetal plasma. This suggests that fetal plasma CRH is not derived from the hypophyseal-portal circulation, but from another source, presumably the placenta.
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Affiliation(s)
- R Gitau
- Fetal and Neonatal Stress Research Group, Wolfson and Weston Research Centre for Family Health, Institute of Reproductive and Developmental Biology, Faculty of Medicine, Imperial College London, London W12 0NN, UK
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Fisk NM, Chan J, O'Donoghue K. Intrauterine stem cell therapy. Ann Acad Med Singap 2003; 32:S8-10. [PMID: 14968717] [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] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Affiliation(s)
- N M Fisk
- Experimental Fetal Medicine Group, Institute of Reproductive and Developmental Biology, Division of Paediatrics Obstetrics and Gynaecology, Imperial College London (Hammersmith Campus) Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital, UK
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O'Donoghue K, Choolani M, Chan J, de la Fuente J, Kumar S, Campagnoli C, Bennett PR, Roberts IAG, Fisk NM. Identification of fetal mesenchymal stem cells in maternal blood: implications for non-invasive prenatal diagnosis. Mol Hum Reprod 2003; 9:497-502. [PMID: 12837927 DOI: 10.1093/molehr/gag063] [Citation(s) in RCA: 108] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Strategies for genetic prenatal diagnosis on fetal cells in the maternal circulation have been limited by lack of a cell type present only in fetal blood. However, the recent identification of mesenchymal stem cells (MSC) in first trimester fetal blood offers the prospect of targeting MSC for non-invasive prenatal diagnosis. We developed protocols for fetal MSC enrichment from maternal blood and determined sensitivity and specificity in mixing experiments of male fetal MSC added to female blood, in dilutions from 1 in 10(5) to 10(8). We then used the optimal protocol to isolate fetal MSC from maternal blood in the first trimester, using blood taken after surgical termination of pregnancy as a model of increased feto-maternal haemorrhage. In model mixtures, we could amplify one male fetal MSC in 2.5 x 10(7) adult female nucleated cells, yielding a 100% pure population of fetal cells, but not one fetal MSC in 10(8) nucleated cells. Fetal MSC were identified in one of 20 post-termination maternal blood samples and confirmed as fetal MSC by XY fluorescence in-situ hybridization (FISH), immunophenotyping and osteogenic and adipogenic differentiation. We report the isolation of fetal MSC from maternal blood; however, their rarity in post-termination blood suggests they are unlikely to have a role in non-invasive prenatal diagnosis. Failure to locate these cells routinely may be attributed to their low frequency in maternal blood, to sensitivity limitations of enrichment technology, and/or to their engraftment in maternal tissues soon after transplacental passage. We speculate that gender microchimerism in post-reproductive maternal tissues might result from feto-maternal trafficking of MSC in early pregnancy.
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Affiliation(s)
- K O'Donoghue
- Institute of Reproductive and Developmental Biology, Division of Paediatrics, Obstetrics and Gynaecology, Imperial College London, Hammersmith Hospital Campus, Du Cane Road, London W12 0NN, UK.
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35
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Wee LY, Taylor MJ, Vanderheyden T, Talbert D, Fisk NM. Transmitted arterio-arterial anastomosis waveforms causing cyclically intermittent absent/reversed end-diastolic umbilical artery flow in monochorionic twins. Placenta 2003; 24:772-8. [PMID: 12852868 DOI: 10.1016/s0143-4004(03)00114-0] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES To characterize the phenomenon of retrograde transmission of arterio-arterial anastomosis (AAA) interference patterns on umbilical artery (UA) waveform by (a) documenting the periodicity, (b) correlation with in vivo and in vitro demonstration of AAAs and (c) reproducing these patterns by computer modelling. METHODS Monochorionic twins (MC) twins underwent placental and umbilical Doppler studies. AAAs were sought by pulse wave Doppler of their bi-directional interference pattern and confirmed by postnatal injection studies. The periodicity of transmitted patterns in the UA was determined. Determinants of the transmitted patterns were ascertained by computer modelling of physiological and fetal variables. RESULTS Among 83 prospectively studied MC twin pregnancies; a transmitted pattern was observed in 6 (7 per cent) patients for 15-114 days. This was found in 20 per cent (6/30) of smaller MC twins discordant for growth restriction but in no appropriately grown twins. It was only observed in association with AAAs validated both in vivo and in ex vivo. Computer modelling demonstrated that this pattern could be reproduced by summating end diastolic flow with a high pulsatility index in the UA in the presence of a large AAA. Consistent with this, MC twins with a transmitted pattern had larger AAAs (median diameter 4.3 mm interquartile range 4.1-5.2) compared to MC twins discordant for intrauterine growth restriction (2.1 mm interquartile range 1.5 to 2.8) (P<0.05) without a transmitted pattern. Perinatal mortality was similar in the fetuses with and without transmitted patterns (0/12 vs. 2/48 P=0.7).
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Affiliation(s)
- L Y Wee
- Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital and Institute of Reproductive and Developmental Biology, Imperial College London, Hammersmith Campus, Du Cane Road, W12 0NN, London, UK.
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36
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Wee LY, Taylor MJO, Talbert D, Fisk NM. Variable umbilical artery end-diastolic frequency is associated with arterio-arterial anastomosis. Ultrasound Obstet Gynecol 2003; 21:626. [PMID: 12808687 DOI: 10.1002/uog.175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
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Tan LK, Kumar S, Jolly M, Gleeson C, Johnson P, Fisk NM. Test amnioinfusion to determine suitability for serial therapeutic amnioinfusion in midtrimester premature rupture of membranes. Fetal Diagn Ther 2003; 18:183-9. [PMID: 12711874 DOI: 10.1159/000069375] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2001] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate whether a test amnioinfusion procedure is useful in selecting cases of midtrimester preterm premature rupture of membranes (PPROM) which may benefit from serial amnioinfusions if the initial fluid is retained. STUDY DESIGN The Centre for Fetal Care database between 1992 and 2000 was reviewed for women with PPROM <26 weeks who had undergone amnioinfusion. Amniotic fluid index (AFI) was assessed before and after a test amnioinfusion procedure. Those who retained fluid > or =48 h underwent serial AFI assessment with a view to serial amnioinfusion when oligohydramnios recurred. RESULTS Eighty-five amnioinfusion procedures were performed in 60 women with oligohydramnios. Nineteen of these women presented with confirmed PPROM at a median gestation of 19 (range 15-22) weeks and severe olighohydramnios (median AFI 1, range 0-3 cm), in whom 20 test amnioinfusions were carried out. Two amnioinfusions were abandoned during the procedure because of fetal bradycardia and both mothers opted for termination of pregnancy. Only 4 women retained fluid during the test amnioinfusion, 1 of whom miscarried at 19 weeks before serial amnioinfusion could be started. The remaining 3 underwent a median of 4 (range 1-6) serial amnioinfusion procedures; none had evidence of pulmonary hypoplasia. Thirteen (68%) leaked fluid within 48 h; within this group there was 1 subsequent miscarriage and 9 pregnancy terminations. The remaining 3 pregnancies resulted in livebirths 2 of which had pulmonary hypoplasia with 1 early neonatal death. Overall survival was poor (4/19), largely attributed to the high incidence of terminations in the presence of persistent severe oligohydramnios. In continuing pregnancies reaching viability survival was 67% (4 of 6). CONCLUSION Three quarters of women with mid-trimester PPROM lose fluid at test amnioinfusion and therefore would not be suitable candidates for serial amnioinfusion. However, if infused fluid is retained, this allows subsequent serial amnioinfusion and prolongation of pregnancy in about 75%, with an attendant decrease in the risk of pulmonary hypoplasia. However, even successful serial amnioinfusion remains associated with procedure-related complications (i.e. chorioamnionitis, placental abruption) which themselves may predispose to preterm delivery.
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Affiliation(s)
- L-K Tan
- Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital, and Institute of Reproductive and Developmental Biology, Faculty of Medicine, Imperial College, Hammersmith Campus, London, UK
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Abstract
Multiple pregnancy rates remain high after assisted conception because of a misconceived assumption that transferring three or more embryos will maximize pregnancy rates. Maternal morbidity is sevenfold greater in multiple pregnancies than in singletons, perinatal mortality rates are fourfold higher for twins and sixfold higher for triplets, while cerebral palsy rates are 1-1.5% in twin and 7-8% in triplet pregnancies. Therefore, multiple pregnancies must be considered a serious adverse outcome of assisted reproductive techniques. Primary prevention of multiple pregnancies is the solution. The overwhelming evidence presented in this chapter demonstrates that limiting the embryo transfer in in vitro fertilization to two embryos would significantly reduce adverse maternal and perinatal outcomes by reducing the incidence of high order multiple pregnancies without reducing take-home-baby rates. Secondary prevention by multifetal pregnancy reduction is effective, but not acceptable to all patients. New developments in blastocyst culture, single embryo transfer, embryo cryopreservation and pre-implantation aneuploidy exclusion, should allow improvements in pregnancy rates without increasing multiple pregnancies.
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Affiliation(s)
- R C Wimalasundera
- Centre For Fetal Care, Queen Charlotte's & Chelsea Hospital, Du Cane Road, Hammersmith, London W12 0HS, UK
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O'donoghue K, Choolani M, Chan J, Kumar S, Bennett PR, Roberts IAG, Fisk NM. Fetomaternal trafficking of fetal mesenchymal stem cells (MSC). J OBSTET GYNAECOL 2003. [DOI: 10.1080/718591783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Taylor MJO, Cox PM, Wee L, Fisk NM. Why laser fails: inaccuracy of visual identification of arterio-venous anastomoses in a validation study of monochorionic placentae. J OBSTET GYNAECOL 2003. [DOI: 10.1080/718591730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Wee LY, Franke V, Watkins N, Parker K, Taylor MJO, Fisk NM. Characterisation of vascular anastomoses in monochorionic placenta by vascular casts. J OBSTET GYNAECOL 2003. [DOI: 10.1080/718591733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Vanderheyden T, Kumar S, Cowan F, Fisk NM, Rutherford M. Posterior fossa pathology: high-resolution US vs. fetal MRI. J OBSTET GYNAECOL 2003. [DOI: 10.1080/718591732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Wimalasundera RC, Fichera A, Pasquini L, Taylor MJO, Wee LY, Kumar S, Fisk NM. Perinatal survival in monoamniotic twin pregnancies managed with transplacental prophylactic sulindac. J OBSTET GYNAECOL 2003. [DOI: 10.1080/714038658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Wimalasundera RC, Fisk NM. Serial amnioreduction with selective reduction by cord occlusion in the treatment of advanced twin–twin transfusion syndrome. J OBSTET GYNAECOL 2003. [DOI: 10.1080/718591788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Wee LY, Sebire NJ, Tadrous P, Taylor MJO, Fisk NM. Histomorphometric characterisation of shared and non-shared villus territories in monochorionic (MC) twin placentae. J OBSTET GYNAECOL 2003. [DOI: 10.1080/713938706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Vanderheyden T, Kumar S, Cowan F, Fisk NM, Rutherford M. Fetal MRI for CNS anomalies: an audit of 74 fetuses. J OBSTET GYNAECOL 2003. [DOI: 10.1080/718591731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Wee LY, Cox P, Taylor MJO, Fisk NM. Chronic reversal of twin–twin transfusion syndrome: frequency, vascular anatomy and associated anomalies. J OBSTET GYNAECOL 2003. [DOI: 10.1080/718591734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Abstract
OBJECTIVE To validate an established staging system for twin-twin transfusion syndrome. METHODS Prospective observational study in a tertiary referral fetal medicine center of 52 consecutive cases of twin-twin transfusion syndrome. Each pregnancy was assessed longitudinally for a variety of prognostic factors including fetal biometry, amniotic fluid volume, arterial and venous Doppler sonogram abnormalities, and the presence of hydrops. Data were used to determine stage at diagnosis and first treatment, and worst stage throughout pregnancy. Perinatal outcome was assessed by stage. Management comprised serial amnioreduction, septostomy, selective reduction, or delivery, alone or in combination. RESULTS Median gestation at presentation and first treatment were both 21 weeks (range 14-34 and 15-34), and at delivery it was 29 weeks (range 16-40). Sixty-three percent of pregnancies (33 of 52) were at least stage III at presentation. Forty-five percent of pregnancies (22 of 49) progressed to a more advanced stage. Overall survival was 47% (47 of 100), with no difference between donor and recipient fetuses (40% [20 of 50] versus 54% [27 of 50] [chi(2) P =.5]). Survival rates were 58% (15 of 26), 60% (six of ten), 42% (20 of 48), 43% (six of 14), and 0% (none of two) for stages I-V, respectively, with no significant influence of stage at presentation on survival. Survival was poorer where stage increased, versus decreased (27% [12 of 44] versus 94% [17 of 18] chi(2) P <.001). Kaplan-Meier survival curves indicated that staging at presentation identified pregnancies at greater risk of earlier rather than later gestational perinatal loss. CONCLUSION The Quintero staging system did not distinguish good from bad outcome at presentation, and thus should be used with caution in guiding initial management of twin-twin transfusion syndrome. However, prognosis was influenced by a change in stage, and pregnancies progressing to higher stage disease were at increased risk of earlier perinatal loss. Staging may thus be more useful in monitoring disease progression.
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Affiliation(s)
- M J O Taylor
- Centre for Fetal Care, Department of Maternal and Fetal Medicine, Imperial College of Science, Technology and Medicine, Queen Charlotte's and Chelsea Hospital, London, United Kingdom.
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Karatza AA, Wolfenden JL, Taylor MJO, Wee L, Fisk NM, Gardiner HM. Influence of twin-twin transfusion syndrome on fetal cardiovascular structure and function: prospective case-control study of 136 monochorionic twin pregnancies. Heart 2002; 88:271-7. [PMID: 12181221 PMCID: PMC1767329 DOI: 10.1136/heart.88.3.271] [Citation(s) in RCA: 126] [Impact Index Per Article: 5.7] [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] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To test the hypothesis that identical twins show no inter-twin differences in cardiovascular structure or physiology in fetal life unless there has been twin-twin transfusion syndrome. DESIGN Unselected prospective case-control observational study of fetoplacental haemodynamics including echocardiography at a median of 24 (16.7 to 32.3) weeks, with postnatal confirmation of congenital heart disease or normality. SETTING Fetal medicine unit. PATIENTS 136 women with monochorionic diamniotic twin pregnancies, of which 47 fetal twin pairs (35%) had twin-twin transfusion syndrome. RESULTS There were no haemodynamic differences between the bigger fetus (twin 1) and the smaller co-twin (twin 2) in uncomplicated monochorionic diamniotic pairs. In twin-twin transfusion syndrome, recipient fetuses had increased aortic and pulmonary velocities compared with their donor co-twins (mean (SD): 0.73 (0.23) m/s and 0.63 (0.14) m/s), respectively, v 0.53 (0.16) m/s and 0.48 (0.10) m/s in donor twins; p = 0.003 (aortic) and < 0.0001 (pulmonary)), and also in comparison with twin 1 and twin 2. The overall prevalence of congenital heart disease was increased above that in singletons (3.8% v 0.56%; 6.9% in twin-twin transfusion v 2.3% in uncomplicated monochorionic diamniotic twins), with inter-twin discordance for defects. The prevalence in recipient twins was 11.9% (p = 0.014 v uncomplicated control twins). CONCLUSIONS Fetuses with an identical genome but no circulatory imbalance have similar cardiovascular physiology but discordant phenotypic expression of congenital heart disease. The high prevalence of congenital heart disease in monochorionic diamniotic twins merits detailed fetal echocardiography.
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Affiliation(s)
- A A Karatza
- Department of Maternal-Fetal Medicine, Queen Charlotte's and Chelsea Hospital, Imperial College, London, UK
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Taylor MJO, Shalev E, Tanawattanacharoen S, Jolly M, Kumar S, Weiner E, Cox PM, Fisk NM. Ultrasound-guided umbilical cord occlusion using bipolar diathermy for Stage III/IV twin-twin transfusion syndrome. Prenat Diagn 2002; 22:70-6. [PMID: 11810656 DOI: 10.1002/pd.256] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVES To evaluate bipolar diathermy as a technique for selective fetocide in the treatment of advanced (Stage III/IV) twin-twin transfusion syndrome (TTTS). METHODS A prospective observational study in two tertiary referral fetal medicine centres: Queen Charlotte's Hospital, London, UK and Haemek Hospital, Afula, Israel. Fifteen cases of TTTS (14 twins and one triplet pregnancy) were treated by selective occlusion of either the donor (n=8) or recipient's (n=7) umbilical cord using ultrasound-guided bipolar diathermy. Following each procedure, patients were scanned serially for fetal growth, liquor volume and umbilical Doppler measurements. Procedural complications and obstetric outcome were recorded. Postnatal placental injection studies were performed. RESULTS Overall co-twin survival in Stage III/IV TTTS was 13/14 (93%). There were no treatment failures. The incidence of preterm prelabour rupture of membranes (PPROM) within 3 weeks of the procedure was 3/15 (20%). In those cases where pre-procedure umbilical artery Dopplers were abnormal, the Doppler findings normalised post-procedure in all non-cord-occluded fetuses. Growth velocities of surviving donors were similar to those of surviving recipients. CONCLUSIONS Bipolar diathermy appears an effective technique for the selective reduction of monochorionic twins complicated by severe as well as preterminal TTTS, with recipient and donor fetuses being equally appropriate choices for fetocide. We suggest that for advanced-stage disease where the parents can contemplate this option, cord occlusion as a single preemptive procedure maximises the opportunity for intact survival of a single survivor.
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Affiliation(s)
- M J O Taylor
- Centre for Fetal Care, Department of Maternal & Fetal Medicine, Imperial College School of Medicine, Queen Charlotte's & Chelsea Hospital, Du Cane Road, London W12 0HS, UK.
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