[Monochorionic biamniotic twin pregnancies outcomes in Reunion Island with indication of in utero transfert]

OBJECTIVE

Complicated monochorionic biamniotic (MCBA) twin pregnancies may require treatment with fetoscopic laser photocoagulation, in case of Twin Oligo-Polyhydramnios Sequence or need of a selective termination of pregnancy. Patients requiring these treatments would need medical transfer to Metropolitan France because these are unavailable in Réunion Island. We evaluated the outcomes of MCBA pregnancies in Reunion Island with indications for fetoscopy, with a view to discussing the interest of training doctors on the Reunion Island, to practice fetoscopy on site.

MATERIALS AND METHODS

Retrospective hospital study running from 2015 to 2018. We included all MCBA pregnancies between 15 and 25 weeks of gestation, with indications for in utero transfer. Our objective was to examine whether and why they were transferred and pregnancy outcomes.

RESULTS

Of the 23 patients, 17 (73.9%) benefited from sanitary transfers. The survival rate of the fetuses in 15 pregnancies with Twin Oligo-Polyhydramnios Sequence (TOPS) was 73.3% for one twin and 53.3% for both twins. For the eight cases of Selective Termination of the pregnancy (ST), the survival rate of the twin was better with a transfer (n=5/6, 83.3%) than without a transfer (n=1/2 or 50%). The rate of premature rupture of the membranes after sanitary transfer among patients with TOPS was 63.6%.

CONCLUSION

The sanitary transfer allows the management in expert center of complicated MCBA twin pregnancies, but is not always feasible and is accompanied by a high rate of premature ruptures of membranes.

Infantile neurodevelopmental outcome after fetoscopic laser photocoagulation for twin-to-twin transfusion syndrome: the first prospective experience from Iran

Objective

We sought to evaluate the neurodevelopmental outcomes at 12 months of age among infants with twin-to-twin transfusion syndrome (TTTS) undergoing fetoscopic laser photocoagulation (FLP).

Materials and methods

In this prospective longitudinal study, neurodevelopmental assessment was performed among the infants at the corrected age of 12 months, who were diagnosed with TTTS and treated by FLP. The Ages and Stages Questionnaire (ASQ) was filled out by parents. In the next step in infants with abnormal ASQ, motor and cognitive developments were evaluated by Bayley’s infant and toddler development scoring system (Bayley 3-Third edition).

Results

In 39 FLP procedures the rate of live birth of at least one twin was 73.8%. Four neonatal deaths were recorded, three of which were due to prematurity and one was due to heart anomaly. The ASQ was normal in 89.7% (35/39) of the infants (group I), 5.1% (2/39) had minor neurodevelopmental impairment (NDI) (group II), and 5.1% (2/39) had major NDI (group III). The 4 infants with abnormal ASQ had Bayley examination which showed two with mild to moderate cerebral palsy and two had delayed verbal skills and autistic spectrum disorder. No significant difference was noted between survivors with and without NDI with respect to donor or recipient status, birth weight, gestational age at birth, Quintero stage of TTTS. In addition, the relationship between gestational age at the time of undergoing FLC and NDI was not significant.

Conclusion

In our population, minor and major neurodevelopmental impairment were seen in 10.2% of the infants. This information is useful for counseling our couples in this population prior the procedure.

Prevalence of Extraplacental Anastomoses in Monochorionic Twin Pregnancies

OBJECTIVES

To evaluate the prevalence of extraplacental anastomoses (EPA) and the factors associated.

METHODS

A retrospective study including 144 placentas from monochorionic diamniotic (MCDA) twins delivering at one institution was performed. EPA were defined as any intertwin anastomosis located outside the chorionic plate on macroscopic inspection. The association with perinatal factors and with umbilical cord insertion site was analyzed.

RESULTS

The prevalence of EPA was 4.9% (7/144). Velamentous cord insertion of both twins was significantly associated with the presence of EPA in the multivariate logistic regression model (p = 0.045).

DISCUSSION

EPA was found in ≈5% of MCDA twin pregnancies.

Management and perinatal outcome of selective intrauterine growth restriction in monochorionic pregnancies

Introduction: Selective intrauterine growth restriction (sIUGR) is a complication observed in about 10-15% of all monochorionic (MC) pregnancies, causing a significant increase in perinatal mortality and morbidity.Objective: To evaluate clinical management options and perinatal outcomes of sIUGR in MC pregnancies monitored in a single tertiary center.Methods: A retrospective study was performed on 55-MC pregnancies with sIUGR between January 2012 and May 2018 at the Fetal Medicine Unit of La Paz Hospital. Cases were classified according to the umbilical artery (UA) Doppler pattern as type I (positive end-diastolic flow; n = 25), type II [persistently absent or reversed end-diastolic flow (AREDF); n = 5] and type III [intermittently absent or reversed end-diastolic flow (iAREDF); n = 25]. Types II and III were then merged together as severe sIUGR cases. Subsequently, two possible approaches were considered: expectant management (EM) with elective preterm delivery in case of fetal deterioration, or in-utero therapy via fetoscopic laser photocoagulation (FLP) of intertwin anastomosis or selective umbilical cord occlusion (CO) of the growth-restricted fetus.Results: Gestational age (GA) at diagnosis was progressively lower with each type. Severe sIUGR cases delivered significantly earlier than type I, showing lower birth weights and higher intertwin biometric discordance. Unintended fetal demise occurred in 14% (6/25) of severe sIUGR pregnancies as opposed to 0% (0/19) in type I, p = .028. A significantly higher proportion of twins was admitted in NICU in severe cases when compared to type I [87% (33/38) versus 47% (18/38), p < .001]. In addition, brain damage at birth was also found to be more prevalent in this group [21% (8/38) versus 11% (4/38), p = .346], especially in the larger twin, when comparing any short-term neurological sequel [30% (7/23) versus 0% (0/19), p = .011] or specifically periventricular leukomalacia [PVL; 22% (5/23) versus 0% (0/19), p = .053]. Although the overall mortality rate was significantly higher in severe sIUGR that underwent CO instead of EM [58% (7/12) versus 11% (4/36), p = .002], NICU admissions were higher in the latter [94% (17/18) versus 40% (2/5), p = .021]. Neurological sequels at birth were similar in both groups [39% (7/18) versus 40% (2/5), p = 1.000], similarly when considering only the larger twin for any brain lesion [28% (5/18) versus 40% (2/5), p = .621] or just PVL [22% (4/18) versus 20% (1/5), p = 1.000].Conclusion: Given the good prognosis of type I sIUGR, expectant management is the first approach to consider. However, due to the poorer clinical evolution of types II and III sIUGR, the decision-making is challenging and needs to be individualized depending on the UA Doppler pattern, GA at diagnosis, severity of growth restriction and biometric discordance, technical issues and parents' preferences.

A double dilemma: treatment of stage IV fetal twin-twin transfusion syndrome in the setting of maternal recurrent venous thromoembolism: a case report

Background

Fetal conditions can pose significant challenges in the management of pregnancies complicated by pre-existing maternal medical conditions.

Case presentation

We report a case of a 34-year-old woman with Stage IV Twin Twin Transfusion syndrome in the presence of maternal recurrent complex venous thromboembolic disease. Following a previous pregnancy loss, complicated by a third episode of thromboembolic disease, an inferior vena cava filter was placed. One month later, a pregnancy was confirmed and subsequently identified as a monochorionic twin pregnancy. Twin-Twin Transfusion syndrome was identified at 18 weeks’ gestation and progressed rapidly to Quintero Stage IV. In consultation with a multi-disciplinary international team, fetoscopic laser photocoagulation was performed. The pregnancy progressed to delivery of female infants at 33 weeks gestation, who have achieved all developmental milestones at 2 years of age.

Conclusions

We describe the multi-disciplinary effort to optimise the maternal condition to allow fetoscopic laser photocoagulation and continued management of the maternal and fetal conditions to a successful pregnancy outcome.

The roles of superficial anastomoses in twin-twin transfusion syndrome

OBJECTIVE

We aimed to evaluate whether types of vascular anastomoses affect fetal demise (FD) in twin-twin transfusion syndrome (TTTS) after fetoscopic laser photocoagulation (FLP).

METHODS

All TTTS patients who underwent FLP in our institution from 2005 to 2017 were included. We described vascular anastomoses during FLP as either arterio-arterial (AA), veno-venous (VV), or arterial-venous (AV), and abnormal fetal Doppler waveforms before FLP. We also analyzed risk factors for FD following FLP.

RESULTS

In total, 184 TTTS placentas following FLP were analyzed (36 cases of donor-only FD, 12 cases of recipient-only FD, 3 cases of double FD, and 133 cases of both alive). AA anastomoses prevalence, absent or reverse end-diastolic velocity of umbilical artery (UAAREDV) of donor before FLP, gestational age at the time of FLP and operation time of FLP were independent risk factors for donor FD. VV anastomoses prevalence and UAAREDV of recipient before FLP were independent risk factors for recipient FD. VV anastomoses prevalence was higher in double FD cases than in FD of one twin or both alive (p = 0.002). AV anastomoses number and number of cases with more AV anastomoses from donor to recipient were not significantly different between FD and non-FD cases.

DISCUSSION

AA anastomoses are associated FD of the donor following FLP and may protect the donor from hypovolemia before FLP. VV anastomoses are detected more frequently in FD of the recipient and double FD placentas following FLP and may rescue hypervolemia of the recipient or circulations of both fetuses before FLP.

Maternal Anemia and Coagulation/Fibrinolysis after Fetoscopic Laser Photocoagulation for Twin-to-Twin Transfusion Syndrome

AIM

This study was performed to evaluate maternal changes in laboratory characteristics after fetoscopic laser photocoagulation (FLP) for twin-to-twin transfusion syndrome (TTTS).

METHODS

A retrospective review was conducted among 30 women with monochorionic diamniotic twin pregnancy with TTTS who underwent FLP at 16-26 weeks of gestation. Maternal laboratory parameters were measured before and after FLP.

RESULTS

The pre-FLP mean hemoglobin level (10.0 g/dL), hematocrit level (30.0%), platelet count (229 × 109/mL), fibrinogen level (461 mg/dL), and antithrombin activity (96.8%) decreased after FLP (8.5 g/dL, 25.5%, 204 × 109/mL, 403 mg/dL, and 83.6%, respectively) and returned to normal spontaneously within 2 weeks (9.6 g/dL, 29.4%, 293 × 109/mL, 460 mg/dL, and 102.4%, respectively). The D-dimer level before FLP (2.41 μg/mL) increased after FLP (4.28 μg/mL), and the elevated level was maintained for 2 weeks (3.24 μg/mL). The symptomatic venous thromboembolism (VTE) was not detected after FLP in any of the 30 patients. However, one woman had pulmonary embolism after subsequent cesarean section.

CONCLUSION

Changes in maternal anemia and coagulation/fibrinolysis after FLP for TTTS returned to normal spontaneously within 2 weeks. Maternal elevation of D-dimer level after FLP might be a warning indicator of VTE.

Modified fetoscopic laser surgery in twin-to-twin transfusion syndrome with proximate cord insertions: a report of two cases and literature review

Proximate cord insertions (PxCIs) are a variant of umbilical cord insertions (CIs) that can be identified in monochorionic (MC) twins, making fetoscopic laser photocoagulation for twin-to-twin transfusion syndrome (TTTS) technically challenging. The existing literature is controversial for successful fetoscopic laser photocoagulation in TTTS cases with PxCIs. We presented two cases with TTTS complicated by PxCIs that underwent a successful laser ablation using our proposed technique.

Preoperative Ultrasound Prediction of Essential Landmarks for Successful Fetoscopic Laser Treatment of Twin-Twin Transfusion Syndrome

INTRODUCTION

The insertion site of the fetoscope for laser occlusion (FLOC) treatment of twin-twin transfusion syndrome (TTTS) determines the likelihood of treatment success. We assessed a standardized preoperative ultrasound approach for its ability to identify critical landmarks for successful FLOC.

METHODS

Three surgeons independently performed preoperative ultrasound and deduced the likely orientation of the intertwin membrane (ITM) and vascular equator (VE) based on the sites of the cord insertion, the lie of the donor, and the size discordance between twins. At FLOC, these landmarks were visually verified and compared to preoperative assessments.

RESULTS

Fifty consecutive FLOC surgeries had 127 preoperative assessments. Basic ITM and VE orientation were accurately predicted in 115 (90.6%), 109 (85.8%), and 105 (82.7%) assessments. Predictions were anatomically correct in 96 (75.6%), 70 (55.1%), and 58 (45.7%) assessments with no differences in accuracy between operators of different training level. The ITM/VE relationship was most poorly predicted in stage-3 TTTS (χ2, p = 0.016).

CONCLUSION

In TTTS, preoperative ultrasound identification of placental cord insertion sites, lie of the donor twin, and size discordance enables preoperative prediction of key landmarks for successful FLOC.