1
|
Tedjawirja VN, van Klink JM, Haak MC, Klumper FJ, Middeldorp JM, Miller JL, Rosner M, Baschat AA, Lopriore E, Oepkes D. Questionable benefit of intrauterine transfusion following single fetal death in monochorionic twin pregnancy. Ultrasound Obstet Gynecol 2022; 59:824-825. [PMID: 35137996 DOI: 10.1002/uog.24876] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/29/2022] [Accepted: 02/01/2022] [Indexed: 06/14/2023]
Affiliation(s)
- V N Tedjawirja
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - J M van Klink
- Department of Medical Psychology, Leiden University Medical Center, Leiden, The Netherlands
| | - M C Haak
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - F J Klumper
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - J M Middeldorp
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - J L Miller
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Baltimore, MD, USA
| | - M Rosner
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Baltimore, MD, USA
| | - A A Baschat
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Baltimore, MD, USA
| | - E Lopriore
- Department of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - D Oepkes
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| |
Collapse
|
2
|
Tollenaar LS, Lopriore E, Faiola S, Lanna M, Stirnemann J, Ville Y, Lewi L, Devlieger R, Weingertner AS, Favre R, Hobson SR, Ryan G, Rodo C, Arévalo S, Klaritsch P, Greimel P, Hecher K, de Sousa MT, Khalil A, Thilaganathan B, Bergh EP, Papanna R, Gardener GJ, Carlin A, Bevilacqua E, Sakalo VA, Kostyukov KV, Bahtiyar MO, Wilpers A, Kilby MD, Tiblad E, Oepkes D, Middeldorp JM, Haak MC, Klumper FJ, Akkermans J, Slaghekke F. Post-Laser Twin Anemia Polycythemia Sequence: Diagnosis, Management, and Outcome in an International Cohort of 164 Cases. J Clin Med 2020; 9:E1759. [PMID: 32517071 PMCID: PMC7355738 DOI: 10.3390/jcm9061759] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 05/19/2020] [Accepted: 05/25/2020] [Indexed: 02/02/2023] Open
Abstract
The aim of this study was to investigate the management and outcome in the post-laser twin anemia polycythemia sequence (TAPS). Data of the international TAPS Registry, collected between 2014 and 2019, were used for this study. The primary outcomes were perinatal mortality and severe neonatal morbidity. Secondary outcomes included a risk factor analysis for perinatal mortality and severe neonatal morbidity. A total of 164 post-laser TAPS pregnancies were included, of which 92% (151/164) were diagnosed antenatally and 8% (13/164) postnatally. The median number of days between laser for TTTS and detection of TAPS was 14 (IQR: 7-28, range: 1-119). Antenatal management included expectant management in 43% (62/151), intrauterine transfusion with or without partial exchange transfusion in 29% (44/151), repeated laser surgery in 15% (24/151), selective feticide in 7% (11/151), delivery in 6% (9/151), and termination of pregnancy in 1% (1/151). The median gestational age (GA) at birth was 31.7 weeks (IQR: 28.6-33.7; range: 19.0-41.3). The perinatal mortality rate was 25% (83/327) for the total group, 37% (61/164) for donors, and 14% (22/163) for recipients (p < 0.001). Severe neonatal morbidity was detected in 40% (105/263) of the cohort and was similar for donors (43%; 51/118) and recipients (37%; 54/145), p = 0.568. Independent risk factors for spontaneous perinatal mortality were antenatal TAPS Stage 4 (OR = 3.4, 95%CI 1.4-26.0, p = 0.015), TAPS donor status (OR = 4.2, 95%CI 2.1-8.3, p < 0.001), and GA at birth (OR = 0.8, 95%CI 0.7-0.9, p = 0.001). Severe neonatal morbidity was significantly associated with GA at birth (OR = 1.5, 95%CI 1.3-1.7, p < 0.001). In conclusion, post-laser TAPS most often occurs within one month after laser for TTTS, but may develop up to 17 weeks after initial surgery. Management is mostly expectant, but varies greatly, highlighting the lack of consensus on the optimal treatment and heterogeneity of the condition. Perinatal outcome is poor, particularly due to the high rate of perinatal mortality in donor twins.
Collapse
Affiliation(s)
- Lisanne S.A. Tollenaar
- Department of Obstetrics, Division of Fetal therapy, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (D.O.); (J.M.M.); (M.C.H.); (F.J.C.M.K.); (J.A.); (F.S.)
| | - Enrico Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands;
| | - Stefano Faiola
- Fetal Therapy Unit “U. Nicolini”, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy; (S.F.); (M.L.)
| | - Mariano Lanna
- Fetal Therapy Unit “U. Nicolini”, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy; (S.F.); (M.L.)
| | - Julien Stirnemann
- Department of Obstetrics and Maternal-Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, 75015 Paris, France; (J.S.); (Y.V.)
| | - Yves Ville
- Department of Obstetrics and Maternal-Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, 75015 Paris, France; (J.S.); (Y.V.)
| | - Liesbeth Lewi
- Department of Obstetrics and Gynecology, University Hospitals Leuven, 3000 Leuven, Belgium; (L.L.); (R.D.)
| | - Roland Devlieger
- Department of Obstetrics and Gynecology, University Hospitals Leuven, 3000 Leuven, Belgium; (L.L.); (R.D.)
| | - Anne Sophie Weingertner
- Department of Obstetrics and Gynecology, Strasbourg University Hospital, CEDEX, 67000 Strasbourg, France; (A.S.W.); (R.F.)
| | - Romain Favre
- Department of Obstetrics and Gynecology, Strasbourg University Hospital, CEDEX, 67000 Strasbourg, France; (A.S.W.); (R.F.)
| | - Sebastian R. Hobson
- Fetal Medicine Unit, Department of Obstetrics & Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, ON M5G 1X5, Canada; (S.R.H.); (G.R.)
| | - Greg Ryan
- Fetal Medicine Unit, Department of Obstetrics & Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, ON M5G 1X5, Canada; (S.R.H.); (G.R.)
| | - Carlota Rodo
- Maternal Fetal Medicine Unit, Department of Obstetrics, Vall d’Hebron University Hospital, 08035 Barcelona, Spain; (C.R.); (S.A.)
| | - Silvia Arévalo
- Maternal Fetal Medicine Unit, Department of Obstetrics, Vall d’Hebron University Hospital, 08035 Barcelona, Spain; (C.R.); (S.A.)
| | - Philipp Klaritsch
- Division of Obstetrics and Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Medical University of Graz, 8036 Graz, Austria; (P.K.); (P.G.)
| | - Patrick Greimel
- Division of Obstetrics and Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Medical University of Graz, 8036 Graz, Austria; (P.K.); (P.G.)
| | - Kurt Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (K.H.); (M.T.d.S.)
| | - Manuela Tavares de Sousa
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (K.H.); (M.T.d.S.)
| | - Asma Khalil
- Fetal Medicine Unit, St George University Hospital NHS Foundation Trust, London SW17 0RE, UK; (A.K.); (B.T.)
| | - Basky Thilaganathan
- Fetal Medicine Unit, St George University Hospital NHS Foundation Trust, London SW17 0RE, UK; (A.K.); (B.T.)
| | - Eric P. Bergh
- The Fetal Center, Department of Obstetrics, Children’s Memorial Hermann Hospital, Gynecology and Reproductive Sciences, UT Health, McGovern Medical School, University of Texas, Houston, TX 77030, USA; (E.P.B.); (R.P.)
| | - Ramesha Papanna
- The Fetal Center, Department of Obstetrics, Children’s Memorial Hermann Hospital, Gynecology and Reproductive Sciences, UT Health, McGovern Medical School, University of Texas, Houston, TX 77030, USA; (E.P.B.); (R.P.)
| | - Glenn J. Gardener
- Department of Maternal Fetal Medicine, Mater Mothers’ Hospital, South Brisbane, QLD 4101, Australia;
| | - Andrew Carlin
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, 1020 Brussels, Belgium; (A.C.); (E.B.)
| | - Elisa Bevilacqua
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, 1020 Brussels, Belgium; (A.C.); (E.B.)
| | - Victorya A. Sakalo
- Acad. V.I. Kulakov Research Center of Obstetrics, Gynecology, and Perinatology, Ministry of Health of the Russian Federation, 495 Moscow, Russia; (V.A.S.); (K.V.K.)
| | - Kirill V. Kostyukov
- Acad. V.I. Kulakov Research Center of Obstetrics, Gynecology, and Perinatology, Ministry of Health of the Russian Federation, 495 Moscow, Russia; (V.A.S.); (K.V.K.)
| | - Mert O. Bahtiyar
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT 06510, USA; (M.O.B.); (A.W.)
| | - Abigail Wilpers
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT 06510, USA; (M.O.B.); (A.W.)
| | - Mark D. Kilby
- Fetal Medicine Centre, Birmingham Women’s and Children’s Foundation Trust, University of Birmingham, Birmingham B4 6NH, UK;
| | - Eleonor Tiblad
- Center for Fetal Medicine, Karolinska University Hospital, 171 76 Stockholm, Sweden;
| | - Dick Oepkes
- Department of Obstetrics, Division of Fetal therapy, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (D.O.); (J.M.M.); (M.C.H.); (F.J.C.M.K.); (J.A.); (F.S.)
| | - Johanna M. Middeldorp
- Department of Obstetrics, Division of Fetal therapy, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (D.O.); (J.M.M.); (M.C.H.); (F.J.C.M.K.); (J.A.); (F.S.)
| | - Monique C. Haak
- Department of Obstetrics, Division of Fetal therapy, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (D.O.); (J.M.M.); (M.C.H.); (F.J.C.M.K.); (J.A.); (F.S.)
| | - Frans J.C.M. Klumper
- Department of Obstetrics, Division of Fetal therapy, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (D.O.); (J.M.M.); (M.C.H.); (F.J.C.M.K.); (J.A.); (F.S.)
| | - Joost Akkermans
- Department of Obstetrics, Division of Fetal therapy, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (D.O.); (J.M.M.); (M.C.H.); (F.J.C.M.K.); (J.A.); (F.S.)
| | - Femke Slaghekke
- Department of Obstetrics, Division of Fetal therapy, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (D.O.); (J.M.M.); (M.C.H.); (F.J.C.M.K.); (J.A.); (F.S.)
| |
Collapse
|
3
|
Donepudi R, Akkermans J, Mann L, Klumper FJ, Middeldorp JM, Lopriore E, Moise KJ, Bebbington M, Johnson A, Oepkes D, Papanna R. Impact of cannula size on recurrent twin-twin transfusion syndrome and twin anemia-polycythemia sequence after fetoscopic laser surgery. Ultrasound Obstet Gynecol 2018; 52:744-749. [PMID: 28925589 DOI: 10.1002/uog.18904] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Revised: 07/28/2017] [Accepted: 09/08/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE The optimal outcome after fetoscopic laser surgery (FLS) for twin-twin transfusion syndrome (TTTS) depends on the successful ablation of all placental anastomoses. The objective of this study was to determine the incidence of and risk factors for recurrent TTTS (rTTTS) or twin anemia-polycythemia sequence (TAPS) after FLS, focusing on the impact of cannula diameter. METHODS This was a secondary analysis of data collected prospectively at two centers from 666 consecutive patients undergoing FLS for TTTS. The main outcomes were rTTTS and TAPS following FLS. Variables assessed included gestational age at intervention, stage of disease, recipient maximum vertical pocket, anterior placenta, number of anastomoses ablated, cannula diameter/operative scopes and use of the Solomon technique. Cannula diameter and corresponding scopes used were as follows: 8 Fr and 1.3 mm/0°; 9 Fr and 2.7 mm/0°; 10 Fr and 3 mm/0°; or 12 Fr and 3.3-3.7 mm/30-70°. Cannula diameter was used as a surrogate for scopes during analysis. Multivariate logistic regression analysis was performed to identify risk factors associated with rTTTS or TAPS after FLS; 'center' was considered an independent variable to account for variations in practice. In a nested cohort of pregnancies in which both fetuses survived, placental dye injection was performed in 315 placentae. Multivariate logistic regression analysis was performed to evaluate variables associated with the presence of residual anastomoses. RESULTS rTTTS or TAPS occurred in 61 (9%) cases following FLS (rTTTS in eight (1%) and TAPS in 53 (8%)). Factors associated significantly with the risk of rTTTS/TAPS on multivariate analysis were cannula diameter (when an 8-Fr, 9-Fr, 10-Fr or 12-Fr cannula was used, there was rTTTS/TAPS in 24%, 13%, 2% or 0.8% of cases, respectively (P < 0.001)) and use of the Solomon technique (rTTTS/TAPS occurred in 4.2% of those in which it was used vs 18.1% in those in which it was not (P < 0.001)). Only use of the Solomon technique was associated significantly with no residual anastomoses found after delivery. CONCLUSIONS Following FLS for TTTS, a lower incidence of rTTTS/TAPS was seen when the Solomon technique was used, as well as when a 10-Fr or 12-Fr cannula was used. A lower complication rate may be due to the use of a scope with better optics during placental mapping. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
Collapse
Affiliation(s)
- R Donepudi
- The Fetal Center, Children's Memorial Hermann Hospital, Department of Obstetrics and Gynecology, McGovern Medical School, University of Texas Health Science Center at Houston, TX, USA
| | - J Akkermans
- Department of Obstetrics, Division of Fetal Therapy, Leiden University Medical Center, Leiden, The Netherlands
| | - L Mann
- The Fetal Center, Children's Memorial Hermann Hospital, Department of Obstetrics and Gynecology, McGovern Medical School, University of Texas Health Science Center at Houston, TX, USA
| | - F J Klumper
- Department of Obstetrics, Division of Fetal Therapy, Leiden University Medical Center, Leiden, The Netherlands
| | - J M Middeldorp
- Department of Obstetrics, Division of Fetal Therapy, Leiden University Medical Center, Leiden, The Netherlands
| | - E Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - K J Moise
- The Fetal Center, Children's Memorial Hermann Hospital, Department of Obstetrics and Gynecology, McGovern Medical School, University of Texas Health Science Center at Houston, TX, USA
| | - M Bebbington
- The Fetal Center, Children's Memorial Hermann Hospital, Department of Obstetrics and Gynecology, McGovern Medical School, University of Texas Health Science Center at Houston, TX, USA
| | - A Johnson
- The Fetal Center, Children's Memorial Hermann Hospital, Department of Obstetrics and Gynecology, McGovern Medical School, University of Texas Health Science Center at Houston, TX, USA
| | - D Oepkes
- Department of Obstetrics, Division of Fetal Therapy, Leiden University Medical Center, Leiden, The Netherlands
| | - R Papanna
- The Fetal Center, Children's Memorial Hermann Hospital, Department of Obstetrics and Gynecology, McGovern Medical School, University of Texas Health Science Center at Houston, TX, USA
| |
Collapse
|
4
|
Aziz NA, Peeters-Scholte CM, de Bruine FT, Klumper FJ, Adama van Scheltema PN, Lopriore E, Steggerda SJ. Fetal cerebellar hemorrhage: three cases with postnatal follow-up. Ultrasound Obstet Gynecol 2016; 47:785-786. [PMID: 26426778 DOI: 10.1002/uog.15772] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 09/14/2015] [Accepted: 09/26/2015] [Indexed: 06/05/2023]
Affiliation(s)
- N A Aziz
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
| | - C M Peeters-Scholte
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
| | - F T de Bruine
- Department of Neuroradiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - F J Klumper
- Department of Obstetrics and Fetal Medicine, Leiden University Medical Centre, Leiden, The Netherlands
| | - P N Adama van Scheltema
- Department of Obstetrics and Fetal Medicine, Leiden University Medical Centre, Leiden, The Netherlands
| | - E Lopriore
- Department of Neonatology, Leiden University Medical Centre, Albinusdreef 2, 2333 AZ, Leiden, The Netherlands
| | - S J Steggerda
- Department of Neonatology, Leiden University Medical Centre, Albinusdreef 2, 2333 AZ, Leiden, The Netherlands
| |
Collapse
|
5
|
Peeters SHP, Akkermans J, Slaghekke F, Bustraan J, Lopriore E, Haak MC, Middeldorp JM, Klumper FJ, Lewi L, Devlieger R, De Catte L, Deprest J, Ek S, Kublickas M, Lindgren P, Tiblad E, Oepkes D. Simulator training in fetoscopic laser surgery for twin-twin transfusion syndrome: a pilot randomized controlled trial. Ultrasound Obstet Gynecol 2015; 46:319-326. [PMID: 26036333 DOI: 10.1002/uog.14916] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Revised: 05/17/2015] [Accepted: 05/22/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To evaluate the effect of a newly developed training curriculum on the performance of fetoscopic laser surgery for twin-twin transfusion syndrome (TTTS) using an advanced high-fidelity simulator model. METHODS Ten novices were randomized to receive verbal instructions and either skills training using the simulator (study group; n = 5) or no training (control group; n = 5). Both groups were evaluated with a pre-training and post-training test on the simulator. Performance was assessed by two independent observers and comprised a 52-item checklist for surgical performance (SP) score, measurement of procedure time and number of anastomoses missed. Eleven experts set the benchmark level of performance. Face validity and educational value of the simulator were assessed using a questionnaire. RESULTS Both groups showed an improvement in SP score at the post-training test compared with the pre-training test. The simulator-trained group significantly outperformed the control group, with a median SP score of 28 (54%) in the pre-test and 46 (88%) in the post-test vs 25 (48%) and 36 (69%), respectively (P = 0.008). Procedure time decreased by 11 min (from 44 to 33 min) in the study group vs 1 min (from 39 to 38 min) in the control group (P = 0.69). There was no significant difference in the number of missed anastomoses at the post-training test between the two groups (1 vs 0). Subsequent feedback provided by the participants indicated that training on the simulator was perceived as a useful educational activity. CONCLUSIONS Proficiency-based simulator training improves performance, indicated by SP score, for fetoscopic laser therapy. Despite the small sample size of this study, practice on a simulator is recommended before trainees carry out laser therapy for TTTS in pregnant women.
Collapse
Affiliation(s)
- S H P Peeters
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - J Akkermans
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - F Slaghekke
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - J Bustraan
- PLATO, Center for Research and Development in Education and Training, Faculty of Social Sciences, Leiden, The Netherlands
| | - E Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - M C Haak
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - J M Middeldorp
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - F J Klumper
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - L Lewi
- Department of Obstetrics and Gynecology, Division of Fetal Medicine, University Hospitals KU Leuven, Leuven, Belgium
| | - R Devlieger
- Department of Obstetrics and Gynecology, Division of Fetal Medicine, University Hospitals KU Leuven, Leuven, Belgium
| | - L De Catte
- Department of Obstetrics and Gynecology, Division of Fetal Medicine, University Hospitals KU Leuven, Leuven, Belgium
| | - J Deprest
- Department of Obstetrics and Gynecology, Division of Fetal Medicine, University Hospitals KU Leuven, Leuven, Belgium
| | - S Ek
- Center for Fetal Medicine, Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
| | - M Kublickas
- Center for Fetal Medicine, Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
| | - P Lindgren
- Center for Fetal Medicine, Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
| | - E Tiblad
- Center for Fetal Medicine, Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
| | - D Oepkes
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| |
Collapse
|
6
|
van Klink J, Koopman HM, Middeldorp JM, Klumper FJ, Rijken M, Oepkes D, Lopriore E. Long-term neurodevelopmental outcome after selective feticide in monochorionic pregnancies. BJOG 2015; 122:1517-24. [PMID: 26147116 DOI: 10.1111/1471-0528.13490] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To assess the incidence of and risk factors for adverse long-term neurodevelopmental outcome in complicated monochorionic pregnancies treated with selective feticide at our centre between 2000 and 2011. DESIGN Observational cohort study. SETTING National referral centre for fetal therapy (Leiden University Medical Centre, the Netherlands). POPULATION Neurodevelopmental outcome was assessed in 74 long-term survivors. METHODS Children, at least 2 years of age, underwent an assessment of neurologic, motor and cognitive development using standardised psychometric tests and the parents completed a behavioural questionnaire. MAIN OUTCOME MEASURES A composite outcome termed neurodevelopmental impairment including cerebral palsy (GMFCS II-V), cognitive and/or motor test score of <70, bilateral blindness or bilateral deafness requiring amplification. RESULTS A total of 131 monochorionic pregnancies were treated with selective feticide at the Leiden University Medical Centre. Overall survival rate was 88/131 (67%). Long-term outcome was assessed in 74/88 (84%). Neurodevelopmental impairment was detected in 5/74 [6.8%, 95% confidence interval (CI), 1.1-12.5] of survivors. Overall adverse outcome, including perinatal mortality or neurodevelopmental impairment was 48/131 (36.6%). In multivariate analysis, parental educational level was associated with cognitive test scores (regression coefficient B 3.9, 95% CI 1.8-6.0). Behavioural problems were reported in 10/69 (14.5%). CONCLUSIONS Adverse long-term outcome in survivor twins of complicated monochorionic pregnancies treated with selective feticide appears to be more prevalent than in the general population. Cognitive test scores were associated with parental educational level. TWEETABLE ABSTRACT Neurodevelopmental impairment after selective feticide was detected in 5/74 (6.8%, 95% CI 1.1-12.5) of survivors.
Collapse
Affiliation(s)
- Jmm van Klink
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Centre, Leiden, the Netherlands
| | - H M Koopman
- Clinical Psychology, Faculty of Social Sciences, Leiden University, Leiden, the Netherlands
| | - J M Middeldorp
- Division of Fetal Therapy, Department of Obstetrics, Leiden University Medical Centre, Leiden, the Netherlands
| | - F J Klumper
- Division of Fetal Therapy, Department of Obstetrics, Leiden University Medical Centre, Leiden, the Netherlands
| | - M Rijken
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Centre, Leiden, the Netherlands
| | - D Oepkes
- Division of Fetal Therapy, Department of Obstetrics, Leiden University Medical Centre, Leiden, the Netherlands
| | - E Lopriore
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Centre, Leiden, the Netherlands
| |
Collapse
|
7
|
Peeters SHP, Akkermans J, Westra M, Lopriore E, Middeldorp JM, Klumper FJ, Lewi L, Devlieger R, Deprest J, Kontopoulos EV, Quintero R, Chmait RH, Smoleniec JS, Otaño L, Oepkes D. Identification of essential steps in laser procedure for twin-twin transfusion syndrome using the Delphi methodology: SILICONE study. Ultrasound Obstet Gynecol 2015; 45:439-446. [PMID: 25504904 DOI: 10.1002/uog.14761] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 11/27/2014] [Accepted: 12/04/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To determine, by expert consensus, the essential substeps of fetoscopic laser surgery (FLS) for twin-twin transfusion syndrome (TTTS) that could be used to create an authority-based curriculum for training in this procedure among fetal medicine specialists. METHODS A Delphi survey was conducted among an international panel of experts (n = 98) in FLS. Experts rated the substeps of FLS on a five-point Likert-type scale to indicate whether they considered them to be essential, and were able to comment on each substep, using a dedicated online platform accessed by the invited tertiary care facilities that specialize in fetal therapy. Responses were returned to the panel until consensus was reached (Cronbach's α ≥ 0.80). All substeps that were rated ≥ 4 by 80% of the experts were included in the evaluation instrument. RESULTS After the first iteration of the Delphi procedure, a response rate of 74% (73/98) was reached, and in the second and third iterations response rates of 90% (66/73) and 81% (59/73) were reached, respectively. Among a total of 81 substeps rated in the first round, 21 substeps had to be re-rated in the second round. Finally, from the initial list of substeps, 55 were agreed by experts to be essential. In the third round, the 18 categorized substeps were ranked in order of importance, with 'coagulation of all anastomoses that cross the equator' and 'determination of fetoscope insertion site' as the most important. CONCLUSIONS A total of 55 substeps of FLS for TTTS were defined by a panel of experts to be essential in the procedure. This list is the first authority-based evidence to be used in the development of a final training model for future fetal surgeons.
Collapse
Affiliation(s)
- S H P Peeters
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
8
|
Akkermans J, Peeters SHP, Middeldorp JM, Klumper FJ, Lopriore E, Ryan G, Oepkes D. A worldwide survey of laser surgery for twin-twin transfusion syndrome. Ultrasound Obstet Gynecol 2015; 45:168-174. [PMID: 25251913 DOI: 10.1002/uog.14670] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 09/01/2014] [Accepted: 09/04/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVES To evaluate differences between international fetal centers in their treatment of twin-twin transfusion syndrome (TTTS) by fetoscopic placental laser coagulation. METHODS Fetal therapy centers worldwide were sent a web-based questionnaire. Participants were identified through networks and through scientific presentations and papers. Questions included physician and center demographics, treatment criteria, operative technique and instrumentation. Laser treatment was compared between low-volume (< 20 procedures/year) and high-volume (≥ 20 procedures/year) centers. Data were analyzed using descriptive statistics. RESULTS Of 106 fetal therapy specialists approached, 76 (72%) from 64 centers in 25 countries responded. Of these, 48% (31/64) of centers and 63% (48/76) of operators performed fewer than 20 laser procedures annually. Comparison of low- and high-volume centers showed differences in technique, gestational age limits for treatment and geography. High-volume centers more often used the Solomon technique and applied wider gestational age limits for treatment. Europe and Asia had more high-volume centers, whereas South America, the Middle East and Australia had mainly low-volume centers. CONCLUSION This survey revealed significant differences between fetal centers in several aspects of fetoscopic placental laser therapy for TTTS. Increasing awareness of TTTS, and of laser coagulation as its preferred treatment, will lead to an increase in centers offering this modality, especially in Asia, Africa, South America and the Middle East. Considering the rarity of TTTS and the relative complexity of the procedure, developing international guidelines for techniques, instrumentation and suggested minimum volumes per center may aid in optimizing perinatal outcome.
Collapse
Affiliation(s)
- J Akkermans
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | | | | | | | | |
Collapse
|
9
|
Peeters SHP, Stolk TT, Slaghekke F, Middeldorp JM, Klumper FJ, Lopriore E, Oepkes D. Iatrogenic perforation of intertwin membrane after laser surgery for twin-to-twin transfusion syndrome. Ultrasound Obstet Gynecol 2014; 44:550-556. [PMID: 24961923 DOI: 10.1002/uog.13445] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 06/02/2014] [Accepted: 06/09/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To evaluate management and outcome of iatrogenic monoamniotic twins (iMAT) compared with twins with intact intertwin dividing membranes after laser surgery for twin-to-twin transfusion syndrome (TTTS). METHODS This was a retrospective analysis of twins with and without iatrogenic rupture of the intertwin membranes that had been treated for TTTS with laser surgery at our center between 2004 and 2012. Primary outcomes were perinatal survival and severe neonatal morbidity. Secondary outcomes were mode of delivery, gestational age at birth and cord entanglement. RESULTS In total, 338 pregnancies were included. In 67/338 (20%) pregnancies, iMAT was suspected antenatally. In 47 of these 67 (70%), a preterm Cesarean section was performed for monoamnionicity. Perinatal survival was 108/134 (81%) vs 396/542 (73%) in twins with intact intertwin membranes (P = 0.13). Mean gestational age at birth in iMAT was 31 completed weeks, compared to 33 weeks in twins with intact membranes (P < 0.01). At birth, cord entanglement was present in 8/67 (12%) iMAT pregnancies. Severe neonatal morbidity was assessed in 106/110 (96%) in iMAT cases and 392/416 (94%) in controls. The incidence of severe neonatal morbidity was 28/106 (26%) in iMAT vs 72/392 (18%) in controls (P = 0.25). Severe cerebral injury was significantly increased in the iMAT group as compared with controls, at 16/106 (15%) vs 18/392 (5%) (P < 0.01). CONCLUSIONS Iatrogenic rupture of intertwin membranes was suspected in 20% of pregnancies treated with laser therapy for TTTS and was associated with a lower gestational age at birth and increased neonatal morbidity.
Collapse
Affiliation(s)
- S H P Peeters
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | | | | | | | | |
Collapse
|
10
|
Slaghekke F, Favre R, Peeters SHP, Middeldorp JM, Weingertner AS, van Zwet EW, Klumper FJ, Oepkes D, Lopriore E. Laser surgery as a management option for twin anemia-polycythemia sequence. Ultrasound Obstet Gynecol 2014; 44:304-310. [PMID: 24706478 DOI: 10.1002/uog.13382] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 03/27/2014] [Accepted: 03/27/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To evaluate the effectiveness of laser treatment for antenatally detected twin anemia-polycythemia sequence (TAPS) compared with intrauterine transfusion or expectant management. METHODS All monochorionic twin pregnancies with TAPS managed between 2005 and 2013 in two European fetal therapy centers were evaluated. The outcomes of TAPS cases treated primarily with laser surgery were compared with the outcomes of cases managed expectantly or treated with intrauterine transfusion. RESULTS In this retrospective study 52 cases of TAPS were detected antenatally and were managed with either laser surgery (n=8; 15%) or intrauterine blood transfusion (n=17; 33%) or expectantly (n=27; 52%). Perinatal survival in the laser group was 94% (15/16) vs 85% (29/34) in the intrauterine-transfusion group and 83% (45/54) in the expectant-management group (P=0.30). The rates of severe neonatal morbidity in liveborn neonates in the laser, intrauterine-transfusion and expectant-management groups were 7% (1/15), 38% (12/32) and 24% (12/50), respectively (P=0.17). There was a significant reduction in respiratory distress syndrome in cases treated by laser. No severe postnatal hematological complications were detected in the laser group compared with 72% (23/32) in the intrauterine-transfusion group and 52% (26/50) in the expectant-management group (P<0.01). Median time between diagnosis and birth was 11 weeks in the laser group compared to 5 weeks after intrauterine transfusion and 8 weeks after expectant management (P<0.01). After injection of colored dye no residual anastomoses were found in the laser group. CONCLUSIONS Laser surgery for TAPS appears to improve perinatal outcome by prolonging pregnancy and reducing respiratory distress syndrome. Larger, adequately controlled studies are needed to reach firm conclusions on the optimal management of TAPS.
Collapse
Affiliation(s)
- F Slaghekke
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | | | | | | | | | | | | |
Collapse
|
11
|
van den Bos EM, van Klink JMM, Middeldorp JM, Klumper FJ, Oepkes D, Lopriore E. Perinatal outcome after selective feticide in monochorionic twin pregnancies. Ultrasound Obstet Gynecol 2013; 41:653-658. [PMID: 23335029 DOI: 10.1002/uog.12408] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 11/23/2012] [Accepted: 12/06/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To evaluate the incidence and risk factors of adverse perinatal outcome in complicated monochorionic twin pregnancies treated with selective feticide. METHODS This was a retrospective analysis of prospectively collected data from a consecutive, national cohort. All monochorionic twin pregnancies treated with selective feticide at Leiden University Medical Center between June 2000 and November 2011 were included. Obstetric and neonatal data were recorded. The primary outcome measure was adverse perinatal outcome, including fetal or neonatal demise or severe neonatal morbidity. RESULTS Data on perinatal outcome were obtained in all cases (n = 131). Overall perinatal survival rate was 67.2% (88/131). Median gestational age at delivery was 34 (interquartile range, 23-38) weeks. Neonatal mortality and morbidity rate in liveborn children was 4.3% (4/92) and 12.0 % (11/92), respectively. Severe cerebral injury was detected in three children. The overall incidence of adverse perinatal outcome was 41.2% (54/131). Median gestational age at occurrence of preterm prelabor rupture of membranes (PPROM) was 19.0 weeks and 32.0 weeks in cases with and without adverse perinatal outcome, respectively (P = 0.017). Liveborn children with adverse perinatal outcome were born at a lower median gestational age (29.0 weeks) than were children without adverse perinatal outcome (38.0 weeks) (P < 0.001). CONCLUSIONS The risk of adverse perinatal outcome after selective feticide is high and associated with low gestational age at occurrence of PPROM and low gestational age at delivery. Long-term follow-up to assess neurodevelopmental outcome in survivors is required.
Collapse
Affiliation(s)
- E M van den Bos
- Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | | | | | | |
Collapse
|
12
|
Devlieger R, Sluimers C, Lewi L, Klumper FJ, Deprest J, Oepkes D. 432: Fetal surgery in monoamniotic pregnancies. Am J Obstet Gynecol 2011. [DOI: 10.1016/j.ajog.2010.10.451] [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: 10/18/2022]
|
13
|
Deurloo KL, Devlieger R, Lopriore E, Klumper FJ, Oepkes D. Isolated fetal hydrothorax with hydrops: a systematic review of prenatal treatment options. Prenat Diagn 2008; 27:893-9. [PMID: 17605152 DOI: 10.1002/pd.1808] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [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: 02/02/2023]
Abstract
OBJECTIVE To evaluate the effect of prenatal therapeutic interventions on perinatal outcome in pregnancies complicated by isolated fetal hydrothorax with hydrops. METHODS A systematic review of the literature from January 1982 to January 2006 of perinatal outcome in pregnancies with isolated fetal hydrothorax with hydrops with any form of prenatal treatment was conducted. RESULTS Forty-four articles met our selection criteria, reporting a total of 172 fetuses treated prenatally. Reported treatment options were single (n = 13) or serial thoracocentesis (n = 18), thoraco-amniotic shunt placement (n = 100) or a combination of thoracocentesis and shunting (n = 36). Four case-reports described pleurodesis with OK-432, (n = 3) and intrapleural injection of autologous blood (n = 2). Overall survival rate was 63%, ranging from 54% for single thoracocentesis to 80% in the 5 cases treated with pleurodesis, without statistically significant differences between the treatment modalities. Shunt-placement with or without prior thoracocentesis was most often described, with survival rates of 67 and 61% respectively. DISCUSSION The available literature consists exclusively of case reports and case series. This systematic review suggests that with prenatal intervention, perinatal survival rates around 63% are possible. There is a need for prospective, adequately controlled studies with long-term follow-up to determine the best treatment and more reliable outcome data in pregnancies complicated by fetal hydrothorax with hydrops.
Collapse
Affiliation(s)
- K L Deurloo
- Fetal Medicine Unit, Department of Obstetrics, Leiden University Medical Centre, Leiden, The Netherlands
| | | | | | | | | |
Collapse
|
14
|
Middeldorp JM, Klumper FJ, Oepkes D, Lopriore E, Kanhai HH, Vandenbussche FP. Selective Feticide in Monoamniotic Twin Pregnancies by Umbilical Cord Occlusion and Transection. Fetal Diagn Ther 2007; 23:121-5. [DOI: 10.1159/000111591] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2006] [Accepted: 11/02/2006] [Indexed: 11/19/2022]
|
15
|
van Wamelen DJ, Klumper FJ, de Haas M, Meerman RH, van Kamp IL, Oepkes D. Obstetric History and Antibody Titer in Estimating Severity of Kell Alloimmunization in Pregnancy. Obstet Gynecol 2007; 109:1093-8. [PMID: 17470588 DOI: 10.1097/01.aog.0000260957.77090.4e] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [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: 11/25/2022]
Abstract
OBJECTIVE To evaluate the usefulness of the obstetric history and the maternal serum Kell antibody titer in the management of pregnancies with Kell alloimmunization. METHODS In a retrospective cohort study of 41 pregnancies complicated by Kell alloimmunization, the obstetric history, divided into presence or absence of a previous Kell-positive child, and Kell antibody titers in the index pregnancy were correlated with the gestational age at the onset of fetal anemia. RESULTS Women with a previous Kell-positive child had a lower gestational age at the first intrauterine transfusion compared with those without a previous Kell-positive child (P=.01). However, in two of 29 pregnancies in the latter group, severe fetal anemia requiring transfusion was detected before 20 weeks of gestation. In neither group were maternal Kell antibody titers significantly correlated with gestational age at first intrauterine transfusion (P=.62 and P=.72, respectively). In all but two pregnancies (1:2 and 1:4, respectively), antibody titers were at least 1:32 before the first intrauterine transfusion. CONCLUSION For timely detection of all cases of severe fetal anemia, Kell-alloimmunized pregnancies with a Kell-positive fetus and titers greater than or equal to 1:2 should be closely monitored from 16 to 17 weeks of gestation onward.
Collapse
Affiliation(s)
- D J van Wamelen
- Department of Obstetrics, Leiden University Medical Center, Leiden
| | | | | | | | | | | |
Collapse
|
16
|
Abstract
OBJECTIVE Vesico-amniotic shunting can be used for the treatment of fetal obstructive uropathy. However, the procedure is associated with a significant risk of complications. We report a case of a complicated vesico-amniotic placement, where a vesico-amniotic shunt ultimately resulted in, fortunately reversible, infertility. CASE A 36-year-old multigravida was referred to our center at 13 weeks' gestation for the evaluation of fetal lower urinary obstruction. A vesico-amniotic shunt placement requiring several attempts was performed. A few weeks later premature rupture of the membranes occurred. At the request of the parents, the pregnancy was terminated at 22 weeks'gestation. The patient visited us again for secondary infertility, which turned out to be caused by a shunt left behind in the uterus, acting as an IUD. After hysteroscopic removal, she soon became pregnant again. CONCLUSION This case illustrates the importance of careful documentation relating to each and every operation, of all materials used and what was retained in the patient. At delivery, obstetric staff should be completely aware of the prenatal treatment procedures performed, to ensure that no foreign objects are left by oversight, inside the patient's body.
Collapse
Affiliation(s)
- M M Kamphuis
- Department of Obstetrics and Gynaecology, Bronovo Hospital, The Haque, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | | |
Collapse
|
17
|
Lopriore E, Middeldorp JM, Oepkes D, Klumper FJ, Walther FJ, Vandenbussche FPHA. Residual Anastomoses After Fetoscopic Laser Surgery in Twin-to-Twin Transfusion Syndrome: Frequency, Associated Risks and Outcome. Placenta 2007; 28:204-8. [PMID: 16644009 DOI: 10.1016/j.placenta.2006.03.005] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [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: 01/24/2006] [Revised: 03/01/2006] [Accepted: 03/03/2006] [Indexed: 11/25/2022]
Abstract
Fetoscopic laser coagulation of placental vascular anastomoses is considered to be the treatment of choice in severe twin-to-twin transfusion syndrome. The aim of fetoscopic laser surgery is to separate completely the inter-twin placental circulation. Incomplete laser coagulation may result in residual vascular anastomoses. The incidence and clinical implications of residual anastomoses in twin-to-twin transfusion syndrome treated with fetoscopic laser surgery has not yet been studied. We examined all placentas treated with fetoscopic laser surgery and delivered at our center between June 2002 and December 2005 with vascular injection using colored dyes. Presence of residual anastomoses was studied in association with adverse outcome and inter-twin hemoglobin difference at birth. Adverse outcome was defined as fetal demise, neonatal death or severe cerebral injury. The relation between residual anastomoses and placental localization (anterior or posterior uterine wall) was evaluated. A total of 52 laser-treated placentas were studied. Residual anastomoses were detected in 33% (17/52) of placentas. Adverse outcome was similar in the groups with and without residual anastomoses, 18% (6/34) and 29% (20/70), respectively (p=0.23). Large inter-twin hemoglobin differences (>5g/dL) were found in 65% (11/17) of cases with residual anastomoses and 20% (7/35) of cases without residual anastomoses (p<0.01). Anterior placental localization was not associated with a more frequent presence of residual anastomoses. In conclusion, residual anastomoses at our institution are seen in one-third of monochorionic placentas treated with fetoscopic laser surgery. Although residual anastomoses in our study were not associated with adverse outcome, they were often associated with neonatal hematological complications.
Collapse
Affiliation(s)
- E Lopriore
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands.
| | | | | | | | | | | |
Collapse
|
18
|
Middeldorp JM, Klumper FJ, Oepkes D, Lopriore E, Kanhai HH, Vandenbussche FP. [The initial results of fetoscopic laser treatment for severe second trimester twin-to-twin transfusion syndrome in the Netherlands are comparable to international results]. Ned Tijdschr Geneeskd 2004; 148:1203-8. [PMID: 15224433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
OBJECTIVE Evaluation of the initial results of selective fetoscopic laser coagulation of placental blood vessels for severe second-trimester twin-to-twin transfusion syndrome in the Netherlands. DESIGN Prospective cohort study. METHOD Between August 2000 and December 31, 2002, 49 patients were included with severe second-trimester twin-to-twin transfusion syndrome. Treatment took place in the Leiden University Medical Centre and consisted of selective fetoscopic laser coagulation of anastomoses along the vascular equator on the placental surface. Follow-up was complete until six weeks after delivery. RESULTS Median gestational age was 20 weeks at fetoscopy and 34 weeks at birth. Perinatal survival rate was 65% (64/98). The treatment resulted in at least one surviving child in 80% of pregnancies. CONCLUSION The results of fetoscopic laser treatment for severe second-trimester twin-to-twin transfusion syndrome in the Netherlands are similar to the recent results in specialised foreign centres.
Collapse
Affiliation(s)
- J M Middeldorp
- Afd. Verloskunde, Leids Universitair Medisch Centrum, Postbus 9600, 2300 RC Leiden.
| | | | | | | | | | | |
Collapse
|
19
|
van Kamp IL, Klumper FJ, Bakkum RS, Oepkes D, Meerman RH, Scherjon SA, Kanhai HH. The severity of immune fetal hydrops is predictive of fetal outcome after intrauterine treatment. Am J Obstet Gynecol 2001; 185:668-73. [PMID: 11568796 DOI: 10.1067/mob.2001.116690] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.0] [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: 11/22/2022]
Abstract
OBJECTIVE This study was undertaken to test the hypothesis that the degree of immune fetal hydrops predicts outcome in red blood cell-alloimmunized pregnancies. STUDY DESIGN In an 11-year period, 213 fetuses received 599 intrauterine transfusions. The outcome of 208 pregnancies, including two pairs of twins, was analyzed in a retrospective study. Eighty fetuses demonstrated ultrasonographic signs of hydrops at the start of treatment; 42 of these were classified as mildly hydropic and 38 were classified as severely hydropic. Reversal of hydrops as a result of treatment, survival, and neonatal morbidity was studied. RESULTS The overall survival rate of fetuses with hydrops was 78%. Of the fetuses with mild hydrops, 98% survived, whereas in cases of severe hydrops the survival rate was 55%. Intrauterine reversal of hydrops occurred in 65% of the fetuses with hydrops. The reversal rate was 88% in fetuses with mild hydrops and 39% in fetuses classified as severely hydropic. After reversal of hydrops, almost all of the fetuses survived (98%), whereas in cases of persistent hydrops outcome was unfavorable, with a survival rate of 39% for all fetuses and 26% for fetuses classified as severely hydropic. CONCLUSION In contrast with severe hydrops, there is a high rate of reversal of mild hydrops after adequate treatment. In our study 98% of fetuses survived after reversal of hydrops. To improve the outcome of red blood cell-alloimmunized pregnancies, early diagnosis of fetal anemia and referral to a specialized center are important; these steps enable the start of intrauterine treatment when hydrops is absent or still mild.
Collapse
Affiliation(s)
- I L van Kamp
- Department of Obstetrics, Fetal Medicine Unit, Leiden University Medical Center, The Netherlands
| | | | | | | | | | | | | |
Collapse
|
20
|
Radder CM, Kanhai HH, de Beaufort AJ, Klumper FJ, Brand A. [Evaluation of gradual conversion to a less invasive therapeutic strategy for pregnant women with alloimmune thrombocytopenia in the fetus for prevention of intracranial hemorrhage]. Ned Tijdschr Geneeskd 2000; 144:2015-8. [PMID: 11072521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
OBJECTIVE To evaluate a less invasive management strategy for pregnant women with neonatal alloimmune thrombocytopenia without a history of intracranial haemorrhage. DESIGN Retrospective and descriptive. METHOD In Leiden University Medical Centre, the Netherlands, in the period 1994-August 1999, 31 women with 32 pregnancies were treated. Six women had a history of a sibling with thrombocytopenia and intracranial haemorrhage and 26 a history of a sibling with (severe) thrombocytopenia without haemorrhage. Treatment options consisted of weekly administered intravenous immunoglobulin (ivIG) to the mother without diagnostic cordocentesis, cordocentesis with foetal blood sampling and intrauterine platelet transfusions to the fetus. In the group without history of intracranial haemorrhage fetal blood sampling and platelet transfusion were gradually abandoned as much as possible. RESULTS In the children of the treated pregnant women there were no instances of intracranial haemorrhage. In addition, the platelet count in cord blood was higher, compared with patients treated before 1994 and with literature data. CONCLUSION A less invasive management strategy in case of a history without intracranial haemorrhage seems justified based on results in our population. Administration of ivIG without diagnostic cordocentesis, however, results in a lost opportunity to verify the indication and the effectiveness of treatment.
Collapse
Affiliation(s)
- C M Radder
- Afd. Verloskunde, Leids Universitair Medisch Centrum, Leiden
| | | | | | | | | |
Collapse
|
21
|
Klumper FJ, van Kamp IL, Vandenbussche FP, Meerman RH, Oepkes D, Scherjon SA, Eilers PH, Kanhai HH. Benefits and risks of fetal red-cell transfusion after 32 weeks gestation. Eur J Obstet Gynecol Reprod Biol 2000; 92:91-6. [PMID: 10986440 DOI: 10.1016/s0301-2115(00)00430-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.3] [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: 10/18/2022]
Abstract
OBJECTIVE To compare the outcome after intrauterine transfusion (IUT) between fetuses treated before and those treated after 32 weeks gestation. SETTING National referral center for intrauterine treatment of red-cell alloimmunization in The Netherlands. STUDY DESIGN Retrospective evaluation of an 11 year period, during which 209 fetuses were treated for alloimmune hemolytic disease with 609 red-cell IUTs. We compared fetal and neonatal outcome in three groups: fetuses only treated before 32 weeks gestation (group A, n=46), those treated both before and after 32 weeks (group B, n=117), and those where IUT was started at or after 32 weeks (group C, n=46). RESULTS Survival rate was 48% in group A, 100% in group B, and 91% in group C. Moreover, fetuses in group A were hydropic significantly more often. Short-term perinatal loss rate after IUT was 3.4% in the 409 procedures performed before 32 weeks and 1.0% in the 200 procedures performed after 32 weeks gestation. CONCLUSION Perinatal losses were much more common in fetuses only treated before 32 weeks gestation. Two procedure-related perinatal losses in 200 IUT after 32 weeks remain a matter of concern because of the good prospects of alternative extrauterine treatment.
Collapse
Affiliation(s)
- F J Klumper
- Department of Obstetrics and Fetal Medicine, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands.
| | | | | | | | | | | | | | | |
Collapse
|
22
|
van Kamp IL, Klumper FJ, Meerman RH, Brand A, Bennebroek Gravenhorst J, Kanhai HH. [Blood group immunization: results of treatment of fetal anemia with intra-uterine intravascular blood transfusion in the Netherlands, 1987-1995]. Ned Tijdschr Geneeskd 1999; 143:2527-31. [PMID: 10627756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
OBJECTIVE To evaluate outcome of red cell alloimmunized pregnancies treated with intravascular intrauterine blood transfusions. DESIGN Retrospective. METHODS Medical records of all women and neonates treated with intrauterine transfusions in the period March 1987-December 1995, were reviewed. Survival rates of the infants were analysed in relation to both gestational age and the presence or absence of hydrops at the time of the first transfusion. RESULTS In 153 pregnancies 155 foetuses underwent 462 transfusions (median: 3; range: 1-7). Patients were immunized against RhD in 88%. Kell in 7% and Rhe in 5% of the cases. Overall survival rate was 83%. No difference in survival rate was found between children with the first transfusion early (< or = 26 weeks) or late (> 26 weeks) in pregnancy. Survival rate for foetuses without hydrops was significantly higher than for those with hydrops (90% versus 73%). The mildly hydropic foetuses had a significantly higher survival rate than the severely hydropic foetuses (94% versus 53%). Absence of intrauterine reversal of hydrops was associated with a bad outcome. CONCLUSION Intravascular transfusion is an effective and safe procedure for correction of foetal anaemia provided it is performed by an experienced multidisciplinary team. In contrast to gestational age at first transfusion severity of hydrops is predictive for successful treatment, so timely institution of treatment is of paramount importance.
Collapse
MESH Headings
- Blood Group Antigens/immunology
- Blood Group Incompatibility/epidemiology
- Blood Group Incompatibility/immunology
- Blood Transfusion, Intrauterine/mortality
- Blood Transfusion, Intrauterine/statistics & numerical data
- Erythroblastosis, Fetal/immunology
- Erythroblastosis, Fetal/mortality
- Erythroblastosis, Fetal/therapy
- Female
- Gestational Age
- Humans
- Hydrops Fetalis/complications
- Hydrops Fetalis/prevention & control
- Infant, Newborn
- Isoantibodies/blood
- Netherlands/epidemiology
- Population Surveillance
- Pregnancy
- Pregnancy Complications, Hematologic/blood
- Pregnancy Complications, Hematologic/epidemiology
- Pregnancy Complications, Hematologic/immunology
- Pregnancy Complications, Hematologic/therapy
- Retrospective Studies
- Severity of Illness Index
- Survival Rate
Collapse
Affiliation(s)
- I L van Kamp
- Afd. Verloskunde, Leids Universitair Medisch Centrum, Leiden
| | | | | | | | | | | |
Collapse
|
23
|
Lub A, Schuitemaker NW, van Roosmalen J, Klumper FJ, Vandenbussche FP. [Continuation of pregnancy in infaust fetal prognosis]. Ned Tijdschr Geneeskd 1997; 141:2273-6. [PMID: 9550809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In three pregnant women, lethal anomalies of the fetus were diagnosed ultrasonographically in the second trimester. These women decided to continue their pregnancies for different reasons. One woman strongly regretted her decision to abort a previous pregnancy. The second hoped that the doctors were mistaken on the prognosis. The third woman was afraid of medical interventions. In case of lethal anomalies of the fetus, doctors should advise their patients to consider both options: termination as well as continuation of their pregnancy. Irrespective of the women's choice, doctors ought to be committed to support the pregnant women in such a troublesome situation.
Collapse
Affiliation(s)
- A Lub
- Academisch Ziekenhuis, afd. Verloskunde, Leiden
| | | | | | | | | |
Collapse
|
24
|
Admiraal B, Klumper FJ, van der Hoeven JG, Taal JC, van Roosmalen J. [Beyond maternal death?]. Ned Tijdschr Geneeskd 1997; 141:1177-80. [PMID: 9380150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Three women, aged 33, 27, and 31 years, had serious gestational problems (pre-eclampsia with cerebral haemorrhage, toxic shock syndrome with multiple organ failure, and hypertension complicated by prolonged circulatory arrest, respectively), but eventually survived, albeit with serious handicap (cognitive and motor disturbances, blindness, and persistent vegetative state, respectively). When the maternal mortality ratio is as low as it currently is in the Netherlands (10 women in 100,000 live births), it is worthwhile to assess cases of severe maternal morbidity. The cases presented lead to the pertinent question whether obstetric interventions to prevent death may not sometimes be worse than accepting death itself.
Collapse
Affiliation(s)
- B Admiraal
- Afd. Verloskunde, Academisch Ziekenhuis, Leiden
| | | | | | | | | |
Collapse
|