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Hamer J, Eltaweel N, Man R, Rogerson M, Hodgetts Morton V, Morris RK, Marton T, Gurney L. Placental architectural characteristics following laser ablation within monochorionic twins complicated by twin-twin transfusion syndrome: A systematic review and meta-analysis of outcomes. Acta Obstet Gynecol Scand 2024. [PMID: 38873725 DOI: 10.1111/aogs.14891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 05/27/2024] [Accepted: 05/28/2024] [Indexed: 06/15/2024]
Abstract
INTRODUCTION Twin-twin transfusion syndrome (TTTS) complicates approximately 10%-15% of all monochorionic twin pregnancies. The aim of this review was to evaluate the placental architectural characteristics within TTTS twins following laser and elucidate their impact on fetal outcomes and operative success. MATERIAL AND METHODS Five databases were searched from inception to August 2023. Studies detailing post-delivery placental analysis within TTTS twins post-laser were included. Studies were categorized into two main groups: (1) residual anastomoses following laser and (2) abnormal cord insertion: either velamentous and/or marginal or proximate. The primary outcome was to determine the proportion of TTTS placentas with residual anastomoses and abnormal cord insertions post-laser. Secondary outcomes included assessing residual anastomoses on post-laser fetal outcomes and assessing the relationship between abnormal cord insertion and TTTS development. Study bias was critiqued using the Joanna Briggs Institute checklists and Cochrane risk of bias tool. Random-effects meta-analysis was used, and results were reported as pooled proportions or odds ratio (OR) with 95% confidence interval (CI). PROSPERO registration: CRD42023476875. RESULTS Twenty-six studies, comprising 4013 monochorionic twins, were included for analysis. The proportion of TTTS placentas with residual anastomoses following laser was 24% (95% CI, 0.12-0.41), with a mean and standard deviation of 4.03 ± 2.95 anastomoses per placenta. Post-laser residual anastomoses were significantly associated with intrauterine fetal death (OR, 2.38 [95% CI, 1.33-4.26]), neonatal death (OR, 3.37 [95% CI, 1.65-6.88]), recurrent TTTS (OR, 24.33 [95% CI, 6.64-89.12]), and twin anemia polycythemia sequence (OR, 13.54 [95% CI, 6.36-28.85]). Combined abnormal cord (velamentous and marginal), velamentous cord, and marginal cord insertions within one or both twins following laser were reported at rates of 49% (95% CI, 0.39-0.59), 27% (95% CI, 0.18-0.38), and 28% (95% CI, 0.21-0.36), respectively. Combined, velamentous and marginal cord insertions were not significantly associated with TTTS twins requiring laser (p = 0.72, p = 0.38, and p = 0.71, respectively) versus non-TTTS monochorionic twins. CONCLUSIONS To the best of our knowledge, this is the first review to conjointly explore outcomes of residual anastomoses and abnormal cord insertions within TTTS twins following laser. A large prospective study is necessitated to assess the relationship between abnormal cord insertion and residual anastomoses development post-laser.
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Affiliation(s)
- Jack Hamer
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Nashwa Eltaweel
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Rebecca Man
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Matilde Rogerson
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Victoria Hodgetts Morton
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - R Katie Morris
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Tamas Marton
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
- Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Leo Gurney
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
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Couck I, Cauwberghs B, Van Aelst M, Vivanti AJ, Deprest J, Lewi L. The association between vein-to-vein anastomoses and birth weight discordance in relation to placental sharing in monochorionic twin placentas. Placenta 2022; 118:16-19. [PMID: 34995916 DOI: 10.1016/j.placenta.2021.12.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/19/2021] [Accepted: 12/29/2021] [Indexed: 01/14/2023]
Abstract
INTRODUCTION This study aims to examine the association between the presence and size of a vein-to-vein (VV) anastomosis and birth weight discordance relative to placental discordance in monochorionic diamniotic twin pregnancies. METHODS Placentas of two previous prospective studies were included in this retrospective analysis. After injection with color dye, we measured the placental surface of each twin and VV, artery-to-artery (AA), and artery-to-vein (AV) anastomoses on a digital photograph. We calculated the birth weight ratio (BWR), placental ratio (PR), and birth weight ratio/placenta ratio (BWR/PR), as well as total AV size and net AV transfusion. Placental characteristics were compared between placentas with and without VV anastomoses. We performed univariate analyses to assess the following predictors for BWR/PR: VV size, AA size, total AV size, and net AV transfusion. Multivariate analysis was then performed, including the variables significant in univariate analysis. RESULTS We analyzed 247 placentas: 58 (23%) with VV anastomoses and 189 without (77%). The BWR and PR were higher in the group with VV. In contrast, BWR/PR was lower in the group with VV anastomoses than in those without. The size of AA anastomoses was larger in placentas with VV anastomoses than in those without. In univariate analysis, VV size and AA size were significantly associated with BWR/PR. However, in multivariate regression, only VV size remained significantly associated with the BWR/PR. DISCUSSION VV anastomoses are associated with a decreased birth weight discordance relative to the placental sharing discordance, independent of the AA anastomoses.
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Affiliation(s)
- Isabel Couck
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | | | | | - Alexandre Joseph Vivanti
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium; Department of Obstetrics and Gynecology, Antoine Béclère Hospital, Paris Saclay University, APHP, Clamart, France
| | - Jan Deprest
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium; Institute for Women's Health University College London Hospital, London, United Kingdom
| | - Liesbeth Lewi
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium.
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Lipa M, Kosinski P, Stanirowski P, Wielgos M, Bomba-Opon D. Vascular anastomoses in intrauterine growth in monochorionic twins. J Perinat Med 2020; 48:539-543. [PMID: 32304312 DOI: 10.1515/jpm-2020-0028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 03/23/2020] [Indexed: 11/15/2022]
Abstract
Objectives To evaluate the impact of placental anastomoses on the intrauterine growth of monochorionic (MC) twins. Methods A prospective study was conducted in a group of 53 MC twins. Intrapartally umbilical cords were clamped to identify placental sides corresponding to each twin. The postnatal dye injection technique was administered to evaluate vascular anastomoses, their number and type and visualize placental territory sharing patterns. Data from digital analysis were correlated with obstetrical follow-up. Results Vascular anastomoses were revealed in 88.7% of cases. Arteriovenous (AV) anastomoses occurred in 75.4% and arterioarterial (AA) in 71.1% while venovenous (VV) in 26.4%. In the subgroup of MC twins without placental anastomoses, significantly higher birthweight difference and discordance were revealed when compared to MC twins without anastomoses (382.0 vs. 22 g; P = 0.03 and 49.14% vs. 16.02%; P = 0.03). On the other hand, in subgroups of MC twins with at least one AA anastomosis, twins' birthweights were similar (p = ns) despite significantly higher placental territory sharing discordance (30.44% vs. 15.81%; P = 0.31). Conclusions Vascular anastomoses have a major impact on the intrauterine growth of MC twins. In certain cases, they may cause specific complications; however, in general, they regulate intertwin blood exchange and may compensate unequal placental territory.
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Affiliation(s)
- Michał Lipa
- 1st Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland
| | - Przemysław Kosinski
- 1st Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland
| | - Paweł Stanirowski
- 1st Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland
| | - Mirosław Wielgos
- 1st Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland
| | - Dorota Bomba-Opon
- 1st Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland
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Sun W, Chen L, Yin S, Cai A, Yang Z. Non-invasive dynamic observation of placental vascular anastomoses in monochorionic twins: Assessment using three-dimensional sonography combined with tomographic ultrasound imaging. Placenta 2020; 95:84-90. [PMID: 32452406 DOI: 10.1016/j.placenta.2020.04.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 04/20/2020] [Accepted: 04/21/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Three-dimensional (3D) sonography combined with tomographic ultrasound imaging (TUI) to observe placental vascular anastomoses in monochorionic diamniotic (MCDA) twin pregnancies was evaluated. METHODS Women with MCDA twin pregnancies at a gestational age of 16-32 weeks were enrolled in this retrospective study. Placental anastomoses were detected using two-dimensional (2D) and 3D sonography. Two-dimensional data were obtained by color and spectral Doppler and 3D data with high-definition flow within the area between twins' umbilical cord insertions. Volume post-processing using TUI mode identified anastomoses. Anastomotic findings on ultrasound were compared with fetoscopic surgery or postnatally injected placentas for diagnostic value. Anastomoses detection was compared between the two imaging modalities. RESULTS Seventy-six twin pregnancies were analyzed: 11 selective intrauterine growth restrictions (sIUGR), 10 twin-to-twin transfusion syndrome (TTTS), and 55 without complications. Seventy-one twin pregnancies had arterio-arterial (AA) anastomoses and 75 had arterio-venous (AV) anastomoses. Three-dimensional sonography combined with TUI was more sensitive (87.3%) and accurate (88.2%) in detecting AA anastomoses than 2D sonography (74.6%, 76.3%, respectively; P < 0.05), but had comparable sensitivity for AV anastomoses. The specificity of both modalities for anastomoses was 100%. The detection rate of AA anastomoses by 3D modality was (40%) TTTS vs. (87.3%) normal (P < 0.05), but comparable (90.9%) for sIUGR. The detection rates of AV anastomoses (90%, 81.8%) in TTTS and sIUGR were comparable with (87.3%) normal (P > 0.05). DISCUSSION Three-dimensional sonography combined with TUI highlighted placental anastomoses and may be useful for the clinical diagnosis and therapy of MCDA twin complications.
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Affiliation(s)
- Wei Sun
- Department of Ultrasound, Shengjing Hospital of China Medical University, Shenyang, China
| | - Lizhu Chen
- Department of Ultrasound, Shengjing Hospital of China Medical University, Shenyang, China
| | - Shaowei Yin
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Ailu Cai
- Department of Ultrasound, Shengjing Hospital of China Medical University, Shenyang, China.
| | - Zeyu Yang
- Department of Ultrasound, Shengjing Hospital of China Medical University, Shenyang, China.
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Pregnancy and Multiple Gestations. CHIMERISM 2018. [DOI: 10.1007/978-3-319-89866-7_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Comparison Between Monochorionic and Dichorionic Placentas With Special Attention to Vascular Anastomoses and Placental Share. Twin Res Hum Genet 2016; 19:191-6. [DOI: 10.1017/thg.2016.19] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Placental vascular anastomoses in twins lead to a shared circulation and may subsequently enable the development of severe complications such as twin–twin transfusion syndrome (TTTS) and twin anemia–polycythemia sequence (TAPS). The presence of vascular anastomoses has frequently and systematically been studied in monochorionic (MC) placentas, but only rarely in dichorionic (DC) placentas. The aim of this study was to compare the prevalence of vascular anastomoses and evaluate the sharing discordance in MC and DC placentas. All consecutive placentas of MC and DC twins delivered at the Leiden University Medical Center (the Netherlands) and Medical University of Warsaw (Poland) from 2012 to 2015 were routinely injected with colored dye and included in the study. We excluded twin pregnancies treated with fetoscopic laser surgery. A total of 258 placentas were analyzed in this study, including 134 MC placentas and 124 DC placentas. Vascular anastomoses were present in 99% (133/134) of MC placentas and 0% of DC placentas (p < .01). Placental share discordance between MC twins was significantly larger compared to DC twins, 19.8 (interquartile range [IQR] 8.1–33.3) and 10.8 (IQR 6.2–19.0), respectively (p < .01). Vascular anastomoses associated complications occurred in 16% (22/134) MC twins. Our findings show that vascular anastomoses are almost ubiquitous in MC placentas, but non-existent in DC placentas. In addition, unequal placental sharing appears to be more common in MC than in DC placentas.
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Zhao D, Dang Q, Haak M, Middeldorp J, Klumper F, Oepkes D, Lopriore E. ‘Superficial’ anastomoses in monochorionic placentas are not always superficial. Placenta 2015; 36:1059-61. [DOI: 10.1016/j.placenta.2015.07.127] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 07/17/2015] [Accepted: 07/21/2015] [Indexed: 10/23/2022]
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De Paepe ME, Luks FI. What-and why-the pathologist should know about twin-to-twin transfusion syndrome. Pediatr Dev Pathol 2013; 16:237-51. [PMID: 23617829 DOI: 10.2350/13-03-1315-misc.1] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Approximately 20% of all twin pregnancies are monochorionic. Between 9% and 15% of all monochorionic twin gestations are complicated by severe chronic twin-to-twin transfusion syndrome (TTTS), characterized by a gradual shift of blood volume from the donor twin to the recipient twin through placental vascular connections [1 - 3] . The prognosis of severe, untreated chronic TTTS diagnosed in midtrimester fetuses is extremely poor, with mortality rates exceeding 70% [4] . Since publication of the results of the Eurofoetus trial in 2004, laser photocoagulation of the intertwin anastomoses has become accepted as the optimal first-line therapy for severe TTTS diagnosed before 26 weeks of gestation. While laser treatment of vascular communications was initially limited to selected fetal treatment centers, its increasingly widespread use has resulted in the exposure of more pathologists, even in less specialized institutions, to laser-treated placentas. Furthermore, the surge in laser coagulation has revived the general medical, scientific, and public interest in the placental and choriovascular findings in monochorionic twin placentas. The pathologist's understanding of the pathophysiology of TTTS and of TTTS-associated placental pathology, including the findings related to laser ablation of the anastomoses, can be of great benefit to the involved obstetric/neonatal/surgical team and, ultimately, to the patients. In this review, we summarize the current knowledge of the placental contributions to TTTS and other complications of monochorionic twinning and describe the strengths and limitations of placental examination in these settings. It is our expectation that overviews such as this may serve as a template to generate consensus guidelines for standardized and evidence-based pathologic evaluation of monochorionic twin placentas.
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Affiliation(s)
- Monique E De Paepe
- Department of Pathology, Women and Infants Hospital, Providence, RI, USA.
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Chen K, Chmait RH, Vanderbilt D, Wu S, Randolph L. Chimerism in monochorionic dizygotic twins: Case study and review. Am J Med Genet A 2013; 161A:1817-24. [DOI: 10.1002/ajmg.a.35957] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Accepted: 03/04/2013] [Indexed: 11/06/2022]
Affiliation(s)
- Kristen Chen
- University of Southern California; Los Angeles, CA
| | - Ramen H. Chmait
- Department of Obstetrics & Gynecology; University of Southern California; Los Angeles, CA
| | - Douglas Vanderbilt
- Department of Pediatrics; Children's Hospital Los Angeles; Los Angeles, CA
| | - Samuel Wu
- Department of Pathology; Children's Hospital Los Angeles; Los Angeles, CA
| | - Linda Randolph
- Department of Pediatrics; Children's Hospital Los Angeles; Los Angeles, CA
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van den Wijngaard JPHM, Schwarz JCV, van Horssen P, van Lier MGJTB, Dobbe JGG, Spaan JAE, Siebes M. 3D Imaging of vascular networks for biophysical modeling of perfusion distribution within the heart. J Biomech 2012; 46:229-39. [PMID: 23237670 DOI: 10.1016/j.jbiomech.2012.11.027] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2012] [Accepted: 11/09/2012] [Indexed: 02/07/2023]
Abstract
One of the main determinants of perfusion distribution within an organ is the structure of its vascular network. Past studies were based on angiography or corrosion casting and lacked quantitative three dimensional, 3D, representation. Based on branching rules and other properties derived from such imaging, 3D vascular tree models were generated which were rather useful for generating and testing hypotheses on perfusion distribution in organs. Progress in advanced computational models for prediction of perfusion distribution has raised the need for more realistic representations of vascular trees with higher resolution. This paper presents an overview of the different methods developed over time for imaging and modeling the structure of vascular networks and perfusion distribution, with a focus on the heart. The strengths and limitations of these different techniques are discussed. Episcopic fluorescent imaging using a cryomicrotome is presently being developed in different laboratories. This technique is discussed in more detail, since it provides high-resolution 3D structural information that is important for the development and validation of biophysical models but also for studying the adaptations of vascular networks to diseases. An added advantage of this method being is the ability to measure local tissue perfusion. Clinically, indices for patient-specific coronary stenosis evaluation derived from vascular networks have been proposed and high-resolution noninvasive methods for perfusion distribution are in development. All these techniques depend on a proper representation of the relevant vascular network structures.
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Affiliation(s)
- Jeroen P H M van den Wijngaard
- Department of Biomedical Engineering and Physics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
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Breckpot J, Thienpont B, Gewillig M, Allegaert K, Vermeesch JR, Devriendt K. Differences in Copy Number Variation between Discordant Monozygotic Twins as a Model for Exploring Chromosomal Mosaicism in Congenital Heart Defects. Mol Syndromol 2012; 2:81-87. [PMID: 22511896 DOI: 10.1159/000335284] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2011] [Indexed: 12/21/2022] Open
Abstract
Studies addressing the role of somatic copy number variation (CNV) in the genesis of congenital heart defects (CHDs) are scarce, as cardiac tissue is difficult to obtain, especially in non-affected individuals. We explored the occurrence of copy number differences in monozygotic (MZ) twins discordant for the presence of a CHD, as an illustrative model for chromosomal mosaicism in CHDs. Array comparative genomic hybridization was performed on peripheral blood-derived DNA obtained from 6 discordant MZ twin pairs and on sex-matched reference samples. To identify CNV differences between both twin members as well as potential CNVs in both twins contributing to the phenotype, DNA from each twin was hybridized against its co-twin, and against a normal control. Three copy number differences in 1 out of 6 MZ twin pairs were detected, confirming the occurrence of somatic CNV events in MZ twins. Further investigation by copy number and (epi)genome sequencing analyses in MZ twins, discordant for the presence of CHDs, is required to improve our knowledge on how postzygotic genetic, environmental and stochastic factors can affect human heart development.
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Affiliation(s)
- J Breckpot
- Center for Human Genetics, University Hospitals Leuven, Leuven, Belgium
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Placental markers of twin-to-twin transfusion syndrome in diamniotic–monochorionic twins: A morphometric analysis of deep artery-to-vein anastomoses. Placenta 2010; 31:269-76. [DOI: 10.1016/j.placenta.2009.12.024] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2009] [Revised: 11/05/2009] [Accepted: 12/22/2009] [Indexed: 11/20/2022]
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Bebbington M. Twin-to-twin transfusion syndrome: current understanding of pathophysiology, in-utero therapy and impact for future development. Semin Fetal Neonatal Med 2010; 15:15-20. [PMID: 19539549 DOI: 10.1016/j.siny.2009.05.001] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Whereas monochorionic twins account for only 30% of twin gestations, they contribute to a disproportionate extent to the overall twin perinatal morbidity and mortality. Twin-to-twin transfusion syndrome can occur at any point in a monochorionic gestation but is associated with significant increases in both morbidity and mortality when it develops before 26 weeks of gestation. It is still not possible to predict accurately those pregnancies that will be affected. This has resulted in the practice of routine ultrasound surveillance beginning at the end of the first trimester. Our understanding of the physiology still has many gaps but there is an increased recognition of the heterogeneity that exists especially in the early stages of the disease. The role of the cardiovascular response of the recipient twin offers the potential for further refining the application of our current treatment modalities and may offer insight into future therapies. The optimal therapy at this point in time resides clearly with selective laser photocoagulation, and further refinements of techniques and patient selection may continue to improve outcomes. Finally, the in-utero responses generated by the fetuses to the physiologic stress of twin-to-twin transfusion may influence their response or ability to respond to cardiovascular stress in later life. If there is in-utero programming, then the detection and timely treatment of conditions such as twin-twin transfusion syndrome may have lifelong implications for both members of the twin pair.
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Affiliation(s)
- Michael Bebbington
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA.
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Lopriore E, Oepkes D, van den Wijngaard JPHM, van Gemert MJC, Middeldorp JM, Vandenbussche FPHA. Twin anemia-polycythemia sequence (TAPS) without a cause. Prenat Diagn 2008; 28:559-60. [PMID: 18509864 DOI: 10.1002/pd.2011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Lopriore E, Oepkes D. Fetal and neonatal haematological complications in monochorionic twins. Semin Fetal Neonatal Med 2008; 13:231-8. [PMID: 18356125 DOI: 10.1016/j.siny.2008.02.002] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Placental vascular anastomoses are almost invariably present in monochorionic (MC) placentas. These anastomoses are the essential anatomical substrate for the development of several haematological complications in MC twins, in particular twin-to-twin transfusion syndrome (TTTS). Several forms of TTTS have been described, including chronic TTTS, acute perimortem TTTS, twin anaemia-polycythaemia sequence, acute perinatal TTTS and twin reversed arterial perfusion sequence. A significant evolution in prenatal care strategies and management options for patients with TTTS has occurred during the last decade. In chronic TTTS, endoscopic laser ablation of communicating placental vessels has led to an increase in survival rates. This review analyzes the possible pathophysiologic mechanisms involved, discusses the latest findings in diagnosis, therapy and prognosis, and focuses on fetal and neonatal haematologic complications associated with the various forms of TTTS.
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Affiliation(s)
- E Lopriore
- Leiden University Medical Centre, Leiden, The Netherlands.
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van den Wijngaard JPHM, Umur A, Ross MG, van Gemert MJC. Twin–twin transfusion syndrome: mathematical modelling. Prenat Diagn 2008; 28:280-91. [DOI: 10.1002/pd.1944] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Lewi L, Cannie M, Blickstein I, Jani J, Huber A, Hecher K, Dymarkowski S, Gratacós E, Lewi P, Deprest J. Placental sharing, birthweight discordance, and vascular anastomoses in monochorionic diamniotic twin placentas. Am J Obstet Gynecol 2007; 197:587.e1-8. [PMID: 18060944 DOI: 10.1016/j.ajog.2007.05.009] [Citation(s) in RCA: 143] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2006] [Revised: 02/26/2007] [Accepted: 05/01/2007] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study was to examine the relationship between placental territory and birthweight discordance and vascular anastomoses in monochorionic diamniotic twin placentas from pregnancies that were not complicated by twin-to-twin transfusion syndrome with 2 liveborn twins. STUDY DESIGN Placentas originated from a prospective follow-up study of monochorionic diamniotic twins included in the first trimester. After injection with dyed barium sulphate, a digital x-ray angiography and high-resolution digital photograph were taken. The 2 venous territories were delineated on the angiogram. The diameter of each arterioarterial anastomosis and of each vein that participated in an arteriovenous anastomosis was measured on the digital photograph. Net transfusion over the arteriovenous anastomoses was calculated as the difference between the total venous diameters of the 2 placental parts. RESULTS One hundred placentas were analyzed. Birthweight discordance increased with placental territory discordance (P < .0001). Arterioarterial diameter (P < .01), net arteriovenous transfusion (P < .001), and total anastomotic diameter (P < .01) increased with placental territory discordance. On the other hand, birthweight discordance for a given placental territory discordance decreased with increasing arterioarterial diameter (P < .01), net arteriovenous transfusion (P < .001), and total anastomotic diameter (P < .01). CONCLUSION In unequally shared placentas, the 2 fetal circulations are more tightly linked than in equally shared placentas, which may reduce the birthweight discordance for a given placental territory discordance.
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Affiliation(s)
- Liesbeth Lewi
- Department of Obstetrics and Gynecology, University Hospital, Leuven, Belgium
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