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Active Learning: A Shift from Passive Learning to Student Engagement Improves Understanding and Contextualization of Nutrition and Community Health. EDUCATION SCIENCES 2022. [DOI: 10.3390/educsci12070430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Challenging the notion of “teaching by telling,” active learning utilizes a student-oriented approach by emphasizing the concept of knowledge retention through peer interaction. To further examine the potential of active learning, we created a workshop based on didactic education and student collaboration. Participants included undergraduate students from traditionally underrepresented and disadvantaged backgrounds. The workshop was part of our summer academic enrichment program run in an urban, medically underserved community. The workshop focused on clinical and biochemical nutrition, wherein students synthesized information by discussing dietary choices and the socioeconomic aspects of nutrition. Student reception of the workshop was adjudged by anonymous surveys. The survey questions were designed to gauge how the workshop objectives were achieved. Cronbach alpha (0.276) confirmed that there was more than a single theme contained in the questions. The majority of students (97%) agreed that the workshop met the learning objectives: (1) acquire basic clinical knowledge, (2) gain a better understanding of nutrition, (3) formulate a linkage between clinical nutrition and disease, and (4) benefit from peer interaction. Students’ performance in the post-quiz (100% correct answers) had improved significantly compared to the pre-quiz (25% correct answers) suggesting acquisition, understanding and application of nutrition aspects taught in the workshop. Overall, the present study demonstrated the engagement and understanding of students with respect to learning about nutrition and community health in an active learning setting. These types of active-learning-based sessions may have broad applicability for any academic discipline to improve student engagement and knowledge retention.
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Single fetal demise following fetoscopic ablation for twin-to-twin transfusion syndrome-cohort study, systematic review, and meta-analysis. Am J Obstet Gynecol 2022; 226:843.e1-843.e28. [PMID: 35257668 DOI: 10.1016/j.ajog.2022.02.035] [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: 12/10/2021] [Revised: 02/27/2022] [Accepted: 02/28/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Several studies have assessed preoperative and operative factors associated with fetal demise after laser for TTTS, yet these findings are not completely conclusive. OBJECTIVE This study aimed to identify risk factors for single fetal demise (recipient and donor twins) after fetoscopic laser photocoagulation for twin-to-twin transfusion syndrome. STUDY DESIGN We searched PubMed, Scopus, and Web of Science systematically from the inception of the database to June 2020. We conducted a systemic review on studies investigating risk factors for fetal demise (donor and/or recipient) after fetoscopic laser photocoagulation in monochorionic pregnancies complicated with twin-to-twin transfusion syndrome. Initially, we investigated the cohort of women with twin-to-twin transfusion syndrome that underwent fetoscopic laser photocoagulation at our 2 high-volume fetal centers between 2012 and 2020 to identify risk factors for donor demise and recipient demise. Furthermore, we conducted a systematic review of the literature to better characterize these factors. Among studies that met the entry criteria, multiple preoperative and operative factors were tabulated. The random-effect model was used to pool the standardized mean differences or odds ratios and corresponding 95% confidence intervals. Heterogeneity was assessed using the I2 value. RESULTS A total of 514 pregnancies with twin-to-twin transfusion syndrome managed with fetoscopic laser photocoagulation were included in the final analysis. Following the logistic regression, factors that remained significant for donor demise were selective fetal growth restriction (odds ratio, 1.9; 95% confidence interval, 1.3-2.8; P=.001) and umbilical artery blood flow with absent or reversed end-diastolic velocity of the donor (odds ratio, 2.06; 95% confidence interval, 1.2-3.4; P=.004). A significant factor associated with recipient demise was absent or reversed a-wave in the ductus venosus of the recipient (odds ratio, 1.74; 95% confidence interval, 1.07-3.13; P=.04). Data from 23 studies and our current cohort were included. A total of 4892 pregnancies with twin-to-twin transfusion syndrome managed with fetoscopic laser photocoagulation were analyzed for risk factors for donor demise, and 4594 pregnancies with twin-to-twin transfusion syndrome were analyzed for recipient demise. Among studies, the overall incidence rates ranged from 10.9% to 35.8% for donor demise and 7.3% to 24.5% for recipient demise. Significant risk factors for donor demise were intertwin estimated fetal weight discordance of >25% (odds ratio, 1.86; 95% confidence interval, 1.44-2.4; I2, 0.0%), selective fetal growth restriction (odds ratio, 1.78; 95% confidence interval, 1.4-2.27; I2, 0.0%), twin-to-twin transfusion syndrome stage III (odds ratio, 2.18; 95% confidence interval, 1.53-3.12; I2, 0.0%), umbilical artery blood flow with absent or reversed end-diastolic velocity of the donor (odds ratio, 2.31; 95% confidence interval, 1.9-2.8; I2, 23.7%), absent or reversed a-wave in the ductus venosus of the donor (odds ratio, 1.83; 95% confidence interval, 1.45-2.3; I2, 0.0%), and presence of arterioarterial anastomoses (odds ratio, 2.81; 95% confidence interval, 1.35-5.85; I2, 90.7%). Sequential selective coagulation was protective against donor demise (odds ratio, 0.31; 95% confidence interval, 0.16-0.58; I2, 0.0%). Significant risk factors for recipient demise were twin-to-twin transfusion syndrome stage IV (odds ratio, 2.18; 95% confidence interval, 1.01-4.6; I2, 16.5%), umbilical artery blood flow with absent or reversed end-diastolic velocity of the recipient (odds ratio, 2.68; 95% confidence interval, 1.91-3.74; I2, 0.0%), absent or reversed a-wave in the ductus venosus of the recipient (odds ratio, 2.37; 95% confidence interval, 1.55-3.64; I2, 60.2%), and middle cerebral artery peak systolic velocity of >1.5 multiple of the median (odds ratio, 3.06; 95% confidence interval, 1.36-6.88; I2, 0.0%). CONCLUSION Abnormal blood flow patterns represented by abnormal Doppler studies and low fetal weight were associated with single fetal demise in women with twin-to-twin transfusion syndrome undergoing laser therapy. Although sequential selective coagulation was protective against donor demise, the presence of arterioarterial anastomoses was considerably associated with donor demise. This meta-analysis extensively investigated the association of a wide range of preoperative and operative factors with fetal demise. These findings may be important inpatient counseling, in further understanding the disease, and perhaps in improving surgical techniques.
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Yamamoto R, Kuruma A, Moriuchi K, Shiro M, Wagata M, Yamamoto R, Kawaguchi H, Hayashi S, Ishii K. Re-evaluation of the predictive value of Quintero staging of twin-twin transfusion syndrome for fetal death after fetoscopic laser photocoagulation. Prenat Diagn 2021; 41:1560-1567. [PMID: 34586692 DOI: 10.1002/pd.6053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 09/07/2021] [Accepted: 09/09/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To elucidate the significance of sonographic indices, including Doppler waveforms, that constitute the Quintero classification for predicting death of the recipient or donor after fetoscopic laser photocoagulation (FLP) for twin-twin transfusion syndrome (TTTS). METHODS Prospectively collected data of twins who underwent FLP for TTTS were reviewed. Among the abnormal indices of ultrasound performed just before FLP, factors that were significantly associated with fetal and neonatal deaths in the log-rank test, including fetal demise of co-twins and preterm birth before 28 weeks of gestation, were introduced into the Cox proportional-hazards model to calculate risk ratio (RR). RESULTS We included 235 cases with a prevalence of recipient and donor deaths of 7% and 14%, respectively. In the proportional-hazards model, absent or reversed umbilical artery end-diastolic velocity (UA AREDV) of recipients (n = 7) was independently associated with recipient death (RR = 6.97). In recipients without UA AREDV, reversed ductus venosus (DV) a-wave of recipients (RR = 3.55) was independently associated with recipient death. In donors, UA AREDV with a visible bladder (stage III atypical donor) was independently associated with donor death (RR = 4.24). CONCLUSION Some individual components of the Quintero stage are associated with death of either recipient or donor twins following FLP.
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Affiliation(s)
- Ryo Yamamoto
- Department of Fetal Maternal Medicine, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Airi Kuruma
- Department of Fetal Maternal Medicine, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Kaori Moriuchi
- Department of Fetal Maternal Medicine, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Michihisa Shiro
- Department of Fetal Maternal Medicine, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Maiko Wagata
- Department of Fetal Maternal Medicine, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Rumiko Yamamoto
- Department of Fetal Maternal Medicine, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Haruna Kawaguchi
- Department of Fetal Maternal Medicine, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Shusaku Hayashi
- Department of Fetal Maternal Medicine, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Keisuke Ishii
- Department of Fetal Maternal Medicine, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
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Purnell ME, Chon AH, Korst LM, Llanes A, Grubbs BH, Chmait RH. Percent Absent End-Diastolic Velocity in the Umbilical Artery and Donor Twin Demise after Laser Surgery for Twin-Twin Transfusion Syndrome. Fetal Diagn Ther 2020; 47:572-579. [PMID: 32023611 DOI: 10.1159/000505780] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 01/07/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION To examine the association of preoperative absent end-diastolic velocity (AEDV) and percent AEDV (%AEDV) in the umbilical artery (UA) with donor twin intrauterine fetal demise (IUFD) after laser surgery for twin-twin transfusion syndrome (TTTS). METHODS We performed a retrospective study of stage III/IV TTTS patients who underwent laser surgery from 2006 to 2016. Donors were classified as having preoperative persistent AEDV (yes/no). %AEDV was calculated for those with AEDV as 100× the proportion of the total cardiac cycle in AEDV. Using multiple logistic regression, we tested for an association between the outcome donor IUFD and AEDV risk factors (part 1) and %AEDV (part 2). We stratified these analyses by estimated fetal weight (EFW) discordance ≥20 versus <20%. RESULTS Of 344 cases, 153 (44.5%) donors had AEDV. Part 1 did not confirm an independent association between AEDV and donor IUFD. In the part 2 analysis of the 153 patients with AEDV, %AEDV was a positive risk factor for donor IUFD only in those with discordance (n = 129) (OR 1.04, 95% CI 1.01-1.08, p = 0.0278) when adjusting for %EFW discordance, presence of arterioarterial anastomoses, and multiparity. DISCUSSION Among stage III/IV TTTS patients with AEDV, %AEDV was a risk factor for donor IUFD only in the presence of EFW discordance.
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Affiliation(s)
- Margaret E Purnell
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Andrew H Chon
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Lisa M Korst
- Childbirth Research Associates, LLC, Los Angeles, California, USA
| | - Arlyn Llanes
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Brendan H Grubbs
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Ramen H Chmait
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA,
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Rotar IC, Zaharie G, Staicu A, Preda A, Mureşan D. Fetal cardiovascular alterations in twin-to-twin transfusion syndrome. Med Pharm Rep 2020; 93:5-11. [PMID: 32133441 PMCID: PMC7051825 DOI: 10.15386/mpr-1481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 12/15/2019] [Accepted: 12/30/2019] [Indexed: 11/23/2022] Open
Abstract
Twin-to-twin transfusion syndrome (TTTS) is the consequence of vascular anastomoses of the shared placenta of monochorionic twin pregnancies. Both circulating inter-twin blood flow and vasoactive mediators imbalance cause hypovolemia in the donor and hypervolemia in the recipient fetus. If left untreated, TTTS has a high perinatal mortality rate and adverse long-term outcomes mainly cardiovascular and neurological. The recipient has cardiovascular changes including atrioventricular valve regurgitation, diastolic dysfunction and pulmonary stenosis/atresia. The maladaptive response to vascular changes determines a constant decreased blood flow in the donor that permanently modifies the arterial structure leading to postnatal alterations in the vascular system. Fetoscopic LASER surgery of placental vascular anastomoses may disrupt the underlying pathophysiology and improves cardiovascular function with normalization of systolic and diastolic function within weeks after treatment. The impact of cardiovascular changes is relevant for the safety of the management of a TTTS case. The improvement of the perinatal survival after intrauterine surgery leads to viable infants with the longer-term sequelae. Therefore accurate quantification of cardiovascular involvement is essential for clinicians for pregnancy management but also for patient counseling about the potential treatment options the outcome.
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Affiliation(s)
- Ioana Cristina Rotar
- 1 Department of Obstetrics and Gynecology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.,1 Clinic of Obstetrics and Gynecology, Emergency County Hospital, Cluj-Napoca, Romania
| | - Gabriela Zaharie
- Neonatal Department, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.,Neonatal Department, Emergency County Hospital, Cluj-Napoca, Romania
| | - Adelina Staicu
- 1 Department of Obstetrics and Gynecology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Andreia Preda
- 1 Department of Obstetrics and Gynecology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Daniel Mureşan
- 1 Department of Obstetrics and Gynecology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.,1 Clinic of Obstetrics and Gynecology, Emergency County Hospital, Cluj-Napoca, Romania
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Gijtenbeek M, Eschbach SJ, Middeldorp JM, Klumper FJCM, Slaghekke F, Oepkes D, Haak MC. The value of echocardiography and Doppler in the prediction of fetal demise after laser coagulation for TTTS: A systematic review and meta-analysis. Prenat Diagn 2019; 39:838-847. [PMID: 31237967 PMCID: PMC6771838 DOI: 10.1002/pd.5511] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 05/09/2019] [Accepted: 06/18/2019] [Indexed: 01/10/2023]
Abstract
This study aimed to investigate the value of echocardiography and Doppler before fetoscopic laser coagulation for twin‐twin transfusion syndrome (TTTS) in the prediction of intrauterine fetal demise (IUFD). We performed a systematic review and meta‐analysis to compare preoperative parameters between fetuses with and without demise after laser surgery. Eighteen studies were included. Recipient twins have an increased risk of demise in case of preoperative absent/reversed flow (A/REDF) in the umbilical artery (odds ratio [OR] 2.76, 95% confidence interval [CI], 1.78‐4.28), absent or reversed a‐wave in the ductus venosus (OR 2.32, 95% CI, 1.70‐3.16), or a middle cerebral artery peak systolic velocity > 1.5 multiples of the median (MoM) (OR 7.59, 95% CI, 2.56‐22.46). In donors, only A/REDF in the umbilical artery (OR 3.40, 95% CI, 2.68‐4.32) and absent or reversed a‐wave in the ductus venosus (OR 1.66, 95% CI, 1.12‐2.47) were associated with IUFD. No association was found between donor‐IUFD and preoperative myocardial performance index (MPI). Two studies found an association between abnormal MPI and recipient demise. With this study, we have identified a set of preoperative Doppler parameters predictive of fetal demise after laser surgery. More research is needed to assess the utility of preoperative echocardiographic parameters such as the MPI in predicting IUFD. What's already known about this topic?
Doppler parameters are associated with fetal demise after laser surgery. Echocardiographic parameters are currently not used in risk stratification.
What does this study add?
A more extensive set of preoperative Doppler parameters is defined to predict post‐laser fetal demise. The utility of preoperative echocardiographic parameters such as the MPI in predicting fetal demise remains unclear.
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Affiliation(s)
- Manon Gijtenbeek
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Sanne J Eschbach
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Johanna M Middeldorp
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Frans J C M Klumper
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Femke Slaghekke
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Dick Oepkes
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Monique C Haak
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
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Delabaere A, Leduc F, Reboul Q, Fuchs F, Wavrant S, Dubé J, Fouron JC, Audibert F. Factors associated to early intrauterine fetal demise after laser for TTTS by preoperative fetal heart and Doppler ultrasound. Prenat Diagn 2018; 38:523-530. [PMID: 29740835 DOI: 10.1002/pd.5280] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 04/18/2018] [Accepted: 04/22/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To determine the prognostic value of fetal Doppler and echocardiographic parameters for intrauterine fetal demise (IUFD) within 24 hours and within 1 week after laser coagulation in monochorionic pregnancies complicated by twin-twin transfusion syndrome. METHOD This retrospective study correlated the preoperative hemodynamic and echocardiography parameters to the outcome in fetuses with twin-twin transfusion syndrome undergoing laser therapy. RESULTS One hundred and twelve laser coagulations were performed between February 2006 and June 2015. The total (single and double) IUFD rate was 27.7%. Further, 59% of IUFD occurred within 24 hours and 74.4% occurred within 1 week after laser. The following were associated to IUFD within 24 hours: the middle cerebral arterial pulsatility index in the donor, abnormal umbilical artery (UA) end diastolic flow, increased middle cerebral artery peak systolic velocity, and right ventricular myocardial performance index (RV-MPI) z-score in the recipient. For IUFD within 1 week were the pulsatility index in the donor UA and the recipient abnormalities in UA, ductus venosus, middle cerebral artery-peak systolic velocity, and RV-MPI z-score. CONCLUSION Following laser was early IUFD that was associated with Doppler findings suggesting donor cerebroplacental redistribution, and recipient overload cardiomyopathy, such as abnormal ductus venosus and UA Dopplers as well as an increase of RV-MPI.
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Affiliation(s)
- Amélie Delabaere
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, CHU Sainte-Justine, Montreal University, Montreal, Québec, Canada
| | - France Leduc
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, CHU Sainte-Justine, Montreal University, Montreal, Québec, Canada
| | - Quentin Reboul
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, CHU Sainte-Justine, Montreal University, Montreal, Québec, Canada
| | - Florent Fuchs
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, CHU Sainte-Justine, Montreal University, Montreal, Québec, Canada
| | - Sandrine Wavrant
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, CHU Sainte-Justine, Montreal University, Montreal, Québec, Canada
| | - Johanne Dubé
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, CHU Sainte-Justine, Montreal University, Montreal, Québec, Canada
| | - Jean-Claude Fouron
- Fetal Cardiology Unit, Pediatric Cardiology, Department of Pediatrics, CHU Sainte-Justine, Montreal University, Montreal, Québec, Canada
| | - François Audibert
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, CHU Sainte-Justine, Montreal University, Montreal, Québec, Canada
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Persico N, D'Ambrosi F, Fabietti I, Boito S, Aiello E, Bulfoni A, Ciralli F, Kustermann A, Mosca F, Fedele L. Fetal Doppler changes 1 week after endoscopic equatorial laser for twin-to-twin transfusion syndrome: A longitudinal study. Prenat Diagn 2018; 38:344-348. [PMID: 29436718 DOI: 10.1002/pd.5234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Revised: 12/27/2017] [Accepted: 02/03/2018] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To investigate sequential Doppler changes in donors and recipients before and 1 week after endoscopic laser for twin-to-twin transfusion syndrome (TTTS) and to examine factors that may be associated with such changes. METHODS In TTTS pregnancies undergoing laser treatment, we examined fetal Doppler changes before and 1 week postintervention. Intrauterine death rates and preoperative factors were analyzed in relation to Doppler changes. RESULTS Among 129 (85.4%) donors surviving at 1 week after laser, there was normalization of umbilical artery flow in 26 (72.2%) of 36 cases with preoperative abnormal Dopplers. In the remaining 10 (27.8%) fetuses, abnormal findings persisted. The rate of later intrauterine death was significantly higher in the latter group (6 of 10, 60.0%) compared with fetuses in which Doppler findings normalized (4 of 26, 15.4%; P < .05), with no difference in the rate of severe donor growth restriction between the 2 groups (80.0% vs 65.4%, respectively; P = .688). CONCLUSIONS In about 70% of TTTS donors with preoperative abnormal umbilical artery Doppler, there was normalization 1 week after endoscopic laser. The incidence of fetal growth restriction was not significantly different in donors with persistence of Doppler abnormalities compared with those with normalized findings.
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Affiliation(s)
- Nicola Persico
- Department of Obstetrics and Gynecology 'L. Mangiagalli', Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Science and Community Health, University of Milan, Milan, Italy
| | - Francesco D'Ambrosi
- Department of Obstetrics and Gynecology 'L. Mangiagalli', Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Isabella Fabietti
- Department of Obstetrics and Gynecology 'L. Mangiagalli', Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Simona Boito
- Department of Obstetrics and Gynecology 'L. Mangiagalli', Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Elisa Aiello
- Department of Obstetrics and Gynecology 'L. Mangiagalli', Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Fabrizio Ciralli
- Neonatal Intensive Care Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessandra Kustermann
- Department of Obstetrics and Gynecology 'L. Mangiagalli', Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Fabio Mosca
- Neonatal Intensive Care Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Science and Community Health, University of Milan, Milan, Italy
| | - Luigi Fedele
- Department of Obstetrics and Gynecology 'L. Mangiagalli', Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Science and Community Health, University of Milan, Milan, Italy
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Murata S, Takano M, Kagawa Y, Sumie M, Nakata M. The experience of modified sequential selective laser photocoagulation of communicating vessels technique for twin-twin transfusion syndrome. J Matern Fetal Neonatal Med 2017; 31:1137-1141. [DOI: 10.1080/14767058.2017.1311309] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Susumu Murata
- Department of Obstetrics and Gynecology, Kawasaki Medical School, Okayama, Japan
| | - Mayumi Takano
- Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - Yukiko Kagawa
- Department of Obstetrics and Gynecology, Kawasaki Medical School, Okayama, Japan
| | - Masahiro Sumie
- Department of Obstetrics, Fukuoka Children’s Hospital, Fukuoka, Japan
| | - Masahiko Nakata
- Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
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10
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Gil Guevara E, Pazos A, Gonzalez O, Carretero P, Molina FS. Doppler assessment of patients with twin-to-twin transfusion syndrome and survival following fetoscopic laser surgery. Int J Gynaecol Obstet 2017; 137:241-245. [PMID: 28281301 DOI: 10.1002/ijgo.12143] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 01/13/2017] [Accepted: 03/06/2017] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To investigate fetal-survival rates following laser surgery for twin-to-twin transfusion syndrome (TTTS) and the impact of Doppler analysis. METHODS The present retrospective single-center study included data from patients with pregnancies exhibiting TTTS treated with fetoscopic laser surgery between January 1, 2007, and December 31, 2016. Perinatal outcomes were examined and variables were compared between the donor and recipient fetuses that survived and died, respectively. RESULTS There were 86 pregnancies exhibiting TTTS treated with fetoscopic laser surgery included in the study. The median length of pregnancy at the time of surgery was 21.1 weeks. Both twin fetuses and at least one fetus survived in 61 (71%) and 73 (85%) pregnancies, respectively. Among recipient fetuses, ductus venosus a-wave anomalies (P=0.026), shorter cervical length (P=0.044), and a greater than 25% discrepancy in the estimated weight of the twin fetuses (P=0.045) were associated with reduced survival. CONCLUSION Among pregnancies exhibiting TTTS, laser surgery was associated with significant dual-fetus survival. Preoperative ductus venosus anomalies were associated with lower survival among recipient fetuses, and 1-week postsurgical ultrasonography data demonstrated lower survival among recipient fetuses with persistent anomalous ductus venosus compared with normalized ductus venosus.
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Affiliation(s)
- Enrique Gil Guevara
- The Center for Fetal, Cellular and Molecular Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Maternal-Fetal Medicine Unit, Department of Obstetrics and Gynaecology, University Hospital of Granada (CHUG), Granada, Spain
| | - Andrea Pazos
- Maternal-Fetal Medicine Unit, Department of Obstetrics and Gynaecology, University Hospital of Granada (CHUG), Granada, Spain
| | - Otilia Gonzalez
- Maternal-Fetal Medicine Unit, Department of Obstetrics and Gynaecology, University Hospital of Granada (CHUG), Granada, Spain
| | - Pilar Carretero
- Maternal-Fetal Medicine Unit, Department of Obstetrics and Gynaecology, University Hospital of Granada (CHUG), Granada, Spain
| | - Francisca S Molina
- Maternal-Fetal Medicine Unit, Department of Obstetrics and Gynaecology, University Hospital of Granada (CHUG), Granada, Spain
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Finneran MM, Pickens R, Templin M, Stephenson CD. Impact of recipient twin preoperative myocardial performance index in twin-twin transfusion syndrome treated with laser . J Matern Fetal Neonatal Med 2016; 30:767-771. [PMID: 27150066 DOI: 10.1080/14767058.2016.1187124] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To validate the efficacy of laser therapy for twin-twin transfusion syndrome (TTTS) in the treatment of recipient twin cardiomyopathy and investigate whether severity of preoperative cardiomyopathy can predict fetal survival postoperatively. STUDY DESIGN Retrospective study of monochorionic-diamniotic (MCDA) pregnancies complicated by TTTS treated by selective fetoscopic laser photocoagulation (SFLP) performed between March 2010 and October 2014 at a single center. The recipient right ventricular (RV) and left ventricular (LV) myocardial performance index (MPI) were measured both pre- and postoperatively. The data were analyzed with the Wilcoxon signed rank and parametric t-tests. RESULTS Forty-three women met inclusion criteria during the study period. There was a substantial improvement in recipient LV (0.57 ± 0.13 versus 0.43 ± 0.13, p ≤ 0.0001) and RV (0.60 ± 0.16 versus 0.49 ± 0.18, p ≤ 0.0001) MPI postoperatively (median = 8 days). Recipient preoperative LV and RV MPI did not correlate with recipient or donor survival at 24 hours, 7 days or at birth. Thirty-seven recipients (95%) showed improvement in either LV or RV MPI and 22 (56%) showed complete resolution of cardiac dysfunction. CONCLUSION Laser treatment for TTTS causes rapid improvement in the cardiac function of recipient fetuses. The severity of recipient preoperative MPI does not correlate with survival of either twin postoperatively.
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Affiliation(s)
| | | | - Megan Templin
- b Dickson Advanced Analytics, Carolinas Medical Center , Charlotte , NC , USA , and
| | - Courtney D Stephenson
- c Division of Maternal Fetal Medicine , Charlotte Fetal Care Center , Charlotte , NC , USA
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Eschbach SJ, Boons LSTM, Wolterbeek R, Middeldorp JM, Klumper FJCM, Lopriore E, Oepkes D, Haak MC. Prediction of single fetal demise after laser therapy for twin-twin transfusion syndrome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 47:356-362. [PMID: 26395988 DOI: 10.1002/uog.15753] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 07/16/2015] [Accepted: 09/02/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE Single fetal demise (SFD) occurs in up to 20% of monochorionic pregnancies treated with laser coagulation for twin-twin transfusion syndrome (TTTS). We aimed to determine the independent factors associated with SFD to improve outcome in the care of TTTS pregnancies in the future. METHODS This was a case-control study on twin pregnancies treated for TTTS between 2007 and 2013. Data on ultrasound, laser surgery and outcome were retrieved from our monochorionic twin database. We analyzed separately cases of SFD in donor and recipient twins, and compared them with treated pregnancies that resulted in two live births. RESULTS Of the 273 TTTS pregnancies treated with laser coagulation, SFD occurred in 30 donors (11.0%) and 27 recipients (9.9%). In 67% of pregnancies with SFD, the death occurred within 1 week after laser treatment. For SFD in donors, absent/reversed end-diastolic flow in the umbilical artery was the strongest predictor (odds ratio (OR), 3.0 (95% CI, 1.1-8.0); P = 0.01), followed by the presence of an arterioarterial anastomosis (OR, 4.2 (95% CI, 1.4-13.1); P = 0.03) and discordance in estimated fetal weight (OR, 1.0 (95% CI, 1.0-1.1); P = 0.04). For SFD in recipients, independent predictors were absent/reversed A-wave in the ductus venosus (OR, 3.6 (95% CI, 1.2-10.5); P = 0.02) and the absence of recipient-to-donor arteriovenous anastomoses (OR, 10.6 (95% CI, 1.8-62.0); P < 0.01). CONCLUSIONS Our findings confirm earlier reports that suggest that abnormal blood flow is associated with SFD after laser treatment for TTTS. The association of SFD with the type of anastomoses is a new finding. We speculate that the type of anastomoses present determines the degree of hemodynamic change during laser therapy. Future strategies should aim at stabilizing fetal circulation before laser therapy to decrease the vulnerability to acute preload and afterload changes. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- S J Eschbach
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - L S T M Boons
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - R Wolterbeek
- Department of Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands
| | - J M Middeldorp
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - F J C M Klumper
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - E Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - D Oepkes
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - M C Haak
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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Donor Death After Selective Fetoscopic Laser Surgery for Twin–Twin Transfusion Syndrome. Obstet Gynecol 2015; 126:74-80. [DOI: 10.1097/aog.0000000000000858] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Patel S, Quintero RA, Kontopoulos EV, Korst LM, Llanes A, Chmait RH. Abnormal umbilical artery Doppler findings in the recipient twin before laser surgery for twin-twin transfusion syndrome. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2015; 34:843-846. [PMID: 25911718 DOI: 10.7863/ultra.34.5.843] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVES In twin-twin transfusion syndrome (TTTS), persistent absent or reversed end-diastolic flow in the umbilical artery is a rare finding in the recipient twin, and the clinical implications of this finding are not well characterized. We sought to study the clinical importance of abnormal umbilical artery Doppler waveforms in recipient twins and determine the perinatal survival of these twins after laser surgery. METHODS A retrospective study of patients with TTTS treated with laser surgery between 2006 and 2012 was conducted. Recipient twins with absent or reversed umbilical artery end-diastolic flow on preoperative sonography were identified, and clinical and perinatal outcomes were compared to the remaining cohort. Statistical analyses were performed with Fisher exact and χ(2) tests. RESULTS Of 369 consecutive TTTS cases, 14 (3.8%) had absent or reversed umbilical artery end-diastolic flow in the recipient twin. The rate of hydrops was higher in this group compared to those without absent or reversed flow (35.7% [5 of 14] versus 10.1% [36 of 355]; P = .0125). The rate of recipient twin growth restriction was also higher in the absent or reversed flow group (28.6% [4 of 14] versus 3.9% [14 of 355]; P = .0029). There was an increased rate of recipient fetal demise within 24 hours after surgery in those with absent or reversed flow (21.4% [3 of 14] versus 2.5% [9 of 355]; P = .0078), although there was no statistical difference in 30-day survival between the groups (78.6% [11 of 14] versus 89.9% [319 of 355]; P = .1751). CONCLUSIONS Doppler findings of absent or reversed umbilical artery end-diastolic flow are rare in recipient twins. Although immediate post-laser surgery survival is relatively decreased in this group, overall perinatal survival rates appear to be favorable.
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Affiliation(s)
- Shivani Patel
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California USA (S.P., L.M.K., A.L., R.H.C.); and Jackson Fetal Therapy Institute, Jackson Memorial Hospital, Miami, Florida USA (R.A.Q., E.V.K.)
| | - Rubén A Quintero
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California USA (S.P., L.M.K., A.L., R.H.C.); and Jackson Fetal Therapy Institute, Jackson Memorial Hospital, Miami, Florida USA (R.A.Q., E.V.K.)
| | - Eftichia V Kontopoulos
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California USA (S.P., L.M.K., A.L., R.H.C.); and Jackson Fetal Therapy Institute, Jackson Memorial Hospital, Miami, Florida USA (R.A.Q., E.V.K.)
| | - Lisa M Korst
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California USA (S.P., L.M.K., A.L., R.H.C.); and Jackson Fetal Therapy Institute, Jackson Memorial Hospital, Miami, Florida USA (R.A.Q., E.V.K.)
| | - Arlyn Llanes
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California USA (S.P., L.M.K., A.L., R.H.C.); and Jackson Fetal Therapy Institute, Jackson Memorial Hospital, Miami, Florida USA (R.A.Q., E.V.K.)
| | - Ramen H Chmait
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California USA (S.P., L.M.K., A.L., R.H.C.); and Jackson Fetal Therapy Institute, Jackson Memorial Hospital, Miami, Florida USA (R.A.Q., E.V.K.)
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Tachibana D, Glosemeyer P, Diehl W, Nakagawa K, Wada N, Kurihara Y, Fukui M, Koyama M, Hecher K. Time-interval analysis of ductus venosus flow velocity waveforms in twin-to-twin transfusion syndrome treated with laser surgery. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 45:544-550. [PMID: 24975921 DOI: 10.1002/uog.13449] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 06/15/2014] [Accepted: 06/19/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVES To investigate time-interval variables of ductus venosus (DV) flow velocity waveforms (FVWs) in twin-to-twin transfusion syndrome (TTTS), comparing the results with reference ranges from normal singleton fetuses. The impact of laser surgery and the effect of prognostic factors were also evaluated. METHODS In 107 TTTS cases, DV-FVWs of both recipients and donors were recorded 1 day before and 2 days after laser therapy. Time intervals for systolic (S) and early diastolic (D) peaks were analyzed retrospectively with regard to acceleration time (acc-S and acc-D for S and D, respectively) and deceleration time (dec-S and dec-D for S and D, respectively). For each variable, Z-scores were calculated with respect to previously reported normal reference ranges. RESULTS Z-scores for all variables showed statistically significant differences from those observed previously in normal fetuses, with the exception of dec-S of donors. The most striking differences were observed in longer dec-S of recipients (P < 0.001) and longer dec-D of donors (P < 0.001). Laser therapy showed significant impact on dec-S and acc-D in recipients and on all variables in donors. Regarding the short-term prognosis, acc-S and dec-S showed significant differences for the prediction of intrauterine fetal demise in donors (P = 0.009 and P = 0.011, respectively). CONCLUSION This study demonstrates that time-interval variables of DV-FVWs may differentiate the characteristic hemodynamic changes caused by unbalanced blood volume between recipients and donors.
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Affiliation(s)
- D Tachibana
- Department of Obstetrics and Gynecology, Osaka City University Graduate School of Medicine, Osaka, Japan; Department of Obstetrics and Fetal Medicine, University Medical Center, Hamburg-Eppendorf, Hamburg, Germany
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Eixarch E, Valsky D, Deprest J, Baschat AA, Lewi L, Ortiz JU, Martinez-Crespo JM, Gratacos E. Preoperative prediction of the individualized risk of early fetal death after laser therapy in twin-to-twin transfusion syndrome. Prenat Diagn 2013; 33:1033-8. [DOI: 10.1002/pd.4191] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Revised: 05/29/2013] [Accepted: 06/25/2013] [Indexed: 11/08/2022]
Affiliation(s)
- Elisenda Eixarch
- Department of Maternal-Fetal Medicine, Institut Clinic de Ginecologia, Obstetricia i Neonatologia (ICGON); Hospital Clinic; Barcelona Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS); University of Barcelona; Barcelona Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER); Barcelona Spain
| | - Dan Valsky
- Department of Maternal-Fetal Medicine, Institut Clinic de Ginecologia, Obstetricia i Neonatologia (ICGON); Hospital Clinic; Barcelona Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS); University of Barcelona; Barcelona Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER); Barcelona Spain
- Department of Obstetrics and Gynecology; Hadassah-Hebrew University Medical Center; Mt. Scopus Jerusalem Israel
| | - Jan Deprest
- Department of Obstetrics and Gynecology; University Hospitals Leuven; Leuven Belgium
| | - Ahmet A. Baschat
- Department of Obstetrics, Gynecology & Reproductive Sciences; University of Maryland School of Medicine; Baltimore MD 21201-1559 USA
| | - Liesbeth Lewi
- Department of Obstetrics and Gynecology; University Hospitals Leuven; Leuven Belgium
| | - Javier U. Ortiz
- Department of Maternal-Fetal Medicine, Institut Clinic de Ginecologia, Obstetricia i Neonatologia (ICGON); Hospital Clinic; Barcelona Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS); University of Barcelona; Barcelona Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER); Barcelona Spain
- Frauenklinik und Poliklinik; Technische Universität München; Munich Germany
| | - Josep Maria Martinez-Crespo
- Department of Maternal-Fetal Medicine, Institut Clinic de Ginecologia, Obstetricia i Neonatologia (ICGON); Hospital Clinic; Barcelona Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS); University of Barcelona; Barcelona Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER); Barcelona Spain
| | - Eduard Gratacos
- Department of Maternal-Fetal Medicine, Institut Clinic de Ginecologia, Obstetricia i Neonatologia (ICGON); Hospital Clinic; Barcelona Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS); University of Barcelona; Barcelona Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER); Barcelona Spain
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Walsh CA, McAuliffe FM. Recurrent twin-twin transfusion syndrome after selective fetoscopic laser photocoagulation: a systematic review of the literature. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2012; 40:506-512. [PMID: 22378622 DOI: 10.1002/uog.11105] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/03/2012] [Indexed: 05/31/2023]
Abstract
OBJECTIVES Selective fetoscopic laser photocoagulation (SFLP) is now the treatment of choice for twin-twin transfusion syndrome (TTTS). The incidence of recurrent TTTS following SFLP has been inconsistently reported across different studies. We performed a systematic review of TTTS recurrence following SFLP. METHODS PubMed and MEDLINE online databases were searched for articles published between 2000 and August 2011, using combinations of the terms 'twin-twin transfusion', 'TTTS', 'laser', 'recur' and 'outcome'. Citations identified in the primary search were screened for eligibility. Studies reporting outcomes from selective SFLP for TTTS in twin pregnancies, which addressed specifically the issue of TTTS recurrence, were included. The primary outcome was rate of TTTS recurrence. Secondary outcomes were therapeutic preference and fetal outcomes in cases of recurrent TTTS. RESULTS The primary search identified 22 eligible studies that are included in this review (n = 2447 twin pregnancies). Two studies included a minority of non-selective procedures. The published incidence of recurrent TTTS ranged from 0 to 16%. Clinical management was reported in 65.7% (71/108) cases, with repeat SFLP the most commonly performed secondary intervention. Only three studies provided comprehensive outcome data for cases of recurrent TTTS. The overall rate of neurologically-intact survival was 44% (23/52). The data were inadequate to determine the effects of secondary therapeutic approach, placental location or gestational age on perinatal outcome in cases of recurrent TTTS. CONCLUSIONS The published rate of TTTS recurrence following SFLP in monochorionic twin pregnancies ranges from 0 to 16%. Although limited follow-up data suggest that recurrence is associated with significant perinatal mortality and morbidity, further study is needed. Currently, there are insufficient data available to guide recommendations for clinical management of TTTS recurrence. Future studies on SFLP for TTTS must include details on recurrence rates and provide outcome data specific to the recurrent subset.
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Affiliation(s)
- C A Walsh
- Department of Fetal Medicine, National Maternity Hospital, Dublin, Ireland
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Prise en charge du syndrome transfuseur-transfusé. ACTA ACUST UNITED AC 2012; 40:174-81. [DOI: 10.1016/j.gyobfe.2012.01.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Accepted: 01/20/2012] [Indexed: 11/18/2022]
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Ishii K, Saito M, Nakata M, Takahashi Y, Hayashi S, Murakoshi T, Murotsuki J, Kawamoto H, Sago H. Ultrasound prognostic factors after laser surgery for twin-twin transfusion syndrome to predict survival at 6 months. Prenat Diagn 2011; 31:1097-100. [PMID: 21905054 DOI: 10.1002/pd.2845] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Revised: 07/25/2011] [Accepted: 07/26/2011] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To evaluate the significance of ultrasound findings, detected one or two weeks after laser surgery for twin-twin transfusion syndrome, in predicting the mortality at 6 months of age. METHODS Ultrasound evaluation including fetal biometry, amniotic fluid volume estimation and Doppler examination was performed between 7 and 14 days after surgery for 181 cases. The presence of one or more effusions and single fetal death were also determined. Associations between ultrasound findings and mortality at 6 months of age were evaluated using multiple logistic regression analysis. RESULTS Of the total 181 pairs, 145 (80.1%) donor and 160 (88.1%) recipient twins survived in utero for more than 7 days after surgery, and hence were included in the analysis. The survival rate at 6 months was 66.9% for the donor and 80.7% for the recipient twins. Risk factors for death in the donor were the presence of severe intrauterine growth restriction and effusions. In recipients, elevation in the middle cerebral artery peak systolic velocity coincided with fetal death, but this occurred in only three cases. CONCLUSION Ultrasound risk factors one week after surgery included severe intrauterine growth restrictions and effusions in the donor twins.
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Affiliation(s)
- Keisuke Ishii
- Division of Perinatology, Maternal and Perinatal Care Center, Seirei Hamamatsu General Hospital, Hamamatsu, Japan.
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Chalouhi GE, Essaoui M, Stirnemann J, Quibel T, Deloison B, Salomon L, Ville Y. Laser therapy for twin-to-twin transfusion syndrome (TTTS). Prenat Diagn 2011; 31:637-46. [PMID: 21660997 DOI: 10.1002/pd.2803] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Revised: 05/10/2011] [Accepted: 05/10/2011] [Indexed: 11/06/2022]
Abstract
Monochorionic twins are subjected to specific complications which originate in either imbalance or abnormality of the single placenta serving two twins including twin-to-twin transfusion syndrome. The diagnosis is well established in overt clinical forms with the association of polyuric polyhydramnios and oliguric oligohydramnios. The best treatment of cases presenting before 26 weeks of gestion is fetoscopic laser ablation of the intertwin anastomoses on the chorionic plate. Although subjected to subtle variations, the core technique follows robust guidelines which could help understanding and acquiring the required skills and experience to perform this procedure. However appropriate and tailored hands-on training and appropriate perinatal set-up are critical not only for surgical management but also for the follow-up and management of related complications.
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Affiliation(s)
- G E Chalouhi
- National Referral Centre for the Management of Complicated Monochorionic Pregnancies, Department of Obstetrics and Fetal Medicine, Paris Descartes University, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants-Malades, 75015 Paris, France
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Use of the Learning Curve-Cumulative Summation test for quantitative and individualized assessment of competency of a surgical procedure in obstetrics and gynecology: fetoscopic laser ablation as a model. Am J Obstet Gynecol 2011; 204:218.e1-9. [PMID: 21111398 DOI: 10.1016/j.ajog.2010.10.910] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2010] [Revised: 10/08/2010] [Accepted: 10/13/2010] [Indexed: 11/22/2022]
Abstract
OBJECTIVE We sought to determine the learning curve (LC) for fetoscopic laser photocoagulation (FLP) as a model for the evaluation of training in surgical procedures. STUDY DESIGN A retrospective review of consecutive case series of FLP from 2 centers with 3 operators (operator I [O-I], observer trained; operator II [O-II], hands-on trained; and operator III [O-III], clinical fellow) was performed and the LC-cumulative summation (CUSUM) test was plotted. RESULTS The acceptable and unacceptable success rates for at least 1 fetus survival after FLP were set at 82% and 70%, respectively, from a systematic review. A total of 171 consecutive cases were performed by the 3 operators (O-I, 91; O-II, 49; and O-III, 31). From LC-CUSUM test O-I needed 60 procedures, O-II needed 20 procedures, and O-III needed 20 procedures to reach an acceptable performance rate for at least 1 survivor. CONCLUSION The LC-CUSUM test can be used to accurately assess the LC in a surgical procedure in obstetrics and gynecology. Hands-on trained operators exhibit a shorter LC.
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Papanna R, Mann LK, Molina S, Johnson A, Moise KJ. Changes in the recipient fetal Tei index in the peri-operative period after laser photocoagulation of placental anastomoses for twin-twin transfusion syndrome. Prenat Diagn 2011; 31:176-80. [DOI: 10.1002/pd.2673] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2010] [Revised: 09/19/2010] [Accepted: 10/24/2010] [Indexed: 11/09/2022]
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Abstract
ABSTRACT
Ductus venosus is a tiny vessel with a central role in fetal circulation. Combining B-mode with color and pulsed Doppler is feasible to identify this vessel and evaluate the blood flow waveform at 11 to 13 weeks. The higher prevalence of abnormal A-wave in fetuses with abnormal karyotype and/or cardiac defects turned DV evaluation into a useful marker for chromosomal abnormalities and cardiopathies. Even when combined with nuchal translucency (NT) or biochemical markers, DV blood flow evaluation contributes to an increase in sensitivity and reduces false-positive rate. Abnormal ductal flow is also related to a worse fetal and perinatal outcome. In monochorionic twin pregnancies, in addition to NT measurement at 11 to 14 weeks, the Doppler assessment of DV blood flow increases relevantly the performance of screening for those at higher risk of developing twin-to-twin transfusion syndrome. This story of 14 years surely contributed to change the way first trimester screening is being implemented.
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Sago H, Hayashi S, Saito M, Hasegawa H, Kawamoto H, Kato N, Nanba Y, Ito Y, Takahashi Y, Murotsuki J, Nakata M, Ishii K, Murakoshi T. The outcome and prognostic factors of twin-twin transfusion syndrome following fetoscopic laser surgery. Prenat Diagn 2010; 30:1185-91. [DOI: 10.1002/pd.2647] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Skupski DW, Luks FI, Walker M, Papanna R, Bebbington M, Ryan G, O'Shaughnessy R, Moldenhauer J, Bahtiyar O. Preoperative predictors of death in twin-to-twin transfusion syndrome treated with laser ablation of placental anastomoses. Am J Obstet Gynecol 2010; 203:388.e1-388.e11. [PMID: 20691964 DOI: 10.1016/j.ajog.2010.06.018] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2010] [Revised: 04/27/2010] [Accepted: 06/07/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To determine preoperative predictive factors for donor and recipient death after laser ablation of placental vessels in twin-to-twin transfusion syndrome. STUDY DESIGN Retrospective analysis of North American Fetal Therapy Network center laser procedures, 2002-2009. Factors associated with donor and recipient death were identified by regression analysis. RESULTS There were 466 patients from 8 centers. Factors significantly associated with donor fetal death were low donor estimated fetal weight (odds ratio [OR], 0.69; 95% confidence interval [CI], 0.55-0.87) and reversed end diastolic velocity in the umbilical artery (OR, 4.0; 95% CI, 1.54-10.2); for recipient fetal death-low recipient estimated fetal weight (OR, 0.65; 95% CI, 0.44-0.95), recipient reversed "a" wave in the ductus venosus (OR, 2.39; 95% CI, 1.27-4.51) and hydrops (OR, 3.7; 95% CI, 1.1-12.7); for recipient neonatal death-low donor estimated fetal weight (OR, 0.54; 95% CI, 0.30-0.95), high recipient estimated fetal weight (OR, 1.55; 95% CI, 1.06-2.26) and recipient reversed end diastolic velocity in the umbilical artery (OR, 7.8; 95% CI, 1.03-59.3). CONCLUSION Preoperative findings predict fetal and neonatal demise in twin-to-twin transfusion syndrome treated with laser therapy.
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Nakata M, Murakoshi T, Sago H, Ishii K, Takahashi Y, Hayashi S, Murata S, Miwa I, Sumie M, Sugino N. Modified sequential laser photocoagulation of placental communicating vessels for twin-twin transfusion syndrome to prevent fetal demise of the donor twin. J Obstet Gynaecol Res 2009; 35:640-7. [DOI: 10.1111/j.1447-0756.2009.01034.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Quintero RA, Ishii K, Chmait RH, Bornick PW, Allen MH, Kontopoulos EV. Sequential selective laser photocoagulation of communicating vessels in twin–twin transfusion syndrome. J Matern Fetal Neonatal Med 2009; 20:763-8. [PMID: 17763279 DOI: 10.1080/14767050701591827] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE We have previously described the selective laser photocoagulation of communicating vessels (SLPCV) technique for the treatment of twin-twin transfusion syndrome (TTTS). Because TTTS is thought to result from a net transfer of blood from the donor twin to the recipient twin, we hypothesized that lasering the arteriovenous anastomoses from the donor to the recipient (AVDRs) first (sequential SLPCV or SQLPCV) would result in an improved hemodynamic status and decreased likelihood of intrauterine fetal demise of the donor twin (IUFD-D). MATERIALS AND METHODS The diagnosis of TTTS was made by ultrasound showing the combined presence of a maximum vertical pocket > or = 8 cm in one sac and < or =2 cm in the other in a monochorionic/diamniotic twin pregnancy. Triplet pregnancies and monoamniotic pregnancies were excluded. Severity of TTTS was assessed using the Quintero staging system. All vascular anastomoses were endoscopically identified and classified as AVDR (AV from donor to recipient), AVRD (AV from recipient to donor), arterio-arterial (AA), or veno-venous (VV). The surgical procedure was coded as SQLPCV if all AVDRs were lasered first. Outcome measures included intrauterine fetal demise and perinatal survival. RESULTS One hundred and ninety-three TTTS patients (137 SQLPCV, 56 SLPCV) underwent surgery from May 2003 to August 2005. Gestational age at surgery or at delivery, Stage, patent anastomoses, or persistent/reverse TTTS were not different between the groups. IUFD-D was significantly lower in the SQLPCV than in the SLPCV group (7.3% vs 21.4%, respectively, p = 0.005). Dual perinatal survival was significantly higher in the SQLPCV than in the SLPCV group (73.7% vs 57.1%, respectively, p = 0.02), although the incidence of at least one survivor was not different between the groups (90.5% vs 87.5%, respectively). Logistic regression showed SQLPCV, but not placental location, operating time or number of anastomoses to be significantly associated with a decreased likelihood of IUFD-D (p = 0.007). CONCLUSION SQLPCV is associated with a decreased likelihood of IUFD-D and an increased rate of dual survivors compared to SLPCV. SQLPCV represents both an anatomical and functional surgical approach to the laser treatment of twin-twin transfusion syndrome.
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Affiliation(s)
- Rubén A Quintero
- Division of Maternal-Fetal Medicine, University of South Florida, Tampa, FL 33606, USA.
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Kontopoulos EV, Quintero RA. Assessment of the peak systolic velocity of the middle cerebral artery in twin-twin transfusion syndrome. Part I: preoperative assessment. Am J Obstet Gynecol 2009; 200:61.e1-5. [PMID: 19121658 DOI: 10.1016/j.ajog.2008.10.036] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2008] [Revised: 07/29/2008] [Accepted: 10/07/2008] [Indexed: 11/16/2022]
Abstract
OBJECTIVE We sought to assess the incidence of an elevated peak systolic velocity of the middle cerebral artery (MCA-PSV) in twin-twin transfusion syndrome prior to laser surgery and its prognostic value for intrauterine fetal demise 24 hours after surgery (IUFD-24). STUDY DESIGN An elevated MCA-PSV was defined as a velocity > .5 multiples of the median by transabdominal pulsed Doppler. Gestational age, Quintero stage, and number and/or type of placental vascular anastomoses were assessed as risk factors for an elevated MCA-PSV. Risk of IUFD-24 was assessed relative to an elevated MCA-PSV. RESULTS An elevated MCA-PSV was present in 4.2% of donors, 3.2% of recipients (P = .5), and 1.5% of both twins in 189 patients with twin-twin transfusion syndrome. An elevated MCA-PSV was unrelated to gestational age, stage, and number or type of anastomoses. An elevated MCA-PSV in the recipient twin was associated with an increased risk of IUFD-24 of this fetus (P = .01). CONCLUSIONS An elevated MCA-PSV is present in < 5% of donor and recipient twins. An elevated MCA-PSV is a risk factor for IUFD-24 of the recipient twin.
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Affiliation(s)
- Eftichia V Kontopoulos
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of South Florida, Tampa, FL, USA
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Muratore CS, Carr SR, Lewi L, Delieger R, Carpenter M, Jani J, Deprest JA, Luks FI. Survival after laser surgery for twin-to-twin transfusion syndrome: when are they out of the woods? J Pediatr Surg 2009; 44:66-9; discussion 70. [PMID: 19159719 DOI: 10.1016/j.jpedsurg.2008.10.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2008] [Accepted: 10/07/2008] [Indexed: 10/21/2022]
Abstract
PURPOSE Severe, progressive twin-to-twin transfusion syndrome (TTTS) is associated with near-100% mortality if left untreated. Endoscopic laser ablation of placental vessels (ELA) is associated with 75% to 80% survival of at least one twin. The actuarial risk of fetal demise after ELA has not yet been described. STUDY DESIGN A retrospective cohort study from 2 centers on a consecutive series of 163 sets of monochorionic twins with severe TTTS (18 Quintero stage I, 55 stage II, 71 stage III, 19 stage IV) who underwent ELA. Actuarial survival was calculated and stratified for donor vs recipient and according to stage. RESULTS Median gestational age at diagnosis was 20.1 weeks; median operative time was 60 minutes. Overall survival was 63%, and survival of at least one twin was seen in 76% of pregnancies. Of fetal demises, 10% occurred within 48 hours after ELA, and 90% of all fetal demises occurred within 1 month. There was a 10% survival advantage of recipients over donors. Survival was similar for stages I, II, and IV (75%-80%), compared with 55% for stage III. CONCLUSIONS Actuarial survival curves for TTTS confirms a greater burden on donor than on recipient but not at a previously reported 2:1 ratio. The current staging system does not accurately reflect post-ELA mortality risk. The unexpected higher mortality in stage III may reflect a more acute progression of the disorder in this group, an adverse effect of LA on an as yet unknown subgroup with stage III or, alternatively, preoperative demise of fulminant stage IV patients, leaving a stage IV subgroup with a more benign course and better outcome.
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Affiliation(s)
- Christopher S Muratore
- Fetal Treatment Program, The Warren Alpert Medical School of Brown University, Providence, RI 02903, USA.
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Murakoshi T, Ishii K, Nakata M, Sago H, Hayashi S, Takahashi Y, Murotsuki J, Matsushita M, Shinno T, Naruse H, Torii Y. Validation of Quintero stage III sub-classification for twin-twin transfusion syndrome based on visibility of donor bladder: characteristic differences in pathophysiology and prognosis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2008; 32:813-818. [PMID: 18956440 DOI: 10.1002/uog.6226] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVE To validate the Quintero stage III subclassification for twin-twin transfusion syndrome (TTTS) based on visibility of the bladder of the donor twin. METHODS Between July 2002 and August 2006, there were 131 pregnant Japanese women affected by severe TTTS before 26 weeks' gestation, treated with fetoscopic laser surgery at five centers in Japan, whose pregnancies continued beyond 22 weeks. Outcome data were available in all cases and surviving infants were followed up for at least 6 years. This study focused on the Stage III TTTS patients. These were subclassified into Stage III atypical (abnormal Doppler flow with visible donor bladder) and Stage III classical (abnormal Doppler flow with non-visible donor bladder) groups. Perioperative data and postnatal outcomes were compared between the groups. RESULTS Seven Stage I, 22 Stage II, 82 Stage III and 20 Stage IV pregnancies continued beyond 22 weeks. There was a significantly higher incidence of absent or reversed end-diastolic velocity in the umbilical artery (UA-AREDV) of the donor in Stage III atypical than in Stage III classical patients (83.8% vs. 53.3%, P = 0.004). Stage III atypical cases also had a significantly higher incidence of arterioarterial (AA) anastomoses (72.9% vs. 17.8%, P < 0.001) and intrauterine fetal demise (IUFD) of the donor (43.2% vs. 13.3%, P = 0.002). However, there were no differences in overall survival or in abnormal brain scans of surviving infants. Donors with both UA-AREDV and AA anastomoses had a significantly higher incidence of IUFD compared with the others (53.3%, P < 0.001). CONCLUSIONS Quintero stage III atypical was characterized by a high incidence of AA anastomoses and UA-AREDV of the donor, resulting in IUFD. Subclassification of Stage III based on visibility of the bladder of the donor twin was adequate for and compatible with differentiating prognosis and pathophysiology.
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Affiliation(s)
- T Murakoshi
- Division of Perinatology, Fetal Diagnosis and Therapy, Maternal and Perinatal Care Center, Seirei Hamamatsu General Hospital, Hamamatsu, Japan.
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Laser therapy and serial amnioreduction as treatment for twin-twin transfusion syndrome: a metaanalysis and review of literature. Am J Obstet Gynecol 2008; 198:147-52. [PMID: 18068144 DOI: 10.1016/j.ajog.2007.09.043] [Citation(s) in RCA: 113] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2007] [Revised: 09/05/2007] [Accepted: 09/24/2007] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The objective of the study was to review current controversy on laser therapy (LT) vs serial amnioreduction (SA) performed for twin-twin transfusion syndrome (TTTS). STUDY DESIGN A search in PubMed from 1997-2007 was performed. Inclusion criteria were diamniotic monochorionic pregnancy, TTTS diagnosed with standard parameters, and peri- and neonatal outcomes well defined. Triplets and investigations on other topics of TTTS rather than perinatal outcomes were excluded. A metaanalysis was performed by fixed-effect model (heterogeneity <25%). RESULTS Ten articles provided 611 cases of TTTS (LT: 70%; SA: 30%) and included 4 studies comparing the 2 treatments (395 cases: LT, 58%; SA, 42%). Fetuses undergoing LT were more likely to survive than fetuses undergoing SA (overall survival rate: P < .0001; odds ratio [OR], 2.04; 95% confidence interval [CI], 1.52-2.76; neonatal death: P < .0001; OR, 0.24; 95% CI, 0.15-0.40; neurologic morbidity: P < .0001; OR, 0.20; 95% CI, 0.12-0.33). CONCLUSION This metaanalysis shows that LT is associated with better outcomes than SA and proposes new topics for future research.
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Sueters M, Middeldorp JM, Vandenbussche FPHA, Teunissen KA, Lopriore E, Kanhai HHH, Le Cessie S, Oepkes D. The effect of fetoscopic laser therapy on fetal cardiac size in twin-twin transfusion syndrome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2008; 31:158-163. [PMID: 18254146 DOI: 10.1002/uog.5246] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
OBJECTIVES To evaluate the influence of fetoscopic laser therapy on fetal cardiac size in monochorionic twins complicated by twin-twin transfusion syndrome (TTTS). METHODS In a longitudinal, prospective study, we assessed fetal cardiac size sonographically in monochorionic diamniotic twins with TTTS treated by laser therapy and in monochorionic twins without TTTS. The fetal cardiothoracic ratio (cardiac circumference divided by thoracic circumference) of TTTS twins was determined within 24 h before, 12-24 h after and 1 week after laser treatment, and from then on every 2-4 weeks until birth. TTTS twins were classified into Quintero Stages 1-2 (n = 18) and Stages 3-4 (n = 16), and measurements were compared with biweekly measurements of non-TTTS monochorionic twins matched for gestational age (n = 38). Cardiomegaly was defined as a cardiothoracic ratio above the 97.5th percentile. RESULTS Before laser treatment, cardiomegaly was observed in 44% (8/18) and 50% (8/16) of recipients in Quintero Stages 1-2 and Stages 3-4, respectively. Cardiomegaly occurred in none of the donors before treatment. After laser treatment, cardiomegaly was observed in 76% (13/17) and 50% (7/14) of recipients in Stages 1-2 and Stages 3-4, respectively, and in 17% (3/18) and 13% (2/15) of donors in Stages 1-2 and Stages 3-4, respectively. Cardiomegaly was present in 18% (7/38) and 8% (2/25) of non-TTTS monochorionic twins and singletons. After laser therapy, the cardiothoracic ratio of recipients in Stages 1-2 and Stages 3-4 was not significantly changed (P = 0.34 and P = 0.67, respectively). The cardiothoracic ratio of donors in Stages 1-2 and Stages 3-4 was increased compared with that before laser therapy (P = 0.0002 and P = 0.005, respectively). Cardiothoracic ratios of non-TTTS monochorionic twins were not significantly different from our reference range in singletons throughout gestation, and were smaller than those in both recipients and donors after laser therapy. CONCLUSIONS TTTS recipients show cardiomegaly before as well as after fetoscopic laser therapy for TTTS. Donors develop cardiomegaly only after laser treatment. Our findings emphasize the significant effect of TTTS and fetoscopic laser therapy on the fetal heart of both recipient and donor twins.
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Affiliation(s)
- M Sueters
- Department of Obstetrics, Leiden University Medical Center, 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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Russell Z, Quintero RA, Kontopoulos EV. Intrauterine growth restriction in monochorionic twins. Semin Fetal Neonatal Med 2007; 12:439-49. [PMID: 17761462 DOI: 10.1016/j.siny.2007.06.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Intrauterine growth restriction (IUGR) occurs in approximately 3-10% of singleton pregnancies, in 9.1% of all twins, and in 9.9% of monochorionic twins. Spontaneous demise of the IUGR twin may occur and may result in concomitant demise or severe neurological handicap of the other twin. Currently, monochorionic twins with selective IUGR (SIUGR) are managed expectantly. Alternatively, all adverse consequences resulting from the potential demise of the SIUGR twin could be averted by unlinking the circulations between the two fetuses. The latter can be achieved by laser photocoagulation of communicating vessels or by umbilical-cord occlusion. The purpose of this chapter is to review this important entity in obstetrics.
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Affiliation(s)
- Zoi Russell
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of South Florida, 4 Columbia Drive, Suite 529, Tampa, FL 33606, USA
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Kontopoulos EV, Quintero RA, Chmait RH, Bornick PW, Russell Z, Allen MH. Percent absent end-diastolic velocity in the umbilical artery waveform as a predictor of intrauterine fetal demise of the donor twin after selective laser photocoagulation of communicating vessels in twin-twin transfusion syndrome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2007; 30:35-9. [PMID: 17587216 DOI: 10.1002/uog.4055] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
OBJECTIVE Absent end-diastolic velocity (AEDV) in the umbilical artery of the donor twin is a known risk factor for intrauterine fetal demise (IUFD) of this fetus after selective laser photocoagulation of communicating vessels (SLPCV) for twin-twin transfusion syndrome (TTTS). The aim of this study was to assess the proportion of time, expressed as a percentage, of the cardiac cycle spent in AEDV (%AEDV) as a predictor of IUFD of the donor. METHODS All patients referred for possible SLPCV underwent complete preoperative staging evaluation including Doppler assessment of the umbilical artery. %AEDV was calculated retrospectively as 100 x (time of the cycle spent in AEDV divided by duration of total cardiac cycle). Patients without AEDV were considered to have a %AEDV of 0. Follow-up Doppler studies were performed 16-24 h after SLPCV. IUFD of the donor was recorded if the donor twin died any time prior to delivery. RESULTS Of 401 patients undergoing SLPCV, 127 had AEDV. Preoperative AEDV of the donor twin was associated with an increased risk of IUFD of the donor (40.9% vs. 14.2%, P < 0.0001). %AEDV was measured in 72/127 (56.7%) donors with AEDV for whom digital images were available. Within these 72 patients, the mean %AEDV was significantly higher in patients with IUFD of the donor (36.5% vs. 29.6%, P = 0.01). IUFD of the donor was similar in patients with AEDV, regardless of whether %AEDV was measured (36% vs. 47%, P = 0.2). A %AEDV > 30 was associated with a 4.3-fold increase in the risk of IUFD of the donor (95% CI, 1.4-12.7), a sensitivity of 77% and a negative predictive value of 81.3%. Logistic regression showed that %AEDV, but not number of anastomoses, placental location, presence of artery-to-artery anastomoses or the presence or absence of EDV was associated significantly with IUFD of the donor. CONCLUSION %AEDV is a novel Doppler parameter in the assessment of patients with TTTS. %AEDV, rather than AEDV alone, is a significant risk factor for IUFD of the donor twin and %AEDV > 30 is associated with an increased risk of IUFD of the donor in TTTS patients treated with SLPCV. Assessment of %AEDV should be considered part of the preoperative evaluation of TTTS patients.
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Affiliation(s)
- E V Kontopoulos
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of South Florida, Tampa, FL 33606, USA.
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Gratacós E, Lewi L, Muñoz B, Acosta-Rojas R, Hernandez-Andrade E, Martinez JM, Carreras E, Deprest J. A classification system for selective intrauterine growth restriction in monochorionic pregnancies according to umbilical artery Doppler flow in the smaller twin. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2007; 30:28-34. [PMID: 17542039 DOI: 10.1002/uog.4046] [Citation(s) in RCA: 261] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
OBJECTIVES To evaluate a classification of selective intrauterine growth restriction (sIUGR) in monochorionic (MC) twins based on the characteristics of umbilical artery (UA) Doppler flow in the smaller twin, in terms of association with clinical outcome and with the pattern of placental anastomoses. METHODS One hundred and thirty-four MC twins diagnosed with sIUGR at 18-26 weeks were classified as Type I (UA Doppler with positive diastolic flow, n = 39), Type II (persistent absent or reversed end-diastolic flow, n = 30) and Type III (intermittent absent or reversed end-diastolic flow, n = 65). Perinatal outcome, placental sharing and the pattern of anastomoses were compared with those in 76 uncomplicated MC twins. RESULTS Mean gestational age at delivery was 35.5 (range, 30-38) weeks in controls, 35.4 (range, 16-38) weeks in Type I, 30.7 (range, 27-40) weeks in Type II (P < 0.0001) and 31.6 (range, 23-39) weeks in Type III (P < 0.0001) pregnancies. Fetal weight discordance was significantly higher in Type II (38%) and Type III (36%) than in Type I (29%) (P < 0.0001) pregnancies. Deterioration of the growth-restricted fetus occurred in 90% of Type II cases, compared with 0% and 10.8% of Types I and III, respectively (P < 0.001). Unexpected intrauterine fetal death of the smaller twin occurred in 15.4% of Type III cases, compared with 2.6% and 0% of Types I and II respectively (P < 0.05). Parenchymal brain lesions in the larger twin were observed in 19.7% of Type III cases and less than 5% in the other groups (P < 0.05). Placental discordance (larger/smaller) was 1.3 in controls, compared with 1.8, 2.6 and 4.4 in Types I, II and III, respectively (P < 0.01). The proportion of cases with arterioarterial anastomoses > 2 mm in diameter was 55% in controls, 70% in Type I, 18% in Type II (P < 0.01) and 98% in Type III (P < 0.01). CONCLUSION sIUGR can be classified on the basis of umbilical artery Doppler into three types that correlate with different clinical behavior and different patterns of placental anastomoses. This classification may be of help in clinical decision-making and when comparing clinical studies.
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Affiliation(s)
- E Gratacós
- Fetal Medicine Unit and Department of Obstetrics, Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain.
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van den Wijngaard JPHM, Westerhof BE, Ross MG, van Gemert MJC. A mathematical model of twin-twin transfusion syndrome with pulsatile arterial circulations. Am J Physiol Regul Integr Comp Physiol 2007; 292:R1519-31. [PMID: 17158266 DOI: 10.1152/ajpregu.00534.2006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The twin-twin transfusion syndrome (TTTS) is a severe complication of monochorionic twin pregnancies caused by a net transfusion of blood from one twin (the donor) to the other (the recipient) through placental anastomoses. To examine the pathophysiology of TTTS evolving through clinical stages I to IV, we extended our mathematical model to include pulsating circulations propagating along the arterial tree as well as placental and cerebral vascular resistances, and arterial wall thickness and stiffness. The model demonstrates that abnormal umbilical arterial flow (TTTS stage III) in the donor twin results from increased placental resistance as well as reduced resistance in the cerebral arteries. In contrast, recipient twin abnormal umbilical arterial flow requires a significantly greater increase in placental resistance, resulting from the compressive effects of high amniotic fluid pressure. Thus simulated abnormalities of donor umbilical arterial pulsations occur in the donor more commonly and earlier than in the recipient. The “normal” staging sequence (I, II, III, IV) correlates with the presence of compensating placental anastomoses, constituting the majority of monochorionic twin placentas. However, TTTS stage III may occur before manifestations of stage II (lack of donor bladder filling), in our model correlating with severe TTTS from a single arteriovenous anastomosis, an infrequent occurring placental angioarchitecture. In conclusion, this mathematical model describes the onset and development of the four stages of TTTS, reproduces a variety of clinical manifestations, and may contribute to identifying the underlying pathophysiology of the staging sequence in TTTS.
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Ishii K, Hayashi S, Nakata M, Murakoshi T, Sago H, Tanaka K. Ultrasound Assessment prior to Laser Photocoagulation for Twin-Twin Transfusion Syndrome for Predicting Intrauterine Fetal Demise after Surgery in Japanese Patients. Fetal Diagn Ther 2006; 22:149-54. [PMID: 17139174 DOI: 10.1159/000097116] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2006] [Accepted: 04/21/2006] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate the use of ultrasound before selective laser photocoagulation of communicating vessels (SLPCV) for twin-twin transfusion syndrome in predicting intrauterine fetal demise (IUFD). METHODS Fifty-five patients underwent SLPCV in Japan. Fetal biometry and Doppler studies of the umbilical artery, ductus venosus, and umbilical vein were performed prior to SLPCV. The visualization of the bladder and hydrops was recorded. Association between the parameters and IUFD was analyzed using multiple logistic regression analysis. The study was approved by the Institutional Review Board and patients gave their informed consent. RESULTS The IUFD incidence was 25.5% (14/55) in the donors and 12.7% (7/55) in the recipients. Twelve donors and 4 recipients of them ended in unexplainable IUFD. In the analysis of 53 donors, absent or reversed end-diastolic flow of umbilical artery (UAAREDF) was only associated with IUFD (p = 0.016). No parameters could predict IUFD in 52 recipients. CONCLUSIONS UAAREDF may be useful for predicting IUFD of the donor after SLPCV.
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Affiliation(s)
- Keisuke Ishii
- Department of Obstetrics and Gynecology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan.
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Chang YL, Chmait RH, Bornick PW, Allen MH, Quintero RA. The role of laser surgery in dissecting the etiology of absent or reverse end-diastolic velocity in the umbilical artery of the donor twin in twin-twin transfusion syndrome. Am J Obstet Gynecol 2006; 195:478-83. [PMID: 16707082 DOI: 10.1016/j.ajog.2006.02.037] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2005] [Revised: 02/19/2006] [Accepted: 02/26/2006] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study was undertaken to gain insight on the cause of absent or reverse end-diastolic velocity (AREDV) in the umbilical artery (UA) of the donor twin by analysis of individual placental mass and vascular anastomoses in patients with twin-twin transfusion syndrome (TTTS) treated with laser. STUDY DESIGN TTTS patients who successfully underwent selective laser photocoagulation of communicating vessels (SLPCV), 16 and 26 weeks' gestation, with both twins born alive and complete Doppler and placental data were considered eligible for the study. Doppler examination of the UA was performed before and 24 hours after SLPCV. Abnormal UA Doppler findings were defined as persistent AREDV. Pre- and post-SLPCV UA Doppler results yielded the following 4 groups: (1) normal-normal; (2) normal-abnormal; (3) abnormal-normal; and (4) abnormal-abnormal. The types of vascular anastomoses were categorized during surgery. Individual placental territory (IPT) was defined as individual placental weight divided by total placental weight x 100. RESULTS There were 132 cases in group 1 and no patients in group 2. AREDV resolved in 78% (28/36) of patients (group 3) and remained unchanged in 22% (8/36) (group 4). The mean IPT-donor in group 4 was significantly smaller than in group 1 (P = .015). Patients with preoperative AREDV (groups 3 and 4) were more likely to have artery-to-artery anastomoses (P = .002). However, AREDV resolved in 57% (16/28) patients without artery-to-artery anastomoses. CONCLUSION Preoperative AREDV may result from a small IPT, placental vascular anastomoses, or both. AREDV resulting from a small IPT may have a similar cause to that of singletons, and may be inferred by lack of postoperative resolution. Resolution of AREDV after SLPCV implies the presence of an adequate IPT and removal of donor hypotension.
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Affiliation(s)
- Yao-Lung Chang
- Chang Gung Memorial Hospital, Linkou Medical Center, Tao-Yuan Hsien, Taiwan
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Abstract
PURPOSE OF REVIEW Despite the recent demonstration of the benefit of the primary laser over amnioreduction, overall survival is far from optimal (70-80%), and therefore diagnosis and management of early and late complications following placental surgery became of great importance. RECENT FINDINGS Laser therapy has proven to be better than amnioreduction in treating twin-to-twin transfusion syndrome. Miscarriage, preterm premature rupture of the membranes and preterm delivery account for more than 20% of perinatal mortality after treatment. In those who die despite treatment, recurrence of twin-to-twin transfusion syndrome, placental insufficiency or feto-fetal hemorrhage with anemia/polycythemia are complications that have to be managed with different secondary therapeutic options, such as amnioreduction, cord coagulation, intrauterine transfusion or repeat fetoscopy-guided laser. Ex-vivo placental angiography has confirmed that these complications occur when anastomoses are missed. Early predictors of laser efficacy in twin-to-twin transfusion syndrome treatment, such as improvement in the umbilical vein flow imbalance and urine production, are being evaluated, because they are earlier predictors of outcome than amniotic fluid discordance. SUMMARY Optimization of laser treatment of twin-to-twin transfusion syndrome and new insight into the follow-up are likely to become the key to a better prognosis, and they are therefore important issues that have to be addressed in forthcoming studies.
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Affiliation(s)
- Masami Yamamoto
- Unidad de Medicina Perinatal, Clínica Alemana, Hospital Padre Hurtado, Universidad del Desarrollo, Santiago, Chile
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Cavicchioni O, Yamamoto M, Robyr R, Takahashi Y, Ville Y. Fetal medicine: Intrauterine fetal demise following laser treatment in twin-to-twin transfusion syndrome. BJOG 2006; 113:590-4. [PMID: 16579799 DOI: 10.1111/j.1471-0528.2006.00913.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the incidence, risk factors and consequences of intrauterine fetal demise (IUFD) of at least one twin in twin-to-twin transfusion syndrome (TTTS) treated by laser. DESIGN Retrospective analysis. SETTING Experience of a single centre between 1999 and 2004. POPULATION A subgroup of 45 cases with fetal demise of one or both twins from a series of 120 cases of TTTS treated by laser. METHODS All cases were entered prospectively into a dedicated database and the results were analysed retrospectively. MAIN OUTCOME MEASURES Fetal demise prognostic factors, survival, fetal anaemia, brain lesions, neonatal death and intact survival. RESULTS IUFD of one twin occurred in 40 of 120 cases (19 donors and 21 recipients). IUFD of both twins occurred in another five cases. From these 40 cases, miscarriage occurred in two and pregnancy termination was requested in another two cases because of antenatal brain lesions. Two neonates died and two presented severe morbidity, survivors were therefore neurologically normal at 6-44 months of life in 89% (32/36) of the cases. Univariate analysis showed that preoperative abnormal umbilical artery Doppler in the donor before laser treatment and in the recipient following laser treatment was associated with their demise. Incomplete coagulation was suspected in cases where anaemia or cerebral lesions developed following the death of the first twin (10). CONCLUSIONS IUFD of one or both twins occurred in 45 of 120 (38%) cases of severe TTTS treated by laser. In these, separation of the placental circulations was incomplete in at least 22% (10/45) of the cases. Umbilical artery Doppler abnormalities before laser were found to be risk factors for the donors' demise following the procedure.
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Affiliation(s)
- O Cavicchioni
- Service de Gynécologie Obstétrique, Hôpital de Poissy-St-Germain, Poissy, France
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43
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Affiliation(s)
- Masami Yamamoto
- Unidad de Ecografía, Clínica Alemana, Hospital Padre Hurtado, Universidad del Desarrollo, Santiago, Chile
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44
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Abstract
Monochorionic twins have placental anastomoses that to varying degrees create a common circulation. This presents unique challenges for the performance of selective fetal termination in cases of twin-twin transfusion syndrome, twin reversed arterial perfusion sequence, or discordant twin abnormalities. Multiple methods of interrupting the affected twin's circulation have been attempted with variable success. One of the most frequent complications of any approach is iatrogenic preterm premature rupture of membranes. Laser coagulation in the midtrimester appears to be safe and effective; however, it is only available at limited centers. Currently, bipolar coagulation is the method of choice in the second half of pregnancy. The recently reported technique of radiofrequency ablation appears to be successful with minimal complications. Exploration of further percutaneous and noninvasive techniques, as well as interventions to decrease the morbidity arising from preterm membrane rupture, may lead to increased survival of the remaining twin and reduced risk of maternal complications.
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Affiliation(s)
- Alexandra C Spadola
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY 10032, USA
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45
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Abstract
Management of Twin-Twin Transfusion Syndrome (TTTS) is one of the most challenging clinical problems concerning multiple gestations. The pathophysiology of TTTS and Quintero staging system are described. The importance of fetal echocardiograms in assessing prognosis and response to therapy is highlighted. Treatment modalities, particularly amnioreduction, microseptostomy, and fetoscopic laser photocoagulation, are discussed. Questions still remain as to how various treatment options affect short- and long-term cardiac and neurodevelopmental outcomes and which patients will benefit most from selective laser photocoagulation therapy.
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Affiliation(s)
- Ursula F Harkness
- University of Cincinnati College of Medicine, Cincinnati, OH 45229-3039, USA
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46
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Robyr R, Boulvain M, Lewi L, Huber A, Hecher K, Deprest J, Ville Y. Cervical length as a prognostic factor for preterm delivery in twin-to-twin transfusion syndrome treated by fetoscopic laser coagulation of chorionic plate anastomoses. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2005; 25:37-41. [PMID: 15690555 DOI: 10.1002/uog.1798] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
OBJECTIVE To evaluate the risk of spontaneous preterm delivery in relation to cervical length in severe cases of twin-to-twin transfusion syndrome (TTTS) diagnosed before 26 weeks of gestation and treated by laser coagulation of the intertwin placental anastomoses. METHODS This was an observational study of cases of severe TTTS diagnosed before 26 weeks of gestation and treated by fetoscopic laser coagulation between January 2002 and December 2003 in three centers. Laser was the first-line treatment in all cases. Elective preterm deliveries before 34 weeks' for maternal or fetal indications, including intrauterine death of both fetuses, were excluded. Transvaginal sonographic measurement of cervical length prior to laser treatment and other risk factors of preterm delivery were evaluated by univariate and logistic regression analysis. RESULTS Among the 137 women included, the mean cervical length was 32 and 38 mm in women delivering before and at or after 34 weeks, respectively (P < 0.001). For a cervical length of < 30 mm, the risk of delivery before 34 weeks was 74%. Severity of the disease, deepest vertical pool of amniotic fluid and amniotic fluid volume drained after the procedure were not associated with preterm delivery. Logistic regression analysis identified three independent factors to predict preterm delivery: short cervical length (increased risk), parity (increased risk) and intrauterine death of one twin (decreased risk). CONCLUSION In TTTS treated by laser, without indications for elective preterm birth, cervical length before treatment is significantly associated with gestational age at delivery, and this is independent of parity, intrauterine death of one fetus and other risk factors.
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Affiliation(s)
- R Robyr
- Department of Obstetrics and Gynecology, Paris-Ouest University Versailles-St Quentin, Paris, France
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Huber A, Hecher K. How can we diagnose and manage twin–twin transfusion syndrome? Best Pract Res Clin Obstet Gynaecol 2004; 18:543-56. [PMID: 15279816 DOI: 10.1016/j.bpobgyn.2004.04.006] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Severe mid-trimester twin-twin transfusion syndrome (TTS) complicates about 15% of monochorionic twin pregnancies. If left untreated, the mortality is 80-100%. The pathophysiological prerequisite for the onset of TTS is unequal blood flow via arteriovenous placental anastomoses from the so-called donor to the recipient twin. This can result in hypovolemia, hypotension and oligo- or anuria in the donor, and hypervolemia, hypertension, polyuria and finally heart failure in the recipient. Leading sonographic signs of TTS include severe oligo- or anhydramnios and a small or absent bladder filling in the donor in contrast to polyhydramnios with increased bladder filling in the recipient. Patients might present with clinical symptoms due to massive polyhydramnios. In severe mid-trimester TTS, fetoscopic laser occlusion of the anastomosing vessels on the placental surface under local anaesthesia plus subsequent amniodrainage is the most promising therapeutic option at present. In acute TTS after 26 weeks of gestation, amniodrainage is the therapy of choice. All patients suspected of this high-risk condition should be referred to a specialized fetal medicine centre.
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Affiliation(s)
- Agnes Huber
- Department of Obstetrics and Fetal Medicine, Universitäts Klinikum-Eppendorf, Martimistrasse 52 D-20246 Hamburg, Germany
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Ishii K, Chmait RH, Martínez JM, Nakata M, Quintero RA. Ultrasound assessment of venous blood flow before and after laser therapy: approach to understanding the pathophysiology of twin-twin transfusion syndrome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2004; 24:164-168. [PMID: 15287054 DOI: 10.1002/uog.1104] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
OBJECTIVE To estimate direction and volume of blood exchange between the donor twin and recipient twin by ultrasound assessment of blood flow in the umbilical vein before and after selective laser photocoagulation of communicating vessels (SLPCV) for twin-twin transfusion syndrome (TTTS). METHODS Forty-one TTTS patients underwent Doppler examination of the umbilical vein before and 24 h after SLPCV. The diameter and mean time-averaged velocity of the umbilical vein were estimated. Total umbilical venous flow (TUVF) was calculated as follows: TUVF (mL/min) = mean time-averaged velocity (cm/s) x mean cross-sectional area (cm2) x 60 (s). RESULTS TUVF was significantly higher in the recipient (111.2 mL/min) than in the donor twin (44.8 mL/min) before SLPCV (P < 0.0001). However, TUVF was no different between the recipient and the donor twin after SLPCV (93.1 vs. 70.7 mL/min, recipient and donor twin, respectively, P = 0.11). The donor twin's TUVF increased after surgery (P < 0.0001), while the recipient twin's TUVF decreased (P = 0.041). The median postoperative increase in the donor twin's TUVF of 25.9 mL/min had a corresponding decrease of TUVF in the recipient twin of 18.1 mL/min (P = 0.27). CONCLUSIONS Our data suggest that untreated TTTS is characterized by excessive umbilical venous blood flow in the recipient twin relative to the donor twin. Laser surgery results in concordant changes in umbilical venous flow in opposite directions between the donor and recipient twins, eliminating the initial imbalance. Our results lend support to the fundamental hypothesis of unbalanced blood flow exchange (net flow from donor to recipient) between monochorionic twins as the cause for TTTS and that laser surgery eliminates the pathophysiological cause.
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Affiliation(s)
- K Ishii
- Florida Institute for Fetal Diagnosis and Therapy, St Joseph's Women's Hospital, Tampa, FL, USA
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