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da Silva Rocha J, Guedes-Martins L, Cunha A. Twin Anemia-Polycythemia Sequence (TAPS): From Basic Research to Clinical Practice. Curr Vasc Pharmacol 2023; 21:91-105. [PMID: 36718965 DOI: 10.2174/1570161121666230131112930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 12/30/2022] [Accepted: 12/30/2022] [Indexed: 02/01/2023]
Abstract
Twin pregnancy is associated with an increased risk of perinatal and maternal complications, and early establishment of the chorionicity type defines this risk. In monochorionic (MC) pregnancies, the fetuses share the same placental mass and exhibit vascular anastomoses crossing the intertwin membrane, and the combination and pattern of anastomoses determine the primary clinical picture and occurrence of future complications. Twin Anemia-Polycythemia Sequence (TAPS) was first described in 2006 after fetoscopic laser surgery in twin-to-twin transfusion syndrome (TTTS) twins, and in 2007, the first spontaneous cases were reported, recognizing TAPS as an individualized vascular identity in fetofetal transfusion syndromes. There are two types of TAPS: spontaneous (3-5%) and iatrogenic or postlaser (2-16%). TAPS consists of small diameter arteriovenous anastomoses (<1 mm) and low-rate, small-caliber AA anastomoses in the absence of amniotic fluid discordances. There are certain antenatal and postnatal diagnostic criteria, which have progressively evolved over time. New, additional secondary markers have been proposed, and their reliability is being studied. The best screening protocol for TAPS in MC twins is still a matter of debate. This review provides a survey of the relevant literature on the epidemiology, vascular pathophysiology, underlying hemodynamic factors that regulate mismatched vascular connections, and diagnostic criteria of this condition. The aim is to increase awareness and knowledge about this recently identified and frequently unrecognized and misdiagnosed pathology.
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Affiliation(s)
- Joana da Silva Rocha
- Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto 4050-313, Portugal
| | - Luís Guedes-Martins
- Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto 4050-313, Portugal
- Centro Hospitalar Universitário do Porto EPE, Centro Materno Infantil do Norte, Centro de Medicina Fetal, Serviço de Obstetrícia, Departamento da Mulher e da Medicina Reprodutiva, Largo Prof. Abel Salazar, Porto 4099-001, Portugal
- Unidade de Investigação e Formação - Centro Materno Infantil do Norte, Porto 4099-001, Portugal
- Instituto de Investigação e Inovação em Saúde, Universidade do Porto, 4200-319 Portugal
| | - Ana Cunha
- Centro Hospitalar Universitário do Porto EPE, Centro Materno Infantil do Norte, Centro de Medicina Fetal, Serviço de Obstetrícia, Departamento da Mulher e da Medicina Reprodutiva, Largo Prof. Abel Salazar, Porto 4099-001, Portugal
- Unidade de Investigação e Formação - Centro Materno Infantil do Norte, Porto 4099-001, Portugal
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Giorgione V, D'antonio F, Manji A, Reed K, Khalil A. Perinatal outcome of pregnancy complicated by twin anemia-polycythemia sequence: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:813-823. [PMID: 33428243 DOI: 10.1002/uog.23585] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/18/2020] [Accepted: 12/29/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To report the perinatal outcome of monochorionic diamniotic (MCDA) twin pregnancies complicated by twin anemia-polycythemia sequence (TAPS), according to the type of TAPS (spontaneous or postlaser) and the management option adopted. METHODS MEDLINE, EMBASE and The Cochrane Library databases were searched for studies reporting on the outcome of twin pregnancies complicated by TAPS. Inclusion criteria were non-anomalous MCDA twin pregnancies with a diagnosis of TAPS. The primary outcome was perinatal mortality; secondary outcomes were neonatal morbidity and preterm birth (PTB). The outcomes were stratified according to the type of TAPS (spontaneous or following laser treatment for twin-twin transfusion syndrome) and the management option adopted (expectant, laser surgery, intrauterine transfusion (IUT) or selective reduction (SR)). Random-effects meta-analysis of proportions was used to analyze the data. RESULTS Perinatal outcome was assessed according to whether TAPS occurred spontaneously or after laser treatment in 506 pregnancies (38 studies). Intrauterine death (IUD) occurred in 5.2% (95% CI, 3.6-7.1%) of twins with spontaneous TAPS and in 10.2% (95% CI, 7.4-13.3%) of those with postlaser TAPS, while the corresponding rates of neonatal death were 4.0% (95% CI, 2.6-5.7%) and 9.2% (95% CI, 6.6-12.3%), respectively. Severe neonatal morbidity occurred in 29.3% (95% CI, 25.6-33.1%) of twins after spontaneous TAPS and in 33.3% (95% CI, 17.4-51.8%) after postlaser TAPS, while the corresponding rates of severe neurological morbidity were 4.0% (95% CI, 3.5-5.7%) and 11.1% (95% CI, 6.2-17.2%), respectively. PTB complicated 86.3% (95% CI, 77.2-93.3%) of pregnancies with spontaneous TAPS and all cases with postlaser TAPS (100% (95% CI, 84.3-100%)). Iatrogenic PTB was more frequent than spontaneous PTB in both groups. Perinatal outcome was assessed according to the management option adopted in 417 pregnancies (21 studies). IUD occurred in 9.8% (95% CI, 4.3-17.1%) of twins managed expectantly and in 13.1% (95% CI, 9.2-17.6%), 12.1% (95% CI, 7.7-17.3%) and 7.6% (95% CI, 1.3-18.5%) of those treated with laser surgery, IUT and SR, respectively. Severe neonatal morbidity affected 27.3% (95% CI, 13.6-43.6%) of twins in the expectant-management group, 28.7% (95% CI, 22.7-35.1%) of those in the laser-surgery group, 38.2% (95% CI, 18.3-60.5%) of those in the IUT group and 23.3% (95% CI, 10.5-39.2%) of those in the SR group. PTB complicated 80.4% (95% CI, 59.8-94.8%), 73.4% (95% CI, 48.1-92.3%), 100% (95% CI, 76.5-100%) and 100% (95% CI, 39.8-100%) of pregnancies after expectant management, laser surgery, IUT and SR, respectively. CONCLUSIONS The present meta-analysis provides pooled estimates of the risks of perinatal mortality, neonatal morbidity and PTB in twin pregnancies complicated by TAPS, stratified by the type of TAPS and the management option adopted. Although a direct comparison could not be performed, the results from this systematic review suggest that spontaneous TAPS may have a better prognosis than postlaser TAPS. No differences in terms of mortality and morbidity were observed when comparing different management options for TAPS, although these findings should be interpreted with caution in view of the limitations of the included studies. Individualized prenatal management, taking into account the severity of TAPS and gestational age, is currently the recommended strategy. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- V Giorgione
- Twin Trust Centre for Research and Clinical Excellence, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - F D'antonio
- Center for Fetal Care and High-risk Pregnancy, University of Chieti, Italy
| | - A Manji
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - K Reed
- Twins Trust, Aldershot, UK
| | - A Khalil
- Twin Trust Centre for Research and Clinical Excellence, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
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Mok T, Afshar Y, Platt LD, Guo R, Rao RR, Pluym ID, Silverman NS, Han CS. Predicting Adverse Outcomes in Monochorionic-Diamniotic Twins: The Role of Intertwin Discrepancy in Middle Cerebral Artery Doppler Measurements and the Cerebroplacental Ratio. Am J Perinatol 2021; 38:1348-1357. [PMID: 34282577 DOI: 10.1055/s-0041-1732456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE This study was aimed to evaluate the role of intertwin discrepancy in middle cerebral artery peak systolic velocity (MCA-PSV) and cerebroplacental ratio (CPR) for the prediction of adverse outcomes in monochorionic-diamniotic (MCDA) twin pregnancies. STUDY DESIGN A retrospective cohort study of MCDA pregnancies that underwent ultrasound surveillance at a perinatal referral center from 2007 to 2017. Intertwin MCA-PSV discrepancy (MCA-ΔPSV-MoM) was defined as the absolute difference of MCA-PSV multiple of the median (MoM) for gestational age between twins. Intertwin CPR discrepancy (CPR-Δ) was defined as the absolute difference of CPR between twins. The maximum MCA-ΔPSV-MoM and CPR-Δ before and after 26 weeks of gestation were assessed as predictors of pregnancy and neonatal outcomes through simple logistic regression models and Pearson's correlation coefficients. Receiver operating characteristic (ROC) curves were generated to determine the predictive value of maximum MCA-ΔPSV-MoM and CPR-Δ. RESULTS A total of 143 MCDA pregnancies met inclusion criteria. There was a significant association between MCA-ΔPSV-MoM at <26 weeks and the development of twin anemia-polycythemia sequence (TAPS; p = 0.007), intrauterine fetal demise (IUFD; p = 0.009), and neonatal intensive care unit (NICU) admission (p < 0.05). MCA-ΔPSV-MoM at ≥26 weeks was associated with the development of TAPS (p < 0.001). CPR-Δ at <26 weeks was associated with the development of twin-twin transfusion syndrome (TTTS; p = 0.03) and NICU admission (p = 0.02). MCA-ΔPSV-MoM at ≥26 weeks was highly predictive of TAPS (area under curve [AUC] = 0.92). A cut-off of 0.44 would identify TAPS with 100% sensitivity and 73% specificity. CONCLUSION In MCDA pregnancies, intertwin MCA and CPR discrepancies are associated with adverse pregnancy and neonatal outcomes, including TAPS, TTTS, IUFD, and NICU admission. Evaluation of intertwin MCA and CPR differences demonstrated the potential for clinical predictive utility in the surveillance of MCDA twin pregnancies. KEY POINTS · Intertwin discrepancy of MCA-PSV and CPR is associated with adverse pregnancy outcomes.. · Intertwin differences in Doppler ultrasound may occur prior to meeting diagnostic criteria for TTTS or TAPS.. · There is potential clinical predictive utility in MCA and CPR surveillance of MCDA twin pregnancies..
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Affiliation(s)
- Thalia Mok
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Yalda Afshar
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Lawrence D Platt
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California.,Division of Maternal Fetal Medicine, Center for Fetal Medicine and Women's Ultrasound, Los Angeles, California
| | - Rong Guo
- Department of Medicine Statistics Core, David Geffen School of Medicine, Los Angeles, California
| | - Rashmi R Rao
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Ilina D Pluym
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Neil S Silverman
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California.,Division of Maternal Fetal Medicine, Center for Fetal Medicine and Women's Ultrasound, Los Angeles, California
| | - Christina S Han
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California.,Division of Maternal Fetal Medicine, Center for Fetal Medicine and Women's Ultrasound, Los Angeles, California
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Wang X, Li L, Zhao Y, Wei Y, Yuan P. Longer distance between umbilical cord insertions is associated with spontaneous twin anemia polycythemia sequence. Acta Obstet Gynecol Scand 2020; 100:229-234. [PMID: 32897576 DOI: 10.1111/aogs.13991] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 09/02/2020] [Accepted: 09/02/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The aim of the study was to investigate the placental characteristics in spontaneous twin anemia polycythemia sequence. MATERIAL AND METHODS A retrospective case-control study of spontaneous twin anemia polycythemia sequence, twin-to-twin transfusion syndrome and normal monochorionic diamniotic twin pregnancies was performed. The primary outcome was placental characteristics. RESULTS The prevalence of artery-artery anastomoses in spontaneous twin anemia polycythemia sequence and twin-to-twin transfusion syndrome groups was significantly lower than in the normal monochorionic diamniotic twin group (40.0% vs 33.3% vs 88.8%, respectively, P < .001). The total number of vascular anastomoses in the spontaneous twin anemia polycythemia sequence group (with range given in parentheses) was significantly lower than in the two control groups (3 [1-6] vs 5 [1-14] vs 6 [1-20], P = .001/<.001/.794). The number of artery-vein anastomoses in the spontaneous twin anemia polycythemia sequence was significantly lower than in the two control groups (2 [1-5] vs 4 [1-13] vs 5 [1-19], P = .011/.001/1.000). The total diameter of all vascular anastomoses was significantly smaller in the spontaneous twin anemia polycythemia sequence than in the two control groups (0.9 mm [0.3-4.7] vs 5.2 mm [0.8-24.6] vs 7.3 mm [1.0-25.1], P < .001/<.001/.104), as was the total diameter of artery-to-artery anastomoses (0.5 mm [0.3-1.3] vs 2.0 mm [0.5-11.8] vs 2.3 mm [0.7-9.7], P = .003/<.001/1.000) and the total diameter of artery-to-vein anastomoses (0.8 mm [0.3-2.1] vs 4.6 mm [0.8-15.3] vs 4.0 mm [0.2-21.8], P < .001/<.001/1.000). The ratio between the distance of the two umbilical cords insertion points and the placental maximum diameter in the spontaneous twin anemia polycythemia sequence group was significantly larger than in the two control groups (0.78 [0.49-0.99] vs 0.64 [0.32-1.00] vs 0.55 [0.05-1.00], P = .033/<.001/.138). CONCLUSIONS In spontaneous twin anemia polycythemia sequence placentas, the number of superficial vascular anastomoses is lower, their diameter is smaller and the distance between the two umbilical cord insertion points is longer.
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Affiliation(s)
- Xueju Wang
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Luyao Li
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Yangyu Zhao
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Yuan Wei
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Pengbo Yuan
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
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Complications of Monochorionic Diamniotic Twins: Stepwise Approach for Early Identification, Differential Diagnosis, and Clinical Management. MATERNAL-FETAL MEDICINE 2020. [DOI: 10.1097/fm9.0000000000000076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Martinez-Portilla RJ, Lopez-Felix J, Hawkins-Villareal A, Villafan-Bernal JR, Paz Y Miño F, Figueras F, Borrell A. Performance of fetal middle cerebral artery peak systolic velocity for prediction of anemia in untransfused and transfused fetuses: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 54:722-731. [PMID: 30932276 DOI: 10.1002/uog.20273] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Revised: 03/13/2019] [Accepted: 03/16/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To evaluate the performance of fetal middle cerebral artery peak systolic velocity (MCA-PSV) ≥ 1.5 multiples of the median (MoM) for the prediction of moderate-severe anemia, in untransfused and transfused fetuses. METHODS A systematic search was performed to identify relevant observational studies reported in the period 2008-2018 that evaluated the performance of MCA-PSV, using a threshold of 1.5 MoM for the prediction of fetal anemia. Diagnosis of fetal anemia by blood sampling was the reference standard. A hierarchical summary receiver-operating characteristics (hSROC) curve was constructed using random-effects modeling. Subgroup and meta-regression analyses, according to the number of previous intrauterine transfusions, were performed. RESULTS Twelve studies and 696 fetuses were included in the meta-analysis. The area under the hSROC curve (AUC) for moderate-severe anemia was 83%. Pooled sensitivity and specificity (95% CI) were 79% (70-86%) and 73% (62-82%), respectively, and positive and negative likelihood ratios were 2.94 (95% CI, 2.13-4.00) and 0.272 (95% CI, 0.188-0.371). When considering only untransfused fetuses, prediction improved, achieving an AUC of 87%, sensitivity of 86% (95% CI, 75-93%) and specificity of 71% (95% CI, 49-87%). A decline in sensitivity for the prediction of moderate-severe anemia by MCA-PSV ≥1.5 MoM was observed (estimate, -5.5% (95% CI, -10.7 to -0.3%), P = 0.039) as the number of previous transfusions increased. CONCLUSIONS MCA-PSV ≥ 1.5 MoM for the prediction of moderate-severe anemia in untransfused fetuses shows moderate accuracy (86% sensitivity and 71% specificity), which declines with increasing number of intrauterine transfusions. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- R J Martinez-Portilla
- Fetal Medicine Research Center, BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Universitat de Barcelona, Barcelona, Catalonia, Spain
- Maternal-Fetal Medicine and Therapy Research Center, Evidence-Based Health Care Department, on behalf of the Iberoamerican Research Network in Translational, Molecular and Maternal-Fetal Medicine, Mexico City, Mexico
- CIMeTA Research Unit-ISSEA, Aguascalientes, Mexico
| | - J Lopez-Felix
- Maternal-Fetal Center Hospital Ángeles Lomas, Mexico City, Mexico
| | - A Hawkins-Villareal
- Fetal Medicine Research Center, BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - J R Villafan-Bernal
- Mexican Consortium of Biomedicine, Biotechnology and Health Dissemination-Consortium BIO2-DIS, Mexico
- CONACYT Researcher, Department of Surgery, Health Science Center, Autonomous University of Aguascalientes, Aguascalientes, Mexico
- Center for Health Sciences, Autonomous University of Aguascalientes, Aguascalientes, Mexico
| | - F Paz Y Miño
- Fetal Medicine Research Center, BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - F Figueras
- Fetal Medicine Research Center, BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Universitat de Barcelona, Barcelona, Catalonia, Spain
- Center for Biomedical Research on Rare Diseases (CIBER-ER), Madrid, Spain
| | - A Borrell
- Prenatal Diagnosis Unit, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Catalonia, Spain
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Nicholas L, Fischbein R, Aultman J, Ernst-Milner S. Dispelling Myths about Antenatal TAPS: A Call for Action for Routine MCA-PSV Doppler Screening in the United States. J Clin Med 2019; 8:jcm8070977. [PMID: 31277521 PMCID: PMC6678166 DOI: 10.3390/jcm8070977] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 06/29/2019] [Accepted: 07/01/2019] [Indexed: 12/28/2022] Open
Abstract
In the United States, routine middle cerebral artery peak systolic velocity (MCA-PSV) Doppler screening for the detection of antenatal twin anemia-polycythemia sequence (TAPS) is not recommended. The current and only national clinical guideline from the highly-influential Society for Maternal-Fetal Medicine states that, “There is no evidence that monitoring for TAPS with MCA PSV Doppler at any time, including > 26 weeks, improves outcomes, so that this additional screening cannot be recommended at this time.” We argue this recommendation has disproportionate influence on patients and the care they are offered and receive. We use current evidence to highlight and dispel pervasive myths surrounding antenatal TAPS and the value of routine MCA-PSV screening. An ethical framework that illustrates the importance of giving patients the opportunity for routine screening is presented. Findings demonstrate that: (1) both spontaneous and post-laser TAPS is a serious, potentially life-threatening complication, (2) treatment for TAPS is effective and includes expectant management, intrauterine transfusion (IUT), or surgery, (3) and routine MCA-PSV, which has satisfactory diagnostic accuracy, is currently the only way to provide early detection of TAPS. We conclude that routine TAPS screening is a medically proven valuable resource that should be offered to patients in need and to the clinicians who are trying to act toward their benefit.
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Affiliation(s)
- Lauren Nicholas
- Department of Social Sciences, D'Youville College, 591 Niagara Street, Buffalo, NY 14201, USA.
| | - Rebecca Fischbein
- Department of Community and Family Medicine, Northeast Ohio Medical University, 4209 State Route 44, PO Box 95, Rootstown, Ohio 44272, USA
| | - Julie Aultman
- Department of Community and Family Medicine, Northeast Ohio Medical University, 4209 State Route 44, PO Box 95, Rootstown, Ohio 44272, USA
| | - Stephanie Ernst-Milner
- Twin Anaemia Polycythemia Sequence (TAPS) Support Group, TAPS Patient Advocate, 1326HS Almere, The Netherlands
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Nicholas LD, Fischbein RL, Bhamidipalli SS. Twin anemia-polycythemia sequence and routine monitoring practices amongst maternal-fetal medicine specialists in the United States: an initial investigation. J Perinat Med 2019; 47:388-392. [PMID: 30763267 DOI: 10.1515/jpm-2018-0240] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 12/30/2018] [Indexed: 01/08/2023]
Abstract
Background The purpose of this initial investigation was to begin to understand the routine twin anemia-polycythemia sequence (TAPS) monitoring practices of maternal-fetal medicine specialists (MFM specialists) in the United States in the absence of a formal guideline. Methods This study used an anonymous, online survey of 90 MFM specialists who were practicing in the United States. A $5 gift card to an online store was used to incentivize participants. Descriptive statistics were calculated. Results All MFM specialists reported at least some familiarity (100.00%) with TAPS. Most participants (92.94%) were familiar with methods for monitoring patients for TAPS and nearly all (97.50%) responded that they use 'Doppler MCA-PSV' to make a prenatal TAPS diagnosis. Nearly two-thirds of MFM specialists surveyed (65.06%) reported performing regular TAPS monitoring for patients with monochorionic-diamniotic (MCDA) pregnancies. Conclusion Despite no formal guidelines, the majority of American MFM specialists surveyed are using routine TAPS screening in their management of MCDA twin pregnancies, suggesting that the MFM specialists included in this study consider it a valuable diagnostic tool. Future research should further explore this possible trend toward routine TAPS monitoring amongst MFM specialists in the United States, as well as the potential value of routine TAPS monitoring in MCDA pregnancy.
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Affiliation(s)
- Lauren D Nicholas
- Department of Liberal Arts, Social Sciences Program, D'Youville College, 591 Niagara Street, Buffalo, New York, NY 14201, USA
| | - Rebecca L Fischbein
- Department of Family and Community Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
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Hill KM, Masoudian P, Fung-Kee-Fung K, El Demellawy D. Intrauterine Interventions for the Treatment of Twin Anemia-Polycythemia Sequence: A Systematic Review. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 41:981-991. [PMID: 31230662 DOI: 10.1016/j.jogc.2018.04.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Revised: 04/03/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Twin anemia-polycythemia sequence (TAPS) is a complication of monochorionic, multiple gestation pregnancies in which blood shunting through placental anastomoses results in chronic anemia in one fetus and chronic polycythemia in another. The outcomes of different treatment modalities for TAPS are not well known. OBJECTIVE To determine the outcomes of the intrauterine interventions used to treat TAPS. STUDY DESIGN A systematic literature search of MEDLINE, EMBASE, and CENTRAL was performed in June 2016. Primary outcomes were mortality, morbidity, and adverse perinatal outcomes. Data were summarized in the form of weighted means, and statistical difference was determined. RESULTS Twenty-one articles were identified for inclusion in this review and were composed of 105 cases of TAPS. In the cases presented in the literature, there was no statistically significant difference in mortality, morbidity, or emergent Caesarean section rates between expectant management, intrauterine transfusion (IUT), and laser ablation therapy. Laser ablation therapy and IUT were found to have a significantly lower rate of adverse perinatal outcomes when compared to expectantly managed cases. CONCLUSIONS The literature looking into the treatment of TAPS is very limited, with no randomized controlled trials and only one includable comparative study. Based on the data in the case report and case study literature, there is no mortality difference between any of the treatment modalities. Expectant management may be associated with an increase in adverse perinatal outcomes when compared to laser therapy and IUT. More comparative studies are needed to assist clinicians in adopting an evidence-based approach to the treatment of TAPS.
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Affiliation(s)
- Kevin M Hill
- Faculty of Medicine, University of Ottawa, Ottawa, ON
| | | | - Karen Fung-Kee-Fung
- Faculty of Medicine, University of Ottawa, Ottawa, ON; Department of Obstetrics and Gynecology, The Ottawa Hospital, Ottawa, ON
| | - Dina El Demellawy
- Faculty of Medicine, University of Ottawa, Ottawa, ON; Department of Pediatric Pathology, Children's Hospital of Eastern Ontario, Ottawa, ON.
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Bahtiyar M, Ekmekci E, Demirel E, Irani R, Copel J. In utero Partial Exchange Transfusion Combined with in utero Blood Transfusion for Prenatal Management of Twin Anemia-Polycythemia Sequence. Fetal Diagn Ther 2018. [DOI: 10.1159/000486198] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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De Paepe ME, Gündoğan F, Mao Q, Chu S, Shapiro S. Redness discordance in monochorionic twin placentas: Correlation with clinical and placental findings. Placenta 2017; 60:54-60. [PMID: 29208240 DOI: 10.1016/j.placenta.2017.10.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 10/18/2017] [Accepted: 10/21/2017] [Indexed: 11/25/2022]
Abstract
INTRODUCTION/OBJECTIVES Recent studies suggest redness (color) discordance of the placental basal plate may be a marker for twin anemia-polycythemia sequence (TAPS), a recently described complication of diamniotic-monochorionic twinning characterized by marked intertwin hemoglobin (Hb) discordance in the absence of oligohydramnios-polyhydramnios. In this study, we determined the clinicoplacental and choriovascular correlates of basal plate color discordance in monochorionic twin placentas, and assessed its value as postnatal indicator of TAPS. METHODS We performed a clinicoplacental analysis of 100 consecutive non-TTTS diamniotic-monochorionic twin placentas with available photographic documentation of the basal plate. Basal plate redness was quantified by computer-assisted analysis of digital images and expressed as intertwin color difference ratio (CDR). RESULTS The CDR ranged between 1.00 and 3.58 (median CDR: 1.14; 90th %ile: 1.98). Compared to twins with low CDR (N = 90), twins with high CDR (≥2.0; N = 10) had significantly higher hemoglobin difference (11.25 g/dL versus 2.55 g/dL) and significantly fewer and smaller artery-to-artery (AA) and artery-to-vein (AV) anastomoses. Apgar scores and birth weights were equivalent in both groups. Among the 10 twin sets with high CDR, six (60%) qualified as TAPS, as defined by intertwin Hb difference >8 g/dL and absent or very small AA and AV anastomoses. Conversely, 6 of 8 (75%) twin sets with TAPS had a CDR ≥ 2.0. CONCLUSION Intertwin CDR correlates with intertwin hemoglobin difference and chorionic angioarchitecture. A CDR value ≥ 2.0 (the 90%ile value for CDR derived from the present cohort) has high specificity (96%), but relatively low positive predictive value (60%) as indicator of TAPS, as currently defined.
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Affiliation(s)
- Monique E De Paepe
- Department of Pathology, Women and Infants Hospital, Providence, RI, 02905, United States; Department of Pathology and Laboratory Medicine, Alpert Medical School of Brown University, Providence, RI, 02905, United States.
| | - Füsun Gündoğan
- Department of Pathology, Women and Infants Hospital, Providence, RI, 02905, United States; Department of Pathology and Laboratory Medicine, Alpert Medical School of Brown University, Providence, RI, 02905, United States
| | - Quanfu Mao
- Department of Pathology, Women and Infants Hospital, Providence, RI, 02905, United States
| | - Sharon Chu
- Department of Pathology, Women and Infants Hospital, Providence, RI, 02905, United States
| | - Svetlana Shapiro
- Department of Pathology, Women and Infants Hospital, Providence, RI, 02905, United States
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Moaddab A, Nassr AA, Espinoza J, Ruano R, Bateni ZH, Shamshirsaz AA, Mandy GT, Welty SE, Erfani H, Popek EJ, Belfort MA, Shamshirsaz AA. Twin anemia polycythemia sequence: a single center experience and literature review. Eur J Obstet Gynecol Reprod Biol 2016; 205:158-64. [DOI: 10.1016/j.ejogrb.2016.08.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 07/23/2016] [Accepted: 08/13/2016] [Indexed: 10/21/2022]
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13
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Fisher KE, Welsh AW, Wilson I, Henry A. Uncommon complications of monochorionic twin pregnancies: Twin anaemia-polycythaemia sequence. Australas J Ultrasound Med 2016; 19:56-63. [PMID: 34760444 DOI: 10.1002/ajum.12013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Introduction Twin anaemia-polycythaemia sequence (TAPS) occurs when significant haemoglobin discordance exists between monochorionic fetuses. Most reported cases occur iatrogenically after twin-to-twin transfusion syndrome (TTTS) laser therapy; spontaneous TAPS is also reported. The purpose of this study was to investigate pregnancy management and immediate neonatal outcomes for monochorionic multiple pregnancies complicated by TAPS referred to the NSW Fetal Therapy Centre (FTC). Methods Retrospective cohort study of multiple pregnancies referred to NSW FTC between April 2006 and April 2014. Fourteen TAPS cases [discordant middle cerebral artery peak systolic volume (MCA-PSV) or clinician diagnosis antenatally, or Hb >20 g/dL vs. <12 g/dL post-natally] were compared to an existing TTTS database (n = 142) and uncomplicated monochorionic diamniotic (MCDA) twin pregnancies (n = 45). Outcomes measured were maternal demographics; ultrasound findings at referral; management, including whether in utero fetal therapy was performed; and pregnancy outcome, including gestation at birth, mode of birth, birthweight, fetal/neonatal complications and neonatal survival to discharge. Results The majority of TAPS cases were spontaneous (9/14) and occurred later in pregnancy than TTTS (median gestation at diagnosis 26.0 ± 4.9 vs. 20.4 ± 2.6 weeks, P < 0.001). However, TAPS perinatal outcome was similar to TTTS (survival of both twins 62% vs. 53%, survival of at least one twin 85% vs. 87%, overall survival 73% vs. 70%) and overall survival significantly lower than for uncomplicated MCDA pregnancies (73% vs. 98%, P < 0.001). Conclusion Overall mortality for TAPS was similar to that of TTTS but significantly higher compared to uncomplicated MCDA pregnancies, underscoring the potential severity of TAPS despite its later gestational onset.
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Affiliation(s)
- Katie E Fisher
- School of Women's and Children's Health University of New South Wales Kensington New South Wales Australia
| | - Alec W Welsh
- School of Women's and Children's Health University of New South Wales Kensington New South Wales Australia.,Department of Maternal-Fetal Medicine Royal Hospital for Women Sydney New South Wales Australia.,Australian Centre for Perinatal Science UNSW Medicine Sydney New South Wales Australia
| | - Isabella Wilson
- School of Women's and Children's Health University of New South Wales Kensington New South Wales Australia
| | - Amanda Henry
- School of Women's and Children's Health University of New South Wales Kensington New South Wales Australia.,Department of Maternal-Fetal Medicine Royal Hospital for Women Sydney New South Wales Australia.,Australian Centre for Perinatal Science UNSW Medicine Sydney New South Wales Australia
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14
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The Placenta in Twin-to-Twin Transfusion Syndrome and Twin Anemia Polycythemia Sequence. Twin Res Hum Genet 2016; 19:184-90. [PMID: 27098457 DOI: 10.1017/thg.2016.29] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Twin-to-twin transfusion syndrome (TTTS) and twin anemia polycythemia sequence (TAPS) are complications unique to monochorionic twin pregnancies and their shared circulation. Both are the result of the transfusion imbalance in the intertwin circulation. TTTS is characterized by an amniotic fluid discordance, whereas in TAPS, there is a severe discordance in hemoglobin levels. The article gives an overview of the typical features of TTTS and TAPS placentas.
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15
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Lucewicz A, Fisher K, Henry A, Welsh AW. Review of the correlation between blood flow velocity and polycythemia in the fetus, neonate and adult: appropriate diagnostic levels need to be determined for twin anemia-polycythemia sequence. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 47:152-157. [PMID: 25580896 DOI: 10.1002/uog.14782] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 12/01/2014] [Accepted: 01/02/2015] [Indexed: 06/04/2023]
Abstract
Twin anemia-polycythemia sequence (TAPS) is recognized increasingly antenatally by the demonstration of an anemic twin and a polycythemic cotwin using the middle cerebral artery peak systolic velocity (MCA-PSV). While the MCA-PSV has been shown to correlate well with anemia in singleton fetuses, the evidence to support its use to diagnose fetal polycythemia appears to be less clear-cut. We aimed to evaluate fetal, neonatal and adult literature used to support the use of MCA-PSV for the diagnosis of polycythemia. Comprehensive literature searches were performed for ultrasound evidence of polycythemia in the human fetus, neonate and adult using key search terms. Only manuscripts in the English language with an abstract were considered for the review, performed in June 2014. Fifteen manuscripts were found for the human fetus, including 38 cases of TAPS. Nine of these defined fetal polycythemia as MCA-PSV < 0.8 multiples of the median (MoM), five used < 1.0 MoM and one used 0.8-1.0 MoM. Only two studies, involving a total of 15 cases, proposed a diagnostic level, acknowledging false-positive and -negative cases, though neither reported sensitivities or specificities. Six neonatal studies (96 neonates) demonstrated evidence of decreased cerebral velocities in polycythemia and a consequent increase with hemodilution. In the adult, five studies (57 polycythemic adults) demonstrated increased flow or velocity with hemodilution. Neither neonatal nor adult studies conclusively defined levels for screening for polycythemia. Despite widespread adoption of a cut-off of < 0.8 MoM in the published literature for the polycythemic fetus in TAPS, this is based upon minimal evidence, with unknown sensitivity and specificity. We recommend caution in excluding TAPS based purely upon the absence of a reduced MCA-PSV.
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Affiliation(s)
- A Lucewicz
- Department of Obstetrics & Gynaecology, Westmead Hospital, Westmead, NSW, Australia
| | - K Fisher
- Faculty of Medicine, School of Women's & Children's Health, University of New South Wales, Sydney, NSW, Australia
| | - A Henry
- Faculty of Medicine, School of Women's & Children's Health, University of New South Wales, Sydney, NSW, Australia
- Department of Obstetrics and Gynaecology, St George Hospital, Kogarah, NSW, Australia
- Australian Centre for Perinatal Science, University of New South Wales, Randwick, NSW, Australia
- Department of Maternal-Fetal Medicine, Royal Hospital for Women, Randwick, NSW, Australia
| | - A W Welsh
- Faculty of Medicine, School of Women's & Children's Health, University of New South Wales, Sydney, NSW, Australia
- Australian Centre for Perinatal Science, University of New South Wales, Randwick, NSW, Australia
- Department of Maternal-Fetal Medicine, Royal Hospital for Women, Randwick, NSW, Australia
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16
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Sananès N, Veujoz M, Severac F, Barthoulot M, Meyer N, Weingertner AS, Kohler M, Guerra F, Gaudineau A, Nisand I, Favre R. Evaluation of the Utility of in utero Treatment of Twin Anemia-Polycythemia Sequence. Fetal Diagn Ther 2015; 38:170-8. [PMID: 25790745 DOI: 10.1159/000380822] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 02/09/2015] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of this study is to evaluate the interest in the in utero treatment of twin anemia-polycythemia sequence (TAPS). METHODS The obstetrical and neonatal data on all cases of TAPS followed up in our institution between 2006 and 2013 were reviewed. Statistical analyses were conducted using Bayesian methods. RESULTS Twenty cases of TAPS were included. Laser therapy or intrauterine transfusion (IUT) was performed on the donor twin in 9 cases. Eleven cases were included in the 'nontreated' group (managed expectantly or diagnosed at birth). The gestational age at diagnosis was lower in the group with treated TAPS [difference (diff) = -22.20 days (-57.13, 14.28), probability (Pr) (diff >0) = 10.6%]. The rate of preterm premature rupture of membranes was higher in the group with treated TAPS [diff = 22.5% (-14, 57), Pr (diff >0) = 89%], but overall mortality was similar. The interval between diagnosis and delivery was longer [diff = 44.37 days (9.41, 77.90), Pr (diff >0) = 99.2%], the TAPS resolution rate was higher [diff = 49.9% (12, 81), Pr (diff >0) = 99.4%], and the neonatal transfusion rate was lower [diff = -30.5% (-60, 0), Pr (diff >0) = 2.6%] in the treated group. CONCLUSION In utero treatment for TAPS is associated with a higher resolution rate of TAPS and a longer time between diagnosis and birth, but overall mortality is the same as with expectant management.
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Affiliation(s)
- Nicolas Sananès
- Department of Obstetrics and Gynecology, Strasbourg University Teaching Hospitals, Strasbourg, France
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17
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Van Winden KR, Quintero RA, Kontopoulos EV, Korst LM, Llanes A, Chmait RH. Pre-Operative Twin Anemia/Polycythemia in the Setting of Twin-Twin Transfusion Syndrome (TTTS). Fetal Diagn Ther 2015; 37:274-80. [DOI: 10.1159/000365919] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 07/07/2014] [Indexed: 11/19/2022]
Abstract
Introduction: Twin-twin transfusion syndrome (TTTS) and twin anemia-polycythemia sequence (TAPS) are classified as distinct clinical disorders associated with unbalanced blood flow through placental vascular communications. Typically, TAPS placentas demonstrate few <1 mm arteriovenous (AV) communications, and at fetoscopy the twins are visibly pale and plethoric. Materials and Methods: In a cohort of TTTS patients who underwent laser surgery, those with preoperative findings suggestive of anemia/polycythemia (AP) were compared to those with TTTS alone. AP was defined as middle cerebral artery peak systolic velocity in one twin >1.5 multiples of the median (MoM), and <1.0 MoM in the other. Results: Of 369 TTTS patients, 9 (2.4%) met criteria for preoperative AP. The mean number (±SD) of AV communications in the TTTS + AP group was 5.6 ± 5.7, compared with 8.8 ± 4.8 in the TTTS-alone group (p = 0.013). Five TTTS + AP patients (56%) had a few thin AV communications (mean 2.8 ± 1.6); all 5 had visibly pale and plethoric twins. The remaining 4 (44%) had large or numerous anastomoses (mean 10.5 ± 6.8); none had fetal skin color discordance. Discussion: Preoperative AP affected 2% of TTTS patients. Of these, approximately half had placental and skin color findings typically reported with isolated TAPS.
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18
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Veujoz M, Sananès N, Severac F, Meyer N, Weingertner AS, Kohler M, Guerra F, Gaudineau A, Nisand I, Favre R. Evaluation of prenatal and postnatal diagnostic criteria for twin anemia-polycythemia sequence. Prenat Diagn 2015; 35:281-8. [DOI: 10.1002/pd.4545] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Revised: 10/30/2014] [Accepted: 12/01/2014] [Indexed: 11/09/2022]
Affiliation(s)
- Marine Veujoz
- Department of Obstetrics and Gynecology; Strasbourg University Teaching Hospital; Strasbourg France
- Federation of Translational Medicine; Strasbourg University Teaching Hospital; Strasbourg France
| | - Nicolas Sananès
- Department of Obstetrics and Gynecology; Strasbourg University Teaching Hospital; Strasbourg France
- Federation of Translational Medicine; Strasbourg University Teaching Hospital; Strasbourg France
- INSERM, UMR-S 1121, ‘Biomatériaux et Bioingénierie’; Strasbourg France
| | - François Severac
- Federation of Translational Medicine; Strasbourg University Teaching Hospital; Strasbourg France
- Department of Public Health; Strasbourg University Teaching Hospital; Strasbourg France
| | - Nicolas Meyer
- Federation of Translational Medicine; Strasbourg University Teaching Hospital; Strasbourg France
- Department of Public Health; Strasbourg University Teaching Hospital; Strasbourg France
| | - Anne-Sophie Weingertner
- Department of Obstetrics and Gynecology; Strasbourg University Teaching Hospital; Strasbourg France
- Federation of Translational Medicine; Strasbourg University Teaching Hospital; Strasbourg France
| | - Monique Kohler
- Department of Obstetrics and Gynecology; Strasbourg University Teaching Hospital; Strasbourg France
- Federation of Translational Medicine; Strasbourg University Teaching Hospital; Strasbourg France
| | - Fernando Guerra
- Department of Obstetrics and Gynecology; Strasbourg University Teaching Hospital; Strasbourg France
- Federation of Translational Medicine; Strasbourg University Teaching Hospital; Strasbourg France
| | - Adrien Gaudineau
- Department of Obstetrics and Gynecology; Strasbourg University Teaching Hospital; Strasbourg France
- Federation of Translational Medicine; Strasbourg University Teaching Hospital; Strasbourg France
| | - Israël Nisand
- Department of Obstetrics and Gynecology; Strasbourg University Teaching Hospital; Strasbourg France
- Federation of Translational Medicine; Strasbourg University Teaching Hospital; Strasbourg France
| | - Romain Favre
- Department of Obstetrics and Gynecology; Strasbourg University Teaching Hospital; Strasbourg France
- Federation of Translational Medicine; Strasbourg University Teaching Hospital; Strasbourg France
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Slaghekke F, Favre R, Peeters SHP, Middeldorp JM, Weingertner AS, van Zwet EW, Klumper FJ, Oepkes D, Lopriore E. Laser surgery as a management option for twin anemia-polycythemia sequence. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 44:304-310. [PMID: 24706478 DOI: 10.1002/uog.13382] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 03/27/2014] [Accepted: 03/27/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To evaluate the effectiveness of laser treatment for antenatally detected twin anemia-polycythemia sequence (TAPS) compared with intrauterine transfusion or expectant management. METHODS All monochorionic twin pregnancies with TAPS managed between 2005 and 2013 in two European fetal therapy centers were evaluated. The outcomes of TAPS cases treated primarily with laser surgery were compared with the outcomes of cases managed expectantly or treated with intrauterine transfusion. RESULTS In this retrospective study 52 cases of TAPS were detected antenatally and were managed with either laser surgery (n=8; 15%) or intrauterine blood transfusion (n=17; 33%) or expectantly (n=27; 52%). Perinatal survival in the laser group was 94% (15/16) vs 85% (29/34) in the intrauterine-transfusion group and 83% (45/54) in the expectant-management group (P=0.30). The rates of severe neonatal morbidity in liveborn neonates in the laser, intrauterine-transfusion and expectant-management groups were 7% (1/15), 38% (12/32) and 24% (12/50), respectively (P=0.17). There was a significant reduction in respiratory distress syndrome in cases treated by laser. No severe postnatal hematological complications were detected in the laser group compared with 72% (23/32) in the intrauterine-transfusion group and 52% (26/50) in the expectant-management group (P<0.01). Median time between diagnosis and birth was 11 weeks in the laser group compared to 5 weeks after intrauterine transfusion and 8 weeks after expectant management (P<0.01). After injection of colored dye no residual anastomoses were found in the laser group. CONCLUSIONS Laser surgery for TAPS appears to improve perinatal outcome by prolonging pregnancy and reducing respiratory distress syndrome. Larger, adequately controlled studies are needed to reach firm conclusions on the optimal management of TAPS.
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Affiliation(s)
- F Slaghekke
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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20
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Abdel-Sattar M, Platt LD, DeVore G, Porto M, Benirschke K, Chmait RH. Treatment of Complicated Spontaneous Twin Anemia-Polycythemia Sequence via Fetoscopic Laser Ablation of the Vascular Communications. Fetal Diagn Ther 2014; 38:233-7. [DOI: 10.1159/000362271] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 03/14/2014] [Indexed: 11/19/2022]
Abstract
Monochorionic diamniotic twins share a single placenta and have intertwin vascular communications that link the circulatory systems of the twins together. Twin anemia-polycythemia sequence (TAPS) is an atypical form of twin-twin transfusion syndrome (TTTS) caused by net transfer of blood from one fetus to the other and is characterized by large intertwin hemoglobin differences in the absence of oligohydramnios and polyhydramnios. This condition may develop spontaneously (sTAPS) or as a result of residual vascular communications after prior laser surgery. Because of the relatively low prevalence and lack of clinical awareness, the natural history of sTAPS is unclear and the antenatal treatment remains controversial. Case series of sTAPS have described expectant management with timed delivery, intrauterine blood transfusion, and fetoscopic laser treatment. Favorable outcomes have been described in cases of uncomplicated sTAPS that underwent conservative measures. However, we believe that there may be a subgroup of high-risk or complicated sTAPS patients that may benefit from definitive treatment afforded by fetoscopic laser therapy. We describe 3 complicated cases of sTAPS successfully treated with selective laser photocoagulation of communicating vessels. In 2 of the cases, placental pathology identified thrombosed fetal vessels of the polycythemic twin.
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Sobreira I, Sousa C, Paiva C, Freitas S, Proença E, Carvalho C. Twin anemia-polycythemia sequence: the importance of an accurate diagnosis. CASE REPORTS IN PERINATAL MEDICINE 2014. [DOI: 10.1515/crpm-2013-0051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Twin anemia-polycythemia sequence (TAPS), which was first described in 2007, is an atypical chronic form of twin-twin transfusion syndrome (TTTS). It presents as a large intertwin hemoglobin difference, with one twin developing anemia and the other polycythemia, without the traditional “polyhydramnios-oligohydramnios sequence” that is usually seen in TTTS. So far, ideal management of TAPS is not clear. We report here the case of a monochorionic biamniotic gestation, complicated by TAPS, detected at 30 weeks’ gestation that led to an emergent cesarean section. The recipient twin had an uneventful evolution. The donor twin was severely anemic, with a hemoglobin level of 2.5 g/dL that required immediate blood transfusion and intensive care management measures. Clinical evolution was favorable with good outcome in both twins. This case report intends to emphasize the association between hydrops fetalis and severe anemia, as well as the relevance of antenatal Doppler ultrasound investigations and the importance of an accurate management decision.
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Affiliation(s)
- Inês Sobreira
- Neonatology Department, Maternidade Júlio Dinis – Oporto Hospital Center, Oporto, Portugal
| | - Cátia Sousa
- Neonatology Department, Maternidade Júlio Dinis – Oporto Hospital Center, Oporto, Portugal
| | - Catarina Paiva
- Obstetrics and Gynecology Department, Maternidade Júlio Dinis – Oporto Hospital Center, Oporto, Portugal
| | - Serafina Freitas
- Neonatology Department, Maternidade Júlio Dinis – Oporto Hospital Center, Oporto, Portugal
| | - Elisa Proença
- Neonatology Department, Maternidade Júlio Dinis – Oporto Hospital Center, Oporto, Portugal
| | - Carmen Carvalho
- Neonatology Department, Maternidade Júlio Dinis – Oporto Hospital Center, Oporto, Portugal
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Rossi AC, Prefumo F. Perinatal Outcomes of Twin Anemia–Polycythemia Sequence: A Systematic Review. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2014; 36:701-707. [DOI: 10.1016/s1701-2163(15)30512-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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23
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Movva VC, Rijhsinghani A. Discrepancy in placental echogenicity: a sign of twin anemia polycythemia sequence. Prenat Diagn 2014; 34:809-11. [DOI: 10.1002/pd.4371] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Revised: 03/26/2014] [Accepted: 03/26/2014] [Indexed: 11/07/2022]
Affiliation(s)
- Vani C. Movva
- Perinatal Care Division, Department of Obstetrics and Gynecology and College of Medicine; University of Iowa Hospitals and Clinics; Iowa City IA 52242-1080 USA
| | - Asha Rijhsinghani
- Perinatal Care Division, Department of Obstetrics and Gynecology and College of Medicine; University of Iowa Hospitals and Clinics; Iowa City IA 52242-1080 USA
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Ishii K, Hayashi S, Mabuchi A, Taguchi T, Yamamoto R, Murata M, Mitsuda N. Therapy by Laser Equatorial Placental Dichorionization for Early-Onset Spontaneous Twin Anemia-Polycythemia Sequence. Fetal Diagn Ther 2013; 35:65-8. [DOI: 10.1159/000354985] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Accepted: 08/08/2013] [Indexed: 11/19/2022]
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25
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Favre R, Koch A, Weingertner AS, Sananes N, Trieu NT, Kohler M, Guerra F, Nisand I. Vascular pattern in monochorionic placentas with spontaneous TAPS and TTTS with residual anastomoses after laser: a case-control study. Prenat Diagn 2013; 33:979-82. [DOI: 10.1002/pd.4177] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2012] [Revised: 04/13/2013] [Accepted: 05/30/2013] [Indexed: 11/08/2022]
Affiliation(s)
- Romain Favre
- Fetal Medicine; CMCO-HUS; 19 Rue Louis Pasteur 67300 Schiltigheim/Strasbourg France
| | - Antoine Koch
- Fetal Medicine; CMCO-HUS; 19 Rue Louis Pasteur 67300 Schiltigheim/Strasbourg France
| | | | - Nicolas Sananes
- Fetal Medicine; CMCO-HUS; 19 Rue Louis Pasteur 67300 Schiltigheim/Strasbourg France
| | - Ngoc Tu Trieu
- Fetal Medicine; CMCO-HUS; 19 Rue Louis Pasteur 67300 Schiltigheim/Strasbourg France
| | - Monique Kohler
- Fetal Medicine; CMCO-HUS; 19 Rue Louis Pasteur 67300 Schiltigheim/Strasbourg France
| | - Fernando Guerra
- Fetal Medicine; CMCO-HUS; 19 Rue Louis Pasteur 67300 Schiltigheim/Strasbourg France
| | - Israel Nisand
- Fetal Medicine; CMCO-HUS; 19 Rue Louis Pasteur 67300 Schiltigheim/Strasbourg France
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Lopriore E, Slaghekke F, Kersbergen KJ, de Vries LS, Drogtrop AP, Middeldorp JM, Oepkes D, Benders MJ. Severe cerebral injury in a recipient with twin anemia-polycythemia sequence. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2013; 41:702-706. [PMID: 23124777 DOI: 10.1002/uog.12337] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/19/2012] [Indexed: 06/01/2023]
Abstract
Twin anemia-polycythemia sequence (TAPS) results from slow intertwin blood transfusion through minuscule placental vascular anastomoses and is characterized by large intertwin hemoglobin differences in the absence of amniotic fluid discordance. The optimal management of TAPS is not clear. We report a case of TAPS detected antenatally by Doppler ultrasound examination at 15 + 6 weeks' gestation. After counseling, the parents opted for expectant management. Regular Doppler measurements were performed and these remained fairly stable. An emergency Cesarean section was performed at 34 + 5 weeks following signs of fetal distress. The donor twin was severely anemic while the recipient twin had severe polycythemia-hyperviscosity syndrome. On day 1, the recipient developed respiratory insufficiency and subclinical status epilepticus. Magnetic resonance imaging showed a total loss of gray-white matter differentiation as a sign of severe diffuse cerebral ischemia and bilateral intra- and extra-axial hemorrhages. There was almost complete lack of arterial and venous cerebral blood flow. On day 3 intensive care treatment was withdrawn in view of the severity of the brain injury. This case report demonstrates that TAPS may lead to severe cerebral injury and fatal outcome in the recipient twin, and highlights the importance of antenatal Doppler ultrasound monitoring and choice of management.
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Affiliation(s)
- E Lopriore
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands.
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Placental characteristics in monochorionic twins with spontaneous versus post-laser twin anemia-polycythemia sequence. Placenta 2013; 34:456-9. [DOI: 10.1016/j.placenta.2013.02.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Revised: 01/25/2013] [Accepted: 02/14/2013] [Indexed: 11/22/2022]
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Genova L, Slaghekke F, Klumper F, Middeldorp J, Steggerda S, Oepkes D, Lopriore E. Management of Twin Anemia-Polycythemia Sequence Using Intrauterine Blood Transfusion for the Donor and Partial Exchange Transfusion for the Recipient. Fetal Diagn Ther 2013; 34:121-6. [DOI: 10.1159/000346413] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2012] [Accepted: 12/10/2012] [Indexed: 11/19/2022]
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de Villiers S, Slaghekke F, Middeldorp J, Klumper F, Walther F, Oepkes D, Lopriore E. Arterio-arterial vascular anastomoses in monochorionic twin placentas with and without twin anemia-polycythemia sequence. Placenta 2012; 33:227-9. [DOI: 10.1016/j.placenta.2012.01.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Revised: 01/04/2012] [Accepted: 01/05/2012] [Indexed: 12/01/2022]
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Gratacós E, Ortiz J, Martinez J. A Systematic Approach to the Differential Diagnosis and Management of the Complications of Monochorionic Twin Pregnancies. Fetal Diagn Ther 2012; 32:145-55. [DOI: 10.1159/000342751] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Accepted: 08/04/2012] [Indexed: 11/19/2022]
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Placental characteristics in growth-discordant monochorionic twins: a matched case-control study. Placenta 2011; 33:171-4. [PMID: 22197628 DOI: 10.1016/j.placenta.2011.12.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Revised: 12/04/2011] [Accepted: 12/05/2011] [Indexed: 10/14/2022]
Abstract
OBJECTIVE To compare the placental characteristics in monochorionic (MC) twin pregnancies with and without birth weight discordance (BWD). METHODS We performed a matched case-control study to compare the placental characteristics of MC placentas from pregnancies with BWD (≥25%) (n = 47) with a control group of MC placentas without BWD (n = 47), matched for gestational age at birth. Placental sharing, angioarchitecture and diameter of the arterio-arterial (AA) anastomosis were assessed by placental injection with colored dye. RESULTS The rate of velamentous cord insertion in MC placentas with and without BWD was 30% (28/94) and 16% (15/94), respectively (p = 0.036). Placental sharing discordance in MC placentas with and without BWD was 36% and 17%, respectively (p < 0.001). The mean diameter of the AA anastomosis in MC placentas with and without BWD was 2.2 mm and 1.8 mm, respectively (p = 0.024). CONCLUSION MC placentas from growth-discordant twins are more unequally shared, have a higher rate of velamentous cord insertions and larger diameter of AA anastomosis compared to gestational age matched controls.
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Lopriore E, Slaghekke F, Middeldorp JM, Klumper FJ, van Lith JM, Walther FJ, Oepkes D. Accurate and simple evaluation of vascular anastomoses in monochorionic placenta using colored dye. J Vis Exp 2011:e3208. [PMID: 21912373 PMCID: PMC3230184 DOI: 10.3791/3208] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
The presence of placental vascular anastomoses is a conditio sine qua non for the development of twin-to-twin transfusion syndrome (TTTS) and twin anemia polycythemia sequence (TAPS)(1,2). Injection studies of twin placentas have shown that such anastomoses are almost invariably present in monochorionic twins and extremely rare in dichorionic twins(1). Three types of anastomoses have been documented: from artery to artery, from vein to vein and from artery to vein. Arterio-venous (AV) anastomoses are unidirectional and are referred to as "deep" anastomoses since they proceed through a shared placental cotyledon, whereas arterio-arterial (AA) and veno-venous (VV) anastomoses are bi-directional and are referred to as "superficial" since they lie on the chorionic plate. Both TTTS and TAPS are caused by net imbalance of blood flow between the twins due to AV anastomoses. Blood from one twin (the donor) is pumped through an artery into the shared placental cotyledon and then drained through a vein into the circulation of the other twin (the recipient). Unless blood is pumped back from the recipient to the donor through oppositely directed deep AV anastomoses or through superficial anastomoses, an imbalance of blood volumes occurs, gradually leading to the development of TTTS or TAPS. The presence of an AA anastomosis has been shown to protect against the development of TTTS and TAPS by compensating for the circulatory imbalance caused by the uni-directional AV anastomoses(1,2). Injection of monochorionic placentas soon after birth is a useful mean to understand the etiology of various (hematological) complications in monochorionic twins and is a required test to reach the diagnosis of TAPS(2). In addition, injection of TTTS placentas treated with fetoscopic laser surgery allows identification of possible residual anastomoses(3-5). This additional information is of paramount importance for all perinatologists involved in the management and care of monochorionic twins with TTTS or TAPS. Several placental injection techniques are currently being used. We provide a simple protocol to accurately evaluate the presence of (residual) vascular anastomoses using colored dye injection.
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Affiliation(s)
- Enrico Lopriore
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center.
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