Prediction of Twin-to-Twin Transfusion Syndrome Using Characteristic Waveforms of Ductus Venosus in Recipient Twins

Sensitive detection of hemodynamic changes after fetoscopic laser photocoagulation by assessing intraventricular pressure difference in fetuses with twin-to-twin transfusion syndrome

OBJECTIVES

To assess the hemodynamics of twin-to-twin transfusion syndrome (TTTS), we measured the intraventricular pressure difference (IVPD), a sensitive marker of myocardial diastolic function, using fetal echocardiography.

METHODS

We included 28 monochorionic diamniotic (MD) twins diagnosed with TTTS who underwent fetoscopic laser photocoagulation (FLP) between 2018 and 2022. Color M-mode Doppler images of both cardiac ventricles were obtained before and after FLP. According to this evaluation, the IVPDs were divided into three groups; those with total, basal, and mid-apical IVPD.

RESULTS

Of the 28 twins, 21 were available for analysis (including eight, eight, three, and two cases in stages Quintero Ⅰ, Ⅱ, Ⅲd, and Ⅲr, respectively). Comparing the pre and postFLP results, significant increases in total and mid-apical IVPD in the left ventricle (LV) of recipient twins were noted (total and mid-apical IVPD: p=0.026 and 0.013, respectively). In the LV of the donor twins, all IVPDs were significantly increased after FLP (total, basal, and mid-apical IVPD: p=0.003, 0.001, and 0.022, respectively). In addition, comparisons between the donor and recipient groups did not show significant differences in either ventricle before FLP.

CONCLUSIONS

IVPD detected subtle hemodynamics changes, such as volume overload and diastolic dysfunction in TTTS before and after FLP. Therefore, IVPD may be a useful marker for monitoring myocardial diastolic function in TTTS.

Different expressions of cardiac biomarkers between different types of acquired right ventricular outflow tract abnormality in monochorionic twins

OBJECTIVE

To investigate the differences in amniotic fluid cardiac biomarkers and clinical features among types of right ventricular outflow tract (RVOT) abnormality in monochorionic (MC) twins.

METHOD

This prospective study included MC twins that underwent laser surgery. Recipient or larger twins (group A) and donor or smaller twins (group B) were assessed and divided into those with a normal right ventricular outflow tract (normal RVOT), functional pulmonary atresia (fPA), or pulmonary stenosis (PS). Amniotic fluid levels of NT-proBNP (afNT-proBNP) and cardiac troponin T (afTnT) were examined during surgery.

RESULTS

Of 190 fetuses in group A, there were 14 RVOT abnormality cases (including 7 fPA and 7 PS). No group B fetuses showed RVOT abnormality findings. In group A, later and earlier gestational age at surgery were observed in fPA (25.1±2.8 weeks) and PS groups (17.8±0.9 weeks). All survived PS cases demonstrated progressive pulmonary valve obstruction, not observed in fPA groups. AfNT-proBNP were significantly higher in fPA and PS than in normal RVOT group (p<0.05). AfTnT was significantly higher in group A with PS than fPA and normal RVOT groups (p<0.05).

CONCLUSION

Among RVOT abnormality types in group A, amniotic fluid cardiac biomarkers were differently expressed, and clinical features were also differentiated. These findings provide insight into the pathophysiological influence on RVOT in MC twins. This article is protected by copyright. All rights reserved.

Association of amniotic fluid natriuretic peptide levels with ductus venosus Doppler flow in recipient twins with twin-to-twin transfusion syndrome : DV flow and NT-proBNP in TTTS recipient twins

PURPOSE

This study examined the relationships between fetal quantitative Doppler parameters and amniotic fluid N-terminal prohormone brain natriuretic peptide (afNT-proBNP) levels as a biomarker of the increased cardiac load in recipient twins with twin-to-twin transfusion syndrome (TTTS).

METHODS

This single-center, prospective study included all monochorionic diamniotic (MD) twin pregnancies that were diagnosed with TTTS and underwent fetoscopic laser surgery. Doppler flow was used to measure the pulsatility index (PI) of the umbilical artery (UA), ductus venosus (DV), and middle cerebral artery (MCA) of each recipient and donor twins. The afNT-proBNP levels of recipient twins were examined at the time of surgery. The Spearman or Pearson correlation coefficients were used to assess the relationships between afNT-proBNP levels and Doppler parameters.

RESULTS

A total of 150 MD twin pregnancies were included. The afNT-proBNP levels of the recipient twins showed a stronger correlation with the DV-PI (r = 0.637; P < 0.001) of recipient twins than with the UA-PI and MCA-PI of recipient twins. The Doppler parameters of donor twins were scarcely correlated with the afNT-proBNP levels of the recipient twins.

CONCLUSION

A positive correlation between the DV-PI and afNT-proBNP levels of recipient twins with TTTS was observed. The recipient twin with an increased DV-PI is expected to be under a high cardiac load; therefore, DV-PI is a useful parameter for assessing increased NT-proBNP levels consecutively and noninvasively.

CLINICAL TRIAL REGISTRATION

This study was registered with Japanese Clinical Trial Registry "UMIN-CTR" ( http://www.umin.ac.jp/ctr/index-j.htm ; trial ID numbers UMIN000024486 and 000037702).

Medication-Wide Association Study Using Electronic Health Record Data of Prescription Medication Exposure and Multifetal Pregnancies: Retrospective Study

Background

Medication-wide association studies (MWAS) have been applied to assess the risk of individual prescription use and a wide range of health outcomes, including cancer, acute myocardial infarction, acute liver failure, acute renal failure, and upper gastrointestinal ulcers. Current literature on the use of preconception and periconception medication and its association with the risk of multiple gestation pregnancies (eg, monozygotic and dizygotic) is largely based on assisted reproductive technology (ART) cohorts. However, among non-ART pregnancies, it is unknown whether other medications increase the risk of multifetal pregnancies.

Objective

This study aimed to investigate the risk of multiple gestational births (eg, twins and triplets) following preconception and periconception exposure to prescription medications in patients who delivered at Penn Medicine.

Methods

We used electronic health record data between 2010 and 2017 on patients who delivered babies at Penn Medicine, a health care system in the Greater Philadelphia area. We explored 3 logistic regression models: model 1 (no adjustment); model 2 (adjustment for maternal age); and model 3—our final logistic regression model (adjustment for maternal age, ART use, and infertility diagnosis). In all models, multiple births (MBs) were our outcome of interest (binary outcome), and each medication was assessed separately as a binary variable. To assess our MWAS model performance, we defined ART medications as our gold standard, given that these medications are known to increase the risk of MB.

Results

Of the 63,334 distinct deliveries in our cohort, only 1877 pregnancies (2.96%) were prescribed any medication during the preconception and first trimester period. Of the 123 medications prescribed, we found 26 (21.1%) medications associated with MB (using nominal P values) and 10 (8.1%) medications associated with MB (using Bonferroni adjustment) in fully adjusted model 3. We found that our model 3 algorithm had an accuracy of 85% (using nominal P values) and 89% (using Bonferroni-adjusted P values).

Conclusions

Our work demonstrates the opportunities in applying the MWAS approach with electronic health record data to explore associations between preconception and periconception medication exposure and the risk of MB while identifying novel candidate medications for further study. Overall, we found 3 novel medications linked with MB that could be explored in further work; this demonstrates the potential of our method to be used for hypothesis generation.