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Kontopoulos E, Quintero RA. Fetoscopic demonstration of feto-fetal hemorrhage before actual demise of a monochorionic twin, successful antenatal treatment, and narrative review of the literature. J Matern Fetal Neonatal Med 2023; 36:2215898. [PMID: 37290961 DOI: 10.1080/14767058.2023.2215898] [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: 04/17/2023] [Revised: 05/10/2023] [Accepted: 05/15/2023] [Indexed: 06/10/2023]
Abstract
Feto-fetal hemorrhage (FFH) through placental vascular anastomoses is believed to be responsible for the death or damage of a "second twin" after the demise of a "first twin (co-twin)" in monochorionic twin pregnancies. However, the timing of FFH has been difficult to determine. The resulting anemia in the surviving twin can be suspected by the finding of an elevated middle cerebral artery peak-systolic velocity (MCA-PSV), but this elevation may lag for at least 4 h after the demise of the first twin. Knowledge of the timing of FFH may have important clinical implications, as it may dictate if and when attempts to prevent death or damage to the second twin by delivery or intrauterine fetal transfusion would be warranted. We present a case that supports the notion that FFH occurs before the actual demise of the first twin. A review of the literature was also conducted.
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Affiliation(s)
- Eftichia Kontopoulos
- The USFetus Research Consortium, Miami, FL, USA
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Florida International University, Herbert Wertheim School of Medicine, Miami, FL, USA
- The Fetal Institute, Miami, FL, USA
| | - Ruben A Quintero
- The USFetus Research Consortium, Miami, FL, USA
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Florida International University, Herbert Wertheim School of Medicine, Miami, FL, USA
- The Fetal Institute, Miami, FL, USA
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Iwagaki S, Takahashi Y, Chiaki R, Asai K, Matsui M, Katsura D. Case of resuscitation from cardiac failure by intrauterine transfusion after single fetal death in monochorionic twin pregnancy. J Obstet Gynaecol Res 2019; 45:2105-2110. [PMID: 31368163 DOI: 10.1111/jog.14082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 07/15/2019] [Indexed: 11/30/2022]
Abstract
In case of a single fetal death in monochorionic twin pregnancy, the surviving fetus is thought to become hypovolemic. However, there is no report of any evidence of fetal circulatory insufficiency in such cases. We present a case of a single fetal death in a monochorionic twin pregnancy with type III selective intrauterine growth restriction that involved low fractional shortening, high myocardial performance index, elevated pulsatility index in the middle cerebral artery and fetal ascites. After immediate intrauterine transfusion, each parameter improved promptly. The surviving baby grew up without cardiac and neurological complications. To the best of our knowledge, this is the first report on transient circulatory insufficiency and decreased cardiac function in the surviving fetus.
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Affiliation(s)
- Shigenori Iwagaki
- Department of Fetal Maternal Medicine, National Nagara Medical Center, Gifu, Japan
| | - Yuichiro Takahashi
- Department of Fetal Maternal Medicine and Obstetrics, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Rika Chiaki
- Department of Fetal Maternal Medicine, National Nagara Medical Center, Gifu, Japan
| | - Kazuhiko Asai
- Department of Fetal Maternal Medicine, National Nagara Medical Center, Gifu, Japan
| | - Masako Matsui
- Department of Fetal Maternal Medicine, National Nagara Medical Center, Gifu, Japan
| | - Daisuke Katsura
- Department of Fetal Maternal Medicine, National Nagara Medical Center, Gifu, Japan
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Shue EH, Soares B, Courtier J, Hogue J, Shimotake T, MacKenzie TC. Type IV intestinal atresia, congenital bilateral perisylvian syndrome, and chronic pulmonary hypertension secondary to multiple vascular disruption syndrome in a monochorionic twin. J Pediatr Surg 2012; 47:1938-42. [PMID: 23084212 DOI: 10.1016/j.jpedsurg.2012.08.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2012] [Revised: 08/16/2012] [Accepted: 08/17/2012] [Indexed: 10/27/2022]
Abstract
We describe a rare case of multiple intestinal atresias, congenital bilateral perisylvian polymicrogyria, and chronic pulmonary hypertension in a surviving monochorionic twin with co-twin demise. This constellation of congenital anomalies represents a multiple vascular disruption syndrome due to intrauterine vascular compromise in the setting of possible twin-to-twin transfusion syndrome.
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Affiliation(s)
- Eveline H Shue
- Department of Surgery, University of California, San Francisco, CA 94143-0570, USA
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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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Kline-Fath BM, Calvo-Garcia MA, O'Hara SM, Crombleholme TM, Racadio JM. Twin-twin transfusion syndrome: cerebral ischemia is not the only fetal MR imaging finding. Pediatr Radiol 2007; 37:47-56. [PMID: 17063351 DOI: 10.1007/s00247-006-0337-5] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2006] [Revised: 08/24/2006] [Accepted: 09/13/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND Twin-twin transfusion syndrome (TTTS) is a complication of monochorionic/diamniotic twin pregnancies. An imbalance of blood flow occurs through placental anastomoses, causing potentially significant morbidity and mortality in both twins. Although the sonographic findings of TTTS are well documented, we believe that MR imaging is a valuable adjunct. OBJECTIVE We describe the fetal MR imaging findings associated with TTTS. MATERIALS AND METHODS From 2003 to 2005, 37 consecutive MR imaging studies were performed on multiple-gestation pregnancies. Of the 37, 25 were consistent with TTTS, correlated and confirmed by sonographic criteria. MR fetal abnormalities were documented. RESULTS Cerebral ischemia, which could not be demonstrated by sonography, was delineated well by MR imaging. New findings noted on fetal MR imaging were enlargement of cerebral venous sinuses in both twins, dilatation of the renal collecting system in the recipient, lung lesions in the recipient and cerebral malformations in the donor. CONCLUSION MR imaging is an important adjunct in TTTS imaging. Its benefit over sonography is its clear definition of cerebral pathology, which is important for intervention and counseling. The new findings, particularly in the urinary tract and cerebral venous sinuses, also help support the diagnosis of TTTS and might reveal additional consequences of the altered hemodynamics that occur in TTTS.
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Affiliation(s)
- Beth M Kline-Fath
- Department of Radiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati Medical Center, Cincinnati, OH, USA
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Nakata M, Sumie M, Murata S, Miwa I, Kusaka E, Sugino N. A Case of Monochorionic Twin Pregnancy Complicated with Intrauterine Single Fetal Death with Successful Treatment of Intrauterine Blood Transfusion in the Surviving Fetus. Fetal Diagn Ther 2006; 22:7-9. [PMID: 17003547 DOI: 10.1159/000095834] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2005] [Accepted: 01/21/2006] [Indexed: 11/19/2022]
Abstract
We report a case of monochorionic twin pregnancy complicated with single fetal demise that received successful treatment of intrauterine transfusion for severe anemia of the surviving fetus. A single fetal demise occurred at 20 weeks of gestation and middle cerebral artery peak systolic velocity (MCA-PSV), a marker for fetal anemia, showed marked elevation in the surviving fetus. Fetal blood sampling was immediately done and severe fetal anemia (hemoglobin = 5.5 g/dl, hematocrit = 16.8%) was confirmed, and then intrauterine transfusion was performed. After transfusion, MCA-PSV rapidly decreased to the normal value and remained within normal range until delivery. A healthy 2,640 g male infant was delivered at 35 weeks of gestation without anemic status and no neurological problem was found at 1-year old. The present report supports that intrauterine rescue transfusion is a useful treatment to prevent the adverse outcome of surviving fetus in monochorionic twin pregnancy complicated with single fetal demise, and monitoring of MCA-PSV is also useful to assess anemic status of the surviving fetus.
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Affiliation(s)
- Masahiko Nakata
- Perinatal Care Center, Yamaguchi University Hospital, Ube, Japan.
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Ishii K, Murakoshi T, Numata M, Kikuchi A, Takakuwa K, Tanaka K. An Experience of Laser Surgery for Feto-Fetal Transfusion Syndrome Complicated with Unexpected Feto-Fetal Hemorrhage in a Case of Monochorionic Triamniotic Triplets. Fetal Diagn Ther 2006; 21:339-42. [PMID: 16757908 DOI: 10.1159/000092462] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2005] [Accepted: 08/11/2005] [Indexed: 11/19/2022]
Abstract
Feto-fetal transfusion syndrome (FFTS) in monochorionic triplets is a rare clinical entity which may share the principal adverse perinatal outcomes of twin-twin transfusion syndrome. Recently, favorable prognoses regarding morbidity and mortality in twins after selective laser photocoagulation of placental communicating vessels (SLPCV) have been described. But descriptions of this procedure in monochorionic triplet cases are limited. This is the case report of an experience of SLPCV applied to monochorionic triamniotic triplets with FFTS. Triplet A had polyhydramnios, while absent end-diastolic flow in the umbilical artery of triplet B, the triplet with anhydramnios, was persistent. Triplet C looked normal, vertical amniotic pocket and Doppler studies yielding normal results. At the beginning of the SLPCV procedure, feto-fetal hemorrhage, subsequent to the fetal death of the donor triplet, occurred. Both surviving cofetuses showed persistent bradycardia; and 1 fetus died while the other recovered from the fetal bradycardia. All vascular anastomoses between the 3 triplets could be identified and obliterated, requiring two trocars. Our fetoscopic observation revealed feto-fetal hemorrhage after demise of monochorionic triplet, which led to injury of other fetuses due to hypovolemia in an instant. In conclusion, SLPCV might be a valid option for FFTS in triplet cases, while further experience is required in order to evaluate the risks and benefits of this procedure in triplet cases.
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Affiliation(s)
- Keisuke Ishii
- Department of Obstetrics and Gynecology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, and Maternal and Perinatal Care Center, Seirei Hamamatsu General Hospital, Shizuoka, Japan.
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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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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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Current Awareness in prenatal diagnosis. Prenat Diagn 2003; 23:269-75. [PMID: 14533647 DOI: 10.1002/pd.527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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