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Ventura W, Sugajara R, Quintana W, Llancarí P, Novoa RH. A systematic review of early intrauterine intervention at 12 + 0 to 16 + 6 weeks in twin reversed arterial perfusion sequence. Eur J Obstet Gynecol Reprod Biol 2024; 295:92-97. [PMID: 38342009 DOI: 10.1016/j.ejogrb.2024.02.001] [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: 06/17/2023] [Revised: 01/08/2024] [Accepted: 02/01/2024] [Indexed: 02/13/2024]
Abstract
There is some evidence that in twin reversed arterial perfusion sequence, intervention at early gestational age could prevent a spontaneous death of the pump twin, achieving a better global survival. OBJECTIVE To review the perinatal outcomes of early intervention in pregnancies complicated by twin reversed arterial perfusion (TRAP) sequence. STUDY DESIGN A comprehensive search from inception to December 2022 was conducted on databases including MEDLINE, EMBASE, Cochrane Library and LILACS. All studies that reported intervention in twin or triplet pregnancy complicated with TRAP sequence at 12 + 0 to 16 + 6 weeks of gestation were eligible. A descriptive and bivariate analysis was performed. RESULTS Out of the 222 full-text articles, 44 studies reporting 108 cases of early intervention in TRAP sequence were included. A successful procedure was achieved in 105 (95.5 %) interventions: 89 (94.7 %) among twin pregnancies and 16(100 %) among triplet pregnancies. An overall livebirth rate was achieved in 75 patients (70.8 %): intrafetal laser group 55 (73.3 %), radiofrequency 10 (76.9 %) and endoscopic laser 3 (75.0 %). The median gestational age at delivery was 38 + 0 (37 + 4 - 39 + 4) weeks. The median treatment-delivery interval was 23 + 2 (IQR, 21 + 0-25 + 6) weeks. The most frequent adverse outcomes reported were preterm labor in 7 (13.7 %) patients. There were no severe adverse maternal outcomes. CONCLUSION Early intervention with intrafetal laser and radiofrequency in TRAP sequence achieves a livebirth rate of the pump twin of about 75 %.
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Affiliation(s)
- Walter Ventura
- Fetal Medicine Unit, Department of Obstetrics and Perinatology, Instituto Nacional Materno Perinatal, Lima, Peru; Medicina Fetal Peru & Fetal Medicine Unit at Clínica Internacional and Clinica Anglo Americana, Lima, Peru.
| | - Ricardo Sugajara
- Fetal Medicine Unit, Department of Obstetrics and Perinatology, Instituto Nacional Materno Perinatal, Lima, Peru
| | - Willy Quintana
- High-Risk Pregnancy Unit, Department of Obstetrics and Perinatology, Instituto Nacional Materno Perinatal, Lima, Peru
| | - Pedro Llancarí
- Emergency Department, Instituto Nacional Materno Perinatal, Lima, Peru
| | - Rommy H Novoa
- High-Risk Pregnancy Unit, Department of Obstetrics and Perinatology, Instituto Nacional Materno Perinatal, Lima, Peru
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Yang Y, Ye X, Sun X. Clinical outcomes of fetal selective reduction in dichorionic triplet pregnancies. J Chin Med Assoc 2024; 87:103-108. [PMID: 37962135 DOI: 10.1097/jcma.0000000000001017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND It is recommended to reduce triplet pregnancy containing monochorionic (MC) twins to singleton. Given that some couples with infertility are eager to retain twins, better strategy is needed to avoid obstetrical risks and satisfy their strong wish. This retrospective observational study aimed to investigate the outcomes of triplet pregnancy reduction. METHODS Subjects with triplet pregnancies who underwent selective reduction between 2016 and 2019 at our hospital were enrolled. A total of 66 subjects with dichorionic triplet (DCT) with MC twins and an MC singleton were divided into two groups: group A (N = 38), reduced to dichorionic diamniotic (DCDA) twins; group B (N = 28), reduced to MC diamniotic (MCDA) twins. Obstetrical and perinatal outcomes were compared between groups. RESULTS Group A had significantly lower rates of early miscarriage (0% vs 14.3%, p = 0.028), cesarean section (81.6% vs 100%, p = 0.041), and late premature delivery (21.1% vs 45.4%, p = 0.047) than group B. Significantly higher rates of full-term delivery (71% vs 36.4%, p = 0.009) and take-home baby (100% vs 78.6%, p = 0.004), and higher gestational age at delivery (median: 38 [36.9, 39.0] vs 35.8 [34.4, 37.0] weeks, p < 0.001), total neonatal weight (2899.7 ± 647.6 vs 2354.4 ± 651.8 g, p < 0.001), weight of twins (2550 vs 2350 g, p = 0.039), and weight of larger neonate in twins (2790 vs 2500 g, p = 0.045) were observed in group A compared to group B. CONCLUSION DCT reduced to DCDA twins confers better pregnancy outcomes than into MCDA twins. This might benefit for triplet pregnancy subjects who strongly want to retain fraternal twins.
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Affiliation(s)
- Yuezhou Yang
- Shanghai Jiai Genetics and In Vitro Fertilization Center, Obstetrics and Gynecology Hospital affiliated to Fudan University, Shanghai, China
| | - Xuping Ye
- Department of Obstetrics, Obstetrics and Gynecology Hospital affiliated to Fudan University, Shanghai, China
| | - Xiaoxi Sun
- Keyes Laboratory of Female Reproductive Endocrine Related Diseases, Obstetrics and Gynecology Hospital affiliated to Fudan University, Shanghai, China
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Rahimi-Sharbaf F, Shirazi M, Sahebdel B, Golshahi F, Feizabad E, Ghaemi M, Saeedi S. Fetal Outcomes and Prognostic Factors After Radiofrequency Ablation for the Selective Reduction in Complicated Monochorionic Multiple Pregnancies. Acad Radiol 2023; 30 Suppl 2:S184-S191. [PMID: 37414637 DOI: 10.1016/j.acra.2023.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 06/01/2023] [Accepted: 06/02/2023] [Indexed: 07/08/2023]
Abstract
RATIONALE AND OBJECTIVES Monochorionic pregnancies are responsible for some severe complications, and selective reduction of a single fetus can improve pregnancy outcomes. This study evaluated the fetal outcomes and procedure-related prognostic factors after radiofrequency ablation (RFA) in complicated monochorionic multiple pregnancies. MATERIALS AND METHODS This prospective cross-sectional study was conducted in an academic center from June 2020 to January 2022. The participants were 70 women with monochorionic multiple pregnancies who were candidates for selective fetal reduction by RFA. All participants' demographic data, RFA-related information, and pregnancy outcomes were evaluated and reported. RESULTS The RFA procedure was successful in all participants. The most frequent RFA indications were twin-to-twin transfusion syndrome following selective intrauterine growth restriction. The mean gestational age at birth was 33.60 ± 5.62 weeks. Also, 11 (15.7%) of the cases had preterm delivery up to 30 days after RFA. The total pregnancy loss rate was 12 (17.14%), and the total fetal survival rate after RFA was 82.85%. The mean time of the RFA procedure was 130.8 ± 83.3 seconds. The procedure was conducted easily in 31 (44.2%) cases. Although the meantime of RFA procedure was longer in the not-easy group, the difference in surgery time was not significant (P = .296). There was no significant relationship (P = .623) between RFA indications and the gestational age of the remained fetus at delivery. The RFA needle was passed through the placenta in 18 (25.7%) cases. The mean gestational age at the delivery time was significantly lower in this group compared to their counterparts' gestational ages without needle placental passage (P = .030). Also, there was no significant correlation between gestational age at pregnancy termination and RFA cycles (P = .219). CONCLUSION RFA is a relatively safe and minimally invasive procedure for the selective reduction of complicated monochorionic fetuses. Although mortality, premature membrane rupture, and preterm delivery are the potential risk factors for the remaining co-twin. According to this study, gestational age at the time of the procedure and passing the needle through the placenta can affect the outcome. Other procedure-related factors like easy- or hard-access procedures, and the number of RFA cycles are not significantly associated with gestational age at birth.
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Affiliation(s)
- Fatemeh Rahimi-Sharbaf
- Department of Obstetrics and Gynecology, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran (F.R.-S., M.S., B.S., F.G., E.F., S.S.)
| | - Mahboobeh Shirazi
- Department of Obstetrics and Gynecology, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran (F.R.-S., M.S., B.S., F.G., E.F., S.S.)
| | - Behrokh Sahebdel
- Department of Obstetrics and Gynecology, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran (F.R.-S., M.S., B.S., F.G., E.F., S.S.).
| | - Fatemeh Golshahi
- Department of Obstetrics and Gynecology, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran (F.R.-S., M.S., B.S., F.G., E.F., S.S.)
| | - Elham Feizabad
- Department of Obstetrics and Gynecology, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran (F.R.-S., M.S., B.S., F.G., E.F., S.S.)
| | - Marjan Ghaemi
- Vali-E-Asr Reproductive Health Research Center, Family Health Research Institute, Tehran University of Medical Sciences, Tehran, Iran (M.G.)
| | - Sara Saeedi
- Department of Obstetrics and Gynecology, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran (F.R.-S., M.S., B.S., F.G., E.F., S.S.)
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Lee HS, Abbasi N, Van Mieghem T, Mei-Dan E, Audibert F, Brown R, Coad S, Lewi L, Barrett J, Ryan G. Directive clinique n o 440 : Prise en charge de la grossesse gémellaire monochoriale. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:607-628.e8. [PMID: 37541735 DOI: 10.1016/j.jogc.2023.05.019] [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: 08/06/2023]
Abstract
OBJECTIF Cette directive clinique passe en revue les données probantes sur la prise en charge de la grossesse gémellaire monochoriale normale et compliquée. POPULATION CIBLE Les femmes menant une grossesse gémellaire ou multiple de haut rang. BéNéFICES, RISQUES ET COûTS: L'application des recommandations de cette directive devrait améliorer la prise en charge des grossesses gémellaires (ou multiples de haut rang) monochoriales compliquées et non compliquées. Ces recommandations aideront les fournisseurs de soins à surveiller adéquatement les grossesses gémellaires monochoriales ainsi qu'à détecter et prendre en charge rapidement les complications associées de façon optimale afin de réduire les risques de morbidité et mortalité périnatales. Ces recommandations impliquent une surveillance échographique plus fréquente en cas de grossesse monochoriale qu'en cas de grossesse bichoriale. DONNéES PROBANTES: La littérature publiée a été colligée par des recherches dans les bases de données PubMed et Cochrane Library au moyen de termes MeSH pertinents (Twins, Monozygotic; Ultrasonography, Prenatal; Placenta; Fetofetal Transfusion; Fetal Death; Fetal Growth Retardation). Les résultats ont été restreints aux revues systématiques, aux essais cliniques randomisés et aux études observationnelles. Aucune date limite n'a été appliquée, mais les résultats ont été limités aux contenus en anglais ou en français. MéTHODES DE VALIDATION: Les auteurs principaux ont rédigé le contenu et les recommandations et ils se sont entendus sur ces derniers. Le conseil d'administration de la SOGC a approuvé la version définitive aux fins de publication. Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations Assessment, Development and Evaluation). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et conditionnelles [faibles]). PROFESSIONNELS CONCERNéS: Spécialistes en médecine fœto-maternelle, obstétriciens, radiologues, échographistes, médecins de famille, infirmières, sages-femmes, résidents et autres fournisseurs de soins de santé qui s'occupent de femmes menant une grossesse gémellaire ou multiple de haut rang. RéSUMé POUR TWITTER: Directive canadienne (SOGC) pour le diagnostic, la surveillance échographique et la prise en charge des complications de la grossesse gémellaire monochoriale (p. ex., STT, TAPS, retard de croissance sélectif, cojumeau acardiaque, monoamnionicité et mort d'un jumeau). DÉCLARATIONS SOMMAIRES: RECOMMANDATIONS.
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Lee HS, Abbasi N, Van Mieghem T, Mei-Dan E, Audibert F, Brown R, Coad S, Lewi L, Barrett J, Ryan G. Guideline No. 440: Management of Monochorionic Twin Pregnancies. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:587-606.e8. [PMID: 37541734 DOI: 10.1016/j.jogc.2023.05.018] [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] [Indexed: 08/06/2023]
Abstract
OBJECTIVE This guideline reviews the evidence-based management of normal and complicated monochorionic twin pregnancies. TARGET POPULATION Women with monochorionic twin or higher order multiple pregnancies. BENEFITS, HARMS, AND COSTS Implementation of these recommendations should improve the management of both complicated and uncomplicated monochorionic (and higher order multiple) twin pregnancies. They will help users monitor monochorionic twin pregnancies appropriately and identify and manage monochorionic twin complications optimally in a timely manner, thereby reducing perinatal morbidity and mortality. These recommendations entail more frequent ultrasound monitoring of monochorionic twins compared to dichorionic twins. EVIDENCE Published literature was retrieved through searches of PubMed and the Cochrane Library using appropriate MeSH headings (Twins, Monozygotic; Ultrasonography, Prenatal; Placenta; Fetofetal Transfusion; Fetal Death; Fetal Growth Retardation). Results were restricted to systematic reviews, randomized controlled clinical trials, and observational studies. There were no date limits, but results were limited to English or French language materials. VALIDATION METHODS The content and recommendations were drafted and agreed upon by the principal authors. The Board of the SOGC approved the final draft for publication. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations). INTENDED AUDIENCE Maternal-fetal medicine specialists, obstetricians, radiologists, sonographers, family physicians, nurses, midwives, residents, and other health care providers who care for women with monochorionic twin or higher order multiple pregnancies. TWEETABLE ABSTRACT Canadian (SOGC) guidelines for the diagnosis, ultrasound surveillance and management of monochorionic twin pregnancy complications, including TTTS, TAPS, sFGR (sIUGR), acardiac (TRAP), monoamniotic twins and intrauterine death of one MC twin. SUMMARY STATEMENTS RECOMMENDATIONS.
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Application and Influencing Factors of Radiofrequency Ablation in Monochorionic Pregnancy. MATERNAL-FETAL MEDICINE 2022. [DOI: 10.1097/fm9.0000000000000163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
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Twin Reversed Arterial Perfusion Sequence: Prenatal Diagnosis and Treatment. MATERNAL-FETAL MEDICINE 2022. [DOI: 10.1097/fm9.0000000000000172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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Wu T, Gong X, Wang X, Li L, Chen Z, Yuan P, Xie J, Gong L, Wang X, Zhao Y, Wei Y. Perinatal and neurodevelopmental outcome in complicated monochorionic pregnancy after selective fetal reduction: radiofrequency ablation vs microwave ablation. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 60:506-513. [PMID: 35468234 DOI: 10.1002/uog.24919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 04/02/2022] [Accepted: 04/08/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVES To summarize our experience in the application of radiofrequency ablation (RFA) and microwave ablation (MWA) for selective fetal reduction in complicated monochorionic pregnancies and compare the perinatal outcome of the two techniques. METHODS This was a retrospective study of data from a consecutive cohort of all monochorionic twin pregnancies that underwent selective fetal reduction with RFA or MWA at Peking University Third Hospital, Beijing, China from January 2012 to December 2018. All surviving cotwins were followed up to assess their neurodevelopment using the Age & Stage Questionnaire, Chinese version. Perinatal and neurodevelopmental outcomes were compared between the RFA and MWA groups. We also fitted multivariable models to test the association between procedure-related factors and the main perinatal outcomes, including preterm birth (PTB) < 37 weeks' gestation, intrauterine fetal death (IUFD) of the cotwin, adverse outcome (defined as occurrence of IUFD of the cotwin, termination of pregnancy or PTB < 28 weeks) and overall survival. RESULTS In total, 45 cases (42 twin and three triplet pregnancies) underwent RFA and 126 cases (105 twin and 21 triplet pregnancies) underwent MWA. The overall survival rates in monochorionic diamniotic twin pregnancies were similar between the RFA and MWA groups (61.0% vs 67.0%; P = 0.494). However, pregnancies whose indication for fetal reduction was selective intrauterine growth restriction or twin reversed arterial perfusion had higher overall survival rates (75.5% and 82.6%, respectively) compared with those in other indication groups. A total of 104 children were followed up (20 in the RFA group and 84 in the MWA group); four (20.0%) and eight (9.5%) children were assessed as having overall developmental delay in the RFA and MWA groups, respectively, with no significant difference between the two groups. Multivariable analyses showed that procedure indication, number of ablation cycles and gestational age at procedure were associated significantly with the main perinatal outcomes. CONCLUSIONS RFA and MWA for selective fetal reduction in complicated monochorionic pregnancies can achieve similar overall survival rate and neurodevelopmental outcome, but MWA is associated with a lower risk of preterm birth. Moreover, procedure-related factors are associated significantly with perinatal outcome. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- T Wu
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - X Gong
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - X Wang
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - L Li
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Z Chen
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - P Yuan
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - J Xie
- Department of Maternal and Child Health, School of Public Health, Peking University, Beijing, China
| | - L Gong
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - X Wang
- Department of Maternal and Child Health, School of Public Health, Peking University, Beijing, China
| | - Y Zhao
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Y Wei
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
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Duci M, Pulvirenti R, Fascetti Leon F, Capolupo I, Veronese P, Gamba P, Tognon C. Anesthesia for fetal operative procedures: A systematic review. FRONTIERS IN PAIN RESEARCH 2022; 3:935427. [PMID: 36246050 PMCID: PMC9554945 DOI: 10.3389/fpain.2022.935427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 08/24/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveThe anesthetic management of fetal operative procedures (FOP) is a highly debated topic. Literature on fetal pain perception and response to external stimuli is rapidly expanding. Nonetheless, there is no consensus on the fetal consciousness nor on the instruments to measure pain levels. As a result, no guidelines or clinical recommendations on anesthesia modality during FOP are available. This systematic literature review aimed to collect the available knowledge on the most common fetal interventions, and summarize the reported outcomes for each anesthetic approach. Additional aim was to provide an overall evaluation of the most commonly used anesthetic agents.MethodsTwo systematic literature searches were performed in Embase, Medline, Web of Science Core Collection and Cochrane Central Register of Controlled Trials up to December 2021. To best cover the available evidence, one literature search was mostly focused on fetal surgical procedures; while anesthesia during FOP was the main target for the second search. The following fetal procedures were included: fetal transfusion, laser ablation of placental anastomosis, twin-reversed arterial perfusion treatment, fetoscopic endoluminal tracheal occlusion, thoraco-amniotic shunt, vesico-amniotic shunt, myelomeningocele repair, resection of sacrococcygeal teratoma, ligation of amniotic bands, balloon valvuloplasty/septoplasty, ex-utero intrapartum treatment, and ovarian cyst resection/aspiration. Yielded articles were screened against the same inclusion criteria. Studies reporting anesthesia details and procedures’ outcomes were considered. Descriptive statistical analysis was performed and findings were reported in a narrative manner.ResultsThe literature searches yielded 1,679 articles, with 429 being selected for full-text evaluation. A total of 168 articles were included. Overall, no significant differences were found among procedures performed under maternal anesthesia or maternal-fetal anesthesia. Procedures requiring invasive fetal manipulation resulted to be more effective when performed under maternal anesthesia only. Based on the available data, a wide range of anesthetic agents are currently deployed and no consistency has been found neither between centers nor procedures.ConclusionsThis systematic review shows great variance in the anesthetic management during FOP. Further studies, systematically reporting intraoperative fetal monitoring and fetal hormonal responses to external stimuli, are necessary to identify the best anesthetic approach. Additional investigations on pain pathways and fetal pain perception are advisable.
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Affiliation(s)
- Miriam Duci
- Pediatric Surgery Unit, Department of Women’s and Children’s Health, Padua University Hospital, Padua, Italy
| | - Rebecca Pulvirenti
- Pediatric Surgery Unit, Department of Women’s and Children’s Health, Padua University Hospital, Padua, Italy
| | - Francesco Fascetti Leon
- Pediatric Surgery Unit, Department of Women’s and Children’s Health, Padua University Hospital, Padua, Italy
- Correspondence: Francesco Fascetti Leon
| | - Irma Capolupo
- Department of Medical and Surgical Neonatology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Paola Veronese
- Maternal-fetal Medicine Unit, Department of Women’s and Children’s Health, Padua University Hospital, Padua, Italy
| | - Piergiorgio Gamba
- Pediatric Surgery Unit, Department of Women’s and Children’s Health, Padua University Hospital, Padua, Italy
| | - Costanza Tognon
- Anesthesiology Pediatric Unit, Department of Women’s and Children’s Health, Padua University Hospital, Padua, Italy
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Rahimi-Sharbaf F, Shirazi M, Golshahi F, Salari Z, Haghiri M, Ghaemi M, Feizmahdavi H. Comparison of Prenatal and Neonatal Outcomes of Selective Fetal Growth Restriction in Monochorionic Twin Pregnancies with or Without Twin-to-Twin Transfusion Syndrome After Radiofrequency Ablation. IRANIAN JOURNAL OF MEDICAL SCIENCES 2022; 47:433-439. [PMID: 36117585 PMCID: PMC9445864 DOI: 10.30476/ijms.2021.91097.2217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 07/30/2021] [Accepted: 08/28/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND This study aimed to investigate and compare the prenatal and neonatal outcomes of monochorionic twin pregnancies complicated with fetal growth restriction (sFGR) with or without twin-to-twin transfusion syndrome (TTTS) after cord occlusion by radiofrequency ablation (RFA). METHODS This prospective cross-sectional study was conducted in women with monochorionic twin pregnancies of 16 to 26 weeks of gestational age (GA) in an academic hospital from 2016 to 2020. Demographic and obstetrical characteristics such as cervical length, GA of RFA and delivery, amnioreduction, cesarean section (C/S) rate, and maximum vertical pocket as well as prenatal, neonatal, and maternal outcomes were evaluated and compared between groups using Statistical Package for the Social Sciences (SPSS). Mann-Whitney U test or independent t test was used for quantitative data and Chi square test was applied for comparing qualitative variables. The significance level of tests was 0.05. RESULTS Totally 213 (106 sFGR and 107 TTTS+sFGR) cases were enrolled. The mean of maternal age (P=0.787), body mass index (P=0.932), gestational age at RFA (P=0.265), as well as gestational age of delivery (P=0.482), and C/S rate (P=0.124) were not significant between the two groups, but a significant difference (P<0.001) in cervical length was observed between the two groups. No significant differences were found in newborn and fetal outcomes such as fetal demise (P=0.827), PPROM (P=0.233), abortion (P=0.088), and admission to intensive care unit (P=0.822) between the groups. CONCLUSION Although worse fetal and neonatal outcomes were expected in the TTTS+sFGR group after RFA, no significant difference was observed between groups.
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Affiliation(s)
- Fatemeh Rahimi-Sharbaf
- Department of Obstetrics and Gynecology, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahboobeh Shirazi
- Department of Obstetrics and Gynecology, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran,
Maternal Fetal and Neonatal Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Golshahi
- Department of Obstetrics and Gynecology, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran,
Maternal Fetal and Neonatal Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Zohreh Salari
- Department of Obstetrics and Gynecology, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mansoureh Haghiri
- Department of Perinatology, Maternal, Fetal and Neonatal Research Center, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Marjan Ghaemi
- Vali-e-Asr Reproductive Health Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Hanieh Feizmahdavi
- Department of Obstetrics and Gynecology, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran,
Department of Obstetrics and Gynecology, Kermanshah University of Medical Sciences, Kermanshah, Iran
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Donepudi R, Hessami K, Nassr AA, Espinoza J, Sanz Cortes M, Sun L, Shirazi M, Yinon Y, Belfort MA, Shamshirsaz AA. Selective reduction in complicated monochorionic pregnancies: a systematic review and meta-analysis of different techniques. Am J Obstet Gynecol 2022; 226:646-655.e3. [PMID: 34678178 DOI: 10.1016/j.ajog.2021.10.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 10/08/2021] [Accepted: 10/10/2021] [Indexed: 01/10/2023]
Abstract
OBJECTIVE This systematic review and meta-analysis aimed to compare the perinatal outcomes of complicated monochorionic pregnancies after selective reduction by radiofrequency ablation, bipolar cord coagulation, and interstitial laser. DATA SOURCES We searched PubMed, Scopus, and Web of Science, from the inception of the database up to April 26, 2021. STUDY ELIGIBILITY CRITERIA Studies comparing at least 2 selective reduction techniques among complicated monochorionic pregnancies and presenting data on perinatal outcomes, including gestational age at procedure, gestational age at delivery, procedure to delivery interval, preterm premature rupture of membranes, preterm birth, survival rate, and birthweight, were eligible. METHODS The random-effects model was used to pool the mean differences or odds ratios and corresponding 95% confidence intervals. Heterogeneity was assessed using the I2 value. RESULTS A total of 10 studies with 734 cases of fetal reduction met the inclusion criteria, of which 9 studies with 674 fetuses were eligible for quantitative synthesis. In 8 studies that compared radiofrequency ablation with bipolar cord coagulation, radiofrequency ablation was associated with increased procedure to delivery interval (days) (mean difference, 13.42; 95% confidence interval, 1.90-24.94; P=.02; I2=0.0%), decreased preterm birth (odds ratio, 0.50; 95% confidence interval, 0.29-0.85; P=.01; I2=3.0%), and decreased preterm premature rupture of membranes (odds ratio, 0.45; 95% confidence interval, 0.27-0.73; P=.001; I2=0.0%). Radiofrequency ablation and bipolar cord coagulation had comparable survival rates (odds ratio, 0.85; 95% confidence interval, 0.54-1.35; P=.49; I2=0.0%). In 3 studies that compared radiofrequency ablation with interstitial laser, there was no significant difference in gestational age at delivery (P=.07) or survival (P=.15). In 3 studies that compared bipolar cord coagulation with interstitial laser, bipolar cord coagulation was associated with a higher survival rate (odds ratio, 3.21; 95% confidence interval, 1.13-9.10; P=.03; I2=0.0%), but the gestational age at delivery was comparable between groups (P=.16). CONCLUSION This study demonstrated that radiofrequency ablation has a greater procedure to delivery interval and decreased preterm premature rupture of membranes and preterm birth than bipolar cord coagulation. Although there was no difference in gestational age at delivery for either bipolar cord coagulation, radiofrequency ablation, or interstitial laser, survival was higher with bipolar cord coagulation than with interstitial laser.
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Affiliation(s)
- Roopali Donepudi
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX
| | - Kamran Hessami
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX
| | - Ahmed A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX; Department of Obstetrics and Gynecology, Women's Health Hospital, Assiut University, Assiut, Egypt
| | - Jimmy Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX
| | - Magdalena Sanz Cortes
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX
| | - Luming Sun
- Department of Fetal Medicine and Prenatal Diagnosis Center, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Mahboobeh Shirazi
- Maternal, Fetal and Neonatal Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Yoav Yinon
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel HaShomer, Israel
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX
| | - Alireza A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX.
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Anh ND, Hung HS, Sim NT, Ha NTT, Nguyen DL, Bac ND, Tong HV, Ville Y, Thuong PTH. Fetoscopic Laser Ablation for the Selective Fetal Reduction in Twin-Twin Transfusion Syndrome Stage II-IV: The Experience of a New Fetal Medicine Center. Int J Womens Health 2022; 14:555-563. [PMID: 35444472 PMCID: PMC9015043 DOI: 10.2147/ijwh.s350433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 03/18/2022] [Indexed: 11/23/2022] Open
Abstract
Objective To evaluate the surgery outcomes of fetoscopic laser ablation (FLA) for selective umbilical cord in treating twin-twin transfusion syndrome (TTTS) with special conditions and neonatal outcomes post-operation. Methods A prospective study, 21 monochorionic diamniotic (MCDA) twins diagnosed with TTTS stage II–IV according to Quintero classification from 16 to 26 weeks of gestation, among that, 12 cases of TTTS stage II with selective intrauterine growth restriction (sIUGR), 6 cases of TTTS stage II with proximate cord insertions, 3 cases of TTTS stage IV underwent fetoscopic laser ablation for the selective fetal reduction at Hanoi Obstetrics and Gynecology Hospital from September 2019 to July 2021. Complications and surgical outcomes were noted. Prenatal care was carried out every 2 weeks post operation until birth. Newborn neurologic complications were assessed at birth, three months, and six months after birth using Denver II test and magnetic resonance imaging (MRI). Results The mean gestational age at operation was 20.30 weeks. The average operation duration was 39.52 minutes. No complications of operation, such as bleeding or infection, were recorded. The mean gestational age at birth was 34.70 ± 4.33 weeks, with a mean duration of 12.97 ± 6.87 weeks between intervention and delivery. The survival rate of newborns after the operation was 90.48%. There were two stillbirths (9.52%) within seven days after the operation. No short-term neurological complications have been reported with follow-up of the newborn to 6 months after birth. Conclusion Our study showed that fetoscopic laser ablation of selected fetal reduction surgery for treatment of special conditions of TTTS had no complications of operation, high neonatal survival result (90.48%), no short-term neurological complications. This should be considered for TTTS in cases of indication.
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Affiliation(s)
- Nguyen Duy Anh
- Fetal Medicine Centre, Hanoi Obstetrics and Gynecology Hospital, Hanoi, Vietnam.,Hanoi Medical University, Hanoi, Vietnam
| | - Ho Sy Hung
- Hanoi Medical University, Hanoi, Vietnam
| | - Nguyen Thi Sim
- Fetal Medicine Centre, Hanoi Obstetrics and Gynecology Hospital, Hanoi, Vietnam
| | - Nguyen Thi Thu Ha
- Department of Assisted Reproductive and Andrology, Hanoi Obstetrics and Gynecology Hospital, Hanoi, Vietnam
| | | | - Nguyen Duy Bac
- Department of Education and Training, Vietnam Military Medical University, Hanoi, Vietnam
| | - Hoang Van Tong
- Biomedical and Pharmaceutical Applied Research Center, Vietnam Military Medical University, Hanoi, Vietnam
| | - Yves Ville
- Department of Obstetrics and Fetal Medicine at Necker-Enfants-Malades Hospital at the Paris Descartes University, Paris, France
| | - Phan Thi Huyen Thuong
- Hanoi Medical University, Hanoi, Vietnam.,Department of Delivery, Hanoi Obstetrics and Gynecology Hospital, Hanoi, Vietnam
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Li N, Sun J, Wang J, Jian W, Lu J, Miao Y, Li Y, Chen F, Chen D, Ye X, Chen M. Selective termination of the fetus in multiple pregnancies using ultrasound-guided radiofrequency ablation. BMC Pregnancy Childbirth 2021; 21:821. [PMID: 34893028 PMCID: PMC8662893 DOI: 10.1186/s12884-021-04285-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 11/23/2021] [Indexed: 12/02/2022] Open
Abstract
Background To evaluate the perinatal outcomes in women with selective termination using ultrasound-guided radiofrequency ablation (RFA). Methods Complicated monochorionic (MC) twin pregnancies and multiple pregnancies with an indication for selective termination by ultrasound-guided coagulation of the umbilical cord with RFA under local anesthesia between July 2013 and Jan 2020 were reviewed. We analyzed the indications, gestational age at the time of the procedure, cycles of RFA, duration of the procedure, and perinatal outcome. Results Three hundred and thirteen patients were treated during this period. Seven of whom were lost of follow-up. The remaining 306 cases, including 266 pairs of monochorionic diamniotic (MCDA) twins (86.93%), two pairs of monoamniotic twins (0.65%), 30 dichorionic triamniotic (DCTA) triplets (1%), and three monochorionic triamniotic (MCTA) triplets (0.98%), were analyzed. Indications included twin-to-twin transfusion syndrome (TTTS) (n = 91), selective fetal growth restriction (sFGR) (n = 83), severe discordant structural malformation (n = 78), multifetal pregnancy reduction (MFPR) (n = 78), twin reverse arterial perfusion sequence (TRAPS) (n = 19), and twin anemia-polycythemia sequence (TAPS) (n = 3). Upon comparison of RFA performed before and after 20 weeks, the co-twin loss rate (20.9% vs. 21.5%), the incidence of preterm premature rupture of membranes (PPROM) within 24 h (1.5% vs. 1.2%), and the median gestational age at delivery [35.93 (28–38) weeks vs. 36 (28.54–38.14) weeks] were similar (p > 0.05). Conclusions RFA is a reasonable option when indicated in multiple pregnancies and complicated monochorionic pregnancies. In our experience, the overall survival rate was 78.76% with RFA in selective feticide, and early treatment increases the likelihood of survival for the remaining fetus because the fetal loss rate is similar before and after 20 weeks.
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Affiliation(s)
- Nan Li
- Department of Obstetrics and Gynecology, Department of Fetal Medicine and Prenatal Diagnosis, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Liwan District, Guangzhou, China
| | - Jimei Sun
- Department of Obstetrics and Gynecology, Department of Fetal Medicine and Prenatal Diagnosis, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Liwan District, Guangzhou, China
| | - Jiayan Wang
- Department of Obstetrics and Gynecology, Department of Fetal Medicine and Prenatal Diagnosis, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Liwan District, Guangzhou, China
| | - Wei Jian
- Department of Obstetrics and Gynecology, Department of Fetal Medicine and Prenatal Diagnosis, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Liwan District, Guangzhou, China
| | - Jing Lu
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Yonghui Miao
- Department of Obstetrics and Gynecology, Department of Fetal Medicine and Prenatal Diagnosis, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Liwan District, Guangzhou, China
| | - Yufan Li
- Department of Obstetrics and Gynecology, Department of Fetal Medicine and Prenatal Diagnosis, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Liwan District, Guangzhou, China
| | - Fei Chen
- Department of Obstetrics and Gynecology, Department of Fetal Medicine and Prenatal Diagnosis, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Liwan District, Guangzhou, China
| | - Dunjin Chen
- Department of Obstetrics and Gynecology, Department of Fetal Medicine and Prenatal Diagnosis, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Liwan District, Guangzhou, China
| | - Xiaoqing Ye
- Department of Ultrasound, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Min Chen
- Department of Obstetrics and Gynecology, Department of Fetal Medicine and Prenatal Diagnosis, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Liwan District, Guangzhou, China.
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14
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Rao MG, Vieira L, Kaplowitz E, Overbey JR, Johnson S, Paul K, Lookstein R, Rebarber A, Fox NS, Stone J. Elective fetal reduction by radiofrequency ablation in monochorionic diamniotic twins decreases adverse outcomes compared to ongoing monochorionic diamniotic twins. Am J Obstet Gynecol MFM 2021; 3:100447. [PMID: 34314851 DOI: 10.1016/j.ajogmf.2021.100447] [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: 05/16/2021] [Revised: 07/08/2021] [Accepted: 07/20/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Multifetal pregnancy reduction is a technique used to reduce the fetal number to mitigate the risks of adverse outcomes associated with multiple gestations. Monochorionic diamniotic twin pregnancies are subject to unique complications, contributing to adverse pregnancy outcomes. Thus, patients have an option to electively reduce 1 fetus to improve outcomes. OBJECTIVE This study aimed to compare outcomes of elective reduction of monochorionic diamniotic twins by radiofrequency ablation to planned ongoing monochorionic diamniotic twins. STUDY DESIGN We performed a retrospective review of 315 monochorionic diamniotic twin gestations that underwent first-trimester ultrasound within 1 institution. Planned electively reduced twins were compared with ongoing monochorionic diamniotic twins. All reductions were performed via radiofrequency ablation of the cord insertion site into the fetal abdomen. The primary outcome was preterm birth at <36 weeks' gestation. Secondary outcomes included gestational age at delivery; preterm birth at less than 37-, 34-, 32-, and 28-weeks' gestation; unintended loss; and adverse perinatal outcomes. RESULTS Among 315 monochorionic diamniotic pregnancies, 14 (4.4%) underwent elective multifetal pregnancy reduction, and 301 (95.6%) were planned ongoing twins. The mean gestational age of radiofrequency ablation in the elective multifetal pregnancy reduction group was 15.1±0.68 weeks. Patients who underwent elective multifetal pregnancy reduction had significantly higher maternal age (P<.01) and were more likely to be Asian (P<.01). Moreover, they were more likely to have undergone in vitro fertilization (P=.03) and chorionic villus sampling (P<.01). There was a significantly higher rate of term deliveries in the elective radiofrequency ablation group compared with ongoing twins (gestational age, 38 weeks [interquartile range, 36.1-39.1] vs 35.9 weeks [interquartile range, 34.0-36.9]; P<.01). Patients with ongoing pregnancies had a trend of increased rate of preterm birth at <36 weeks' gestation (odds ratio, 3.4; 95% confidence interval, 1.0-12.0; P=.06), a significantly increased risk of preterm birth at <37 weeks' gestation (odds ratio, 8.0; 95% confidence interval, 2.4-26.4; P<.01), and no difference at less than 34-, 32-, or 28- weeks' gestation. All patients who underwent elective radiofrequency ablation had successful pregnancies with no pregnancy losses or terminations. Of ongoing gestations, 36 required procedures, including 16 (5.3%) medically indicated radiofrequency ablation, 14 (4.6%) laser ablation, and 6 (1.9%) amnioreductions. Furthermore, 22 patients (7.3%) with planned ongoing twins had total pregnancy loss at <24 weeks' gestation. Notably, 12 patients (4.0%) had unintended loss of 1 fetus before 24 weeks' gestation in the ongoing pregnancy cohort, and 12 patients (4.0%) had unintended loss of both fetuses before 24 weeks' gestation. Moreover, 5 patients (1.7%) in the ongoing pregnancy group had intrauterine fetal demise at >24 weeks' gestation and 10 patients (3.3%) electively terminated both fetuses. There was no significant difference in loss rates between the 2 groups. CONCLUSION In this study of monochorionic diamniotic twins, patients who elected to undergo multifetal pregnancy reduction had significantly lower rates of preterm birth at <37 weeks and a lower trend of preterm birth at <36 weeks' gestation without an increased risk of pregnancy loss. Median gestational age at delivery was significantly higher in the elective multifetal pregnancy reduction group (38 weeks) than in the ongoing pregnancy group (35.9 weeks). Further research is needed to clarify if multifetal pregnancy reduction improves long-term outcomes.
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Affiliation(s)
- Manasa G Rao
- Departments of Obstetrics, Gynecology, and Reproductive Science (Ms Rao, Drs Vieira and Johnson, Ms Paul, and Drs Lookstein, Rebarber, Fox, and Stone).
| | - Luciana Vieira
- Departments of Obstetrics, Gynecology, and Reproductive Science (Ms Rao, Drs Vieira and Johnson, Ms Paul, and Drs Lookstein, Rebarber, Fox, and Stone)
| | - Elianna Kaplowitz
- Population Health Science and Policy (Ms Kaplowitz and Dr Overbey), Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jessica R Overbey
- Population Health Science and Policy (Ms Kaplowitz and Dr Overbey), Icahn School of Medicine at Mount Sinai, New York, NY
| | - Shaelyn Johnson
- Departments of Obstetrics, Gynecology, and Reproductive Science (Ms Rao, Drs Vieira and Johnson, Ms Paul, and Drs Lookstein, Rebarber, Fox, and Stone)
| | - Keisha Paul
- Departments of Obstetrics, Gynecology, and Reproductive Science (Ms Rao, Drs Vieira and Johnson, Ms Paul, and Drs Lookstein, Rebarber, Fox, and Stone)
| | - Robert Lookstein
- Departments of Obstetrics, Gynecology, and Reproductive Science (Ms Rao, Drs Vieira and Johnson, Ms Paul, and Drs Lookstein, Rebarber, Fox, and Stone)
| | - Andrei Rebarber
- Departments of Obstetrics, Gynecology, and Reproductive Science (Ms Rao, Drs Vieira and Johnson, Ms Paul, and Drs Lookstein, Rebarber, Fox, and Stone)
| | - Nathan S Fox
- Departments of Obstetrics, Gynecology, and Reproductive Science (Ms Rao, Drs Vieira and Johnson, Ms Paul, and Drs Lookstein, Rebarber, Fox, and Stone)
| | - Joanne Stone
- Departments of Obstetrics, Gynecology, and Reproductive Science (Ms Rao, Drs Vieira and Johnson, Ms Paul, and Drs Lookstein, Rebarber, Fox, and Stone)
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15
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Expectant management versus multifetal pregnancy reduction in dichorionic triamniotic (DCTA) triplets: Single centre experience. Eur J Obstet Gynecol Reprod Biol 2021; 264:200-205. [PMID: 34329945 DOI: 10.1016/j.ejogrb.2021.07.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 07/01/2021] [Accepted: 07/12/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVES In trichorionic triplet pregnancies, multifetal pregnancy reduction (MFPR) reduces the risk of preterm birth, neonatal morbidity and mortality without increasing miscarriage. A similar benefit has been suggested in dichorionic triamniotic (DCTA) pregnancy, but multiple methods are currently used. This study investigates if the method of reduction used in DCTA triplet pregnancy influences the evidence of benefit from MFPR. METHODS This is a retrospective cohort study of DCTA pregnancies between 2010 and 2019 who attended a single UK fetal medicine tertiary referral center. Cohorts were defined based on MFPR decision and method. The primary outcome was offspring survival until neonatal discharge. The secondary outcomes included miscarriage, preterm birth, livebirth, rates of small for gestational age (SGA) neonates, ans maternal morbidity. To evaluate the differences in neonatal survival until discharge we used Cox proportional regression to calculate hazard rates (HR) and 95% confidence intervals (CI). Differences in secondary outcomes were compared using univariate analysis. RESULTS The study reports the outcomes for 83 DCTA pregnancies. MFPR to DCDA twins was chosen in 19 pregnancies (14 radiofrequency ablation, RFA; 5 intrafetal laser, IFL); in 9 pregnancies selective reduction to a singleton was performed by KCl injection. The rate of pregnancies in with ≥ 1 fetus born alive was not different between groups (p = 0.90). However, the number of expected neonates alive at discharge from hospital was highest in the RFA group (89%, HR 0.28, 95% CI 0.21-0.87, p = 0.02). Rates of premature delivery before 32 weeks (p = 0.02), low birth weight (p < 0.001) and birthweight < 10th percentile (p = 0.01) were all elevated in the expectant management group, compared to women who opted for reduction. There was no difference in miscarriage between groups. CONCLUSIONS Our study suggests that MFPR by RFA, an established and widely available procedure, is of benefit in promoting neonatal survival until discharge in DCTA triplets.
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Management of Twin Pregnancies: A Comparative Review of National and International Guidelines. Obstet Gynecol Surv 2021; 75:419-430. [PMID: 32735684 DOI: 10.1097/ogx.0000000000000803] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Importance Twin pregnancies are associated with a higher risk of perinatal mortality and morbidity compared with singleton and require more intensive prenatal care. Objective The aim of this study was to review and compare the recommendations from published guidelines on twin pregnancies. Evidence Acquisition A descriptive review of guidelines from the Royal College of Obstetricians and Gynaecologists, the International Society of Ultrasound in Obstetrics and Gynecology, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, the National Institute for Health and Care Excellence, the Institute of Obstetricians and Gynaecologists of the Royal College of Physicians of Ireland, the International Federation of Gynecology and Obstetrics, the Society of Obstetricians and Gynaecologists of Canada, and the American College of Obstetricians and Gynecologists on the management of twin pregnancies was conducted. Results All the guidelines highlight the importance of an accurate assessment of chorionicity, amnionicity, and gestational age in the first trimester. They also recommend the performance of nuchal translucency and a detailed anomaly scan. The ultrasound surveillance protocol is similar in all guidelines, that is, every 2 weeks for monochorionic and every 4 weeks for dichorionic twins. On the other hand, there are differences regarding the timing and mode of delivery, especially in monochorionic diamniotic twins, in the definition and management of fetal growth discordance, the use of cervical length to screen for preterm birth, and the timing of corticosteroids' administration. Conclusions The differences in the reviewed guidelines on the management of twin pregnancies highlight the need for an adoption of an international consensus, in order to improve perinatal outcomes of twin pregnancies.
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Rahimi-Sharbaf F, Ghaemi M, Nassr AA, Shamshirsaz AA, Shirazi M. Radiofrequency ablation for selective fetal reduction in complicated Monochorionic twins; comparing the outcomes according to the indications. BMC Pregnancy Childbirth 2021; 21:189. [PMID: 33676436 PMCID: PMC7937193 DOI: 10.1186/s12884-021-03656-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 02/22/2021] [Indexed: 11/24/2022] Open
Abstract
Background To evaluate the perinatal outcomes in women with complicated monochorionic diamniotic twins who underwent selective reduction using radiofrequency ablation (RFA). Methods This retrospective study included patients with complicated monochorionic diamniotic twins between 16 to 28 weeks who underwent selective reduction using RFA. Results During the study period, 143 women with complicated monochorionic twins underwent RFA including 52 with selective fetal growth restriction (sFGR), 48 with twin to twin transfusion syndrome (TTTS), 33 with major fetal anomalies in one of the twins, and 10 with reversed arterial perfusion sequence (TRAP). The overall survival was 71.3% (102/143). The procedures were technically successful in achieving selective termination in all cases. The mean ± SD of gestational age at the time of the procedure was 21.0 ± 2.3 weeks. The mean ± SD of gestational age at delivery was 34.6 ± 3.3 weeks. The mean ± SD of overall procedure-to-delivery time was 12 ± 1.7 weeks. The pregnancy success rates among sFGR, TRAP, TTTS and anomaly groups were 82.7, 80, 73 and 60.7% respectively. There were no maternal complications. Conclusion Radiofrequency ablation for fetal reduction in complicated monochorionic twin pregnancies appears to be a reasonable option. The pregnancy success rate following RFA selective reduction was highest among sFGR and TRAP groups and lowest in the anomaly group.
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Affiliation(s)
| | - Marjan Ghaemi
- Valie-Asr Reproductive Health Research Center, (VRHRC), Tehran University of Medical Sciences, Tehran, Iran
| | | | | | - Mahboobeh Shirazi
- Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran. .,Maternal, Fetal and Neonatal Research Center, Tehran University Of Medical Sciences, Tehran, Iran.
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Forde B, Habli M. Unique Considerations: Preterm Prelabor Rupture of Membranes in the Setting of Fetal Surgery and Higher Order Pregnancies. Obstet Gynecol Clin North Am 2021; 47:653-669. [PMID: 33121651 DOI: 10.1016/j.ogc.2020.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Two unique aspects of antenatal care occur in the setting of fetal surgery and multiple gestations. As fetal interventions increase, so do the number of cases of iatrogenic preterm prelabor rupture of membranes (PPROM). Because of the amniotic sac's inability to heal, the risk of PPROM after surgery is directly correlated with the number of interventions, the size of the defect, and the surgery performed. Higher order gestations also carry an increased risk of PPROM. This paper reviews the risks and management of PPROM in the setting of the various prenatal interventions as well as in the setting of multiple gestations.
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Affiliation(s)
- Braxton Forde
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Medical Sciences Building, Room 4555, 231 Albert Sabin Way, Cincinnati, OH 45267-0526, USA.
| | - Mounira Habli
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Good Samaritan Hospital, Cincinnati, OH, USA; Fetal Care Center of Cincinnati, Cincinnati Children's Hospital, Cincinnati, OH, USA
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19
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Wang H, Zhou Q, Wang X, Song J, Chen P, Wang Y, Li L, Li H. Influence of indications on perinatal outcomes after radio frequency ablation in complicated monochorionic pregnancies: a retrospective cohort study. BMC Pregnancy Childbirth 2021; 21:41. [PMID: 33422050 PMCID: PMC7797138 DOI: 10.1186/s12884-020-03530-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 12/26/2020] [Indexed: 02/03/2023] Open
Abstract
Background Radiofrequency ablation (RFA) is recommended to prevent potential neurological injury or intrauterine foetal death (IUFD) of the co-twin(s) in complicated monochorionic (MC) pregnancies. However, the impacts of various indications on the pregnancy outcome following RFA remain unclear. This study aimed to determine how the indications influence the perinatal outcomes in complicated MC pregnancies undergoing radiofrequency ablation. Methods This was a retrospective cohort study performed in a single centre. All consecutive MC pregnancies treated with RFA between July 2011 and July 2019 were included. The adverse perinatal outcomes and the survival rate were analysed based on various indications. The continuous variables with and without normal distribution were compared between the groups using Student’s t-test and Mann–Whitney U test, respectively, and for categorical variables, Chi-square and Fisher’s exact tests were used. P < 0.05 indicated a significant difference. Results We performed 272 RFA procedures in 268 complicated MC pregnancies, including 60 selective intrauterine growth restriction (sIUGR), 64 twin–twin transfusion syndrome (TTTS), 12 twin reversed arterial perfusion sequence (TRAPs), 66 foetal anomaly and 66 elective foetal reduction (EFR) cases. The overall survival rate of the co-twin was 201/272 (73.9%). The overall technical successful rate was determined at 201/263 (76.7%). The IUFD rate in the co-twin was 20/272 (7.4%). The TTTS group had recorded the lowest survival rate (37/64, 57. 8%), and the survival rate was significantly correlated with Quintero stages (P = 0.029). Moreover, the sIUGR III subgroup had a lower survival rate compared with sIUGR II (55.6%, versus 84.3%). The subgroup of foetal anomaly of gastroschisis or exomphalos had the highest IUFD rate (4/10, 40%), followed by sIUGR III (2/9, 22.2%) and dichorionic triamniotic (DCTA) subgroup (8/46, 17.9%). In EFR group, eight IUFD cases were all coming from the DCTA subgroup and received RFA before 17 weeks. Conclusions The perinatal outcome of RFA was correlated with the indications, with the lowest survival rate in TTTS IV and the highest IUFD incidence in abdominal wall defect followed by sIUGR III. Elective RFA after 17 weeks may prevent IUFD in DCTA pregnancies.
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Affiliation(s)
- Hongmei Wang
- Department of Obstetrics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Qian Zhou
- Department of Obstetrics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Xietong Wang
- Department of Obstetrics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China.,Department of Obstetrics, Maternal Child Health Care Hospital of Shandong Province, Jinan, Shandong, China.,Key Laboratory of Birth Regulation and Control Technology of National Health Commission of China, Maternal Child Health Care Hospital of Shandong Province, Jinan, Shandong, China
| | - Jia Song
- Department of Neonatology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Pengzheng Chen
- Department of Obstetrics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Yanyun Wang
- Department of Obstetrics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Lei Li
- Department of Obstetrics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Hongyan Li
- Department of Obstetrics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 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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21
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Beriwal S, Impey L, Ioannou C. Multifetal pregnancy reduction and selective termination. ACTA ACUST UNITED AC 2020. [DOI: 10.1111/tog.12690] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Sridevi Beriwal
- Clinical Research Fellow Nuffield Department of Women’s and Reproductive Health University of Oxford OxfordOX3 9DUUK
| | - Lawrence Impey
- Consultant and Lead for Fetal Medicine Fetal Medicine Unit John Radcliffe Hospital OxfordOX3 9DUUK
| | - Christos Ioannou
- Consultant in Fetal Medicine Fetal Medicine Unit John Radcliffe Hospital OxfordOX3 9DUUK
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Gabby LC, Chon AH, Korst LM, Llanes A, Chmait RH. Risk Factors for Co-Twin Fetal Demise following Radiofrequency Ablation in Multifetal Monochorionic Gestations. Fetal Diagn Ther 2020; 47:817-823. [PMID: 32772022 DOI: 10.1159/000509401] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 06/12/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Umbilical cord occlusion via radiofrequency ablation (RFA) is utilized to maximize outcomes of the co-twin in complicated multifetal monochorionic (MC) gestations. However, post-procedure co-twin fetal demise is of concern. OBJECTIVE The aim of this study was to determine risk factors for co-twin fetal demise following RFA. METHODS This is a retrospective study of MC multiples that underwent RFA. Indications for RFA included twin reversed arterial perfusion (TRAP) sequence, selective fetal growth restriction (sFGR) type II, discordant lethal anomalies, and twin-twin transfusion syndrome (TTTS) with proximate placental cord insertion sites. The primary outcome was co-twin fetal demise. Bivariate analyses and multiple logistic regression modeling of identified risk factors were conducted. RESULTS Of 36 patients studied, surgical indications were: TRAP (n = 15, 41.7%), sFGR (n = 10, 27.8%), discordant anomalies (n = 9, 25.0%), and TTTS (n = 2, 5.6%). Nine patients (25.0%) experienced a co-twin fetal demise. In multiple logistic regression analysis, fetal growth restriction (FGR) of one co-twin was associated with increased risk of co-twin fetal demise (OR = 10.85, 95% CI 1.03-114.48, p = 0.0474) and a preoperative diagnosis of TRAP was protective against fetal demise (OR = 0.06, 95% CI 0.00-0.84, p = 0.0368). CONCLUSION Co-twin FGR was associated with an increased risk of post-RFA demise. When compared to other indications, patients with TRAP sequence were less likely to have a co-twin demise.
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Affiliation(s)
- Lauryn C Gabby
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Andrew H Chon
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Lisa M Korst
- Childbirth Research Associates, North Hollywood, California, USA
| | - Arlyn Llanes
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Ramen H Chmait
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA,
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Sebghati M, Khalil A. Reduction of multiple pregnancy: Counselling and techniques. Best Pract Res Clin Obstet Gynaecol 2020; 70:112-122. [PMID: 32859535 DOI: 10.1016/j.bpobgyn.2020.06.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 06/16/2020] [Indexed: 12/01/2022]
Abstract
The incidence of multiple births has risen in the last few decades. This rise is mainly due to the widespread use of assisted reproduction techniques mainly as a result of increasing maternal age at conception. Twin and higher-order multiple pregnancies are associated with increased risk of perinatal, as well as maternal, mortality and morbidity compared to singleton pregnancies. There can also be psychosocial and socioeconomic implications for women and their families. In this chapter, we aim to discuss the risks associated with multiple pregnancies, the pros and cons of fetal reduction, the current techniques used in clinical practice, and how to approach counselling parents, enabling them to make informed decisions.
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Affiliation(s)
- Mercede Sebghati
- Fetal Medicine Unit, St George's University Hospitals, Blackshaw Road, London, UK
| | - Asma Khalil
- Fetal Medicine Unit, St George's University Hospitals, Blackshaw Road, London, UK; Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, Cranmer Terrace, London, UK; Twins Trust Centre for Research and Clinical Excellence, UK.
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Patel V, Ritchie CA, Padula C, McKinney JM. Radiofrequency Ablation, Where It Stands in Interventional Radiology Today. Semin Intervent Radiol 2019; 36:398-404. [PMID: 31798214 PMCID: PMC6887522 DOI: 10.1055/s-0039-1697945] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Radiofrequency ablation (RFA) is one of the first developed minimally invasive definitive cancer therapies. The safety and efficacy of RFA is well documented and has led to its incorporation into multiple international societal guidelines. By expanding on the body of knowledge acquired during the clinical use of RFA, alternative ablative technologies have emerged and are successfully competing for locoregional therapy market share. The adaption of newer ablative technologies is leading to a rapid decline in the utilization of RFA by interventional radiologists despite the lack of proven superiority. In their 2010 article, Hong and Georgiades stated "… RFA is likely to remain the mainstay of ablations for small tumors until sufficient experience emerges for the widespread acceptance for alternative ablative modalities." Within a decade of this publication, has this time arrived?
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Affiliation(s)
| | | | - Carlos Padula
- Department of Radiology, Mayo Clinic, Jacksonville, Florida
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Sacco A, Van der Veeken L, Bagshaw E, Ferguson C, Van Mieghem T, David AL, Deprest J. Maternal complications following open and fetoscopic fetal surgery: A systematic review and meta-analysis. Prenat Diagn 2019; 39:251-268. [PMID: 30703262 PMCID: PMC6492015 DOI: 10.1002/pd.5421] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 01/16/2019] [Accepted: 01/20/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To establish maternal complication rates for fetoscopic or open fetal surgery. METHODS We conducted a systematic literature review for studies of fetoscopic or open fetal surgery performed since 1990, recording maternal complications during fetal surgery, the remainder of pregnancy, delivery, and after the index pregnancy. RESULTS One hundred sixty-six studies were included, reporting outcomes for open fetal (n = 1193 patients) and fetoscopic surgery (n = 9403 patients). No maternal deaths were reported. The risk of any maternal complication in the index pregnancy was 20.9% (95%CI, 15.22-27.13) for open fetal and 6.2% (95%CI, 4.93-7.49) for fetoscopic surgery. For severe maternal complications (grades III to V Clavien-Dindo classification of surgical complications), the risk was 4.5% (95% CI 3.24-5.98) for open fetal and 1.7% (95% CI, 1.19-2.20) for fetoscopic surgery. In subsequent pregnancies, open fetal surgery increased the risk of preterm birth but not uterine dehiscence or rupture. Nearly one quarter of reviewed studies (n = 175, 23.3%) was excluded for failing to report the presence or absence of maternal complications. CONCLUSIONS Maternal complications occur in 6.2% fetoscopic and 20.9% open fetal surgeries, with serious maternal complications in 1.7% fetoscopic and 4.5% open procedures. Reporting of maternal complications is variable. To properly quantify maternal risks, outcomes should be reported consistently across all fetal surgery studies.
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Affiliation(s)
- Adalina Sacco
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Lennart Van der Veeken
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
| | - Emma Bagshaw
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Catherine Ferguson
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Tim Van Mieghem
- Department of Obstetrics and GynaecologyMount Sinai Hospital and University of TorontoTorontoOntarioCanada
| | - Anna L. David
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
- National Institute for Health ResearchUniversity College London Hospitals Biomedical Research CentreLondonUK
| | - Jan Deprest
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
- Clinical Department Obstetrics and GynaecologyUniversity Hospitals LeuvenLeuvenBelgium
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Shinde R, James P, Suresh S, Ram U, Seshadri S. Radiofrequency Ablation in Complicated Monochorionic Pregnancy: Initial Experience. JOURNAL OF FETAL MEDICINE 2018. [DOI: 10.1007/s40556-017-0145-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Radiofrequency ablation for selective reduction in complex monochorionic multiple pregnancies: A case series. Taiwan J Obstet Gynecol 2017; 56:740-744. [DOI: 10.1016/j.tjog.2017.10.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2017] [Indexed: 01/26/2023] Open
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Mone F, Devaseelan P, Ong S. Intervention versus a conservative approach in the management of TRAP sequence: a systematic review. J Perinat Med 2016; 44:619-29. [PMID: 26356357 DOI: 10.1515/jpm-2015-0165] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 08/13/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVE In the management of twin reversed arterial perfusion (TRAP) sequence, we wished to (i) determine if intervention is better than a conservative approach and (ii) assess if any of the apparent adverse prognostic indicators could guide intervention. METHODS A systematic review was conducted between 1994 and 2014. Data extracted were inspected for heterogeneity. Overall rates and confidence intervals (CIs) for each prognostic factor were calculated. Where there were comparative data, the odds ratio (OR) was calculated. RESULTS Twenty-six studies were included in the review. When all cases were considered, intervention either by cord occlusion or by ablation conferred a better survival rate compared with conservative management (OR=2.22, 95% CI 1.23-4.01, heterogeneity I2=37%, P=0.008). This difference was greater in the presence of one or more poor prognostic features (OR=8.58, 95% CI 1.47-49.96, heterogeneity I2=0%, P=0.02). Survival was better using ablative techniques compared to cord occlusion (OR=9.84, 95% CI 1.56-62.00, heterogeneity I2=0%, P=0.01). CONCLUSION Intervention either by cord occlusion or by ablation confers a better survival rate compared to conservative management. This appears more compelling if there are one or more poor prognostic features. Ablative techniques are superior to cord occlusion. There were insufficient data to determine which poor prognostic features should guide management.
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Peng R, Xie HN, Lin MF, Yang JB, Zhou Y, Chen HQ, Zhu YX. Clinical Outcomes after Selective Fetal Reduction of Complicated Monochorionic Twins with Radiofrequency Ablation and Bipolar Cord Coagulation. Gynecol Obstet Invest 2016; 81:552-558. [PMID: 27035917 DOI: 10.1159/000445291] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 03/07/2016] [Indexed: 11/19/2022]
Abstract
AIMS To review pregnancy outcomes, complication rates and neonatal neural development of selective termination procedures for complicated monochorionic (MC) twins. METHODS This was a retrospective review of the pregnancies that underwent selective reduction with radiofrequency ablation (RFA) and bipolar cord coagulation (BCC) in our institution. RESULTS Forty-eight cases underwent selective reduction with BCC and the remaining 45 with RFA. Overall survival was not statistically different between the RFA and BCC groups (71.1 and 62.5%, p = 0.379). With regard to the indications, the survival rates were not significantly different for twin to twin transfusion syndrome, twin reversed arterial perfusion, discordant anomalies and selective intrauterine growth restriction. Preterm premature rupture of membrane was not statistically different between the BCC and RFA groups (47.9 and 33.3%, p = 0.153). Five foetuses presented with abnormal middle cerebral artery-peak systolic velocity in the BCC group and 4 in the RFA group (p = 0.829). In the BCC group, neurological injury was detected in 2 neonates, presenting with cerebral dysplasia on MR scanning. In the RFA group, intracranial haemorrhage Grade III was detected in one neonate with cranial ultrasound (p = 0.607). CONCLUSIONS Overall survival and complication rates following selective reduction in complicated MC twin pregnancies is similar irrespective of whether the reduction was performed using RFA or BCC. Key Message: It seems that selective reduction in MC pregnancies with RFA does not carry a significant decrease in the overall survival and complication rates than the cases with BCC. According to our data, neurodevelopmental impairment of the co-twins is relatively seldom after selective reduction.
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Affiliation(s)
- Ruan Peng
- Department of Ultrasonic Medicine, Fetal Medical Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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Wagata M, Murakoshi T, Ishii K, Muromoto J, Sasahara J, Murotsuki J. Radiofrequency Ablation with an Internally Cooled Electrode for Twin Reversed Arterial Perfusion Sequence. Fetal Diagn Ther 2016; 40:110-5. [PMID: 26928848 DOI: 10.1159/000442152] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 10/30/2015] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The study aims to evaluate the efficacy of radiofrequency ablation (RFA) with an internally cooled electrode for twin reversed arterial perfusion (TRAP) sequence. METHODS From April 2008 through December 2014, we retrospectively reviewed all patients who underwent RFA with an internally cooled electrode for TRAP sequence at 3 tertiary referral centers in Japan. RESULTS Twenty-five monochorionic diamniotic twin pregnancies underwent RFA with an internally cooled electrode for TRAP sequence at 16-27 weeks of gestation. In all cases, umbilical cord blood flow cessation in the acardiac twin was confirmed by ultrasonography with color Doppler. There were 2 cases of procedure-related complications: 1 case of unintentional septostomy and 1 case of anemia in a pump twin. Fetal demise of the pump twin occurred in 3 (12%) cases. Twenty-two (88%) of 25 pump twins were delivered alive. The median gestational age at delivery was 36 + 3 weeks (range 25 + 2-40 + 5 weeks). There were 14 cases (64%) of premature deliveries before 37 weeks and 5 (23%) before 32 weeks. CONCLUSION RFA with an internally cooled electrode is a feasible and effective procedure for the treatment of TRAP sequence.
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Affiliation(s)
- Maiko Wagata
- Division of Perinatology, Fetal Diagnosis and Therapy, Maternal and Perinatal Care Center, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
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Yinon Y, Ashwal E, Weisz B, Chayen B, Schiff E, Lipitz S. Selective reduction in complicated monochorionic twins: prediction of obstetric outcome and comparison of techniques. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 46:670-677. [PMID: 25867754 DOI: 10.1002/uog.14879] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Revised: 04/07/2015] [Accepted: 04/09/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To compare the outcomes of radiofrequency ablation (RFA) and bipolar cord coagulation (BPC) methods for selective feticide in complicated monochorionic (MC) twin gestations and to determine risk factors for adverse pregnancy outcome. METHODS This was a retrospective cohort study of all patients with complicated MC twin pregnancy who underwent selective reduction in a single tertiary care center between 2000 and 2014. We compared the two methods with respect to various demographic, obstetric and perinatal outcome variables. RESULTS Fifty-three selective terminations in complicated MC twin gestations were performed, 36 by RFA and 17 by BPC. Each technique resulted in a similar overall survival rate of the remaining twin (88.9% vs 76.5%, P = 0.25). Likewise, the mean procedure-to-delivery interval, the rate of spontaneous preterm delivery < 37, < 34, < 32 and < 28 weeks and the rate of preterm prelabor rupture of the membranes did not differ between the groups. However, among patients in the BPC group, there was a trend towards earlier gestational age at delivery (31.3 vs 35.0 weeks, P = 0.09) compared with in the RFA group. There was selective reduction by RFA due to selective intrauterine growth restriction (sIUGR) in 19 cases, 17 (89.5%) of which survived perinatally, with delivery at a median gestational age of 37 weeks. There were no significant differences in perinatal outcome, irrespective of whether the procedure was performed pre- or post-viability. All post-viability reductions, most of which were by RFA, resulted in perinatal survival. CONCLUSIONS Perinatal outcome of complicated MC twin gestations undergoing selective feticide seems to be similar regardless of whether termination is by BPC or RFA. Nevertheless, RFA appears to be particularly useful in MC twins complicated by sIUGR and in cases requiring selective reduction beyond the age of viability.
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Affiliation(s)
- Y Yinon
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - E Ashwal
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - B Weisz
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - B Chayen
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - E Schiff
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - S Lipitz
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Gaerty K, Greer RM, Kumar S. Systematic review and metaanalysis of perinatal outcomes after radiofrequency ablation and bipolar cord occlusion in monochorionic pregnancies. Am J Obstet Gynecol 2015; 213:637-43. [PMID: 25935786 DOI: 10.1016/j.ajog.2015.04.035] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 03/31/2015] [Accepted: 04/24/2015] [Indexed: 11/29/2022]
Abstract
The aim of this study was to analyze perinatal outcomes after selective reduction in monochorionic pregnancies with the use of either radiofrequency ablation (RFA) or bipolar cord occlusion (BCO). This was a systematic review and metaanalysis that included all studies with ≥5 cases that described perinatal outcomes after BCO or RFA that were identified in PubMed, Embase, Web of Science, COCHRANE, CINAHL, Academic Search Premier, Science Direct, and MEDLINE that were published between 1965 and July 2014. For count data, incidence risk ratios (IRR; 95% confidence interval [CI]) were calculated with BCO as the reference standard. The analysis included 481 cases of BCO and 320 cases of RFA from 17 studies. The mean median gestations at procedure were 21.1 ± 1.2 weeks (BCO) and 18.8 ± 2.5 weeks (RFA; P = .03). The rate of cotwin death was higher in the RFA group (14.7%) vs the BCO group (10.6%; IRR, 1.38; 95% CI, 0.93-2.05; P = .11). The live birth rate was 81.3% for the RFA group and 86.7% in the BCO group (IRR, 0.93; 95% CI, 0.80-1.09; P = .41). BCO had higher neonatal death rates (8.1%) vs RFA (4.5%; IRR, 0.56; 95% CI, 0.30-1.04; P = .07). Overall survival was 76.8% for RFA and 79.1% for BCO (IRR, 0.97; 95% CI, 0.82-1.14; P = .72); however, none of these differences were statistically significant. Preterm premature rupture of membranes occurred in 17.7% of RFA cases and 28.2% of the BCO cases (IRR, 0.63; 95% CI, 0.43-0.91; P = .01). The mean median gestational age at delivery was 34.7 ± 1.7 weeks in the RFA group and 35.1 ± 1.6 weeks in the BCO group. Our data do not demonstrate clearly the superiority of 1 procedure over the other. The clinical situation and preference of the operator are important considerations. Rates of preterm delivery and preterm premature rupture of membranes remain substantial for both procedures.
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Affiliation(s)
- Kirsten Gaerty
- Mater Mothers' Hospital, South Brisbane, Queensland, Australia
| | - Ristan M Greer
- Mater Research Institute, University of Queensland, South Brisbane, Queensland, Australia
| | - Sailesh Kumar
- Mater Research Institute, University of Queensland, South Brisbane, Queensland, Australia; Mater Mothers' Hospital, South Brisbane, Queensland, Australia.
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Story L, Rutherford M. Advances and applications in fetal magnetic resonance imaging. ACTA ACUST UNITED AC 2015. [DOI: 10.1111/tog.12203] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Lisa Story
- London Deanery; Darent Valley Hospital; Darenth Wood Road Dartford Kent DA2 8DA UK
| | - Mary Rutherford
- King's College London; Perinatal Imaging Unit; St Thomas's Hospital; Westminster Bridge Road London SE1 7EH UK
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Kumar S, Paramasivam G, Zhang E, Jones B, Noori M, Prior T, Vasudeva A, Wimalasundera RC. Perinatal- and procedure-related outcomes following radiofrequency ablation in monochorionic pregnancy. Am J Obstet Gynecol 2014; 210:454.e1-6. [PMID: 24315860 DOI: 10.1016/j.ajog.2013.12.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Revised: 10/24/2013] [Accepted: 12/02/2013] [Indexed: 10/25/2022]
Abstract
OBJECTIVE We sought to assess the efficacy, complication rates, and outcomes for complex monochorionic pregnancies undergoing selective fetal reduction using radiofrequency ablation (RFA). STUDY DESIGN In this prospective observational study, 100 consecutive cases of selective fetal reduction using RFA were analyzed. All cases were managed at the Centre for Fetal Care at Queen Charlotte's and Chelsea Hospital in London. Indications for offering RFA, details of the procedure, and pregnancy outcomes were collected and analyzed. RESULTS The main indications for RFA were discordant fetal anomaly and twin-twin transfusion syndrome. Overall live birth rate was 78% and the median gestation at delivery was 35.15 weeks. Delivery <32 weeks' gestation occurred in 17.9% of cases. Postprocedure abnormal antenatal magnetic resonance imaging occurred in 3% of cases. There was no statistical difference in outcomes with regard to gestation when the procedure was performed or the indication for the RFA. CONCLUSION RFA appears to be a reasonable option for selective fetal reduction in complex monochorionic pregnancies with an overall survival rate of 78%.
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Chaveeva P, Poon LC, Sotiriadis A, Kosinski P, Nicolaides KH. Optimal Method and Timing of Intrauterine Intervention in Twin Reversed Arterial Perfusion Sequence: Case Study and Meta-Analysis. Fetal Diagn Ther 2014; 35:267-79. [DOI: 10.1159/000358593] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Accepted: 12/30/2013] [Indexed: 11/19/2022]
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Peeters SH, Devlieger R, Middeldorp JM, DeKoninck P, Deprest J, Lopriore E, Lewi L, Klumper FJ, Kontopoulos E, Quintero R, Oepkes D. Fetal surgery in complicated monoamniotic pregnancies: case series and systematic review of the literature. Prenat Diagn 2014; 34:586-91. [DOI: 10.1002/pd.4353] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 02/28/2014] [Accepted: 02/28/2014] [Indexed: 11/10/2022]
Affiliation(s)
| | - Roland Devlieger
- Department of Obstetrics and Gynecology; University hospitals of KU Leuven; Leuven Belgium
| | | | - Philip DeKoninck
- Department of Obstetrics and Gynecology; University hospitals of KU Leuven; Leuven Belgium
| | - Jan Deprest
- Department of Obstetrics and Gynecology; University hospitals of KU Leuven; Leuven Belgium
| | - Enrico Lopriore
- Department of Pediatrics, Division of Neonatology; Leiden University Medical Center; Leiden The Netherlands
| | - Liesbeth Lewi
- Department of Obstetrics and Gynecology; University hospitals of KU Leuven; Leuven Belgium
| | - Frans J. Klumper
- Department of Obstetrics; Leiden University Medical Center; Leiden The Netherlands
| | | | - Ruben Quintero
- Jackson Fetal Therapy Institute; Jackson Memorial Hospital; Miami FL USA
| | - Dick Oepkes
- Department of Obstetrics; Leiden University Medical Center; Leiden The Netherlands
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Nobili E, Paramasivam G, Kumar S. Outcome following selective fetal reduction in monochorionic and dichorionic twin pregnancies discordant for structural, chromosomal and genetic disorders. Aust N Z J Obstet Gynaecol 2013; 53:114-8. [PMID: 23577786 DOI: 10.1111/ajo.12071] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Accepted: 01/30/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND To investigate the indications for offering selective fetal reduction in monochorionic (MC) and dichorionic (DC) twins and to correlate obstetric outcome with the antenatal procedure. METHODS All cases of MC and DC twins discordant for structural anomalies and for chromosomal/genetic abnormalities were included. Selective reductions performed for twin-to-twin transfusion syndrome or growth restriction were excluded. For DC twins, feticide was achieved using intracardiac injection of potassium chloride (KCl). For MC twins, bipolar cord occlusion (BCO), interstitial laser or radiofrequency ablation (RFA) was used. RESULTS There were 121 twin pregnancies discordant for structural and chromosomal abnormalities. Only 88 (56 were MC twins and 32 were DC twins) had selective reduction. For both MC and DC twins, the leading indication for selective reduction was structural anomalies with CNS malformations the most common. For all MC fetal reduction techniques, the overall pregnancy loss rate (<24 weeks) was 8.9% with RFA having the lowest procedure loss rate (7.7%). The preterm delivery rate was lowest with reduction in DC pregnancies. The live birth rates for MC twins were >87% and 100% for DC twins. CONCLUSIONS Selective reduction in MC pregnancies carries an increased procedure-related and preterm delivery rate compared with DC pregnancies. The main indication for selective reduction was structural malformations, with a predominance of CNS anomalies.
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Affiliation(s)
- Elena Nobili
- Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital, Imperial College London, London, UK
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Rebarber A, Dolin C, Fox NS, Roman AS. Limb arteriovenous malformation identified after radiofrequency ablation for selective termination in twin-to-twin transfusion syndrome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2013; 42:605-606. [PMID: 23804298 DOI: 10.1002/uog.12554] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 06/11/2013] [Accepted: 06/14/2013] [Indexed: 06/02/2023]
Affiliation(s)
- A Rebarber
- Carnegie Imaging for Women, PLLC, New York, NY, USA; New York University School of Medicine, Department of Obstetrics and Gynecology, New York, NY, USA; Mount Sinai School of Medicine, Department of Obstetrics and Gynecology, New York, NY, USA; Maternal Fetal Medicine Associates, PLLC, 70 East 90th Street, New York, NY, 10128, USA
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van den Bos EM, van Klink JMM, Middeldorp JM, Klumper FJ, Oepkes D, Lopriore E. Perinatal outcome after selective feticide in monochorionic twin pregnancies. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2013; 41:653-658. [PMID: 23335029 DOI: 10.1002/uog.12408] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 11/23/2012] [Accepted: 12/06/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To evaluate the incidence and risk factors of adverse perinatal outcome in complicated monochorionic twin pregnancies treated with selective feticide. METHODS This was a retrospective analysis of prospectively collected data from a consecutive, national cohort. All monochorionic twin pregnancies treated with selective feticide at Leiden University Medical Center between June 2000 and November 2011 were included. Obstetric and neonatal data were recorded. The primary outcome measure was adverse perinatal outcome, including fetal or neonatal demise or severe neonatal morbidity. RESULTS Data on perinatal outcome were obtained in all cases (n = 131). Overall perinatal survival rate was 67.2% (88/131). Median gestational age at delivery was 34 (interquartile range, 23-38) weeks. Neonatal mortality and morbidity rate in liveborn children was 4.3% (4/92) and 12.0 % (11/92), respectively. Severe cerebral injury was detected in three children. The overall incidence of adverse perinatal outcome was 41.2% (54/131). Median gestational age at occurrence of preterm prelabor rupture of membranes (PPROM) was 19.0 weeks and 32.0 weeks in cases with and without adverse perinatal outcome, respectively (P = 0.017). Liveborn children with adverse perinatal outcome were born at a lower median gestational age (29.0 weeks) than were children without adverse perinatal outcome (38.0 weeks) (P < 0.001). CONCLUSIONS The risk of adverse perinatal outcome after selective feticide is high and associated with low gestational age at occurrence of PPROM and low gestational age at delivery. Long-term follow-up to assess neurodevelopmental outcome in survivors is required.
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Affiliation(s)
- E M van den Bos
- Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
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Legendre CM, Moutel G, Drouin R, Favre R, Bouffard C. Differences between selective termination of pregnancy and fetal reduction in multiple pregnancy: a narrative review. Reprod Biomed Online 2013; 26:542-54. [PMID: 23518032 DOI: 10.1016/j.rbmo.2013.02.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Revised: 01/31/2013] [Accepted: 02/05/2013] [Indexed: 10/27/2022]
Abstract
Although selective termination of pregnancy and fetal reduction in multiple pregnancy both involve the termination in utero of the development of live fetuses, these two procedures are different in several aspects. Nevertheless, several authors tend to amalgamate and confuse their psychosocial consequences and the ethical issues they raise. Therefore, this narrative review, derived from a comparative analysis of 91 articles, shines a light on these amalgamations and confusions, as well as on the medical, contextual, experiential and ethical differences specific to selective termination and fetal reduction.
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Affiliation(s)
- Claire-Marie Legendre
- Division of Genetics, Department of Pediatrics, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001 12e Avenue Nord, Sherbrooke, Québec, Canada
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Cabassa P, Fichera A, Prefumo F, Taddei F, Gandolfi S, Maroldi R, Frusca T. The use of radiofrequency in the treatment of twin reversed arterial perfusion sequence: a case series and review of the literature. Eur J Obstet Gynecol Reprod Biol 2013; 166:127-32. [DOI: 10.1016/j.ejogrb.2012.10.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Revised: 07/29/2012] [Accepted: 10/05/2012] [Indexed: 10/27/2022]
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Delabaere A, Favre N, Velemir L, Bentaoui S, Coste K, Laurichesse-Demas H, Lemery D, Gallot D. [Pediatric outcome after selective feticide for 30 complicated monochorionic twin pregnancies]. ACTA ACUST UNITED AC 2013; 41:85-9. [PMID: 23369677 DOI: 10.1016/j.gyobfe.2012.12.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Accepted: 12/21/2012] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To describe perinatal and pediatric outcome after selective feticide for complicated monochorionic twin pregnancy. PATIENTS AND METHODS We reviewed all consecutive cases of umbilical cord occlusion performed for complicated monochorionic twin pregnancy over a 16-year period. Pediatric follow-up was based on medical records and updated by phone calls to the parents. RESULTS Thirty procedures were performed. Indications were: twin-to-twin transfusion syndrome (TTTS) progressing despite serial amniodrainage (n=12) ; twin reversed arterial perfusion (n=9) ; selective growth restriction (n=5) ; severe discordant structural anomalies (n=4). Mean gestational age at procedure was 21.8±3.1gestational weeks (GW) and 31.8±4.8 GW at birth. Overall survival rate was 87%, i.e. 83%, 100%, 60% and 100% for each indication, respectively. Mean pediatric follow-up was 5years (range: 6months to 15years). Medical charts and parents declared normal development in 88% of surviving children, i.e. 67%, 100%, 100%, and 100% for each indication. Cross-comparison between the four groups revealed that in the TTTS group, gestational age at procedure was more advanced (P=0.01) while delivery was slightly earlier (P=0.1), and pediatric development was poorer (P=0.02). DISCUSSION AND CONCLUSION Pediatric outcome after selective feticide appeared to be poorer for TTTS progressing despite serial amniodrainage than for other indications.
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Affiliation(s)
- A Delabaere
- Pôle GOHR, unité de médecine fœtale, CHU d'Estaing, 1, place Lucie-Aubrac, 63003 Clermont-Ferrand cedex 1, France
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Lu J, Ting YH, Law KM, Lau TK, Leung TY. Radiofrequency Ablation for Selective Reduction in Complicated Monochorionic Multiple Pregnancies. Fetal Diagn Ther 2013; 34:211-6. [DOI: 10.1159/000355406] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Accepted: 08/30/2013] [Indexed: 11/19/2022]
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van Mieghem T, Baud D, Devlieger R, Lewi L, Ryan G, De Catte L, Deprest J. Minimally invasive fetal therapy. Best Pract Res Clin Obstet Gynaecol 2012; 26:711-25. [DOI: 10.1016/j.bpobgyn.2012.03.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Accepted: 03/21/2012] [Indexed: 12/31/2022]
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Bebbington MW, Danzer E, Moldenhauer J, Khalek N, Johnson MP. Radiofrequency ablation vs bipolar umbilical cord coagulation in the management of complicated monochorionic pregnancies. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2012; 40:319-324. [PMID: 22302774 DOI: 10.1002/uog.11122] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVE The application of radiofrequency ablation (RFA) termination procedures to complicated cases involving monochorionic twins offers the potential of a less invasive option when compared to endoscopic techniques. The purpose of this study was to compare outcomes between these two techniques. METHODS A retrospective review was undertaken of all cases of complicated monochorionic twin gestations treated at the Children's Hospital of Philadelphia from July 1996 to December 2010. Cases were identified from the fetal treatment database and data extracted in a uniform fashion from the patients' charts. RESULTS A total of 149 cases were identified with procedures performed on 146. Indications for selective termination of one fetus were twin reversed arterial perfusion sequence in 53, severe twin-to-twin transfusion syndrome in 43, discordance for fetal anomalies in 26 and selective intrauterine growth restriction in 24. Eighty-eight cases were managed with bipolar cord coagulation (BCC) and 58 with RFA. The procedures in all cases were technically successful in achieving selective termination. The mean gestational age at the time of the procedure was 20.9 ± 2.7 weeks in the BCC group vs 20.2 ± 2.2 weeks in the RFA group (P = 0.1). The median gestational age at delivery was 34.7 (interquartile range (IQR), 29.2-38.6) weeks for the BCC group vs 33.0 (IQR, 23.4-38.9) weeks in the RFA group (P = 0.073). Mean birth weight did not differ between the two groups. The procedure-to-delivery time was 87.1 ± 42.1 days for the BCC group vs 73.8 ± 47.2 days for the RFA group (P = 0.1). Overall survival was 85.2% in the BCC group vs 70.7% in the RFA group (P = 0.014). This was attributed primarily to a survival rate of 10.5% in the RFA group compared with 31.6% in the BCC group for cases where delivery occurred before 28 weeks' gestation (P = 0.01). Premature rupture of the membranes occurred in 27.3% in the BCC group vs 13.7% in the RFA group (P = 0.05). Preterm labor was more common in the BCC group than in the RFA group (22.4 vs 7%, respectively; P = 0.009). CONCLUSION Despite the smaller caliber of the instrument, RFA is not associated with a decrease in the overall complication rate for selective termination procedures. The technique used for selective termination should still be determined by technical considerations but patients should be informed of the survival rate associated with each technique.
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Affiliation(s)
- M W Bebbington
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
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Hoffmann C, Weisz B, Yinon Y, Hogen L, Gindes L, Shrim A, Sivan E, Schiff E, Lipitz S. Diffusion MRI findings in monochorionic twin pregnancies after intrauterine fetal death. AJNR Am J Neuroradiol 2012; 34:212-6. [PMID: 22859276 DOI: 10.3174/ajnr.a3279] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE Monochorionic twin pregnancies complicated by the IUFD of 1 twin are associated with substantial morbidity to the survivor twin. The aim of this study was to determine whether fetal sonography, T2 MR imaging, and DWI can diagnose acute cerebral lesions in the survivor of an MC twin pregnancy shortly after fetal death of the co-twin. MATERIALS AND METHODS During the study period (2007-2010) 34 cases of single IUFD were evaluated. Group A included 6 cases complicated by spontaneous IUFD. Group B had 10 cases of fetal death shortly after treatment of severe TTTS. These were compared with group C, with 18 pregnancies treated by selective termination due to severe complications in MC pregnancies. RESULTS Altogether 9/34 patients had abnormal prenatal cerebral findings. In group A, in 2/6 of pregnancies with spontaneous death, MR imaging showed findings of severe cerebral infarct, while cerebral damage was not evident by sonography. In another case, the surviving fetus was found to be hydropic on sonography, while MR imaging findings were normal. In group B, in 1/10 cases, cerebral infarct was demonstrated only by DWI. In 2 other cases, sonographic findings were normal, but MR imaging showed germinal matrix bleeding. In group C, in 1/18 cases, only DWI showed bilateral cerebral ischemia. In 2 other cases, MR imaging findings suggested germinal matrix bleeding and focal changes in the basal ganglia. In both cases, fetal sonographic findings were normal. CONCLUSIONS In our study, early manifestations of cerebral ischemia in monochorionic twin pregnancies were better diagnosed with MR imaging, especially with DWI.
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Affiliation(s)
- C Hoffmann
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
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Dixit A, Tanteles G, Ocraft K, McEwan A, Sarkar A. Monozygotic twins discordant for trisomy 13: counselling and management issues. J Perinatol 2012; 32:639-41. [PMID: 22842802 DOI: 10.1038/jp.2011.145] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The diagnosis and management of a heterokaryotypic monochorionic pregnancy, in which one of twins had trisomy 13, is presented. Monozygosity and discordant karyotypes were confirmed by amniocentesis of both the sacs. Radiofrequency ablation of the trisomic twin was successfully performed at 18-weeks gestation and the pregnancy ended at term with the birth of a healthy girl who remains well on follow-up at 12 months of age. We reiterate the importance of early amniocentesis of both the sacs in the presence of discordant fetal abnormalities and consideration of selective fetal termination to optimise the outcome of heterokaryotypic monochorionic twin pregnancies.
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Affiliation(s)
- A Dixit
- Department of Clinical Genetics, Nottingham City Hospital, Nottingham, UK
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Moise KY, Kugler L, Jones T. Contemporary Management of Complicated Monochorionic Twins. J Obstet Gynecol Neonatal Nurs 2012; 41:434-44; quiz 445-6. [DOI: 10.1111/j.1552-6909.2012.01355.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Karen Y Moise
- Texas Fetal Center, University of Texas Health Science Center, Children's Memorial Hermann Hospital, Houston, TX 77030, USA.
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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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