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Sun W, Yang Z, Yin S. Twin reversed arterial perfusion sequence with a cardiac loop. Am J Obstet Gynecol 2023; 229:457-459. [PMID: 36963623 DOI: 10.1016/j.ajog.2023.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 03/19/2023] [Indexed: 03/26/2023]
Affiliation(s)
- Wei Sun
- Shengjing Hospital of China Medical University, Shenyang, China
| | - Zeyu Yang
- Shengjing Hospital of China Medical University, Shenyang, China
| | - Shaowei Yin
- Shengjing Hospital of China Medical University, Shenyang, China.
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Alshanafey S, Al-Nemer M, Tulbah M, Khan RM, Sahan NA, Mugbel MA, Al-Hazzani F, Almutairi G, Kurdi W. Management of twin reversed arterial perfusion sequence: eight cases over 13 years. Ann Saudi Med 2023; 43:199-203. [PMID: 37554025 DOI: 10.5144/0256-4947.2023.199] [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: 08/10/2023] Open
Abstract
BACKGROUND Twin reversed arterial perfusion (TRAP) sequence is a rare condition that affects primarily monozygotic monochorionic twin pregnancies in which a normal twin acts as a pump (donor) for an acardiac recipient (perfuse) twin. OBJECTIVE We report our experience over the last 13 years at a tertiary health care center. DESIGN Descriptive, retrospective case series SETTING: Tertiary health care center PATIENTS AND METHODS: All TRAP cases managed between the years 2009 and 2022 at our Fetal Diagnosis and Therapy Center were included. Data recorded included demographic and clinical information which was used to generate descriptive data. Patients were managed by a multidisciplinary team with variable interventions. MAIN OUTCOME MEASURE Survival of normal twin SAMPLE SIZE: Eight RESULTS: Eight pregnant women with TRAP syndrome were managed at our center during that period. One was monozygotic monochorionic and the others were monochorionic diamniotic. Median maternal age at presentation was 27 years and median gestational age at diagnosis was 23 weeks. All were diagnosed with ultrasound (US) imaging. Three were managed with bipolar ligation of the cord of the acardiac twin under general anesthesia, one US-guided (single port) and 2 fetoscopic (2 ports) with a median operative time of 39 minutes. The last five cases were managed with US-guided radiofrequency ablation (RFA) under local anesthesia, one needed 2 sessions, 1 week apart. The median duration of the RFA procedure was 23 minutes. There were no complications and all had viable normal babies born at a median of 32 weeks of gestation (6 C-section, 2 spontaneous membrane rupture). CONCLUSIONS Acardiac twin cord ligation and RFA are feasible and safe options with excellent outcome for TRAP syndrome. RFA may be preferable owing to its less invasiveness under local anesthesia. LIMITATIONS None, given the rarity of the disease and the study design. CONFLICT OF INTEREST None.
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Affiliation(s)
- Saud Alshanafey
- From the Department of Surgery, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Maha Al-Nemer
- From the Department of Obstetrics and Gynecology Perinatology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Maha Tulbah
- From the Department of Obstetrics and Gynecology Perinatology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Rubina Ma Khan
- From the Department of Obstetrics and Gynecology Perinatology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Nada Al Sahan
- From the Department of Obstetrics and Gynecology Perinatology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Maisoon Al Mugbel
- From the Department of Obstetrics and Gynecology Perinatology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Fahad Al-Hazzani
- From the Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Gawaher Almutairi
- From the Department of Fetal Therapy, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Wesam Kurdi
- From the Department of Obstetrics and Gynecology Perinatology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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Gemert MJCV, Wijngaard JPHMVD, Paarlberg KM, Gardiner HM, Nikkels PGJ. Acardiac twin pregnancies part IV: Acardiac onset from unequal embryonic splitting simulated by a fetoplacental resistance model. Birth Defects Res 2018; 109:211-223. [PMID: 27891739 DOI: 10.1002/bdra.23581] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 09/16/2016] [Accepted: 09/20/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Benirschke postulated that acardiac twinning occurs when markedly unequal embryonic splitting combines with arterioarterial (AA) and venovenous placental anastomoses. We tested this hypothesis by model simulations and by comparison of outcomes with 18 "pseudo-" (twin fetus with beating heart but otherwise with clear signs of an acardiac) and 3 "normal" acardiac cases. METHODS The smaller/larger cell volume ratio at embryonic splitting becomes the smaller/larger embryonic/fetal blood volume ratio (a). From a, we derived nonpulsating blood pressures using normal values (larger twin) and normal values at an appropriate earlier gestational age (smaller twin). These unequal pressure sources were used in a linear resistance fetoplacental network to calculate umbilical venous diameter ratios. Acardiac onset occurs when the smaller twin has 50% left of its normal, singleton placenta. Comparison with clinical cases approximated a by crown-rump-length-ratio to the 3rd power. Input parameters are a and the AA-radius at 40 weeks. RESULTS Acardiacs can be small or large, can occur early or late, earlier at smaller a and larger AA, with larger umbilical venous diameter ratios at smaller a and smaller AA. Comparison with the 21 clinical cases was good, except for 2. CONCLUSION Our analysis supports Benirschke's hypothesis. The smaller twin has to share its placental perfusion with the larger twin, which is a novel finding. The AA size is essential for the future of both fetuses but complicates easy understanding of (pseudo-)acardiac clinical presentations. Late acardiac onset occurs infrequently. Using nonpulsating circulations may have caused our extensive predictions of late onset. An improved model requires including hypoxemia in the smaller twin from chronic placental hypoperfusion. Birth Defects Research 109:211-223, 2017. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Martin J C van Gemert
- Department of Biomedical Engineering & Physics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Jeroen P H M van den Wijngaard
- Department of Biomedical Engineering & Physics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - K Marieke Paarlberg
- Department of Obstetrics and Gynecology, Gelre Hospitals, location Apeldoorn, The Netherlands
| | - Helena M Gardiner
- The Fetal Center, McGovern Medical School at UTHealth, University of Texas, Houston, TX, USA
| | - Peter G J Nikkels
- Department of Pathology, Wilhelmina Children's Hospital, University Medical Center, Utrecht, The Netherlands
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4
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Nizyaeva NV, Кostyukov KV, Gladkova KA, Kulikova GV, Shchegolev AI. [Role of twin reversed arterial perfusion syndrome in the development of fetus acardius]. Arkh Patol 2016; 78:54-57. [PMID: 27600783 DOI: 10.17116/patol201678454-57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Monochorionic multiple pregnancy has a higher risk for obstetric complications, including those due to the development of twin-to-twin transfusion syndrome and reversed arterial perfusion syndrome (TRAP sequence). The latter occurs in 0.1% of all monochorionic pregnancies. The basis for TRAP sequence is a relationship between arterial and venous anastomoses from the appropriate placental areas, causing a recipient fetus to develop at the expense of a donor fetus. The presence of abnormal anastomoses is considered to be a main cause of acardia. The prognosis for a donor fetus is also unfavorable: the mortality rates in the absence of intrauterine correction are as high as 55%.
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Affiliation(s)
- N V Nizyaeva
- Acad. V.I. Kulakov Research Center of Obstetrics, Gynecology, and Perinatology, Ministry of Health of the Russian Federation, Moscow, Russia
| | - K V Кostyukov
- Acad. V.I. Kulakov Research Center of Obstetrics, Gynecology, and Perinatology, Ministry of Health of the Russian Federation, Moscow, Russia
| | - K A Gladkova
- Acad. V.I. Kulakov Research Center of Obstetrics, Gynecology, and Perinatology, Ministry of Health of the Russian Federation, Moscow, Russia
| | - G V Kulikova
- Acad. V.I. Kulakov Research Center of Obstetrics, Gynecology, and Perinatology, Ministry of Health of the Russian Federation, Moscow, Russia
| | - A I Shchegolev
- Acad. V.I. Kulakov Research Center of Obstetrics, Gynecology, and Perinatology, Ministry of Health of the Russian Federation, Moscow, Russia
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5
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Hartge DR, Weichert J. Prenatal diagnosis and outcome of multiple pregnancies with reversed arterial perfusion (TRAP-sequence). Arch Gynecol Obstet 2012; 286:81-8. [DOI: 10.1007/s00404-012-2283-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Accepted: 02/23/2012] [Indexed: 10/28/2022]
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Huss S, Fronhoffs F, Gembruch U, Loeffler K, Born M, Gessi M, Kuchelmeister K, Müller AM. An acardiac twin with advanced brain development and a minor form of holoprosencephaly and intracerebral retina-like pigmented tissue: a case report and review of the literature. Pediatr Dev Pathol 2011; 14:411-7. [PMID: 21488711 DOI: 10.2350/10-09-0916-cr.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The development of an acardiac twin in a monochorionic multiple pregnancy is a rare and severe complication of abnormal placental vascular anastomoses. These malformed fetuses present with a very bizarre morphology and a plethora of different malformations. However, all acardiac twins show either a complete absence or an anlage of the heart. Cerebral development is usually poor. We report, according to our review of the literature, for the first time, a very unusual case of acardius with features of acardius amorphus and acormus (fused head and malformed axial skeleton without macroscopically detectable internal organs) with lobar holoprosencephaly and intracerebral pigmented retina-like tissue.
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Affiliation(s)
- Sebastian Huss
- Department of Paidopathology, University of Bonn Medical Center, Bonn, Germany
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Siebert JR. Cyclopia, aprosencephaly, and acardiac twinning: Is hypoxia-ischemia a unifying mechanism? Am J Med Genet A 2008; 143A:3100-6. [PMID: 18000898 DOI: 10.1002/ajmg.a.32027] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
In a recent case of monochorionic diamniotic twinning we observed one twin with acardia, cyclopia, and aprosencephaly, an association not reported previously. In most cases of acardia, the development of tissues in superior regions of the body is disrupted severely, while inferior structures develop more normally. A common explanation for this disruption is hypoxia-ischemia due to twin reversed arterial perfusion (TRAP). In this condition, arterial-arterial and venous-venous anastomoses in the placenta permit twin-twin transfusion and reversal of blood flow in the umbilical vessels and aorta of the recipient twin. The heart is absent or severely deficient, either by secondary atrophy or possibly a more primary, though currently unknown, mechanism. As a result, cranial tissues are less likely to be perfused with oxygenated blood than caudal tissues. A host of craniocerebral anomalies are observed in acardia, including total absence of the head and brain, rudimentary brain, anencephaly, holoprosencephaly, neuronal migration defects, and near-normal brain. Hypoxia-ischemia could be an important factor in the disruption of tissues in the present case, although a more generalized process affecting heart, head, and brain cannot be excluded. The findings suggest that hypoxia-ischemia may play a role in the pathogenesis of some cases of holoprosencephaly and aprosencephaly. This mechanism has been underreported and requires additional investigation.
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Affiliation(s)
- Joseph R Siebert
- Department of Laboratories, Children's Hospital and Regional Medical Center, Seattle, Washington, USA.
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Pasquini L, Wimalasundera RC, Fisk NM. Management of other complications specific to monochorionic twin pregnancies. Best Pract Res Clin Obstet Gynaecol 2004; 18:577-99. [PMID: 15279818 DOI: 10.1016/j.bpobgyn.2004.04.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Monochorionic (MC) twins have a 3-10-fold higher perinatal mortality and morbidity than dichorionic twins. This is largely attributable to their common vascular architecture and the high rate of discordant fetal growth, growth restriction and congenital abnormalities. In the event of a single intrauterine death (IUD), intertwin agonal transfusion results in up to a 38% risk of death and a 46% risk of neurological injury to the co-twin. This chapter addresses the management of complications unique to MC twins. The primary aim of management is to prevent single IUD or, if inevitable, prevent agonal transfusion occurring by vascular occlusive selective feticide. Older fetoscopic techniques have been replaced by the simpler ultrasound-guided techniques of interstitial laser and bipolar cord occlusion. Their application in twin reversed-arterial perfusion sequence has been associated with a 50% reduction of perinatal mortality in the pump twin. Moreover, prophylactic interstitial laser therapy in early pregnancy might obviate the technical and clinical difficulties in the presence of fetal decompensation in later pregnancy. Recent strategies to reduce the high perinatal mortality due to cord entanglement in antenatally diagnosed monoamniotic twins including medical amnioreduction and elective caesarean delivery at 32 weeks, are also discussed.
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Affiliation(s)
- L Pasquini
- Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital, Du Cane Road, Hammaersmith, W12 0HS London, UK.
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Weisz B, Peltz R, Chayen B, Oren M, Zalel Y, Achiron R, Lipitz S. Tailored management of twin reversed arterial perfusion (TRAP) sequence. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2004; 23:451-455. [PMID: 15133794 DOI: 10.1002/uog.1040] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
OBJECTIVE To describe our management of pregnancies complicated by twin reversed arterial perfusion (TRAP) sequence. METHODS This was a retrospective study involving all cases of TRAP sequence referred to our fetal medicine unit in a 3-year period (2000-2002). Patients were routinely managed by repeat sonographic surveillance with sonographic anatomical evaluation and detailed echocardiography. Cases with signs of impending cardiac failure were treated by in-utero YAG-laser coagulation of the umbilical vessels of the acardiac twin. RESULTS Six cases were studied. Three patients in whom there were no signs of deterioration in the status of the pump twin, and in whom the acardiac twin was smaller than the pump twin, were managed conservatively. However, one of these with monoamniotic twins ended in intrauterine fetal death of the pump twin. The other two cases presented with spontaneous cessation of blood flow in the umbilical artery of the acardiac twin. Both delivered at term normal neonates whose follow-up revealed no signs of neurological sequelae. One case of quadruplet pregnancy (with TRAP sequence and two dichorionic twins) was treated by selective termination of the monochorionic twins. Two cases with signs of impending cardiac failure were treated by in-utero YAG-laser occlusion of the vessels in the acardiac mass. Both interventions had a favorable outcome. CONCLUSIONS Conservative treatment is suitable for milder cases of TRAP sequence in which the pump twin is the larger one. Cases in which the acardiac twin is larger have a poorer prognosis and should be treated by invasive intervention and cord occlusion.
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Affiliation(s)
- B Weisz
- Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel-Hashomer, affiliated to the Sackler School of Medicine, Tel Aviv University, Israel.
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Roqué H, Gillen-Goldstein J, Funai E, Young BK, Lockwood CJ. Perinatal outcomes in monoamniotic gestations. J Matern Fetal Neonatal Med 2003; 13:414-21. [PMID: 12962268 DOI: 10.1080/jmf.13.6.414.421] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE A comprehensive review of monoamniotic twin gestations reported between 1990 and 2002 was performed to estimate current perinatal mortality and morbidity rates, as well as the predictive value of an antenatal diagnosis of cord entanglement for poor obstetric outcomes. METHOD A Medline literature review using the search term 'monoamniotic' and limited to articles published in the English language between 1990 and 2002 was performed. RESULTS A total of 133 continuing, non-conjoined twin monoamniotic pregnancies with delivery information were identified. Perinatal loss per 2-week interval was relatively constant at 2-4% from 15 to 32 weeks. However, of the 131 fetuses reaching 33 weeks, the percentage loss significantly increased to 11.0% at 33-35 weeks and 21.9% at 36-38 weeks compared to that at 30-32 weeks. Overall perinatal mortality was 23.3%. Of all losses, 61.2% involved both twins and 38.8% involved only one fetus. Cord entanglements were documented antenatally in 22.6% of reports. There was a statistically significant decrease in the average number of neonatal intensive care unit days for non-anomalous neonates (10.6 +/- 7.7 vs. 32.6 +/- 32.0), average gestational age at the time of delivery (30.4 +/- 7.6 vs. 32.6 +/- 4.1), as well as a decrease in the prevalence of total (8.3% vs. 27.7%) and non-anomalous (7.0% vs. 21.6%) perinatal mortality in pregnancies with an antenatal diagnosis of cord entanglement compared to those without the antenatal diagnosis of cord entanglement. The presence of fetal anomalies was associated with a 42.9% perinatal mortality rate. CONCLUSIONS Contrary to previous reports, there is a significant increase in the incidence of perinatal loss beyond 32 weeks among monoamniotic twins, suggesting that delivery after corticosteroid therapy should be strongly considered at this gestational age.
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Affiliation(s)
- H Roqué
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Connecticut, Farmington, Connecticut 06030, USA
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Current awareness in prenatal diagnosis. Prenat Diagn 2002; 22:740-6. [PMID: 12227336 DOI: 10.1002/pd.271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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