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Wataganara T, Yapan P, Moungmaithong S, Sompagdee N, Phithakwatchara N, Limsiri P, Nawapun K, Rekhawasin T, Talungchit P. Additional benefits of three-dimensional ultrasound for prenatal assessment of twins. J Perinat Med 2020; 48:102-114. [PMID: 31961794 DOI: 10.1515/jpm-2019-0409] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 12/05/2019] [Indexed: 12/18/2022]
Abstract
Three-dimensional ultrasound (3DUS) may provide additional information for prenatal assessment of twins. It may improve the diagnostic confidence of dating, nuchal translucency (NT) and chorionicity assignment in twin pregnancies. The "virtual 3DUS placentoscopy" can guide selective fetoscopic laser photocoagulation (SFLP) to treat twin-twin transfusion syndrome (TTTS). Volumetric assessment of the dysmorphic acardiac twin with the Virtual Organ Computer-aided Analysis (VOCAL) software is more accurate than the conventional ultrasound measurement. Twin anemia polycythemia (TAP) sequence and selective intrauterine growth restriction (sIUGR) may be clinically monitored with 3DUS placental volume (PV) and power Doppler vascular indices. Congenital anomalies are more common in twins. Evaluation of fetal anomalies with 3DUS could assist perinatal management. The 3DUS power Doppler can provide a better understanding of true and false umbilical cord knots, which are commonly found in monoamniotic (MA) twins. Single demise in monochorionic (MC) twin pregnancies can cause severe neurologic morbidity in the surviving co-twin. Prenatal prediction of brain injury in the surviving co-twin with unremarkable neurosonographic examination is difficult. The 3DUS power Doppler may aid in prenatal detection of subtle abnormal cerebral perfusion. Prenatal assessment of conjoined twins with 3DUS is important if emergency postnatal surgical separation is anticipated. There is no significant additional advantage in using real-time 3DUS to guide prenatal interventions. Assessment of the cervix and pelvic floor during twin pregnancies is enhanced with 3DUS. Due to lack of high-quality studies, routine prenatal 3DUS in twin pregnancies needs to be balanced with risks of excessive ultrasound exposure.
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Affiliation(s)
- Tuangsit Wataganara
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Piengbulan Yapan
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Sakita Moungmaithong
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Nalat Sompagdee
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Nisarat Phithakwatchara
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Pattarawan Limsiri
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Katika Nawapun
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Thanapa Rekhawasin
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Pattarawalai Talungchit
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
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Nawapun K, Phithakwatchara N, Jaingam S, Viboonchart S, Mongkolchat N, Wataganara T. Advanced ultrasound for prenatal interventions. Ultrasonography 2018; 37:200-210. [PMID: 29852543 PMCID: PMC6044223 DOI: 10.14366/usg.18011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 05/02/2018] [Indexed: 12/29/2022] Open
Abstract
Ultrasound is an integral part of prenatal interventions. Doppler studies and 3-dimensional ultrasound (3DUS) are frequently used to determine whether fetal surgery is required. The operator's experience remains crucial for reducing procedure-related morbidity. Real-time 3DUS (or 4DUS) can simultaneously display the needle tip in three orthogonal planes, providing reassurance that no fetal parts are in the path. In experienced hands, 4DUS guidance may not be more effective than B-mode, but its value for less-experienced operators remains to be determined. Recent developments in needle, shunt, and video endoscopic technologies may compliment the use of image-guided in utero procedures. Future developments of higher-dimensional transducers and image software may improve the utility of ultrasound for invasive obstetric interventions.
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Affiliation(s)
- Katika Nawapun
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine, Siriraj Hospital, Bangkok, Thailand
| | - Nisarat Phithakwatchara
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine, Siriraj Hospital, Bangkok, Thailand
| | - Suparat Jaingam
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine, Siriraj Hospital, Bangkok, Thailand
| | - Sommai Viboonchart
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine, Siriraj Hospital, Bangkok, Thailand
| | - Nadda Mongkolchat
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine, Siriraj Hospital, Bangkok, Thailand
| | - Tuangsit Wataganara
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine, Siriraj Hospital, Bangkok, Thailand
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Abstract
PURPOSE OF REVIEW The aim of the review was to give an example of how advances in medical genetics impact a developing country and how Thailand struggles to improve medical genetic services. RECENT FINDINGS Thailand is an example of a developing country with limited resources and low geneticist-to-population ratio. The country formally followed decentralized healthcare system (even though practically centralized) and is a nation with growing public interest in medical genetic technology. Nonetheless, efforts have been and are still being made in expanding clinical genetics services, improving access to laboratory diagnosis, increasing rare disease medication in national formulary, and the training of medical genetics personnel. For an endemic genetic disorder such as thalassemia, a universal prevention and control program is available and has had some success. SUMMARY Lesson learned in country like Thailand may be a useful model for other developing nations. Several strategies can be attempted to integrate the advances in medical genetics into medical practices in developing countries with relatively low income per capita and geographic discrepancy in healthcare distribution.
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Miyazaki M, Honda N, Yokoyama M, Nakata M. Reversal of TTTS after fetoscopic laser photocoagulation for communicating vessels. BMJ Case Rep 2014; 2014:bcr-2013-202711. [PMID: 24810443 DOI: 10.1136/bcr-2013-202711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We report a case of reversal of twin-to-twin transfusion syndrome (Stage IV TTTS) at 24 weeks of gestation after fetoscopic laser photocoagulation (FLP) for communicating vessels. The pathology of reversal of TTTS found that the 'initial' donor developed polyhydramnios whereas the 'initial' recipient developed oligohydramnios. With careful follow-up, the hydrops fetalis of the 'initial' recipient improved at 31 weeks of gestation. Because of the onset of labour pain at 34 weeks of gestation, two live and healthy babies were delivered by emergency caesarean section.
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Affiliation(s)
- Masahide Miyazaki
- Department of Obstetrics and Gynecology, Tagawa Municipal Hospital, Fukuoka, Japan
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De Paepe ME, Luks FI. What-and why-the pathologist should know about twin-to-twin transfusion syndrome. Pediatr Dev Pathol 2013; 16:237-51. [PMID: 23617829 DOI: 10.2350/13-03-1315-misc.1] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Approximately 20% of all twin pregnancies are monochorionic. Between 9% and 15% of all monochorionic twin gestations are complicated by severe chronic twin-to-twin transfusion syndrome (TTTS), characterized by a gradual shift of blood volume from the donor twin to the recipient twin through placental vascular connections [1 - 3] . The prognosis of severe, untreated chronic TTTS diagnosed in midtrimester fetuses is extremely poor, with mortality rates exceeding 70% [4] . Since publication of the results of the Eurofoetus trial in 2004, laser photocoagulation of the intertwin anastomoses has become accepted as the optimal first-line therapy for severe TTTS diagnosed before 26 weeks of gestation. While laser treatment of vascular communications was initially limited to selected fetal treatment centers, its increasingly widespread use has resulted in the exposure of more pathologists, even in less specialized institutions, to laser-treated placentas. Furthermore, the surge in laser coagulation has revived the general medical, scientific, and public interest in the placental and choriovascular findings in monochorionic twin placentas. The pathologist's understanding of the pathophysiology of TTTS and of TTTS-associated placental pathology, including the findings related to laser ablation of the anastomoses, can be of great benefit to the involved obstetric/neonatal/surgical team and, ultimately, to the patients. In this review, we summarize the current knowledge of the placental contributions to TTTS and other complications of monochorionic twinning and describe the strengths and limitations of placental examination in these settings. It is our expectation that overviews such as this may serve as a template to generate consensus guidelines for standardized and evidence-based pathologic evaluation of monochorionic twin placentas.
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Affiliation(s)
- Monique E De Paepe
- Department of Pathology, Women and Infants Hospital, Providence, RI, USA.
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