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Giorgione V, D'antonio F, Manji A, Reed K, Khalil A. Perinatal outcome of pregnancy complicated by twin anemia-polycythemia sequence: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:813-823. [PMID: 33428243 DOI: 10.1002/uog.23585] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/18/2020] [Accepted: 12/29/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To report the perinatal outcome of monochorionic diamniotic (MCDA) twin pregnancies complicated by twin anemia-polycythemia sequence (TAPS), according to the type of TAPS (spontaneous or postlaser) and the management option adopted. METHODS MEDLINE, EMBASE and The Cochrane Library databases were searched for studies reporting on the outcome of twin pregnancies complicated by TAPS. Inclusion criteria were non-anomalous MCDA twin pregnancies with a diagnosis of TAPS. The primary outcome was perinatal mortality; secondary outcomes were neonatal morbidity and preterm birth (PTB). The outcomes were stratified according to the type of TAPS (spontaneous or following laser treatment for twin-twin transfusion syndrome) and the management option adopted (expectant, laser surgery, intrauterine transfusion (IUT) or selective reduction (SR)). Random-effects meta-analysis of proportions was used to analyze the data. RESULTS Perinatal outcome was assessed according to whether TAPS occurred spontaneously or after laser treatment in 506 pregnancies (38 studies). Intrauterine death (IUD) occurred in 5.2% (95% CI, 3.6-7.1%) of twins with spontaneous TAPS and in 10.2% (95% CI, 7.4-13.3%) of those with postlaser TAPS, while the corresponding rates of neonatal death were 4.0% (95% CI, 2.6-5.7%) and 9.2% (95% CI, 6.6-12.3%), respectively. Severe neonatal morbidity occurred in 29.3% (95% CI, 25.6-33.1%) of twins after spontaneous TAPS and in 33.3% (95% CI, 17.4-51.8%) after postlaser TAPS, while the corresponding rates of severe neurological morbidity were 4.0% (95% CI, 3.5-5.7%) and 11.1% (95% CI, 6.2-17.2%), respectively. PTB complicated 86.3% (95% CI, 77.2-93.3%) of pregnancies with spontaneous TAPS and all cases with postlaser TAPS (100% (95% CI, 84.3-100%)). Iatrogenic PTB was more frequent than spontaneous PTB in both groups. Perinatal outcome was assessed according to the management option adopted in 417 pregnancies (21 studies). IUD occurred in 9.8% (95% CI, 4.3-17.1%) of twins managed expectantly and in 13.1% (95% CI, 9.2-17.6%), 12.1% (95% CI, 7.7-17.3%) and 7.6% (95% CI, 1.3-18.5%) of those treated with laser surgery, IUT and SR, respectively. Severe neonatal morbidity affected 27.3% (95% CI, 13.6-43.6%) of twins in the expectant-management group, 28.7% (95% CI, 22.7-35.1%) of those in the laser-surgery group, 38.2% (95% CI, 18.3-60.5%) of those in the IUT group and 23.3% (95% CI, 10.5-39.2%) of those in the SR group. PTB complicated 80.4% (95% CI, 59.8-94.8%), 73.4% (95% CI, 48.1-92.3%), 100% (95% CI, 76.5-100%) and 100% (95% CI, 39.8-100%) of pregnancies after expectant management, laser surgery, IUT and SR, respectively. CONCLUSIONS The present meta-analysis provides pooled estimates of the risks of perinatal mortality, neonatal morbidity and PTB in twin pregnancies complicated by TAPS, stratified by the type of TAPS and the management option adopted. Although a direct comparison could not be performed, the results from this systematic review suggest that spontaneous TAPS may have a better prognosis than postlaser TAPS. No differences in terms of mortality and morbidity were observed when comparing different management options for TAPS, although these findings should be interpreted with caution in view of the limitations of the included studies. Individualized prenatal management, taking into account the severity of TAPS and gestational age, is currently the recommended strategy. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- V Giorgione
- Twin Trust Centre for Research and Clinical Excellence, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - F D'antonio
- Center for Fetal Care and High-risk Pregnancy, University of Chieti, Italy
| | - A Manji
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - K Reed
- Twins Trust, Aldershot, UK
| | - A Khalil
- Twin Trust Centre for Research and Clinical Excellence, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
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Twin Anemia Polycythemia Sequence: Knowledge and Insights After 15 Years of Research. MATERNAL-FETAL MEDICINE 2021. [DOI: 10.1097/fm9.0000000000000065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
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Tollenaar LSA, Slaghekke F, Lewi L, Ville Y, Lanna M, Weingertner A, Ryan G, Arévalo S, Khalil A, Brock CO, Klaritsch P, Hecher K, Gardener G, Bevilacqua E, Kostyukov KV, Bahtiyar M, Kilby M, Tiblad E, Oepkes D, Lopriore E. Treatment and outcome of 370 cases with spontaneous or post-laser twin anemia-polycythemia sequence managed in 17 fetal therapy centers. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:378-387. [PMID: 32291846 PMCID: PMC7497010 DOI: 10.1002/uog.22042] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 03/23/2020] [Accepted: 03/25/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To investigate the antenatal management and outcome in a large international cohort of monochorionic twin pregnancies with spontaneous or post-laser twin anemia-polycythemia sequence (TAPS). METHODS This study analyzed data of monochorionic twin pregnancies diagnosed antenatally with spontaneous or post-laser TAPS in 17 fetal therapy centers, recorded in the TAPS Registry between 2014 and 2019. Antenatal diagnosis of TAPS was based on fetal middle cerebral artery peak systolic velocity > 1.5 multiples of the median (MoM) in the TAPS donor and < 1.0 MoM in the TAPS recipient. The following antenatal management groups were defined: expectant management, delivery within 7 days after diagnosis, intrauterine transfusion (IUT) (with or without partial exchange transfusion (PET)), laser surgery and selective feticide. Cases were assigned to the management groups based on the first treatment that was received after diagnosis of TAPS. The primary outcomes were perinatal mortality and severe neonatal morbidity. The secondary outcome was diagnosis-to-birth interval. RESULTS In total, 370 monochorionic twin pregnancies were diagnosed antenatally with TAPS during the study period and included in the study. Of these, 31% (n = 113) were managed expectantly, 30% (n = 110) with laser surgery, 19% (n = 70) with IUT (± PET), 12% (n = 43) with delivery, 8% (n = 30) with selective feticide and 1% (n = 4) underwent termination of pregnancy. Perinatal mortality occurred in 17% (39/225) of pregnancies in the expectant-management group, 18% (38/215) in the laser group, 18% (25/140) in the IUT (± PET) group, 10% (9/86) in the delivery group and in 7% (2/30) of the cotwins in the selective-feticide group. The incidence of severe neonatal morbidity was 49% (41/84) in the delivery group, 46% (56/122) in the IUT (± PET) group, 31% (60/193) in the expectant-management group, 31% (57/182) in the laser-surgery group and 25% (7/28) in the selective-feticide group. Median diagnosis-to-birth interval was longest after selective feticide (10.5 (interquartile range (IQR), 4.2-14.9) weeks), followed by laser surgery (9.7 (IQR, 6.6-12.7) weeks), expectant management (7.8 (IQR, 3.8-14.4) weeks), IUT (± PET) (4.0 (IQR, 2.0-6.9) weeks) and delivery (0.3 (IQR, 0.0-0.5) weeks). Treatment choice for TAPS varied greatly within and between the 17 fetal therapy centers. CONCLUSIONS Antenatal treatment for TAPS differs considerably amongst fetal therapy centers. Perinatal mortality and morbidity were high in all management groups. Prolongation of pregnancy was best achieved by expectant management, treatment by laser surgery or selective feticide. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- L. S. A. Tollenaar
- Department of Obstetrics, Division of Fetal therapyLeiden University Medical CenterLeidenThe Netherlands
| | - F. Slaghekke
- Department of Obstetrics, Division of Fetal therapyLeiden University Medical CenterLeidenThe Netherlands
| | - L. Lewi
- Department of Obstetrics and GynecologyUniversity Hospitals LeuvenLeuvenBelgium
| | - Y. Ville
- Department of Obstetrics and Maternal‐Fetal MedicineHôpital Necker‐Enfants Malades, AP‐HPParisFrance
| | - M. Lanna
- Fetal Therapy Unit ‘U. Nicolini’, Vittore Buzzi Children's HospitalUniversity of MilanMilanItaly
| | - A. Weingertner
- Department of Obstetrics and GynecologyStrasbourg University HospitalStrasbourg CedexFrance
| | - G. Ryan
- Fetal Medicine Unit, Ontario Fetal Centre, Mount Sinai HospitalUniversity of TorontoTorontoCanada
| | - S. Arévalo
- Maternal Fetal Medicine Unit, Department of ObstetricsVall d'Hebron University HospitalBarcelonaSpain
| | - A. Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation TrustUniversity of LondonLondonUK
- Vascular Biology Research CentreMolecular and Clinical Sciences Research Institute, St George's University of LondonLondonUK
| | - C. O. Brock
- The Fetal Center, Department of Obstetrics, Children's Memorial Hermann Hospital, Gynecology and Reproductive Sciences, UT Health, McGovern Medical SchoolUniversity of TexasHoustonTXUSA
| | - P. Klaritsch
- Division of Obstetrics and Maternal Fetal Medicine, Department of Obstetrics and GynecologyMedical University of Graz, GrazAustria
| | - K. Hecher
- Department of Obstetrics and Fetal MedicineUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - G. Gardener
- Department of Maternal Fetal MedicineMater Mothers' HospitalSouth BrisbaneQueenslandAustralia
| | - E. Bevilacqua
- Department of Obstetrics and Gynecology, University Hospital BrugmannUniversité Libre de BruxellesBrusselsBelgium
| | - K. V. Kostyukov
- Acad. V. I. Kulakov Research Center of ObstetricsGynecology, and Perinatology, Ministry of Health of the Russian FederationMoscowRussia
| | - M. O. Bahtiyar
- Department of Obstetrics, Gynecology and Reproductive SciencesYale School of MedicineNew HavenCTUSA
| | - M. D. Kilby
- Fetal Medicine Centre, Birmingham Women's and Children's Foundation TrustUniversity of BirminghamBirminghamUK
| | - E. Tiblad
- Center for Fetal MedicineKarolinska University HospitalStockholmSweden
| | - D. Oepkes
- Department of Obstetrics, Division of Fetal therapyLeiden University Medical CenterLeidenThe Netherlands
| | - E. Lopriore
- Department of Pediatrics, Division of NeonatologyLeiden University Medical CenterLeidenThe Netherlands
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Brock CO, Bergh EP, Moise, KJ, Johnson A, Hernandez-Andrade E, Lai D, Papanna R. Middle Cerebral Artery Doppler Velocimetry for the Diagnosis of Twin Anemia Polycythemia Sequence: A Systematic Review. J Clin Med 2020; 9:jcm9061735. [PMID: 32512796 PMCID: PMC7355756 DOI: 10.3390/jcm9061735] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 05/23/2020] [Accepted: 06/03/2020] [Indexed: 01/01/2023] Open
Abstract
Twin anemia polycythemia sequence (TAPS) is a rare complication of monochorionic diamniotic (MCDA) twins. Middle cerebral artery peak systolic velocity (MCA-PSV) measurements are used to screen for TAPS while fetal or neonatal hemoglobin levels are required for definitive diagnosis. We sought to perform a systematic review of the efficacy of MCA-PSV in diagnosing TAPS. Search criteria were developed using relevant terms to query the Pubmed, Embase, and SCOPUS electronic databases. Publications reporting diagnostic characteristics of MCA-PSV measurements (i.e., sensitivity, specificity or receiver operator curves) were included. Each article was assessed for bias using the Quality Assessment of Diagnostic Accuracy Studies II (QUADAS II) tool. Results were assessed for uniformity to determine whether meta-analysis was feasible. Data were presented in tabular form. Among publications, five met the inclusion criteria. QUADAS II analysis revealed that four of the publications were highly likely to have bias in multiple areas. Meta-analysis was precluded by non-uniformity between definitions of TAPS by MCA-PSV and neonatal or fetal hemoglobin levels. High-quality prospective studies with consistent definitions and ultrasound surveillance protocols are still required to determine the efficacy of MCA-PSV in diagnosing TAPS. Other ultrasound findings (e.g., placenta echogenicity discordance) may augment Doppler studies.
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Affiliation(s)
- Clifton O. Brock
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, Houston, TX 77030, USA; (C.O.B.); (E.P.B.); (K.J.M.J.); (A.J.); (E.H.-A.)
| | - Eric P. Bergh
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, Houston, TX 77030, USA; (C.O.B.); (E.P.B.); (K.J.M.J.); (A.J.); (E.H.-A.)
- The Fetal Center Children’s Memorial Hermann Hospital, Houston, TX 77030, USA
| | - Kenneth J. Moise,
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, Houston, TX 77030, USA; (C.O.B.); (E.P.B.); (K.J.M.J.); (A.J.); (E.H.-A.)
- The Fetal Center Children’s Memorial Hermann Hospital, Houston, TX 77030, USA
| | - Anthony Johnson
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, Houston, TX 77030, USA; (C.O.B.); (E.P.B.); (K.J.M.J.); (A.J.); (E.H.-A.)
- The Fetal Center Children’s Memorial Hermann Hospital, Houston, TX 77030, USA
| | - Edgar Hernandez-Andrade
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, Houston, TX 77030, USA; (C.O.B.); (E.P.B.); (K.J.M.J.); (A.J.); (E.H.-A.)
| | - Dejian Lai
- Division of Biostatistics, University of Texas, School of Public Health, 1200 Pressler St, Houston, TX 77030, USA;
| | - Ramesha Papanna
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, Houston, TX 77030, USA; (C.O.B.); (E.P.B.); (K.J.M.J.); (A.J.); (E.H.-A.)
- The Fetal Center Children’s Memorial Hermann Hospital, Houston, TX 77030, USA
- Correspondence: ; Tel.: +1-713-500-5859; Fax: +1-713-500-0799
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Hill KM, Masoudian P, Fung-Kee-Fung K, El Demellawy D. Intrauterine Interventions for the Treatment of Twin Anemia-Polycythemia Sequence: A Systematic Review. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 41:981-991. [PMID: 31230662 DOI: 10.1016/j.jogc.2018.04.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Revised: 04/03/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Twin anemia-polycythemia sequence (TAPS) is a complication of monochorionic, multiple gestation pregnancies in which blood shunting through placental anastomoses results in chronic anemia in one fetus and chronic polycythemia in another. The outcomes of different treatment modalities for TAPS are not well known. OBJECTIVE To determine the outcomes of the intrauterine interventions used to treat TAPS. STUDY DESIGN A systematic literature search of MEDLINE, EMBASE, and CENTRAL was performed in June 2016. Primary outcomes were mortality, morbidity, and adverse perinatal outcomes. Data were summarized in the form of weighted means, and statistical difference was determined. RESULTS Twenty-one articles were identified for inclusion in this review and were composed of 105 cases of TAPS. In the cases presented in the literature, there was no statistically significant difference in mortality, morbidity, or emergent Caesarean section rates between expectant management, intrauterine transfusion (IUT), and laser ablation therapy. Laser ablation therapy and IUT were found to have a significantly lower rate of adverse perinatal outcomes when compared to expectantly managed cases. CONCLUSIONS The literature looking into the treatment of TAPS is very limited, with no randomized controlled trials and only one includable comparative study. Based on the data in the case report and case study literature, there is no mortality difference between any of the treatment modalities. Expectant management may be associated with an increase in adverse perinatal outcomes when compared to laser therapy and IUT. More comparative studies are needed to assist clinicians in adopting an evidence-based approach to the treatment of TAPS.
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Affiliation(s)
- Kevin M Hill
- Faculty of Medicine, University of Ottawa, Ottawa, ON
| | | | - Karen Fung-Kee-Fung
- Faculty of Medicine, University of Ottawa, Ottawa, ON; Department of Obstetrics and Gynecology, The Ottawa Hospital, Ottawa, ON
| | - Dina El Demellawy
- Faculty of Medicine, University of Ottawa, Ottawa, ON; Department of Pediatric Pathology, Children's Hospital of Eastern Ontario, Ottawa, ON.
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Hiersch L, Eitan M, Ashwal E, Weisz B, Chayen B, Lipitz S, Yinon Y. Amniotic fluid discordance in monochorionic diamniotic twin pregnancies is associated with increased risk for twin anemia-polycythemia sequence. Prenat Diagn 2016; 36:1099-1103. [DOI: 10.1002/pd.4939] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Revised: 09/05/2016] [Accepted: 09/29/2016] [Indexed: 11/12/2022]
Affiliation(s)
- Liran Hiersch
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Mayan Eitan
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Eran Ashwal
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Boaz Weisz
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Benny Chayen
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Shlomo Lipitz
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Yoav Yinon
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
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Moaddab A, Nassr AA, Espinoza J, Ruano R, Bateni ZH, Shamshirsaz AA, Mandy GT, Welty SE, Erfani H, Popek EJ, Belfort MA, Shamshirsaz AA. Twin anemia polycythemia sequence: a single center experience and literature review. Eur J Obstet Gynecol Reprod Biol 2016; 205:158-64. [DOI: 10.1016/j.ejogrb.2016.08.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 07/23/2016] [Accepted: 08/13/2016] [Indexed: 10/21/2022]
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Fetal Intra-Peritoneal Transfusion for the Management of Very Early Spontaneous Twin Anemia-Polycythemia Sequence in an Obese Patient With a Whole Anterior Placenta. Twin Res Hum Genet 2016; 19:154-7. [DOI: 10.1017/thg.2016.13] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Twin anemia-polycythemia sequence (TAPS) is a rare condition in monochorionic twin pregnancies. Small intertwin placental vascular communications allow transfusion, which results in a hemoglobin difference in the twins in the absence of oligohydramnios or polyhydramnios. We report here a case of TAPS diagnosed at 17 weeks’ gestation in an obese patient (BMI 42) with a whole anterior placenta. The only possible treatment at this stage of pregnancy was intra-uterine transfusion (IUT), which was repeated weekly until photocoagulation of placental anastomoses was feasible. Fetoscopic laser surgery is the only curative treatment, but is challenging in TAPS because of the absence of polyhydramnios and the presence of minuscule anastomoses. An anterior placenta and high BMI can make the procedure even more challenging. This case report demonstrates that very early and rapidly progressing TAPS with technically complicated conditions (elevated BMI and anterior placenta) can be successfully managed with IUT until laser procedure is achievable.
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