From monster to twin reversed arterial perfusion: a history of acardiac twins

Hypothesized pathogenesis of acardius acephalus, acormus, amorphus, anceps, acardiac edema, single umbilical artery, and pump twin risk prediction

Background

Acardiac twinning complicates monochorionic twin pregnancies in ≈2.6%, in which arterioarterial (AA) and venovenous placental anastomoses cause a reverse circulation between prepump and preacardiac embryos and cessation of cardiac function in the preacardiac. Literature suggested four acardiac body morphologies in which select (groups of) organs fail to develop, deteriorate, or become abnormal: acephalus (≈64%, [almost] no head, part of body, legs), amorphus (≈22%, amorphous tissue lump), anceps (≈10%, cranial bones, well‐developed), and acormus (≈4%, head only). We sought to develop hypotheses that could explain acardiac pathogenesis, its progression, and develop methods for clinical testing.

Methods

We used qualitatively described pathophysiology during development, including twin‐specific AA and Hyrtl's anastomoses, the short umbilical cord syndrome, high capillary permeability, properties of spontaneous aborted embryos, and Pump/Acardiac umbilical venous diameter (UVD) ratios.

Results

We propose that each body morphology has a specific pathophysiologic pathway. An acephalus acardius may be larger than an anceps, verifiable from UVD ratio measurements. A single umbilical artery develops when one artery, unconnected to the AA, vanishes due to flow reduction by Hyrtl's anastomotic resistance. Acardiac edema may result from acardiac body hypoxemia combined with physiological high fetal capillary permeability, high interstitial compliance and low albumin synthesis. Morphological changes may occur after acardiac onset. Pump twin risk follows from UVD ratios.

Conclusion

Our suggested outcomes agree reasonably well with reported onset, incidence, and progression of acardiac morphologies. Guidance for clinical prediction and testing requires ultrasound anatomy/circulation study, from the first trimester onward.

Acardiacus acephalus twinning associated with exomphalos major, high impeforate anus and hypospadias

We describe a case report of acardiacus acephalus twinning associated with exomphalos major in both twins. One twin survived, who in addition had an anorectal anomaly and hypospadias. This is the first reported description of this combination of anomalies.

Unequal but monozygous: a history of twin-twin transfusion syndrome

Twin-twin transfusion is the major cause of mortality and morbidity in monochorionic twins. Its pathogenesis has been gradually elucidated over the last three centuries. Among obstetricians, there was a long-lasting controversy on the existence of placental anastomoses and whether or not to tie the placental end of the firstborn infant's cord. However, a twin pregnancy practically never could be excluded. Stalpart van der Wiel described a twin-twin vessel connection in 1687. Studies on interfetal anastomoses using injection of placental vessels were published by Smellie in 1752, Osiander in 1781, and Brachet in 1821. Different types of anastomoses, and their associated fetal disorders were classified by Schatz in a series of papers at the end of the 19(th) century. With the advent of ultrasound and laser techniques, prenatal diagnosis and treatment became available in the last decade of the 20(th) century.