Cunningham FG :Multifetal pregnancy. Williams Obstetrics. 20 ed. Stanford: Appleton & Lange; 1997; 861-894.
Cunningham FG,: Multifetal pregnancy. Williams Obstetrics. 23 ed. Stanford: Appleton & Lange; 2010;859-889.
Sarah Stock, Jane Norman
Preterm and term labour in multiple pregnancies.
Semin Fetal Neonatal Med. 2010 Dec;15(6):336-41. doi: 10.1016/j.siny.2010.06.006.
Abstract/Text
The association between multiple pregnancy and preterm labour is well-established, with >50% of multiple births delivering before 37 weeks. However, there remains limited understanding of the factors predisposing to early delivery of twins. Physiological stimuli to the onset of parturition, including stretch, placental corticotrophin-releasing hormone and lung maturity factors, may be stronger in multiple pregnancies due to the increased fetal and placental mass. Pathological processes including infection and cervical insufficiency also have a role. Treatments that prevent preterm birth in singleton pregnancies, such as progesterone and cervical cerclage appear to be ineffective in multiple pregnancies. This article reviews aspects of preterm birth in twins and higher order multiples including epidemiology, prediction and prevention of preterm labour and potential mechanisms controlling onset of parturition. Evidence relating to the management of labour in preterm and term multiples is also discussed.
Copyright © 2010 Elsevier Ltd. All rights reserved.
村越毅:周産期におよぼすART（assisted reproductive technology）の光と影：多胎妊娠 ～ARTによる多胎妊娠の管理～. 産婦実際 2004;53:1849-1857.
村越毅, et al.:多胎妊娠の短期および長期予後の検討. 周産期新生児誌 2005;41(4):750-755.
Misty C Day, John R Barton, John M O'Brien, Niki B Istwan, Baha M Sibai
The effect of fetal number on the development of hypertensive conditions of pregnancy.
Obstet Gynecol. 2005 Nov;106(5 Pt 1):927-31. doi: 10.1097/01.AOG.0000182578.82926.9c.
Abstract/Text
OBJECTIVE: To estimate the incidence and effect of pregnancy-related hypertensive conditions on multiple gestations.
METHODS: Women with 1-4 fetuses enrolled in an outpatient perinatal services program at 28 or more weeks of gestation were identified. Those without a prior diagnosis of hypertension at enrollment and who delivered at more than 28 weeks of gestation were included in the analysis. The incidence of all pregnancy-related hypertensive conditions, diagnosis of severe hypertensive conditions (hemolysis, elevated liver enzymes and low platelets syndrome; disseminated intravascular coagulation; eclampsia; low platelets; renal failure; and abruption), and interventional delivery related to hypertension were estimated, and compared according to fetal number.
RESULTS: Data were analyzed for 34,374 singleton, twin, triplet, and quadruplet gestations. The incidence of pregnancy-related hypertensive conditions increased with multifetal gestations as compared with singletons (12.7-19.6% for multifetal gestations compared with 6.5% for singletons, P < .001). The incidence of severe pregnancy-related hypertensive conditions was significantly increased in twin (1.6%) and triplet (3.1%) gestations as compared with singletons (0.5%, P < .001). Quadruplet pregnancies were not significantly higher than triplet gestations for these complications. The need for early delivery related to hypertension was greater with increasing fetal number through triplet gestations. By logistic regression, higher fetal number, nulliparity, and advanced maternal age were each independently associated with the development of pregnancy-related hypertensive conditions.
CONCLUSION: Mild and severe pregnancy-related hypertensive disease increases progressively with advancing fetal number from singleton to triplets but is not further increased in quadruplet pregnancies. Multifetal pregnancies should be observed closely for onset of gestational hypertensive disease.
LEVEL OF EVIDENCE: II-2.
Mamoru Morikawa, Takashi Yamada, Emi Hirayama-Kato, Takahiro Yamada, Kazuhiko Okuyama, Hisanori Minakami
Maternal weight gain in twin-twin transfusion syndrome.
Acta Obstet Gynecol Scand. 2011 Dec;90(12):1434-9. doi: 10.1111/j.1600-0412.2011.01254.x. Epub 2011 Sep 21.
Abstract/Text
OBJECTIVE: To examine the association between maternal weight gain and twin-twin transfusion syndrome (TTTS).
DESIGN: Retrospective observational study in two tertiary care centers.
POPULATION: All 124 women with monochorionic diamniotic twin pregnancies who gave birth at ≥ 16 gestational weeks between 2002 and 2010.
METHODS: Analysis of chronological relation between maternal weight gain per week (weekly gain) and the diagnosis of TTTS.
MAIN OUTCOME MEASURE: Sonographic diagnosis of TTTS.
RESULTS: A weekly weight gain ≥ 1.4 kg occurred in 45 women, preceded the diagnosis of TTTS in 22 (78.6%) of the 28 women with TTTS, and was associated with TTTS [women with one weekly weight gain ≥ 1.4 kg vs. women with no weekly weight gains ≥1.4 kg who were diagnosed as having TTTS: 48.9% (22/45) vs. 7.6% (6/79); RR, 6.44; 95%CI, 2.82-14.69]. At given gestational weeks between 16 and 27, the mean (± SD) prospective risk of the development of TTTS within three weeks was 52.0 ± 33.8% among women who showed a weekly weight gain ≥ 1.4 kg for the first time, whereas the risk of the development of TTTS within one week was 1.6 ± 1.7% among women who never showed a weekly weight gain ≥ 1.4 kg.
CONCLUSIONS: Excessive maternal weight gain ≥ 1.4 kg/week is likely to occur during the development of TTTS.
© 2011 The Authors Acta Obstetricia et Gynecologica Scandinavica© 2011 Nordic Federation of Societies of Obstetrics and Gynecology.
Interim report of the Medical Research Council/Royal College of Obstetricians and Gynaecologists multicentre randomized trial of cervical cerclage. MRC/RCOG Working Party on Cervical Cerclage.
Br J Obstet Gynaecol. 1988 May;95(5):437-45.
Abstract/Text
Overall 905 pregnant women whose obstetricians were 'uncertain' whether to recommend cervical cerclage, chiefly because of a history of early delivery or cervical surgery, were randomly allocated to cerclage or no surgery; 92% were treated as allocated. The overall preterm delivery rate was 30%. The results for those allocated cerclage were marginally statistically significant, more favourable in terms of fewer deliveries before 33 weeks [59 (13%) compared with 82 (18%), P = 0.03] and correspondingly for birthweight under 1500 g [48 (11%) compared with 73 (16%), P = 0.01] and for miscarriage, stillbirth or neonatal death [37 (8%) compared with 54 (12%), P = 0.06]. There were similar numbers of deliveries between 33 and 36 weeks [65 (14%) compared with 64 (14%)]. These results suggest that the operation had an important beneficial effect in one in 20 to 25 cases in the trial. But because the observed differences are not strongly statistically significant and because no such benefit has been seen in other randomized trials, there remains uncertainty about how much (if any) of this apparent benefit is real. So, the trial still remains open for randomization of more women whose obstetricians are uncertain about the advisability of cerclage.
J Dor, J Shalev, S Mashiach, J Blankstein, D M Serr
Elective cervical suture of twin pregnancies diagnosed ultrasonically in the first trimester following induced ovulation.
Gynecol Obstet Invest. 1982;13(1):55-60.
Abstract/Text
The efficiency of elective cervical suture in preventing premature delivery thus reducing neonatal mortality was studied in a group of 50 twin pregnancies. All pregnancies occurred after induction of ovulation and twins were diagnosed early by ultrasound. 25 randomly selected patients underwent elective cervical suture. 22 sutured and 23 non-sutured patients were followed until delivery, while 5 patients aborted in the second trimester. The benefit of suturing on the duration of pregnancy and its outcome were assessed. Of the sutured patients, 10 (45.4%) delivered prematurely and the neonatal death rate was 18.2%. In the non-sutured patients, 11 (47.8%) delivered prematurely and the neonatal death rate was 15.2%. This study demonstrates that elective cervical suture was not effective in prolonging gestation or improving fetal outcome in twin pregnancies following induced ovulation.
I Fuchs, E Tsoi, W Henrich, J W Dudenhausen, K H Nicolaides
Sonographic measurement of cervical length in twin pregnancies in threatened preterm labor.
Ultrasound Obstet Gynecol. 2004 Jan;23(1):42-5. doi: 10.1002/uog.951.
Abstract/Text
OBJECTIVE: To determine whether sonographic measurement of cervical length in twin pregnancies presenting with threatened preterm labor helps distinguish between true and false labor.
METHODS: In 87 women with twin pregnancies presenting with regular and painful uterine contractions at 24-36 (median, 30) weeks of gestation, cervical length was measured by transvaginal ultrasound. Women presenting in active labor, defined by the presence of cervical dilation of 3 cm or more, with ruptured membranes and those who underwent a prior or subsequent cervical cerclage, were excluded from the study. The clinical management was determined by the attending obstetrician without taking into account the cervical length. Primary outcome of the study was delivery within 7 days of presentation.
RESULTS: Delivery within 7 days of presentation occurred in 19/87 (22%) pregnancies and this was inversely related to cervical length, decreasing from 80% (4/5) at 1-5 mm, to 46% (6/13) at 6-10 mm, 29% (4/14) at 11-15 mm, 21% (4/19) at 16-20 mm, 7% (1/15) at 21-25 mm and 0% (0/21) at >25 mm. Logistic regression analysis demonstrated that significant independent contribution in the prediction of delivery within 7 days was provided by cervical length (odds ratio (OR) = 0.78, 95% CI 0.68-0.89, P < 0.001) and use of tocolytics (OR = 0.13, 95% CI 0.02-0.76, P = 0.024), with no significant contribution from gestation at presentation, chorionicity, ethnic origin, maternal age, body mass index, parity, previous history of preterm delivery, cigarette smoking, contraction frequency, vaginal bleeding or the administration of antibiotics or steroids.
CONCLUSION: In women with twin pregnancies presenting with threatened preterm labor, sonographic measurement of cervical length helps distinguish between those who deliver within 7 days and those who do not.
Copyright 2004 ISUOG. Published by John Wiley & Sons, Ltd.
R L Goldenberg, J D Iams, M Miodovnik, J P Van Dorsten, G Thurnau, S Bottoms, B M Mercer, P J Meis, A H Moawad, A Das, S N Caritis, D McNellis
The preterm prediction study: risk factors in twin gestations. National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network.
Am J Obstet Gynecol. 1996 Oct;175(4 Pt 1):1047-53.
Abstract/Text
OBJECTIVE: Our purpose was to determine the association between the presence of bacterial vaginosis, fetal fibronectin, and a short cervix and the risk of spontaneous preterm birth of twins.
STUDY DESIGN: We prospectively screened 147 women with twins at 24 and 28 weeks' gestation for more than 50 potential risk factors for spontaneous preterm birth. We also measured cervical length with ultrasound scans and tested for the presence of bacterial vaginosis. Fetal fibronectin level was evaluated every 2 weeks from 24 to 30 weeks' gestation. Outcomes included spontaneous preterm birth at < 32 weeks, < 35 weeks, and < 37 weeks.
RESULTS: Among twin as compared with singleton pregnancies, a cervical length < or = 25 mm was more common at both 24 and 28 weeks, a statistically significant difference. There were no significant differences in most other risk factors. Of the factors evaluated by means of univariate analysis at 24 weeks, only a short cervix (< or = 25 mm) was consistently associated with spontaneous preterm birth. The odds ratio and 95% confidence interval for spontaneous preterm birth at < 32 weeks, < 35 weeks, and < 37 weeks were 6.9 (2.0 to 24.2), 3.2 (1.3 to 7.9), and 2.8 (1.1 to 7.7). At 28 weeks, a cervical length < or = 25 mm was not a strong predictor of spontaneous preterm birth. At both 28 weeks (odds ratio, 9.4; confidence interval, 1.0 to 67.7) and 30 weeks (odds ratio 46.1; confidence interval, 4.2 to 1381), a positive fetal fibronectin result was significantly associated with spontaneous preterm birth at < 32 weeks. Bacterial vaginosis at 24 or 28 weeks was not associated with spontaneous preterm birth of twins. Multivariate analysis confirmed the association between cervical length < or = 25 mm at the 24-week visit and spontaneous preterm birth and also confirmed that at 24 weeks the other risk factors were less consistently and often not statistically significantly associated with spontaneous preterm birth. Of the risk factors evaluated at 28 weeks, only a positive fetal fibronectin was associated with a significantly increased risk for spontaneous preterm birth.
CONCLUSIONS: Most known risk factors for spontaneous preterm birth were not significantly associated with spontaneous preterm birth of twins. At 24 weeks, cervical length < or = 25 mm was the best predictor of spontaneous preterm birth at < 32 weeks, < 35 weeks, and < 37 weeks. Of the risk factors evaluated at 28 weeks, fetal fibronectin was the only statistically significant predictor of spontaneous preterm birth at < 32 weeks.
H M Imseis, T A Albert, J D Iams
Identifying twin gestations at low risk for preterm birth with a transvaginal ultrasonographic cervical measurement at 24 to 26 weeks' gestation.
Am J Obstet Gynecol. 1997 Nov;177(5):1149-55.
Abstract/Text
OBJECTIVE: Because twins are a high-risk group for preterm birth, many clinicians routinely use prophylactic interventions such as home bed rest, hospital bed rest, oral tocolytics, or home uterine activity monitoring to prevent preterm delivery. We sought to identify twin gestations at low risk for spontaneous preterm birth with transvaginal ultrasonography of the cervix to avoid the unnecessary use of prophylactic interventions in these pregnancies.
STUDY DESIGN: We measured cervical length at 24 to 26 weeks' gestation by transvaginal ultrasonography in women with twin gestations referred to our prematurity prevention clinic. Each delivery was classified as (1) spontaneous preterm birth < 34 weeks' gestation, (2) delivery at > or = 34 weeks' gestation with intervention, or (3) delivery at > or = 34 weeks' gestation without intervention. Intervention included strict bed rest at home or in the hospital, either parenteral or oral tocolysis, or both, or home uterine activity monitoring. Indicated preterm deliveries and patients with cerclage were excluded from this analysis. The ability of transvaginal cervical length to predict women who would deliver at > or = 34 weeks without intervention was evaluated. A cervical length of 35 mm was chosen by scatter diagram as the best cutoff to discriminate between the group delivered at term without intervention and the other two groups.
RESULTS: Of 85 women with twin gestations who underwent ultrasonographic cervical length measurements at 24 to 26 weeks' gestation, 17 had spontaneous preterm birth at < 34 weeks, 23 were delivered at > or = 34 weeks but required intervention, and 45 were delivered at > or = 34 weeks without intervention. The mean cervical length for those delivered at > or = 34 weeks' gestation without intervention (36.4 +/- 5.8 mm) was significantly greater (p < 0.0001) than the mean for those delivered preterm (27.4 +/- 8.5) and those delivered at > or = 34 weeks' gestation who required intervention (27.7 +/- 10.5 mm). The sensitivity, specificity, and positive and negative predictive values of a cervical length > 35 mm for predicting delivery at > or = 34 weeks' gestation are 49%, 94%, 97%, and 31%, respectively.
CONCLUSION: A transvaginal ultrasonographic measurement of the cervix of > 35 mm at 24 to 26 weeks in twin gestations can identify patients who are at low risk for delivery before 34 weeks' gestation.
A P Souka, V Heath, S Flint, I Sevastopoulou, K H Nicolaides
Cervical length at 23 weeks in twins in predicting spontaneous preterm delivery.
Obstet Gynecol. 1999 Sep;94(3):450-4.
Abstract/Text
OBJECTIVE: To establish the relationship between cervical length at 23 weeks' gestation in twin pregnancies and risk of spontaneous preterm delivery.
METHODS: Cervical length was measured during routine antenatal care by transvaginal sonography at 23 (range 22-24) weeks' gestation in 215 twin pregnancies. Distribution of cervical length was determined, and sensitivity and false-positive rate for spontaneous preterm delivery at or before 28, 30, 32, and 34 weeks for cutoff cervical lengths of 15, 25, 35, and 45 mm were calculated.
RESULTS: Cervical length distribution was skewed toward shorter length and the median value was 38 mm. In 11.2% and 4.2% of cases, length was up to 25 mm and up to 15 mm, respectively. The spontaneous delivery rates at or before 28, 30, 32, and 34 weeks were 3.8%, 4.7%, 8.0%, and 17.5%, respectively, and were not statistically significantly related to any demographic characteristics, obstetric history, or chorionicity. Sensitivity to predict spontaneous preterm delivery was 100%, 80%, 47%, and 35% for 28, 30, 32, and 34 weeks, respectively, for cervical length up to 25 mm. The corresponding sensitivity values for cervical lengths up to 15 mm were 50%, 40%, 24%, and 11%. The rate of spontaneous delivery at or before 32 weeks increased exponentially with decreasing cervical length at 23 weeks, from 2.9% at or greater than 46 mm, to 4.3% at 36-45 mm, 6.7% at 26-35 mm, 31% at 16-25 mm, and 66% at 15 mm or less.
CONCLUSION: Measurement of cervical length in twin pregnancies predicted risk of spontaneous early preterm delivery.
村越毅, ほか: 多胎妊娠の短期および長期予後の検討. 周産期新生児誌 2005;41(4):750-755.
M F Ashworth, S F Spooner, D A Verkuyl, R Waterman, H M Ashurst
Failure to prevent preterm labour and delivery in twin pregnancy using prophylactic oral salbutamol.
Br J Obstet Gynaecol. 1990 Oct;97(10):878-82.
Abstract/Text
A double blind, controlled study was performed to see whether the use of prophylactic oral salbutamol would reduce the incidence of preterm labour in twin pregnancy. Of the 144 women studied, 74 took salbutamol and 70 placebo. No difference was found in the length of gestation, birthweight or fetal outcome, although fewer babies suffered from respiratory distress syndrome in the salbutamol group. Women did not experience troublesome side-effects from salbutamol.
A H MacLennan, R C Green, R O'Shea, C Brookes, D Morris
Routine hospital admission in twin pregnancy between 26 and 30 weeks' gestation.
Lancet. 1990 Feb 3;335(8684):267-9.
Abstract/Text
Of 141 women with twin pregnancies, 72 were randomly assigned to outpatient care and 69 to hospital admission between 26 and 30 weeks' gestation. There were no differences between the groups in the frequencies of major maternal complications in pregnancy and labour but more of those admitted to hospital than of the outpatient group had to be admitted after 30 weeks. There were no differences between the groups in the mean birthweights of the twins by birth order, or in their mean gestation at birth whether analysed by intention to treat or by the treatment given. 22 infants were delivered before 32 weeks' gestation in the inpatient group compared with 10 in the outpatient group. With the exception of small-for-dates infants, any trend towards greater morbidity or mortality was seen in the inpatient group. The policy of routine hospital admission of women with twin pregnancies from 26 weeks' gestation is not beneficial to mother or babies and should be abandoned.
日本産科婦人科学会, et al., : CQ702 1絨毛膜双胎の取り扱いは？.産婦人科診療ガイドライン 産科編2014. 日本産科婦人科学会; 2014;344-347.
Hanmin Lee, Amy J Wagner, Edgar Sy, Robert Ball, Vickie A Feldstein, Ruth B Goldstein, Diana L Farmer
Efficacy of radiofrequency ablation for twin-reversed arterial perfusion sequence.
Am J Obstet Gynecol. 2007 May;196(5):459.e1-4. doi: 10.1016/j.ajog.2006.11.039.
Abstract/Text
OBJECTIVE: We report our experience in the treatment of patients with twin-reversed arterial perfusion (TRAP) sequence using radiofrequency ablation to stop perfusion to the acardiac twin and protect the pump twin.
STUDY DESIGN: An IRB approved retrospective review of all patients (n = 29) who underwent percutaneous radiofrequency ablation of an acardiac twin, using ultrasound guidance and either a 14 or 17 gauge radiofrequency needle for twin-reversed arterial perfusion sequence, from 1998 to 2005, was performed by review of hospital and outpatient medical records.
RESULTS: The outcomes of all 29 of the patients treated with radiofrequency ablation are known. Twenty-six of the patients had monochorionic-diamniotic pregnancies, whereas 2 had monochorionic-monoamniotic pregnancies. One patient had a triplet pregnancy with a monochorionic-diamniotic pair with TRAP sequence. Overall, 25 of 29 pump twins survived (86%), delivering at a mean gestational age of 34.6 weeks. Survival was 24 of 26 (92%) in monochorionic-diamniotic pregnancies with a mean gestational age of 35.6 weeks. Two women in our early experience sustained thermal injuries from the site of grounding pads.
CONCLUSION: Radiofrequency ablation of the acardiac twin effectively protects the pump twin from high-output cardiac failure and death. Greater than 90% survival can be achieved in monochorionic-diamniotic pregnancies complicated by TRAP sequence with a mean gestation age at time of delivery close to term. Our limited experience in cases of monochorionic-monoamniotic TRAP sequence does not allow the determination of efficacy in this group.
Liesbeth Lewi, Catalina Valencia, Esperanza Gonzalez, Jan Deprest, Kypros H Nicolaides
The outcome of twin reversed arterial perfusion sequence diagnosed in the first trimester.
Am J Obstet Gynecol. 2010 Sep;203(3):213.e1-4. doi: 10.1016/j.ajog.2010.04.018. Epub 2010 Jun 3.
Abstract/Text
OBJECTIVE: The aim of this study was to document the mortality of twin reversed arterial perfusion (TRAP) sequence from the first trimester to planned intervention at 16-18 weeks.
STUDY DESIGN: A retrospective review was performed of the outcome of monochorionic twin pregnancies diagnosed with twin reversed arterial perfusion sequence in the first trimester.
RESULTS: Twenty-six pregnancies were diagnosed with twin reversed arterial perfusion sequence in the first trimester: 2 opted for termination of pregnancy and 24 opted for prophylactic intervention to arrest the reversed flow, which was planned at 16-18 weeks. In 8 of 24 (33%) pregnancies, spontaneous death of the pump twin occurred between diagnosis and planned intervention. In 5 of 24 (21%), there was a spontaneous arrest of flow; whereas, in 11 (46%) there was persistent flow toward the acardiac twin at 16-18 weeks.
CONCLUSION: Twin reversed arterial perfusion carries a high mortality between the first and early second trimester.
Copyright 2010. Published by Mosby, Inc.
Jeffrey C Livingston, Foong-Yen Lim, William Polzin, Jennifer Mason, Timothy M Crombleholme
Intrafetal radiofrequency ablation for twin reversed arterial perfusion (TRAP): a single-center experience.
Am J Obstet Gynecol. 2007 Oct;197(4):399.e1-3. doi: 10.1016/j.ajog.2007.07.051.
Abstract/Text
OBJECTIVE: The objective of the study was to review perinatal outcomes in pregnancies treated with intrafetal radiofrequency ablation (RFA) for twin reversed arterial perfusion (TRAP) sequence.
STUDY DESIGN: Perinatal outcome data from a quaternary care referral center were abstracted from a chart review of pregnancies with TRAP sequence treated in the midtrimester with umbilical cord RFA of the perfused twin.
RESULTS: Twenty-one pregnancies with TRAP sequence were evaluated. Two women had a pump twin demise prior to therapy, 1 with trisomy 21 declined treatment. Four of 20 were treated successfully with RFA but remain undelivered, and 1 was treated with fetoscopic cord coagulation. Twelve of 13 pump twins treated with RFA (94%) survived to 30 days of life. Mean preoperative cardiac combined cardiac output was 588 mL/kg and pump/twin ratio was 0.7 (range 0.4 to 1.1). The effect of RFA on postoperative cardiac output was variable (6-85%). The average gestational age at birth was 37 weeks (range 26-39 weeks).
CONCLUSION: Primary therapy with RFA is a successful modality for pregnancies complicated by TRAP sequence.
Rubén A Quintero, Ramen H Chmait, Takeshi Murakoshi, Zofia Pankrac, Malgorzata Swiatkowska, Patricia W Bornick, Mary H Allen
Surgical management of twin reversed arterial perfusion sequence.
Am J Obstet Gynecol. 2006 Apr;194(4):982-91. doi: 10.1016/j.ajog.2005.10.195.
Abstract/Text
OBJECTIVE: The purpose of this study was to review our experience in the management of twin reversed arterial perfusion sequence to derive management recommendations.
STUDY DESIGN: All patients with twin reversed arterial perfusion sequence who were seen for consultation between 1993 and 2004 were studied. Criteria for umbilical cord occlusion included abdominal circumference of the twin reversed arterial perfusion fetus that was more than or equal to the pump twin, polyhydramnios (maximum vertical pocket > or = 8 cm), abnormal Doppler studies or hydrops of the pump twin, or monoamniotic twins. Various surgical and access techniques for umbilical cord occlusion were used as they were developed.
RESULTS: Seventy-four patients with twin reversed arterial perfusion sequence were studied. Sixty-five patients were considered surgical candidates, of which 51 patients underwent umbilical cord occlusion attempt. The overall perinatal survival for surgical candidates who had umbilical cord occlusion was 65% (33/51 patients) versus 42.9% (6/14 patients) for the surgical candidates who did not undergo umbilical cord occlusion (P = .1). However, perinatal outcomes in surgical patients were significantly better than expectantly treated surgical candidates if the dividing membrane was not disrupted purposely (22/28 patients; 78.5%; P = .02). Surgery within the sac of the twin reversed arterial perfusion fetus was feasible in 23.5% of patients and was associated with no incidence of premature rupture of membranes, with 83% perinatal survival, and with a significantly greater gestational age at delivery (36 weeks). There were no significant differences in perinatal outcome relative to the specific surgical technique that was used.
CONCLUSION: Surgical management of twin reversed arterial perfusion sequence is indicated in high-risk patients. The surgical approach and the surgical technique should be tailored to the specific clinical presentation, preferably by performing the surgery within the sac of the twin reversed arterial perfusion sequence fetus and avoiding disruption of the dividing membrane.
Ramen H Chmait, Eftichia V Kontopoulos, Lisa M Korst, Arlyn Llanes, Ileana Petisco, Rubén A Quintero
Stage-based outcomes of 682 consecutive cases of twin-twin transfusion syndrome treated with laser surgery: the USFetus experience.
Am J Obstet Gynecol. 2011 May;204(5):393.e1-6. doi: 10.1016/j.ajog.2011.02.001. Epub 2011 Mar 15.
Abstract/Text
OBJECTIVE: We sought to describe stage-specific perinatal outcomes after selective laser photocoagulation of communicating vessels (SLPCV) for twin-twin transfusion syndrome.
STUDY DESIGN: Patients with twin-twin transfusion syndrome underwent SLPCV preferentially using sequential vs standard laser technique. Patient characteristics and outcome data were examined by Quintero stage.
RESULTS: Of 682 consecutive women studied, the Quintero stage distribution was: 114 stage I (17%), 177 stage II (26%), 328 stage III (48%), and 63 stage IV (9%). Perinatal survival of at least 1 twin did not differ according to stage (I-92%, II-93%, III-88%, IV-92%; P = .30). However, dual twin survival differed by stage (I-79%, II-76%, III-59%, IV-68%; P < .01), primarily because stage III pregnancies were associated with decreased donor twin survival (P < .01). Sequential SLPCV was associated with improved donor survival, independent of stage (odds ratio, 1.67; 95% confidence interval, 1.16-2.40; P < .01).
CONCLUSION: Stage-specific perinatal outcomes after laser therapy may assist physicians in patient counseling and in planning future studies.
Copyright © 2011 Mosby, Inc. All rights reserved.
Agnes Huber, Werner Diehl, Thomas Bregenzer, Bernd-Joachim Hackelöer, Kurt Hecher
Stage-related outcome in twin-twin transfusion syndrome treated by fetoscopic laser coagulation.
Obstet Gynecol. 2006 Aug;108(2):333-7. doi: 10.1097/01.AOG.0000225945.17022.6b.
Abstract/Text
OBJECTIVE: To assess perinatal outcome in monochorionic twin pregnancies according to different stages of severe mid-trimester twin-twin transfusion syndrome managed by fetoscopic laser coagulation of the placental vascular anastomoses.
METHODS: In a prospective study fetoscopic laser therapy was performed in 200 consecutive pregnancies with severe mid-trimester twin-twin transfusion syndrome at a median gestational age of 20.7 weeks (range 15.9-25.3 weeks). Outcome data were analyzed for the whole group and separately for each stage according to the Quintero staging system.
RESULTS: The overall survival rate was 71.5% (286/400), with survival of both twins in 59.5% (119/200) and survival of at least one of the twins in 83.5% (167/200). The median gestational age at delivery of liveborn neonates was 34.3 weeks (range 23.1-40.4 weeks). There was a significant trend toward reduced survival rates with increasing stage (P=.038). The percentage of pregnancies with survival of both fetuses was 75.9% (22/29) for stage I, 60.5% (49/81) for stage II, 53.8% (43/80) for stage III, and 50% (5/10) for stage IV. At least one of the twins survived in 93.1% (27/29) at stage I, 82.7% (67/81) at stage II, 82.5% (66/80) at stage III, and 70% (7/10) at stage IV. The overall survival rate for donor fetuses was 70.5% (141/200) and for recipient fetuses, 72.5% (145/200).
CONCLUSION: These data show that laser therapy is an effective therapeutic option for all stages of severe twin-twin transfusion syndrome and provide information to counsel patients according to the stage of the syndrome.
T Murakoshi, K Ishii, M Nakata, H Sago, S Hayashi, Y Takahashi, J Murotsuki, M Matsushita, T Shinno, H Naruse, Y Torii, Japan Fetoscopy Group
Validation of Quintero stage III sub-classification for twin-twin transfusion syndrome based on visibility of donor bladder: characteristic differences in pathophysiology and prognosis.
Ultrasound Obstet Gynecol. 2008 Nov;32(6):813-8. doi: 10.1002/uog.6226.
Abstract/Text
OBJECTIVE: To validate the Quintero stage III subclassification for twin-twin transfusion syndrome (TTTS) based on visibility of the bladder of the donor twin.
METHODS: Between July 2002 and August 2006, there were 131 pregnant Japanese women affected by severe TTTS before 26 weeks' gestation, treated with fetoscopic laser surgery at five centers in Japan, whose pregnancies continued beyond 22 weeks. Outcome data were available in all cases and surviving infants were followed up for at least 6 years. This study focused on the Stage III TTTS patients. These were subclassified into Stage III atypical (abnormal Doppler flow with visible donor bladder) and Stage III classical (abnormal Doppler flow with non-visible donor bladder) groups. Perioperative data and postnatal outcomes were compared between the groups.
RESULTS: Seven Stage I, 22 Stage II, 82 Stage III and 20 Stage IV pregnancies continued beyond 22 weeks. There was a significantly higher incidence of absent or reversed end-diastolic velocity in the umbilical artery (UA-AREDV) of the donor in Stage III atypical than in Stage III classical patients (83.8% vs. 53.3%, P = 0.004). Stage III atypical cases also had a significantly higher incidence of arterioarterial (AA) anastomoses (72.9% vs. 17.8%, P < 0.001) and intrauterine fetal demise (IUFD) of the donor (43.2% vs. 13.3%, P = 0.002). However, there were no differences in overall survival or in abnormal brain scans of surviving infants. Donors with both UA-AREDV and AA anastomoses had a significantly higher incidence of IUFD compared with the others (53.3%, P < 0.001).
CONCLUSIONS: Quintero stage III atypical was characterized by a high incidence of AA anastomoses and UA-AREDV of the donor, resulting in IUFD. Subclassification of Stage III based on visibility of the bladder of the donor twin was adequate for and compatible with differentiating prognosis and pathophysiology.
(c) 2008 ISUOG. Published by John Wiley & Sons, Ltd.
A Cristina Rossi, Douglas Vanderbilt, Ramen H Chmait
Neurodevelopmental outcomes after laser therapy for twin-twin transfusion syndrome: a systematic review and meta-analysis.
Obstet Gynecol. 2011 Nov;118(5):1145-50. doi: 10.1097/AOG.0b013e318231827f.
Abstract/Text
OBJECTIVE: To perform a systematic review of the literature regarding the occurrence of neurologic morbidity, neurologic impairment, or neurologic morbidity and impairment of patients treated with laser therapy for twin-twin transfusion syndrome.
DATA SOURCES: The PubMed, MEDLINE, EMBASE databases and reference lists were searched up to December 2010 for studies describing outcomes in laser-treated twin-twin transfusion syndrome pregnancies. METHODS FOR STUDY SELECTION: Inclusion criteria were twin-twin transfusion syndrome diagnosed with standard criteria and treated by laser therapy and neurologic morbidity and neurologic impairment collected at birth or 28 days after birth. Exclusion criteria were omission of at least one criterion; data in graphs or percentage; and non-English publications, letters, personal communications.
TABULATION, INTEGRATION AND RESULTS: Data recorded were rates and length of successful follow-up, age at diagnosis and type of neurologic morbidity, affected donors and recipients, prevalence of neurologic morbidity, and neurologic impairment for twin sets. From 15 articles, the incidence of neurologic morbidity at birth was 55 out of 895 (6.1%), without differences between donors and recipients (19/249, 7.6% compared with 16/273, 5.8%; odds ratio [OR] 1.36; 95% confidence interval [CI] 0.68-2.70). At follow-up, the incidence of neurologic impairment was 140 out of 1,255 (11.1%), with cerebral palsy the most frequent (60/151, 39.7%). Neurologic impairment was identified equally between donors and recipients (48/330, 14.5% compared with 54/364, 14.8%; OR 1.02; 95% CI 0.66-1.57), and between one survivor and two survivors for twin sets (24/139, 17.3% compared with 88/489, 18.0%; OR 0.67; 95% CI 0.18-2.49).
CONCLUSION: A small number (11.1%) of cases of twin-twin transfusion syndrome treated with laser therapy are affected with neurologic impairment that manifests during infancy. A strict follow-up of apparently healthy neonates is warranted.
Haruhiko Sago, Satoshi Hayashi, Mari Saito, Hiromi Hasegawa, Hiroshi Kawamoto, Naomi Kato, Yukiko Nanba, Yushi Ito, Yuichiro Takahashi, Jun Murotsuki, Masahiko Nakata, Keisuke Ishii, Takeshi Murakoshi
The outcome and prognostic factors of twin-twin transfusion syndrome following fetoscopic laser surgery.
Prenat Diagn. 2010 Dec;30(12-13):1185-91. doi: 10.1002/pd.2647.
Abstract/Text
OBJECTIVES: To evaluate the outcome and preoperative risks of twin-twin transfusion syndrome (TTTS) following fetoscopic laser surgery (FLS).
METHODS: A retrospective cohort study of a series of 181 consecutive cases of TTTS before 26 weeks' gestation subjected to FLS at four centers in Japan between July 2002 and December 2006.
RESULTS: The chances of survival of at least one twin at 28 days of age and 6 months of age were 91.2% and 90.1%, respectively. The rate of major neurological complications in survivors at 6 months of age was 4.7%. Preoperative findings that were significant risk factors for death were as follows: (1) being donor [odds ratio (OR): 3.01, 95% confidence interval (CI): 1.24-7.31, P = 0.015]; (2) reversed (OR: 11.78, CI: 3.05-45.55, P < 0.001) and absent (OR: 3.95, CI: 1.66-9.43, P = 0.002) end-diastolic velocity in the umbilical artery (EDV-UA) of the donor; and (3) reversed blood flow in the ductus venosus of the recipient (OR: 2.35, CI: 1.04-5.29, P = 0.040).
CONCLUSIONS: FLS leads to high survival rates and low neurological morbidity for fetuses in TTTS. FLS is an effective therapeutic option for TTTS before 26 weeks of gestation. Preoperative Doppler findings of the umbilical artery and the ductus venosus are useful in predicting prognosis following FLS.
Copyright © 2010 John Wiley & Sons, Ltd.
Marie-Victoire Senat, Jan Deprest, Michel Boulvain, Alain Paupe, Norbert Winer, Yves Ville
Endoscopic laser surgery versus serial amnioreduction for severe twin-to-twin transfusion syndrome.
N Engl J Med. 2004 Jul 8;351(2):136-44. doi: 10.1056/NEJMoa032597. Epub 2004 Jul 6.
Abstract/Text
BACKGROUND: Monochorionic twin pregnancies complicated by severe twin-to-twin transfusion syndrome at midgestation can be treated by either serial amnioreduction (removal of large volumes of amniotic fluid) or selective fetoscopic laser coagulation of the communicating vessels on the chorionic plate. We conducted a randomized trial to compare the efficacy and safety of these two treatments.
METHODS: Pregnant women with severe twin-to-twin transfusion syndrome before 26 weeks of gestation were randomly assigned to laser therapy or amnioreduction. We assessed perinatal survival of at least one twin (a prespecified primary outcome), survival of at least one twin at six months of age, and survival without neurologic complications at six months of age on the basis of the number of pregnancies or the number of fetuses or infants, as appropriate.
RESULTS: The study was concluded early, after 72 women had been assigned to the laser group and 70 to the amnioreduction group, because a planned interim analysis demonstrated a significant benefit in the laser group. As compared with the amnioreduction group, the laser group had a higher likelihood of the survival of at least one twin to 28 days of age (76 percent vs. 56 percent; relative risk of the death of both fetuses, 0.63; 95 percent confidence interval, 0.25 to 0.93; P=0.009) and 6 months of age (P=0.002). Infants in the laser group also had a lower incidence of cystic periventricular leukomalacia (6 percent vs. 14 percent, P=0.02) and were more likely to be free of neurologic complications at six months of age (52 percent vs. 31 percent, P=0.003).
CONCLUSIONS: Endoscopic laser coagulation of anastomoses is a more effective first-line treatment than serial amnioreduction for severe twin-to-twin transfusion syndrome diagnosed before 26 weeks of gestation.
Copyright 2004 Massachusetts Medical Society
Alissa Carver, Sina Haeri, Julie Moldenhauer, Honor M Wolfe, William Goodnight
Monochorionic diamniotic twin pregnancy: timing and duration of sonographic surveillance for detection of twin-twin transfusion syndrome.
J Ultrasound Med. 2011 Mar;30(3):297-301.
Abstract/Text
OBJECTIVE: Twin-twin transfusion syndrome complicates up to 15% of monochorionic diamniotic gestations. Current recommendations for sonographic surveillance in monochorionic diamniotic pregnancies for detection of twin-twin transfusion syndrome vary. Our objective was to determine an appropriate frequency of sonographic surveillance to optimize detection of twin-twin transfusion syndrome in monochorionic diamniotic gestations.
METHODS: A retrospective cohort analysis of all nonanomalous monochorionic diamniotic twins delivered at the University of North Carolina over a 9-year period was performed. The rate and gestational age of twin-twin transfusion syndrome onset were calculated. The time to the diagnosis of twin-twin transfusion syndrome was evaluated by a Kaplan-Meier survival curve; clinical factors at initial sonography were examined for their use in prediction of twin-twin transfusion syndrome.
RESULTS: Of the 577 twin deliveries, 145 (25%) were monochorionic diamniotic and included for analysis. The rate of twin-twin transfusion syndrome was 17.93% (n = 26). The mean frequency of surveillance ± SD before diagnosis of twin-twin transfusion syndrome was 3.1 ± 2.1 weeks. The mean gestational age at diagnosis of twin-twin transfusion syndrome was 21.3 ± 3.4 weeks (range, 15-29 weeks). Both a discordant maximum vertical amniotic fluid pocket (>65% difference) and a discordant estimated fetal weight (>25% difference) at initial sonography showed a significantly shorter time to diagnosis of twin-twin transfusion syndrome (P < .0001).
CONCLUSIONS: Evaluation for twin-twin transfusion syndrome should begin in the second trimester. Weekly surveillance for those pregnancies with estimated fetal weight or maximum vertical pocket discordance is recommended. For those with a concordant estimated fetal weight and maximum vertical pocket, sonographic evaluation every 2 weeks is warranted to 28 to 30 weeks. After that, development of twin-twin transfusion syndrome is less likely, and a different paradigm of antenatal testing may be reasonable.
C Vayssière, R Favre, F Audibert, M P Chauvet, P Gaucherand, D Tardif, G Grangé, A Novoa, P Descamps, M Perdu, E Andrini, J Janse-Marec, F Maillard, I Nisand, Research Group in Obstetrics and Gynecology (GROG)
Cervical assessment at 22 and 27 weeks for the prediction of spontaneous birth before 34 weeks in twin pregnancies: is transvaginal sonography more accurate than digital examination?
Ultrasound Obstet Gynecol. 2005 Dec;26(7):707-12. doi: 10.1002/uog.2616.
Abstract/Text
OBJECTIVES: This study compared the accuracy of ultrasound cervical assessment (cervical length and cervical index) and digital examination (Bishop score and cervical score) in the prediction of spontaneous birth before 34 weeks in twin pregnancies.
METHODS: In a prospective multicenter study, digital examination and transvaginal sonography were performed consecutively in twin pregnancies attending for routine sonography at either 22 weeks (175 women) or 27 weeks (153 women). The digital examination took place first, and the Bishop score and cervical score (cervical length minus cervical dilatation) were calculated. Ultrasound measurements were then made of cervical length and funnel length to yield the cervical index (1 + funnel length/cervical length). The association between each variable and delivery before 34 weeks was tested by the Mann-Whitney U-test. The receiver-operating characteristics (ROC) curves of the ultrasound and digital indicators were determined for both gestational age periods, and the areas under the ROC curves compared. The best cut-off values for each indicator were used to determine predictive values for delivery before 34 weeks.
RESULTS: The median gestational age at delivery among the women included in the 22-week examination period was 36.0 (range, 21-40) weeks; 10.9% (19) gave birth spontaneously before 34 weeks. The median cervical length was 40 (range, 6-65) mm. All four parameters were predictors of delivery before 34 weeks. The areas under the ROC curves for cervical index, cervical length, Bishop score and cervical score did not differ significantly. The median gestational age at delivery among the women in the 27-week examination period was 36.0 (range, 27-40) weeks; 9.2% (14) gave birth spontaneously before 34 weeks. The median cervical length was 35 (range, 1-57) mm. All parameters except the Bishop score were predictors of delivery before 34 weeks. The likelihood ratio of the positive and negative tests for cervical length < or = 25 mm was 5.4 (range, 3.2-9.0) and 0.3 (range, 0.1-0.7), respectively, compared with 2.3 (range, 1.3-4.2) and 0.6 (range, 0.3-1.1), respectively, for cervical score < or = 1. The area under the curve for the cervical index was significantly larger than that for the Bishop score (P = 0.008) or cervical score (P = 0.02).
CONCLUSION: Transvaginal sonography predicted spontaneous delivery before 34 weeks better than digital examination at the 27-week but not the 22-week examination.
H Minakami, T Watanabe, A Izumi, S Matsubara, T Koike, M Sayama, I Moriyama, I Sato
Association of a decrease in antithrombin III activity with a perinatal elevation in aspartate aminotransferase in women with twin pregnancies: relevance to the HELLP syndrome.
J Hepatol. 1999 Apr;30(4):603-11.
Abstract/Text
BACKGROUND/AIMS: Decreased antithrombin III (AT-III) activity and/or thrombocytopenia associated with an elevated serum level of aspartate aminotransferase in late pregnancy can threaten the lives of both the mother and the fetus. We investigated whether antenatal declines in AT-III activity and the platelet count occur in late twin pregnancy and whether reduced AT-III activity and/or thrombocytopenia precedes an increase in the serum level of aspartate aminotransferase.
METHODS: The platelet count, AT-III activity, and the serum level of aspartate aminotransferase were determined weekly or biweekly in 237 women with twin pregnancies in a longitudinal and partly prospective study.
RESULTS: Both AT-III activity and the platelet count decreased gradually in the last month of pregnancy, irrespective of the presence or absence of clinical signs of pre-eclampsia. A perinatal elevation in aspartate aminotransferase occurred in 36 (15%) of 237 women. The risk of a perinatal elevation in aspartate amino-transferase increased as the antenatal AT-III activity and/or the platelet count decreased. Pre-eclampsia developed in 60 women (25%). The relative risk of a perinatal aspartate aminotransferase elevation (95% confidence interval) for the 60 women with pre-eclampsia, the 60 women with a platelet count < or = the 25th percentile (164 x 10(9)/1), and the 60 women with AT-III activity < or = the 25th percentile (76% of normal) was 1.9 (1.0 to 3.4), 4.1 (2.3 to 7.5), and 5.9 (3.2 to 11.1), respectively, compared with the remaining 177 women.
CONCLUSIONS: AT-III activity and platelet count gradually decreased in the last month of twin pregnancies. A perinatal aspartate aminotransferase elevation was preceded by marked decreases in these parameters in women with twin pregnancies. The monitoring of AT-III activity and platelet count in women who exhibit a gradual decline in these parameters may help to avoid the development of severe HELLP syndrome.
Tetsuo Tsunoda, Akihide Ohkuchi, Akio Izumi, Takashi Watanabe, Shigeki Matsubara, Ikuo Sato, Hisanori Minakami
Antithrombin III activity and platelet count are more likely to decrease in twin pregnancies than in singleton pregnancies.
Acta Obstet Gynecol Scand. 2002 Sep;81(9):840-5.
Abstract/Text
BACKGROUND: It is not known whether antithrombin III activity and platelet count are more likely to decrease in women with twin pregnancies than singleton pregnancies.
METHODS: We enrolled 56 consecutive women with twin pregnancies and 692 consecutive women with singleton pregnancies. Antithrombin III activity and platelet count were determined at 26-31 weeks and again at 32-40 weeks of gestation. Thrombin-antithrombin complex, and plasmin-alpha2 plasmin inhibitor complex were measured simultaneously in some women.
RESULTS: In twin pregnancies, both antithrombin III activity (111 +/- 8.2%) and platelet count (244 +/- 60 x 109/l) at 28.6 +/- 1.0 weeks decreased over time to 91 +/- 12% and 205 +/- 59 x 109/l, respectively, at 35.2 +/- 1.2 weeks; these decreases were significantly greater than in singleton pregnancies. However, a small number of women with singleton pregnancies had a significant decrease in antithrombin III activity in the absence of preeclampsia. The serum thrombin-antithrombin complex was significantly higher in twin pregnancies than in singleton pregnancies (9.7 +/- 4.2 ng/ml vs. 6.7 +/- 4.4 ng/ml, respectively, p < 0.01), and this increase correlated significantly with the decrease in antithrombin III activity in twin pregnancies (r = -0.459, p < 0.001).
CONCLUSIONS: Antithrombin III activity and platelet count show a greater decrease in twin than in singleton pregnancies, perhaps due to a greater increase in thrombin generation.
Mamoru Morikawa, Takashi Yamada, Soromon Kataoka, Kazutoshi Cho, Hideto Yamada, Shigenori Suzuki, Noriaki Sakuragi, Hisanori Minakami
Changes in antithrombin activity and platelet counts in the late stage of twin and triplet pregnancies.
Semin Thromb Hemost. 2005 Jun;31(3):290-6. doi: 10.1055/s-2005-872434.
Abstract/Text
It is possible that women with triplet pregnancies are more likely to exhibit pregnancy-induced antithrombin deficiency, gestational thrombocytopenia, and perinatal elevation in serum aspartate aminotransferase (AST) than women with twin pregnancies. We retrospectively reviewed changes in antithrombin activity, platelet count, and blood chemistry in 23 twin and seven triplet pregnancies in which the mothers received antenatal care and gave birth in our hospital during 1999 and 2001. Both antithrombin activity and platelet counts gradually decreased until delivery, then promptly increased after delivery in both twin and triplet pregnancies. A significantly larger number of women developed gestational thrombocytopenia of < 100 x 10 (9)/L (43% [three of seven] versus 4.3% [one of 23]; p < 0.01) and pregnancy-induced antithrombin deficiency of < 60% of normal activity (57% [four of seven] versus 17% [four of 23]; p < 0.05) in triplet than in twin pregnancies. Eight women with pregnancy-induced antithrombin deficiency, including three women with gestational thrombocytopenia, were significantly more likely to develop perinatal elevations of AST, lactate dehydrogenase, serum creatinine, fibrin/fibrinogen degradation products, and D-dimer than were those without pregnancy-induced antithrombin deficiency. These findings suggest that women with triplet pregnancies are at an increased risk of the HELLP syndrome and acute fatty liver of pregnancy compared with women with twin pregnancies.
Mamoru Morikawa, Takashi Yamada, Noriko Turuga, Kazutoshi Cho, Hideto Yamada, Noriaki Sakuragi, Hisanori Minakami
Coagulation-fibrinolysis is more enhanced in twin than in singleton pregnancies.
J Perinat Med. 2006;34(5):392-7. doi: 10.1515/JPM.2006.078.
Abstract/Text
AIMS: To examine whether coagulation-fibrinolysis in late pregnancy in women with twin pregnancies is more pronounced than in women with singleton pregnancies.
PATIENTS AND METHODS: The plasma levels of D-dimer, fibrinogen/fibrin degradation products (FDP), and fibrinogen, the platelet count, and the antithrombin activity were assessed from 3 weeks before delivery until postpartum day 7 in 48 women (24 singleton and 24 twin pregnancies) without preeclampsia who underwent cesarean sections.
RESULTS: Women with singleton or twin pregnancies gave birth at 37.3+/-1.2 weeks or 35.2+/-1.4 weeks, respectively. Compared with singleton mothers, prenatal D-dimer and FDP levels were consistently and significantly higher among women with twin pregnancies. A significantly larger proportion of twin mothers exhibited prenatal levels of D-dimer >5.0 microg/mL, FDP >10.0 microg/mL, fibrinogen <420 mg/mL and antithrombin activity <70%. In addition, prenatal antithrombin activity in plasma was significantly lower.
CONCLUSIONS: Coagulation-fibrinolysis is more enhanced in women with twin gestation than in women with singleton gestation.
American College of Obstetricians and Gynecologists Committee on Practice Bulletins-Obstetrics, Society for Maternal-Fetal Medicine, ACOG Joint Editorial Committee
ACOG Practice Bulletin #56: Multiple gestation: complicated twin, triplet, and high-order multifetal pregnancy.
Obstet Gynecol. 2004 Oct;104(4):869-83.
Abstract/Text
B M Sibai, J Hauth, S Caritis, M D Lindheimer, C MacPherson, M Klebanoff, J P VanDorsten, M Landon, M Miodovnik, R Paul, P Meis, G Thurnau, M Dombrowski, J Roberts, D McNellis
Hypertensive disorders in twin versus singleton gestations. National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units.
Am J Obstet Gynecol. 2000 Apr;182(4):938-42.
Abstract/Text
OBJECTIVE: This study was undertaken to compare rates and severity of gestational hypertension and preeclampsia, as well as perinatal outcomes when these complications develop, between women with twin gestations and those with singleton gestations.
STUDY DESIGN: This was a secondary analysis of prospective data from women with twin (n = 684) and singleton (n = 2946) gestations enrolled in two separate multicenter trials of low-dose aspirin for prevention of preeclampsia. End points were rates of gestational hypertension, rates of preeclampsia, and perinatal outcomes among women with hypertensive disorders.
RESULTS: Women with twin gestations had higher rates of gestational hypertension (relative risk, 2.04; 95% confidence interval, 1.60-2.59) and preeclampsia (relative risk, 2. 62; 95% confidence interval, 2.03-3.38). In addition, women with gestational hypertension during twin gestations had higher rates of preterm delivery at both <37 weeks' gestation (51.1% vs 5.9%; P <. 0001) and <35 weeks' gestation (18.2% vs 1.6%; P <.0001) and also had higher rates of small-for-gestational-age infants (14.8% vs 7. 0%; P =.04). Moreover, when outcomes associated with preeclampsia were compared, women with twin gestations had significantly higher rates of preterm delivery at <37 weeks' gestation (66.7% vs 19.6%; P <.0001), preterm delivery at <35 weeks' gestation (34.5% vs 6.3%; P <.0001), and abruptio placentae (4.7% vs 0.7%; P =.07). In contrast, among women with twin pregnancies, those who remained normotensive had more adverse neonatal outcomes than did those in whom hypertensive complications developed.
CONCLUSIONS: Rates for both gestational hypertension and preeclampsia are significantly higher among women with twin gestations than among those with singleton gestations. Moreover, women with twin pregnancies and hypertensive complications have higher rates of adverse neonatal outcomes than do those with singleton pregnancies.
日本産科婦人科学会周産期委員会報告（水上尚典、他）:早剥、HELLP症候群、ならびに子癇に関して.日産婦誌 2009；61：1559-1567.
Fiona Cheong-See, Ewoud Schuit, David Arroyo-Manzano, Asma Khalil, Jon Barrett, K S Joseph, Elizabeth Asztalos, Karien Hack, Liesbeth Lewi, Arianne Lim, Sophie Liem, Jane E Norman, John Morrison, C Andrew Combs, Thomas J Garite, Kimberly Maurel, Vicente Serra, Alfredo Perales, Line Rode, Katharina Worda, Anwar Nassar, Mona Aboulghar, Dwight Rouse, Elizabeth Thom, Fionnuala Breathnach, Soichiro Nakayama, Francesca Maria Russo, Julian N Robinson, Jodie M Dodd, Roger B Newman, Sohinee Bhattacharya, Selphee Tang, Ben Willem J Mol, Javier Zamora, Basky Thilaganathan, Shakila Thangaratinam, Global Obstetrics Network (GONet) Collaboration
Prospective risk of stillbirth and neonatal complications in twin pregnancies: systematic review and meta-analysis.
BMJ. 2016 Sep 6;354:i4353. doi: 10.1136/bmj.i4353. Epub 2016 Sep 6.
Abstract/Text
OBJECTIVE: To determine the risks of stillbirth and neonatal complications by gestational age in uncomplicated monochorionic and dichorionic twin pregnancies.
DESIGN: Systematic review and meta-analysis.
DATA SOURCES: Medline, Embase, and Cochrane databases (until December 2015).
REVIEW METHODS: Databases were searched without language restrictions for studies of women with uncomplicated twin pregnancies that reported rates of stillbirth and neonatal outcomes at various gestational ages. Pregnancies with unclear chorionicity, monoamnionicity, and twin to twin transfusion syndrome were excluded. Meta-analyses of observational studies and cohorts nested within randomised studies were undertaken. Prospective risk of stillbirth was computed for each study at a given week of gestation and compared with the risk of neonatal death among deliveries in the same week. Gestational age specific differences in risk were estimated for stillbirths and neonatal deaths in monochorionic and dichorionic twin pregnancies after 34 weeks' gestation.
RESULTS: 32 studies (29 685 dichorionic, 5486 monochorionic pregnancies) were included. In dichorionic twin pregnancies beyond 34 weeks (15 studies, 17 830 pregnancies), the prospective weekly risk of stillbirths from expectant management and the risk of neonatal death from delivery were balanced at 37 weeks' gestation (risk difference 1.2/1000, 95% confidence interval -1.3 to 3.6; I(2)=0%). Delay in delivery by a week (to 38 weeks) led to an additional 8.8 perinatal deaths per 1000 pregnancies (95% confidence interval 3.6 to 14.0/1000; I(2)=0%) compared with the previous week. In monochorionic pregnancies beyond 34 weeks (13 studies, 2149 pregnancies), there was a trend towards an increase in stillbirths compared with neonatal deaths after 36 weeks, with an additional 2.5 per 1000 perinatal deaths, which was not significant (-12.4 to 17.4/1000; I(2)=0%). The rates of neonatal morbidity showed a consistent reduction with increasing gestational age in monochorionic and dichorionic pregnancies, and admission to the neonatal intensive care unit was the commonest neonatal complication. The actual risk of stillbirth near term might be higher than reported estimates because of the policy of planned delivery in twin pregnancies.
CONCLUSIONS: To minimise perinatal deaths, in uncomplicated dichorionic twin pregnancies delivery should be considered at 37 weeks' gestation; in monochorionic pregnancies delivery should be considered at 36 weeks.
SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42014007538.
Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
H Minakami, I Sato
Reestimating date of delivery in multifetal pregnancies.
JAMA. 1996 May 8;275(18):1432-4.
Abstract/Text
OBJECTIVE: To clarify the optimal estimated date of delivery for multifetal pregnancies.
DESIGN, SUBJECTS, AND SETTING: A retrospective study of all 88,936 infants born of multifetal pregnancies and all 6,020,542 infants born of singleton pregnancies that occurred at 26 weeks or more of gestation between 1989 and 1993 in Japan.
MAIN OUTCOME MEASURE: Incidence of stillbirth and early neonatal death according to gestational age at delivery.
RESULTS: The mean +/- SD duration of pregnancy was 37.0 +/- 2.7 weeks for multifetal pregnancies and 39.6 +/- 1.6 weeks for singleton pregnancies. In multifetal pregnancies, the incidence of stillbirth and of early neonatal death gradually declined until 37 to 38 weeks' gestation and then increased. These parameters in singleton pregnancies declined until 39 weeks' gestation before increasing. The lowest incidence of perinatal death (Stillbirth plus early neonatal death) seen at 38 weeks' gestation in multifetal pregnancies corresponded to that seen at 43 weeks' gestation in singleton pregnancies (10.5 vs 9.7 per 1000 infants). The fist of perinatal death was more than 6 times as high for fetuses of multifetal pregnancies born at 37 weeks or later than for singleton fetuses born at 40 weeks or later (relative risk, 6.6; 95% confidence internal, 6.1 - 7.1).
CONCLUSION: Fetuses of multifetal pregnancies are at an increased risk of death after reaching the normative gestational age for singleton pregnancies. Limiting the estimated date of delivery to 37 to 38 weeks may be appropriate in multifetal pregnancies.
Fionnuala M Breathnach, Fionnuala M McAuliffe, Michael Geary, Sean Daly, John R Higgins, James Dornan, John J Morrison, Gerard Burke, Shane Higgins, Patrick Dicker, Fiona Manning, Stephen Carroll, Fergal D Malone, Perinatal Ireland Research Consortium
Optimum timing for planned delivery of uncomplicated monochorionic and dichorionic twin pregnancies.
Obstet Gynecol. 2012 Jan;119(1):50-9. doi: 10.1097/AOG.0b013e31823d7b06.
Abstract/Text
OBJECTIVE: To determine the optimum timing for planned delivery of uncomplicated monochorionic and dichorionic twin pregnancies.
METHODS: Unselected twin pregnancies were recruited for this prospective cohort study (N=1,028), which was conducted in eight tertiary referral perinatal centers in Ireland. Perinatal mortality and a composite measure of perinatal morbidity (respiratory distress, necrotizing enterocolitis, hypoxic ischemic encephalopathy, periventricular leukomalacia, or sepsis) were compared between uncomplicated twins that underwent planned preterm delivery compared with monochorionic twins that continued in utero beyond 34 weeks of gestation, and dichorionic twins who continued beyond 36 weeks.
RESULTS: Perinatal outcome data were recorded for 100% of the 1,001 twin pairs that completed the study (n=200 monochorionic and n=801 dichorionic). Overall perinatal mortality was 30 per 1,000 in monochorionic twins and 3.8 per 1,000 among dichorionic twins. The prospective risk of in utero death was 1.5% after 34 weeks of gestation for uncomplicated monochorionic pregnancies, with no deaths among dichorionic twins after 33 weeks. The risk of a composite measure of perinatal morbidity for uncomplicated monochorionic twins fell from 41% (13/32 neonates, 3/6 among elective deliveries) at 34 weeks to 5% (4/84) at 37 weeks (P<.001). Among dichorionic twins, the risk of morbidity fell from 4% (2/52) among elective deliveries at 36 weeks to 1% (5/344) in pregnancies continuing to 38 weeks (P=.231).
CONCLUSION: Applying a strategy of close fetal surveillance, perinatal morbidity can be minimized by allowing uncomplicated monochorionic pregnancies continue to 37 weeks of gestation and dichorionic twins to 38 weeks. Among monochorionic twins, this approach must be balanced against a 1.5% risk of late in utero death.
日本産科婦人科学会, et al:CQ705 双胎の一般的な管理・分娩の方法は？.産婦人科診療ガイドライン 産科編2014. 日本産科婦人科学会; 2014;355-358.
村越毅, et al. 【周産期診療指針2010】 産科編 ハイリスク妊娠での分娩取り扱い 多胎妊娠での分娩方法の選択. 周産期医学 2010;40(増刊):314-317.
Shi Wu Wen, Karen Fung Kee Fung, Lawrence Oppenheimer, Kitaw Demissie, Qiuying Yang, Mark Walker
Occurrence and predictors of cesarean delivery for the second twin after vaginal delivery of the first twin.
Obstet Gynecol. 2004 Mar;103(3):413-9. doi: 10.1097/01.AOG.0000110248.32558.fb.
Abstract/Text
OBJECTIVE: To estimate the occurrence and to assess clinical predictors of emergent cesarean delivery in the second twin after vaginal delivery of the first twin.
METHODS: We conducted a population-based cohort study, using the 1995-1997 linked mother/infant twin data from the United States. The adjusted risk ratios and population attributable risks of clinical predictors of emergent cesarean delivery in second twins were estimated for the overall study sample and for those born at less than 36 or 36 weeks or more of gestation.
RESULTS: Among the 61,845 second twin births with the first twin delivered vaginally, 5,842 (9.45%) were delivered by cesarean. The cesarean delivery rate was increased in infants born to mothers with medical or labor and delivery complications. Breech and other malpresentations were the most important predictors of emergent cesarean delivery for the second twin (population attributable risk 33.2%; 95% confidence interval 31.8%, 34.6%). Operative vaginal delivery of the first twin was associated with a decreased risk of cesarean delivery for the second twin. Prediction of emergent cesarean for the second twin by clinical factors was stronger in term births than preterm births.
CONCLUSION: In the general population, the cesarean delivery rate for the second twin after vaginal delivery of the first twin is approximately 9.5%. With the presence of breech and other malpresentations, the need for emergent cesarean delivery of the second twin after vaginal delivery of the first twin is increased by 4-fold.
LEVEL OF EVIDENCE: II-2
C A Combs, E L Murphy, R K Laros
Factors associated with postpartum hemorrhage with vaginal birth.
Obstet Gynecol. 1991 Jan;77(1):69-76.
Abstract/Text
A case-control study was performed to study risk factors for postpartum hemorrhage. Cases of hemorrhage were defined by a hematocrit decrease of 10 points or more between admission and post-delivery or by the need for red-cell transfusion. Patients with antenatal bleeding were excluded. Among 9598 vaginal deliveries, postpartum hemorrhage occurred in 374 cases (3.9%). Three controls were matched to each case and multiple logistic regression was used to control for covariance among predictor variables. Factors having a significant association with hemorrhage were prolonged third stage of labor (adjusted odds ratio 7.56), preeclampsia (odds ratio 5.02), mediolateral episiotomy (4.67), previous postpartum hemorrhage (3.55), twins (3.31), arrest of descent (2.91), soft-tissue lacerations (2.05), augmented labor (1.66), forceps or vacuum delivery (1.66), Asian (1.73) or Hispanic (1.66) ethnicity, midline episiotomy (1.58), and nulliparity (1.45). These data may help predict postpartum hemorrhage and may be useful in counseling patients about the advisability of home delivery, intravenous access in labor, or autologous blood donation.
Shunji Suzuki, Yoshie Hiraizumi, Hidehiko Miyake
Risk factors for postpartum hemorrhage requiring transfusion in cesarean deliveries for Japanese twins: comparison with those for singletons.
Arch Gynecol Obstet. 2012 Dec;286(6):1363-7. doi: 10.1007/s00404-012-2461-9. Epub 2012 Jul 19.
Abstract/Text
OBJECTIVE: The aim of this study was to identify the factors associated with the increased risk of postpartum hemorrhage requiring transfusion in Japanese twin pregnancies in comparison with those in Japanese singleton pregnancies.
METHODS: We reviewed the obstetric records of all singleton and twin deliveries after 22 weeks' gestation at the Japanese Red Cross Katsushika Maternity Hospital from 2003 through 2011. Potential risk factors for transfusion due to hemorrhage after cesarean delivery were selected according to previous studies of postpartum hemorrhage or transfusion or both after delivery: maternal age, parity, previous cesarean deliveries, history of infertility therapies such as in vitro fertilization, gestational age at delivery, neonatal birth weight, placenta previa, uterine myoma≥6 cm, hypertensive disorders, placental abruption, emergency cesarean deliveries and general anesthesia.
RESULTS: Using multiple logistic regression, the independent risk factors for postpartum hemorrhage requiring transfusion in singleton pregnancies were preterm delivery [odds ratio (OR) 2.40, 95% confidence interval (CI) 1.2-4.6, p<0.01], placenta previa (OR 8.08, 95% CI 3.9-16, p<0.01) and placental abruption (OR 12.8, 95% CI 2.3-76, p<0.01). In twin pregnancies, however, the independent risk factors for postpartum hemorrhage requiring transfusion were gestational age at ≥41 weeks (OR 8.20, 95% CI 1.3-40, p<0.01) and hypertensive disorders (OR 5.45, 95% CI 2.2-14, p<0.01).
CONCLUSIONS: The factors associated with postpartum hemorrhage requiring transfusion in cesarean deliveries of twins seemed to be different from those in singleton cesarean deliveries.
Shunji Suzuki, Fumi Kikuchi, Nozomi Ouchi, Chiaki Nagayama, Michiko Nakagawa, Yusuke Inde, Miwa Igarashi, Hidehiko Miyake
Risk factors for postpartum hemorrhage after vaginal delivery of twins.
J Nippon Med Sch. 2007 Dec;74(6):414-7.
Abstract/Text
We examined vaginal deliveries of twins to identify factors most strongly associated with the increased risk of postpartum hemorrhage (estimated blood loss > or = 1,000 mL). We reviewed the obstetric records of all 171 twin vaginal deliveries at Japanese Red Cross Katsushika Maternity Hospital from January 2002 through August 2006. Of these deliveries, 41 (24%) were complicated by postopartum hemorrhage. Postpartum hemorrhage was significantly more likely in cases with gestational age > or = 39 weeks (odds ratio [OR], 3.47; 95% confidence interval [CI], 1.65-7.28), a combined birth weight of more than 5,500 g (OR, 2.53; 95% CI, 1.00-6.45), induction of labor (OR, 2.87; 95% CI, 1.38-5.98), oxytocin administration during labor (OR, 2.86; 95% CI, 1.27-6.48), or a duration of labor > or = 24 hours (OR, 2.55; 95% CI, 1.15-5.62). Postpartum hemorrhage is a frequent complication in twin pregnancies. Therefore, special attention should be given after birth to patients with induction of labor or intervened delivery especially at > or = 39 weeks gestation.
Claudio G Sosa, Fernando Althabe, José M Belizán, Pierre Buekens
Risk factors for postpartum hemorrhage in vaginal deliveries in a Latin-American population.
Obstet Gynecol. 2009 Jun;113(6):1313-9. doi: 10.1097/AOG.0b013e3181a66b05.
Abstract/Text
OBJECTIVE: To identify risk factors for immediate postpartum hemorrhage after vaginal delivery in a South American population.
METHODS: This was a prospective cohort study including all vaginal births (N=11,323) between October and December 2003 and October and December 2005 from 24 maternity units in two South American countries (Argentina and Uruguay). Blood loss was measured in all births using a calibrated receptacle. Moderate postpartum hemorrhage and severe postpartum hemorrhage were defined as blood loss of at least 500 mL and at least 1,000 mL, respectively.
RESULTS: Moderate and severe postpartum hemorrhage occurred in 10.8% and 1.9% of deliveries, respectively. The risk factors more strongly associated and the incidence of moderate postpartum hemorrhage in women with each of these factors were: retained placenta (33.3%) (adjusted odds ratio [OR] 6.02, 95% confidence interval [CI] 3.50-10.36), multiple pregnancy (20.9%) (adjusted OR 4.67, CI 2.41-9.05), macrosomia (18.6%) (adjusted OR 2.36, CI 1.93-2.88), episiotomy (16.2%) (adjusted OR 1.70, CI 1.15-2.50), and need for perineal suture (15.0%) (adjusted OR 1.66, CI 1.11-2.49). Active management of the third stage of labor, multiparity, and low birth weight were found to be protective factors. Severe postpartum hemorrhage was associated with retained placenta (17.1%) (adjusted OR 16.04, CI 7.15-35.99), multiple pregnancy (4.7%) (adjusted OR 4.34, CI 1.46-12.87), macrosomia (4.9%) (adjusted OR 3.48, CI 2.27-5.36), induced labor (3.5%) (adjusted OR 2.00, CI 1.30-3.09), and need for perineal suture (2.5%) (adjusted OR 2.50, CI 1.87-3.36).
CONCLUSION: Many of the risk factors for immediate postpartum hemorrhage in this South American population are related to complications of the second and third stage of labor.
LEVEL OF EVIDENCE: II.
J F R Barrett, W Knox Ritchie
Twin delivery.
Best Pract Res Clin Obstet Gynaecol. 2002 Feb;16(1):43-56. doi: 10.1053/beog.2002.0254.
Abstract/Text
The incidence of twin pregnancy has increased worldwide over the past 10 years largely as a consequence of the assisted reproductive technologies. Issues such as intrapartum monitoring and operative interventions, especially with regard to the second twin, provide a unique challenge in labour and delivery. Epidemiological data suggest that the term twin has a threefold higher mortality rate than the singleton. It is the authors' view that many aspects of twin delivery deserve as much import as those features of twin gestations such as pre-term birth and intrauterine growth restriction that, to date, have received much of the research and clinical interest in this area. Indications for elective Caesarean section are presented, incorporating new data derived from the delivery of the term singleton breech, and implications on the timing thereof are discussed. Vaginal delivery of both twins presenting by the vertex is recommended as safe as long as guidelines for the conduct of such delivery are followed. The recommended time interval between twins as well as the use of epidural, fetal monitoring and ultrasound in the delivery room are discussed. The second twin presenting as a non-vertex presents an urgent dilemma for accoucheurs. Data suggest that internal version and breech extractions are safer than external cephalic version provided that the appropriate techniques are applied. It is revealed, however, that the use of elective Caesarean section in this group of babies has not been subject to randomized controlled studies of sufficient power to determine the best method of delivery of the second twin - particularly in the low-birth-weight baby.
Copyright 2002 Elsevier Science Ltd.
村越毅:分娩中胎児評価法と管理の実際．双胎第2子.村田雄二編. 新女性医学大系：胎児胎盤機能評価.中山書店, 2002;246-254.
日本産科婦人科学会, et al: CQ701 双胎の膜性診断の時期と方法は？.産婦人科診療ガイドライン 産科編2014.日本産科婦人科学会; 2014;340 -343.
村越毅. 【ハイリスク妊娠・分娩の予知・予防の最前線】 多胎妊娠 膜性診断の重要性. 周産期医学 2011;41(4):459-465.
Adedayo L Adegbite, Shirley Castille, Stuart Ward, Rekha Bajoria
Neuromorbidity in preterm twins in relation to chorionicity and discordant birth weight.
Am J Obstet Gynecol. 2004 Jan;190(1):156-63. doi: 10.1016/j.ajog.2003.07.004.
Abstract/Text
OBJECTIVE: The purpose of this study was to determine the incidence of neurologic morbidity in preterm monochorionic (MC) and dichorionic (DC) twins.
STUDY DESIGN: We collected perinatal, neonatal, and infant follow-up data of 76 MC and 78 DC twins born between 24 and 34 weeks of gestation (295 infants). Risks of neuromorbidity in the surviving infants were evaluated in relation to chorionicity, discordant birth weight (>20%), twin-twin transfusion syndrome (TTTS), and cotwin death.
RESULTS: The overall incidence of cerebral palsy and minor neurologic disabilities in surviving twins was 4% and 9%, respectively. MC infants had a higher incidence of cerebral palsy (8% vs 1%, P<.05) and neurologic morbidity (15% vs 3%, P<.05) than DC infants. The risk of impaired neurodevelopment was higher in MC infants with discordant birth weight (42%, P<.01), TTTS (37%, P<.01), and cotwin death (60%, P<.01) than those with concordant birth weight (8%). In MC pregnancies, the cerebral palsy risk was higher in infants with discordant birth weight than those with chronic TTTS (19% vs 4%, P<.05). Similarly, discordant DC infants had higher neuromorbidity than concordant group (5% vs 1%, P<.05). In both MC and DC discordant infants, neurologic morbidity was independent of growth restriction.
CONCLUSION: Neurologic morbidity in the preterm MC infants was 7-fold higher than DC infants because of chronic TTTS, discordant birth weight, and cotwin death in utero.
H Minakami, Y Honma, S Matsubara, A Uchida, H Shiraishi, I Sato
Effects of placental chorionicity on outcome in twin pregnancies. A cohort study.
J Reprod Med. 1999 Jul;44(7):595-600.
Abstract/Text
OBJECTIVE: To examine the effects of the chorionicity of the placenta on infant outcome at 1 year of age in twin pregnancies.
STUDY DESIGN: Cohort study and retrospective review of the medical records of 44 monochorionic (MC) and 164 dichorionic (DC) twin gestations that had been followed at our institution since < 20 weeks' gestation. Physical and neurologic status was assessed at 1 year of corrected age in infants born to these 208 women.
RESULTS: Adverse infant outcomes, such as death, cerebral palsy and mental retardation, occurred in 9 (10%) of 88 MC infants (4 deaths and 5 disabled infants) as compared with 12 (3.7%) of 328 DC infants (6 deaths and 6 disabled infants) (P < .05). Although delivery occurred one week earlier in MC than in DC twins (34.7 +/- 2.8 vs. 35.7 +/- 2.3 weeks, P < .01), there was no significant difference in gestational age at birth or birth weight between the 9 MC and 12 DC infants with adverse outcomes. A presumptive antenatal diagnosis of twin-twin transfusion syndrome (TTTS) was made in 14 (32%) of the 44 MC twin gestations. TTTS was considered to be responsible for adverse outcome in 7 MC infants. All 9 MC infants with adverse outcomes and 4 (33%) of 12 DC infants with adverse outcomes belonged to pairs that had weight discordance > or = 25% (P < .01).
CONCLUSION: MC twins had an increased risk of adverse outcomes as compared with DC twins, mainly because of TTTS. In both MC and DC twins, a birth weight discordance > or = 25% was associated with adverse infant outcomes. The number of infants with disabilities at 1 year of age was equal to the number of deaths.
上田敏子, et al. 双胎の神経学的長期予後 196組の双胎における産科的リスクファクターに関する検討. 日本周産期・新生児医学会雑誌 2008;44(1):20-24.
Laxmi V Baxi, Colin A Walsh
Monoamniotic twins in contemporary practice: a single-center study of perinatal outcomes.
J Matern Fetal Neonatal Med. 2010 Jun;23(6):506-10. doi: 10.3109/14767050903214590.
Abstract/Text
OBJECTIVE: The previous studies of monochorionic monoamniotic (MCMA) twins reported perinatal mortality rates as high as 70-80%. The recent trends have been towards significantly improved outcomes, though results from all studies have not been consistent.
METHOD: A retrospective cohort analysis of all MCMA pregnancies > or =20 weeks delivered in a single university institution from 2001 to 2009, using a computerised hospital database. MCMA twins are managed by a close antenatal surveillance program, preferably elective admission at 26-28 weeks, daily non-stress tests, regular assessment of fetal growth with the goal of cesarean delivery by 34 weeks.
RESULTS: Of the 25 MCMA pregnancies delivered, 98% (49/50) of twins were live-born. All women were delivered by cesarean section. There was one intrauterine fetal demise, which was secondary to anencephaly. There were three neonatal deaths, two in association with complex congenital heart disease. One twin died outside the neonatal period following cardiac surgery. In total, 28% (7/25) of pregnancies were complicated by major congenital anomalies. There was one case of mild transient twin-twin transfusion syndrome (TTTS). The overall perinatal mortality rate for non-anomalous twins was 2.4% (95% CI = 0.06%-13.59%).
CONCLUSIONS: Traditionally quoted as up to 80%, perinatal mortality rates <10% for MCMA twins are achievable in contemporary practice. It is vital that these high-risk pregnancies are managed in experienced centers with close surveillance and appropriate pediatric support.
Kent D Heyborne, Richard P Porreco, Thomas J Garite, Kimberly Phair, Diana Abril, Obstetrix/Pediatrix Research Study Group
Improved perinatal survival of monoamniotic twins with intensive inpatient monitoring.
Am J Obstet Gynecol. 2005 Jan;192(1):96-101. doi: 10.1016/j.ajog.2004.06.037.
Abstract/Text
OBJECTIVE: The purpose of this study was to evaluate the impact of routine hospitalization for fetal monitoring on the perinatal survival and neonatal morbidity of monoamniotic twins.
STUDY DESIGN: This was a multicenter retrospective cohort analysis of 96 monoamniotic twin gestations from 11 university and private perinatal practices. Overall mortality rates were calculated. The risk of intrauterine fetal death and neonatal morbidity was compared among women who were observed as inpatients versus outpatients.
RESULTS: The overall mortality rate from enrollment was 19.8% (mean gestational age at enrollment, 17.4 weeks). The perinatal mortality and corrected perinatal mortality rates were 15.4% and 12.6%, respectively. Eighty-seven women had both twins who were surviving at 24 weeks of gestation; 43 women were admitted electively for inpatient surveillance at a median gestational age of 26.5 weeks; the remainder of the women were followed as outpatients and admitted only for routine obstetric indications (median gestational age, 30.1 weeks). No intrauterine fetal deaths occurred in any hospitalized patient. The risk of intrauterine fetal death in women who were followed as outpatients was 14.8% (13/88) versus 0 for women who were followed as inpatients (P < .001). There also were statistically significant improvements in birth weight, gestational age at delivery, and neonatal morbidity for women who were followed as inpatients.
CONCLUSION: We observed improved neonatal survival and decreased perinatal morbidity among women who were admitted electively for inpatient fetal monitoring.
K E A Hack, J B Derks, S G Elias, A Franx, E J Roos, S K Voerman, C L Bode, C Koopman-Esseboom, G H A Visser
Increased perinatal mortality and morbidity in monochorionic versus dichorionic twin pregnancies: clinical implications of a large Dutch cohort study.
BJOG. 2008 Jan;115(1):58-67. doi: 10.1111/j.1471-0528.2007.01556.x. Epub 2007 Nov 12.
Abstract/Text
OBJECTIVE: To evaluate mortality and morbidity in a large cohort of twin pregnancies according to chorionicity. We aimed to estimate the optimal time of delivery.
DESIGN: Historical cohort design. Setting Two teaching hospitals.
POPULATION: Twin pregnancies delivered in the University Medical Centre, Utrecht, and the St Elisabeth Hospital, Tilburg (1995-2004), The Netherlands (n = 1407).
METHODS: Pregnancy outcomes were documented according to chorionicity. Mortality >/=32 weeks was reviewed carefully with special attention to antenatal fetal monitoring, autopsy and placental histopathology to find an explanation for adverse outcome.
MAIN OUTCOME MEASURES: Perinatal mortality and morbidity in monochorionic (MC) and dichorionic (DC) twins.
RESULTS: Perinatal mortality was 11.6% in MC twin pregnancies and 5.0% in DC twin pregnancies. After 32 weeks, the risk of intrauterine death (IUD) was significantly higher in MC twins than in DC twins (hazard ratio 8.8, 95% CI 2.7-28.9). In most of these cases of IUD, no antenatal signs of impaired fetal condition had been present. Median gestational age was 1 week longer in DC twins than in MC twins, and the mean birthweight was 221 g higher. Severe birthweight discordancy (>20%) occurred more often in MC twins than in DC twins (OR 1.23, 95% CI 0.97-1.55). The incidence of necrotising enterocolitis (NEC) was higher in MC twins, after adjustment for age and weight at birth (OR 4.05, 95% CI 1.97-8.35). There was a trend towards higher neuromorbidity in MC twins.
CONCLUSIONS: This is the largest cohort study of twin pregnancies evaluating outcome according to chorionicity thus far. MC twins are at increased risk for fetal death (even at term), NEC and neuromorbidity. Current antenatal care is insufficient to predict and prevent this excess perinatal mortality and morbidity. Planned delivery at or even before 37 weeks of gestation seems to be justified for MC twins.
Kiyonori Miura, Norio Niikawa
Do monochorionic dizygotic twins increase after pregnancy by assisted reproductive technology?
J Hum Genet. 2005;50(1):1-6. doi: 10.1007/s10038-004-0216-6. Epub 2004 Dec 15.
Abstract/Text
Although monochorionic (MC) dizygotic twins (DZT) are extremely rare in natural pregnancy, six pairs of such twins have successively been reported in a recent short period. All six cases of MC DZT were the products of pregnancy by assisted reproductive technology (ART). In this overview, we summarize these six cases and discuss possible mechanisms of this twinning and clinical implications of confined blood cell chimerism (CBC). The placental MC membrane was diagnosed ultrasonographically in all cases and pathologically in four. The presence of CBC was confirmed in four cases by haplotyping at polymorphic marker loci in peripheral blood leukocytes, karyotyping of lymphocytes and skin fibroblasts, and/or ABO blood group typing. As CBC is attributable to placental vessel anastomosis between DZT, it may become a risk factor for twin-twin transfusion syndrome (TTTS), mortality, and for other complications in twins. MC DZT may produce psychological trauma, especially in a girl/woman when she grows up and is known to be chimeric for a male karyotype and vice versa, although genital organs are generally normal--unlike freemartin in cattle. In addition, CBC in twins may mislead physicians when genotyping for a disease-susceptibility test is performed in medical practice in the near future. Blood group chimera may also cause confusion if a blood transfusion is necessary. Therefore, sufficient informed consent prior to ART and genetic counseling before/after birth are absolutely necessary for improved quality of life. It is most likely that all six cases are the consequence of fusion between two outer cell masses from two zygotes. The ART used in the six MC DZT included in vitro fertilization-embryonic transfer (IVF-ET) into the uterus, FSH-induced superovulation followed by intrauterine insemination, and/or intracytoplasmic sperm injection (ICSI). The use of an ovulation-inducing agent and implantation of several fertilized eggs at close sites are probably the events common among these cases. Assisted hatching, simultaneous ET, the use of eggs that have developed to the blastcyst stage, and cell culture procedures that lead to changes of the nature of cell surface, all may increase the chance of a cell fusion. This "chance hypothesis" can simply explain why MC DZT are very rare in natural pregnancy. Large-scale research on the prevalence of ART-associated MC DZT and long-term follow-up of the twins are essential.
Vivienne L Souter, Raj P Kapur, Dale R Nyholt, Kristen Skogerboe, David Myerson, Carl C Ton, Kent E Opheim, Thomas R Easterling, Laurence E Shields, Grant W Montgomery, Ian A Glass
A report of dizygous monochorionic twins.
N Engl J Med. 2003 Jul 10;349(2):154-8. doi: 10.1056/NEJMoa030050.
Abstract/Text
Enrico Lopriore, Marieke Sueters, Johanna M Middeldorp, Frans Klumper, Dick Oepkes, Frank P H A Vandenbussche
Twin pregnancies with two separate placental masses can still be monochorionic and have vascular anastomoses.
Am J Obstet Gynecol. 2006 Mar;194(3):804-8. doi: 10.1016/j.ajog.2005.09.015.
Abstract/Text
OBJECTIVE: This study was undertaken to report the occurrence of bipartite monochorionic twin placentas.
STUDY DESIGN: Examination of 109 monochorionic placentas delivered at our institution between June 2002 and June 2005 was performed. Placental characteristics on prenatal ultrasound were studied, including single or double appearance and type of intertwin membrane-placental junction ("T" sign or lambda sign). Monochorionicity was confirmed by postnatal histologic confirmation (diamniotic intertwin membrane without chorionic tissue within the dividing septum). Bipartition was diagnosed when 2 separate placental masses attached by membranes were identified.
RESULTS: Of the 109 monochorionic placentas, 3 were composed of 2 separate placental masses. Prenatal ultrasound examination showed 2 separate placental masses in each case. Monochorionicity was suspected on prenatal ultrasound because of the presence of "T" sign in 2 cases and twin-to-twin transfusion syndrome (TTTS) in another case. Microscopic examination of the dividing septum was consistent with monochorionicity in each case. Vascular anastomoses were present in 2 of the 3 placentas, and led in both cases to the development of TTTS.
CONCLUSION: Two separate placental masses in twin pregnancies are not per se dichorionic and may occur in almost 3% of monochorionic placentas.
Konno H, et al.: Bipartite monochorionic diamniotic placenta without intertwin vascular anastomoses. Jpn J Med Ultrasonics 2019: 46(6): 555-8.
Donald K Bishop
Yolk-sac number in monoamniotic twins.
Obstet Gynecol. 2010 Aug;116 Suppl 2:504-7. doi: 10.1097/AOG.0b013e3181d99268.
Abstract/Text
BACKGROUND: It has been accepted practice to use yolk-sac number to predict amnionicity in twin pairs. Two yolk sacs in a single chorionic sac were thought to confirm diamniotic pregnancy, and a single yolk sac with two fetal poles was thought to indicate monoamniotic twins. Thus, basic ultrasonography could confirm amnionicity early in pregnancy and avoid invasive testing or the more difficult tasks of demonstrating the absence of a dividing membrane or presence of entwined cords later in the pregnancy.
CASE: We present a case of monoamniotic twin gestation in which early ultrasonography confirmed the presence of two yolk sacs. Doppler showed entwined umbilical cords. After elective cesarean delivery, the twins did well in the neonatal intensive care unit and continue to thrive.
CONCLUSION: Yolk-sac number does not predict amnionicity. The diagnosis of monoamniotic twins requires demonstration of entwined cords or an invasive procedure.
T Murakoshi, K Ishii, M Matsushita, T Shinno, H Naruse, Y Torii
Monochorionic monoamniotic twin pregnancies with two yolk sacs may not be a rare finding: a report of two cases.
Ultrasound Obstet Gynecol. 2010 Sep;36(3):384-6. doi: 10.1002/uog.7710.
Abstract/Text
The exact determination of amnionicity is a major issue for the clinical management of monochorionic twin pregnancies, due to the high risk of perinatal mortality and morbidity in monochorionic monoamniotic (MCMA) twins. Counting the number of yolk sacs is believed to be a good indicator of amnionicity in the early first trimester, and it has previously been suggested that the number of yolk sacs is equal to amnionicity in both MCMA and monochorionic diamniotic twin pregnancies. However, the accuracy of the relationship between number of yolk sacs and amnionicity has recently been called into question. To the best of our knowledge, no previous reports have shown two yolk sacs in MCMA twin pregnancies. We report two cases of MCMA twins with two yolk sacs on first-trimester ultrasonography, and confirmed monoamnionicity in the second trimester showing umbilical cord entanglement. Postnatal examination showed an MCMA placenta in both cases, and entangled umbilical cords confirmed monoamnionicity. The possibility of monoamnionicity must still be suspected when two yolk sacs are detected early in the first trimester on ultrasound examination in monochorionic twin pregnancies.
(c) 2010 ISUOG. Published by John Wiley & Sons, Ltd.
O Shen, A Samueloff, U Beller, R Rabinowitz
Number of yolk sacs does not predict amnionicity in early first-trimester monochorionic multiple gestations.
Ultrasound Obstet Gynecol. 2006 Jan;27(1):53-5. doi: 10.1002/uog.2637.
Abstract/Text
OBJECTIVE: To determine the relationship between amnionicity and number of yolk sacs before 11 weeks of gestation.
METHODS: Twenty-two cases of monochorionic multiple pregnancy were scanned before 11 weeks of gestation. There were 21 sets of twins and one of triplets. Amnionicity was determined by visualization of a dividing amniotic membrane between the gestational sacs. The number of yolk sacs was recorded and compared with the presence or absence of a dividing membrane for all fetuses.
RESULTS: In 17/20 (85%) cases of monochorionic diamniotic twins, two yolk sacs were seen. In 3/20 (15%) cases of monochorionic diamniotic twins, a single yolk sac was seen. In the one case of monochorionic diamniotic triplets, two yolk sacs were visualized. In one case of monoamniotic twins, a single yolk sac was observed.
CONCLUSIONS: In monochorionic pregnancies, the presence of two yolk sacs predicts diamnionicity. However, the use of the number of yolk sacs as a predictor of amnionicity may not be accurate in a small proportion of patients. The diagnosis of monoamnionicity can be made only following a careful search for a dividing amniotic membrane.
Copyright 2005 ISUOG.
Koichi Kyono, Yukiko Nakajo, Chikako Nishinaka, Yasuhisa Araki, Masakazu Doshida, Mayumi Toya, Satoru Kanto
A birth of twins-one boy and one girl-from a single embryo transfer and a possible natural pregnancy.
J Assist Reprod Genet. 2009 Sep-Oct;26(9-10):553-4. doi: 10.1007/s10815-009-9348-0. Epub 2009 Oct 14.
Abstract/Text
PURPOSE: To describe a rare case of a birth of dizygotic twins with different-sex infants from a single embryo transfer.
METHODS AND RESULTS: A patient, who had her right ovary and tube removed, and her husband were treated with ICSI and a single embryo transfer. When a single fresh embryo was transferred on day 4, following oocyte retrieval using GnRH agonist-long protocol, two gestational sacs were recognized at 8 weeks of gestation. Healthy twins with a boy and a girl were delivered at 37 weeks 0 days of gestation by a cesarean section. The boy's weight was 2096g, and his height was 45.0 cm, while the girl's weight was 1988g, and her height was 41.5 cm. Peripheral lymphocyte chromosome analysis of the two infants showed normal karyotype, 46, XY (boy) and 46, XX (girl).
CONCLUSIONS: A single embryo transfer could produce different-sex twins.
Hiroko Konno, Takeshi Murakoshi, Kiyonori Miura, Hideaki Masuzaki
The Incidence of Dichorionic Diamniotic Twin Pregnancy After Single Blastocyst Embryo Transfer and Zygosity: 8 Years of Single-Center Experience.
Twin Res Hum Genet. 2020 Feb;23(1):51-54. doi: 10.1017/thg.2020.5. Epub 2020 Mar 25.
Abstract/Text
Dichorionic diamniotic (DCDA) twin pregnancies after single blastocyst embryo transfer have been reported recently, although a blastocyst ovum is generally believed to divide into monochorionic twin pregnancy. We investigated the incidence of DCDA twin pregnancy after single blastocyst embryo transfer and their zygosity. This prospective cohort study included 655 consecutive twin pregnancies that were managed from 2006 to 2014 at our institution. Chorionicity and amnionicity were determined using first-trimester ultrasonography and/or placental pathology. Zygosity was analyzed if the cases were DCDA twins after single blastocyst embryo transfer. Among 655 twin pregnancies, there were 348 DCDA cases, 295 monochorionic diamniotic (MCDA) cases and 12 monochorionic monoamniotic cases. Single blastocyst embryo transfer was performed in 43 cases. Six out of the 43 (14%) cases involved DCDA twin pregnancies and the other 37 cases involved MCDA twin pregnancies. Three DCDA twins born after single blastocyst embryo transfer, wherein frozen embryo transfer (FET) was performed in the natural cycle, were dizygotic, and the other three cases, wherein FET with hormone replacement therapy was performed, were monozygotic. DCDA twin pregnancy occurred in 14% (7% for monozygotic and 7% for dizygotic) of twin pregnancies after single blastocyst embryo transfer cases.
Soichiro Nakayama, Keisuke Ishii, Haruna Kawaguchi, Shusaku Hayashi, Nobuhiro Hidaka, Takeshi Murakoshi, Nobuaki Mitsuda
Perinatal outcome of monochorionic diamniotic twin pregnancies managed from early gestation at a single center.
J Obstet Gynaecol Res. 2012 Apr;38(4):692-7. doi: 10.1111/j.1447-0756.2011.01759.x. Epub 2012 Mar 13.
Abstract/Text
AIM: The aim of this study was to evaluate the perinatal outcome of monochorionic diamniotic (MD) twin gestations managed from early gestation onward at a single center.
MATERIAL AND METHODS: This was a retrospective single-cohort study, spanning 6 years, of 219 MD twin pregnancies who received prenatal care before 14 weeks of gestation and delivered at our center. The subjects were all under the same perinatal management protocol. The incidence of fetal or neonatal death, major neurological complications at 28 days of age, twin-twin transfusion syndrome (TTTS), twin anemia-polycythemia sequence, and discordant birth was evaluated. Laser surgery was offered for TTTS at less than 26 weeks; however, selective feticide was not performed.
RESULTS: Pregnancy termination was selected in two cases. Miscarriage occurred in two (1%) of the cases and preterm delivery occurred in 91 (42%). In regard to perinatal outcome at 28 days of age, 195 (89%) women possessed two live infants and 205 (94%) possessed at least one live infant. The overall survival rate was 92% (403/438). The prevalence of TTTS was 17 cases (8%), seven of whom underwent laser surgery. Four cases of twin anemia-polycythemia sequence were diagnosed postnatally (2%); discordant birth was diagnosed in 24 (12%). Major neonatal neurological abnormalities were noted in six cases (2%).
CONCLUSIONS: The incidence of perinatal complications in 219 sets of MD twins managed from early gestational age to the neonatal period in one perinatal center was demonstrated. The incidence of TTTS was 8%; the survival rate was 89% at 28 days of age.
© 2012 The Authors. Journal of Obstetrics and Gynaecology Research © 2012 Japan Society of Obstetrics and Gynecology.
Mamoru Morikawa, Takashi Yamada, Takahiro Yamada, Shoji Sato, Hisanori Minakami
Prospective risk of intrauterine fetal death in monoamniotic twin pregnancies.
Twin Res Hum Genet. 2012 Aug;15(4):522-6. doi: 10.1017/thg.2012.30.
Abstract/Text
This study was conducted to review the overall short-term outcome of monoamniotic twins in Japan and to determine the prospective risk of fetal death so as to adequately counsel parents with monoamniotic twins. Study subjects were 101 women with monoamniotic twins who were registered with the Japan Society of Obstetrics and Gynecology Successive Pregnancy Birth Registry System and who had given birth at ≥22 weeks of gestation during 2002-2009. The gestational week at delivery (mean±SD) was 31.8±3.7. Fourteen women experienced intrauterine fetal death (IUFD). Short-term outcomes of co-twins born to the 14 women included 8 IUFDs, one early neonatal death within 7 days of life (END), and 5 survivors. Four other women experienced 5 ENDs. Thus, 13.9% (28/202) of infants died perinatally (22 IUFDs and 6 ENDs), 13.9% (14/101) of women experienced IUFD, and 82.2% (83/101) of women experienced neither IUFD nor END. Structural anomalies and twin-to-twin transfusion syndrome explained 17.9% (five infants) and 10.7% (three infants) of the 28 perinatal deaths, respectively. The prospective risk of IUFD was 13.9% (14/101) for women who reached gestational week 22(-0/7), gradually decreasing thereafter but remaining at between 4.5% and 8.0% between gestational week 30(-0/7) and 36(-0/7).
A El Kateb, B Nasr, M Nassar, J P Bernard, Y Ville
First-trimester ultrasound examination and the outcome of monochorionic twin pregnancies.
Prenat Diagn. 2007 Oct;27(10):922-5. doi: 10.1002/pd.1802.
Abstract/Text
OBJECTIVE: To refine the incidence of abnormal first-trimester ultrasound measurements and their correlation with the outcome of monochorionic diamniotic pregnancies.
METHODS: First-trimester crown-rump length (CRL) and nuchal translucency thickness (NT) measurements were studied in three subgroups of a total of 200 monochorionic twin gestations referred to our center between June 2002 and February 2006. Intertwin CRL discordance was defined as > 10% and the 95th percentile of NT thickness for gestational age was used. The first group of 103 consecutive unselected monochorionic diamniotic twin pregnancies was prospectively followed up from 11-14 weeks onwards, throughout the pregnancy. The second group of 136 nonconsecutive monochorionic diamniotic twin pregnancies including 64 that developed TTTS was studied retrospectively. The third group of 100 consecutive cases of TTTS studied retrospectively for the correlation between first trimester measurements and staging and timing of occurrence of TTTS.
RESULTS: In group 1, the incidence of TTTS was 5 in 103 (5%, 95CI [0.7-9]). Large intertwin CRL discordance and increased NT were correlated with perinatal death. In group 2, no significant association was found between first-trimester parameters and the development of TTTS but discordance in early second trimester biometry and Doppler were. In group three, a positive correlation was found between the intertwin discordance in CRL and early occurrence of TTTS before 20 weeks of gestation (p = 0.02).
CONCLUSION: Monochorionic twin gestations who ultimately develop TTTS may exhibit intertwin difference in growth as early as 11-14 weeks of gestation. The earlier the discordance the earlier the development of the disease.
Liesbeth Lewi, Jacques Jani, Isaac Blickstein, Agnes Huber, Leonardo Gucciardo, Tim Van Mieghem, Elisa Doné, Anne-Sophie Boes, Kurt Hecher, Eduardo Gratacós, Paul Lewi, Jan Deprest
The outcome of monochorionic diamniotic twin gestations in the era of invasive fetal therapy: a prospective cohort study.
Am J Obstet Gynecol. 2008 Nov;199(5):514.e1-8. doi: 10.1016/j.ajog.2008.03.050. Epub 2008 Jun 4.
Abstract/Text
OBJECTIVE: The purpose of this study was to document pregnancy and neonatal outcome of monochorionic diamniotic twin pregnancies.
STUDY DESIGN: This observational study describes a prospective series included in the first trimester in 2 centers of the Eurotwin2twin project.
RESULTS: Of the 202 included twin pairs, 172 (85%) resulted in 2 survivors, 15 (7.5%) in 1 survivor, and 15 (7.5%) in no survivors. The mortality was 45 of 404 (11%), and 36 of 45 (80%) were fetal losses of 24 weeks or less, 5 of 45 (11%) between 24 weeks and birth, and 4 of 45 (9%) were neonatal deaths. Twin-to-twin transfusion syndrome (TTTS) occurred in 18 of 202 (9%). The mortality of TTTS was 20 of 36 (55%), which accounted for 20 of 45 (44%) of all losses. Severe discordant growth without TTTS occurred in 29 of 202 (14%). Its mortality was 5 of 58 (9%), which accounted for 5 of 45 (11%) of all losses. Major discordant congenital anomalies occurred in 12 of 202 (6%). Of the 178 pairs that continued after 24 weeks, 10 (6%) had severe hemoglobin differences at birth. After 32 weeks, the prospective risk of intrauterine demise was 2 in 161 pregnancies (1.2%; 95% confidence interval, 0.3-4.6).
CONCLUSION: Of the monochorionic twins recruited in the first trimester, 85% resulted in the survival of both twins, and 92.5% resulted in the survival of at least 1 twin. Most losses were at 24 weeks or less, and TTTS was the most important cause of death. After 32 weeks, the risk of intrauterine demise appears to be small.
R A Quintero, W J Morales, M H Allen, P W Bornick, P K Johnson, M Kruger
Staging of twin-twin transfusion syndrome.
J Perinatol. 1999 Dec;19(8 Pt 1):550-5.
Abstract/Text
OBJECTIVE: The purpose of this study was to evaluate the prognostic value of sonographic and clinical parameters to develop a staging classification of twin-twin transfusion syndrome (TTTS).
STUDY DESIGN: Severe TTTS was defined as the presence of polyhydramnios (maximum vertical pocket of > or = 8 cm) and oligohydramnios (maximum vertical pocket of < or = 2 cm). Nonvisualization of the bladder in the donor twin (-BDT) and absence of presence of hydrops was also noted. The middle cerebral artery, umbilical artery, ductus venosus, and umbilical vein in both fetuses were assessed with pulsed Doppler. Critically abnormal Doppler studies (CADs) were defined as absent/reverse end-diastolic velocity in the umbilical artery, reverse flow in the ductus venosus, or pulsatile flow in the umbilical vein. TTTS was staged as follows: stage I, BDT still visible; stage II, BDT no longer visible, no CADs; stage III, CADs; stage IV, hydrops; stage V, demise of one or both twins. Laser photocoagulation of communicating vessels (LPCV) or umbilical cord ligation was performed depending on the severity of the condition. The study was approved by the Institutional Review Board of St. Joseph's Hospital in Tampa and by the Fetal Therapy Board at Hutzel Hospital, Detroit, and all patients gave informed consent.
RESULTS: A total of 80 of 108 referred patients met criteria for surgery, but only 65 were treated surgically: 48 with LPCV and 17 with umbilical cord ligation. Complete Doppler data were obtainable in 41 of 48 LPCV patients. Survival rates by stage for one or two fetuses were statistically different (chi-squared analysis = 12.9, df = 6, p = 0.044). Neither percent size discordance nor gestational age at diagnosis were predictive of outcome.
CONCLUSION: Staging of TTTS using the proposed criteria has prognostic significance. This staging system may allow comparison of outcome data of TTTS with different treatment modalities.
Rubén A Quintero, Jan E Dickinson, Walter J Morales, Patricia W Bornick, Carlos Bermúdez, Robert Cincotta, Fung Yee Chan, Mary H Allen
Stage-based treatment of twin-twin transfusion syndrome.
Am J Obstet Gynecol. 2003 May;188(5):1333-40.
Abstract/Text
OBJECTIVE: The purpose of this study was to compare the outcomes of patients with twin-twin transfusion syndrome who were treated with either serial amniocentesis or selective laser photocoagulation of communicating vessels according to disease severity (stage).
STUDY DESIGN: Centers that were experienced in the treatment of twin-twin transfusion syndrome were invited to share stage-based perinatal outcome data. All patients met basic standard sonographic criteria for twin-twin transfusion syndrome (polyhydramnios maximum vertical pocket, > or =8 cm; oligohydramnios maximum vertical pocket, < or =2 cm). Gestational age at first treatment was <27 weeks of gestation.
RESULTS: Three centers submitted stage-based data, for a total of 173 patients (serial amniocentesis, 78 patients from all 3 centers) and 95 selective laser photocoagulation of communicating vessels (1 center). The distribution of patients by stage was similar in the two groups. Successful pregnancy outcome (at least 1 surviving infant) was correlated inversely with stage in the serial amniocentesis but not in the selective laser photocoagulation of communicating vessels group and was significantly lower in the serial amniocentesis (66.7%) than in the selective laser photocoagulation of communicating vessels group (83.2%). Neurologic morbidity was related directly to stage in the serial amniocentesis group but not in the selective laser photocoagulation of communicating vessels group and was significantly higher in the serial amniocentesis (24.4%) than in the selective laser photocoagulation of communicating vessels (4.2%) group. Intact neurologic survival (at least 1 surviving infant without neurologic morbidity) was significantly lower in the serial amniocentesis group than in the selective laser photocoagulation of communicating vessel group (51.3% vs 78.9%), particularly in stage III and stage IV (23.5% vs 72.7% in stage IV). Patients who were treated with selective laser photocoagulation of communicating vessels were 2.4 times more likely to have at least one survivor than those treated with serial amniocentesis.
CONCLUSION: Our study suggests a relationship between perinatal morbidity and mortality rates and stage in serial amniocentesis but not in selective laser photocoagulation of communicating vessel-treated twin-twin transfusion syndrome patients. These findings could be used to tailor the treatment of twin-twin transfusion syndrome. A clinical trial to confirm these results is being organized by our research groups.
T Murakoshi, R A Quintero, P W Bornick, M H Allen
In vivo endoscopic assessment of arterioarterial anastomoses: insight into their hemodynamic function.
J Matern Fetal Neonatal Med. 2003 Oct;14(4):247-55. doi: 10.1080/jmf.14.4.247.255.
Abstract/Text
OBJECTIVE: To assess endoscopically the hemodynamic function of arterioarterial (AA) anastomoses in twin-twin transfusion syndrome (TTTS) and monochorionic selective intrauterine growth restriction (IUGR).
MATERIALS AND METHODS: The videotapes of TTTS and IUGR patients undergoing laser surgery between July 1997 and December 2001 were reviewed for the presence of AA anastomoses. The hemodynamic equator was defined as the site within the AA anastomosis with color flashing. AA anastomoses were classified as having unidirectional flow, having bi-directional flow, or being non-functional, depending on whether the hemodynamic equator reached a returning vein to one, both, or neither twin, respectively. TTTS was classified in stages as previously described.
RESULTS: AA anastomoses were present in 35/183 (19.1%) of TTTS and in 12/24 (50%) IUGR patients. Of these, the hemodynamic equator was visible in 8/35 (22.8%) TTTS patients (all in stage III, and mostly in atypical stage III) and in 6/12 (50%) IUGR patients (overall 14/47, 29.8%). Of the 14 patients with a visible hemodynamic equator, 13 (92.8%) AA anastomoses showed unidirectional (9/13, 69.2% from the smaller to the larger twin) flow, and only 1/14 (7.1%) showed bi-directional flow.
CONCLUSION: The hemodynamic equator is visible in approximately 30% of patients with AA anastomoses. Within this group, most AA anastomoses behave as functional arteriovenous anastomoses, and the direction of flow can be from the smaller to the larger twin or vice versa. The data suggest a correlation between sonographic findings and placental vascular design, also implying possible interfetal oxygenation differences. Further assessment of the functional behavior of AA anastomoses is warranted to understand the pathophysiology of TTTS and selective IUGR.
村越毅, et al: 双胎間輸血症候群における胎児鏡下胎盤吻合血管レーザー凝固術の有用性・合併症に関する臨床的検討. 周産期新生児誌 2004;40:823-829.
中田雅彦, et al:多胎妊娠胎児治療. 周産期新生児誌 2005;41(4):736-740.
Masahiko Nakata, Takeshi Murakoshi, Haruhiko Sago, Keisuke Ishii, Yuichiro Takahashi, Satoshi Hayashi, Susumu Murata, Ichiro Miwa, Masahiro Sumie, Norihiro Sugino
Modified sequential laser photocoagulation of placental communicating vessels for twin-twin transfusion syndrome to prevent fetal demise of the donor twin.
J Obstet Gynaecol Res. 2009 Aug;35(4):640-7. doi: 10.1111/j.1447-0756.2009.01034.x.
Abstract/Text
AIMS: Twin-twin transfusion syndrome (TTTS) complicated with absent or reversed end-diastolic flow in the umbilical artery (UA-AREDF) of the donor has a high perinatal mortality rate. To improve the prenatal outcome, we introduced and modified the technique of sequential selective laser photocoagulation of communicating vessels (SQLPCV), and assessed the clinical efficacy.
METHODS: The modified SQLPCV was designed with the following order of coagulation: (i) artery-to-artery (AA) anastomoses; (ii) venous-to-venous anastomoses; (iii) artery-to-venous anastomoses from donor to recipient; and (iv) artery-to-venous anastomoses from recipient to donor. TTTS patients with UA-AREDF of donors were recruited, and the perinatal outcome and its association with the types of anastomoses were compared in patients who underwent the standard selective laser method (SLPCV).
RESULTS: Twenty-three patients underwent modified SQLPCV and 29 underwent SLPCV. Total intrauterine fetal death (IUFD) was significantly lower in modified SQLPCV than in SLPCV (9% vs 38%; P < 0.001). Donor IUFD was significantly lower in modified SQLPCV than in SLPCV (13% vs 52%; P = 0.007); however, no significant effect was noted in the recipient IUFD cases. When AA anastomoses were present, donor IUFD was significantly lower in modified SQLPCV than it was in SLPCV (18% vs 71%; P = 0.018); however, the difference was not significant when AA anastomoses were not present (8% vs 25%; P = 0.59). Logistic regression analysis revealed that modified SQLPCV served as the protective factor against the donor's IUFD (odds ratio = 0.015; 95% confidence interval [0.0001-0.775]; P = 0.037).
CONCLUSION: The modified SQLPCV was useful for the prevention of the donor's IUFD in cases of TTTS with UA-AREDF.
D Di Mascio, A Khalil, A D'Amico, D Buca, P Benedetti Panici, M E Flacco, L Manzoli, M Liberati, L Nappi, V Berghella, F D'Antonio
Outcome of twin-twin transfusion syndrome according to Quintero stage of disease: systematic review and meta-analysis.
Ultrasound Obstet Gynecol. 2020 Dec;56(6):811-820. doi: 10.1002/uog.22054. Epub 2020 Nov 12.
Abstract/Text
OBJECTIVES: To report the outcome of pregnancies complicated by twin-twin transfusion syndrome (TTTS) according to Quintero stage.
METHODS: MEDLINE, EMBASE and CINAHL databases were searched for studies reporting the outcome of pregnancies complicated by TTTS stratified according to Quintero stage (I-V). The primary outcome was fetal survival rate according to Quintero stage. Secondary outcomes were gestational age at birth, preterm birth (PTB) before 34, 32 and 28 weeks' gestation and neonatal morbidity. Outcomes are reported according to the different management options (expectant management, laser therapy or amnioreduction) for pregnancies with Stage-I TTTS. Only cases treated with laser therapy were considered for those with Stages-II-IV TTTS and only cases managed expectantly were considered for those with Stage-V TTTS. Random-effects head-to-head meta-analysis was used to analyze the extracted data.
RESULTS: Twenty-six studies (2699 twin pregnancies) were included. Overall, 610 (22.6%) pregnancies were diagnosed with Quintero stage-I TTTS, 692 (25.6%) were Stage II, 1146 (42.5%) were Stage III, 247 (9.2%) were Stage IV and four (0.1%) were Stage V. Survival of at least one twin occurred in 86.9% (95% CI, 84.0-89.7%) (456/552) of pregnancies with Stage-I, in 85% (95% CI, 79.1-90.1%) (514/590) of those with Stage-II, in 81.5% (95% CI, 76.6-86.0%) (875/1040) of those with Stage-III, in 82.8% (95% CI, 73.6-90.4%) (172/205) of those with Stage-IV and in 54.6% (95% CI, 24.8-82.6%) (5/9) of those with Stage-V TTTS. The rate of a pregnancy with no survivor was 11.8% (95% CI, 8.4-15.8%) (69/564) in those with Stage-I, 15.0% (95% CI, 9.9-20.9%) (76/590) in those with Stage-II, 18.6% (95% CI, 14.2-23.4%) (165/1040) in those with Stage-III, 17.2% (95% CI, 9.6-26.4%) (33/205) in those with Stage-IV and in 45.4% (95% CI, 17.4-75.2%) (4/9) in those with Stage-V TTTS. Gestational age at birth was similar in pregnancies with Stages-I-III TTTS, and gradually decreased in those with Stages-IV and -V TTTS. Overall, the incidence of PTB and neonatal morbidity increased as the severity of TTTS increased, but data on these two outcomes were limited by the small sample size of the included studies. When stratifying the analysis of pregnancies with Stage-I TTTS according to the type of intervention, the rate of fetal survival of at least one twin was 84.9% (95% CI, 70.4-95.1%) (94/112) in cases managed expectantly, 86.7% (95% CI, 82.6-90.4%) (249/285) in those undergoing laser therapy and 92.2% (95% CI, 84.2-97.6%) (56/60) in those after amnioreduction, while the rate of double survival was 67.9% (95% CI, 57.0-77.9%) (73/108), 69.7% (95% CI, 61.6-77.1%) (203/285) and 80.8% (95% CI, 62.0-94.2%) (49/60), respectively.
CONCLUSIONS: Overall survival in monochorionic diamniotic pregnancies affected by TTTS is higher for earlier Quintero stages (I and II), but fetal survival rates are moderately high even in those with Stage-III or -IV TTTS when treated with laser therapy. Gestational age at birth was similar in pregnancies with Stages-I-III TTTS, and gradually decreased in those with Stages-IV and -V TTTS treated with laser and expectant management, respectively. In pregnancies affected by Stage-I TTTS, amnioreduction was associated with slightly higher survival compared with laser therapy and expectant management, although these findings may be confirmed only by future head-to-head randomized trials. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.
Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.
Julien Stirnemann, Femke Slaghekke, Nahla Khalek, Norbert Winer, Anthony Johnson, Liesbeth Lewi, Mona Massoud, Laurence Bussieres, Philippe Aegerter, Kurt Hecher, Marie-Victoire Senat, Yves Ville
Intrauterine fetoscopic laser surgery versus expectant management in stage 1 twin-to-twin transfusion syndrome: an international randomized trial.
Am J Obstet Gynecol. 2020 Nov 26;. doi: 10.1016/j.ajog.2020.11.031. Epub 2020 Nov 26.
Abstract/Text
BACKGROUND: Selective fetoscopic laser coagulation of the intertwin anastomotic chorionic vessels is the first-line treatment for twin-twin transfusion syndrome. However, in stage 1 twin-twin transfusion syndrome, the risks of intrauterine surgery may be higher than those of the natural progression of the condition.
OBJECTIVE: This study aimed to compare immediate surgery and expectant follow-up in stage 1 twin-twin transfusion syndrome.
STUDY DESIGN: We conducted a multicentric randomized trial, which recruited from 2011 to 2018 with a 6-month postnatal follow-up. The study was conducted in 9 fetal medicine centers in Europe and the Unites States. Asymptomatic women with stage 1 twin-twin transfusion syndrome between 16 and 26 weeks' gestation, a cervix of >15 mm, and access to a surgical center within 48 hours of diagnosis were randomized between expectant management and immediate surgery. In patients allocated to immediate laser treatment, percutaneous laser coagulation of anastomotic vessels was performed within 72 hours. In patients allocated to expectant management, a weekly ultrasound follow-up was planned. Rescue fetoscopic coagulation of anastomoses was offered if the syndrome worsened as seen during a follow-up, either because of progression to a higher Quintero stage or because of the maternal complications of polyhydramnios. The primary outcome was survival at 6 months without severe neurologic morbidity. Severe complications of prematurity and maternal morbidity were secondary outcomes.
RESULTS: The trial was stopped at 117 of 200 planned inclusions for slow accrual rate over 7 years: 58 women were allocated to expectant management and 59 to immediate laser treatment. Intact survival was seen in 84 of 109 (77%) expectant cases and in 89 of 114 (78%) (P=.88) immediate surgery cases, and severe neurologic morbidity occurred in 5 of 109 (4.6%) and 3 of 114 (2.6%) (P=.49) cases in the expectant and immediate surgery groups, respectively. In patients followed expectantly, 24 of 58 (41%) cases remained stable with dual intact survival in 36 of 44 (86%) cases at 6 months. Intact survival was lower following surgery than for the nonprogressive cases, although nonsignificantly (78% and 71% following immediate and rescue surgery, respectively).
CONCLUSION: It is unlikely that early fetal surgery is of benefit for stage 1 twin-twin transfusion syndrome in asymptomatic pregnant women with a long cervix. Although expectant management is reasonable for these cases, 60% of the cases will progress and require rapid transfer to a surgical center.
Copyright © 2020 Elsevier Inc. All rights reserved.
Nicole G Gomez, Martha A Monson, Andrew H Chon, Lisa M Korst, Arlyn Llanes, Ramen H Chmait
Outcomes of laser surgery for stage I twin-twin transfusion syndrome.
Prenat Diagn. 2022 Feb;42(2):172-179. doi: 10.1002/pd.6094. Epub 2022 Jan 20.
Abstract/Text
OBJECTIVE: A recent randomized controlled trial (RCT) demonstrated no difference in 6 month survival in expectantly managed stage I twin-twin transfusion syndrome (TTTS) patients and those undergoing immediate laser surgery. We aimed to describe outcomes following immediate laser surgery at a single fetal surgery center.
METHODS: A retrospective study of monochorionic diamniotic twins diagnosed with stage I TTTS who underwent laser surgery between 16 and 26 gestational weeks from 2006 to 2019. The primary outcome was 6 month survivorship. Intact survival was also assessed. Secondarily, outcomes were compared to the RCT expectant management group.
RESULTS: Of 126 consecutive stage I TTTS patients, 114 (90.5%) met inclusion criteria. Median (range) gestational age at delivery was 34.1 (20.6-39.4) weeks. At 6 months, the proportion of patients with at-least-one survivor in the single-center-laser cohort was 97.4%, with 88.6% dual survivorship. Neurological morbidity outcomes were available in 110 pregnancies (220 fetuses). Severe neurological morbidity occurred in 2.7% (6/220), and 6 month survival without severe neurological morbidity was 90.0%. Outcomes compared favorably with the RCT expectant management group.
CONCLUSIONS: Given favorable survival and neurological outcomes, laser surgery is a reasonable treatment option for stage I TTTS at experienced fetal surgery centers. Further study is warranted to optimize treatment strategies.
© 2022 John Wiley & Sons Ltd.
日本産科婦人科学会, et al.:CQ703 双胎間輸血症候群（TTTS）や無心体双胎を疑う所見は？. 産婦人科診療ガイドライン 産科編2014.日本産科婦人科学会; 2014;348-351.
H Rydhström
Discordant birthweight and late fetal death in like-sexed and unlike-sexed twin pairs: a population-based study.
Br J Obstet Gynaecol. 1994 Sep;101(9):765-9.
Abstract/Text
OBJECTIVE: To study the relation between pregnancy loss (one or two fetal deaths in a pair) in twin pregnancy and gender (like-sexed and unlike-sexed pairs), discordant birthweight, and placentation.
DESIGN: The type of placentation for gestations with pregnancy loss was studied, based on material retrieved from the original medical records, for a defined region comprising 20.0% of the total twin population.
SUBJECTS AND SETTING: Four thousand one hundred and ninety-one unlike-sexed and 10,875 like-sexed twin pairs born in Sweden between 1973 and 1989, in most cases with a gestational duration 28 or more completed weeks.
RESULTS: The relative risk (RR) for pregnancy loss in like-sexed pairs, compared with unlike-sexed ones, was 2.3 and the 95% confidence limits (CL) 1.7-3.1. Not until discordance exceeded 999 g did the pregnancy loss rate for unlike-sexed pairs increase significantly, compared with the (first) stratum with discordance less than 250 g (RR = 6.3; CL 3.5-11.3). For like-sexed twin pairs a higher pregnancy loss rate, compared with the first stratum, was seen already in the stratum with discordance 250-499 g (RR = 1.3; CL 1.0-1.8); a significant increase in pregnancy loss rate was found in all the three strata 500-749 g (RR = 2.1; CL 1.5-3.0), 750-999 g (RR = 3.5; CL 2.3-3.0), and 1000 g or more (RR = 10.9; CL 8.4-14.2), respectively. When calculating the discordance as a percentage of the weight of the larger twin, unlike-sexed pairs experienced a significant increase in pregnancy loss when discordance exceeded 40 to 50%. For like-sexed ones, the corresponding figures were 20 to 30%. In the 47 unlike-sexed pregnancies complicated by pregnancy loss, both twins died in two pregnancies (4.3%), whereas for like-sexed pairs the corresponding figures were 65/279 (23.3%). Of 47 gestations with pregnancy loss in a defined region, 32 were monochorionic (monozygous), nine were like-sexed dichorionic (monozygous or dizygous), and six were unlike-sexed (dizygous).
CONCLUSIONS: Pregnancy loss was twice as high in like-sexed compared with unlike-sexed pairs, and only in like-sexed pairs was pregnancy loss strongly correlated to birthweight discordance. In twin pregnancies with one fetal death the risk for the surviving twin to succumb is five to six times higher in like-sexed compared with unlike-sexed pairs and is most probably related to monochorionicity.
C R West, Y Adi, P O Pharoah
Fetal and infant death in mono- and dizygotic twins in England and Wales 1982-91.
Arch Dis Child Fetal Neonatal Ed. 1999 May;80(3):F217-20.
Abstract/Text
AIM: To quantify the level of risk for stillbirth and infant death in singleton compared with twin pregnancies, using national data; to determine the independent effects of zygosity, sex, and birthweight on these risks in twin pregnancies.
METHODS: A retrospective national study was carried out of all singleton and twin birth and death registrations in England and Wales 1982-91, according to sex and birthweight group. Weinberg's rule was applied to the twin pairs to differentiate mono- from dizygotic twins. Relative risks for mono- compared with dizygous twins for both twins being stillbirths and for one of the pair being a stillbirth were determined. For twins where one was stillborn and the other live born, the relative risk of neonatal and infant mortality in the surviving co-twin was determined.
RESULTS: There were 6 563 834 registered singletons and 70772 registered twin pairs for the period under study. Monozygotic twins had a relative risk of: 18.91 (95% CI 12.48-28.64) for both twins being stillborn; 1.63 (95% CI 1.48-1.79) for one twin being a stillbirth; and 2.26 (95% CI 1.45-3.52) for the live born co-twin dying as a neonate. When both twins were live born and among singletons, the odds ratio for neonatal mortality of being male was 1.41 (95% CI 1.37-1.45) and there was a highly significant negative association with birthweight. After adjusting for birthweight group and sex, twins had a reduced neonatal mortality compared with singletons: odds ratio 0.91 (95% CI 0.85-0.96).
CONCLUSIONS: Fetal death in one of monozygotic twins has serious implications for survival of the co-twin. Monochorionicity is probably the essential feature of the increased risk to the co-twin. It is imperative that all fetal deaths in multiple pregnancies are recorded and chorionicity determined if parents are to be adequately counselled.
L Fusi, P McParland, N Fisk, U Nicolini, J Wigglesworth
Acute twin-twin transfusion: a possible mechanism for brain-damaged survivors after intrauterine death of a monochorionic twin.
Obstet Gynecol. 1991 Sep;78(3 Pt 2):517-20.
Abstract/Text
Intrauterine death of one twin in monochorionic pregnancies is associated with increased mortality and morbidity for the survivor. This has been attributed to the consequences of intrauterine disseminated intravascular coagulation (DIC) initiated by the dead twin. We describe a case in which the fetal cerebral and renal lesions typically found in survivors occurred without any derangement in coagulation. Instead, acute twin-twin transfusion was suggested by the presence of severe anemia in the surviving fetus at delivery. We suggest that the lesions frequently found in the survivors are often due to acute hemodynamic and ischemic changes resulting from acute twin-twin transfusion at the time of intrauterine death, rather than to late-onset DIC. This hypothesis has an important implication for future management: Intervention must occur before intrauterine death if neurologic sequelae in the survivor are to be prevented.
E Quarello, J Stirnemann, M Nassar, B Nasr, J-P Bernard, F Leleu-Huard, Y Ville
Outcome of anaemic monochorionic single survivors following early intrauterine rescue transfusion in cases of feto-fetal transfusion syndrome.
BJOG. 2008 Apr;115(5):595-601. doi: 10.1111/j.1471-0528.2007.01659.x.
Abstract/Text
OBJECTIVE: To evaluate the outcome of severely anaemic monochorionic (MC) twins surviving the death of their co-twin following early intrauterine rescue transfusion in cases of feto-fetal transfusion syndrome (FFTS).
STUDY DESIGN: We reviewed all MC pregnancies complicated with FFTS following primary management, in which a single intrauterine fetal death (IUFD) was diagnosed with certainty within 24 hours between January 1999 and December 2006. We included MC survivors who presented ultrasound or Doppler features of fetal anaemia following the death of their co-twin. Intrauterine transfusion (IUT) was given to all survivors who were anaemic.
RESULTS: Nineteen MC twin pregnancies presented a single intrauterine death (IUD) associated with an anaemic co-twin. Median gestational age at IUD was 23 [20-28] weeks. The median interval between IUD and IUT was 12 [8-24] hours. There were 58% (11/19) healthy survivors. Perinatal death rate was 26% (5/19) including 16% (3/19) intrauterine and 10% (2/19) neonatal deaths. Abnormal prenatal cerebral findings developed in 21% (4/19) cases, always within 1 month after the death of the co-twin. Considering occlusive techniques and other management separately, there were 64% (7/11) and 50% (4/8) healthy survivors, respectively, and perinatal death occurred in 36% (4/11) and 12.5% (1/8) of fetuses, respectively. Prenatal fetal cerebral lesions developed in 9% (1/11) of cases following occlusive techniques and in 37.5% (3/8) of fetuses when managed differently. The median gestational age at delivery in the survivors was 31 [25-38] weeks.
CONCLUSION: In cases of FFTS with single anaemic survivors, early IUT could be offered following extensive counselling and close follow up.
Keisuke Ishii, Takeshi Murakoshi, Masahiro Numata, Akira Kikuchi, Koichi Takakuwa, Kenichi Tanaka
An experience of laser surgery for feto-fetal transfusion syndrome complicated with unexpected feto-fetal hemorrhage in a case of monochorionic triamniotic triplets.
Fetal Diagn Ther. 2006;21(4):339-42. doi: 10.1159/000092462.
Abstract/Text
Feto-fetal transfusion syndrome (FFTS) in monochorionic triplets is a rare clinical entity which may share the principal adverse perinatal outcomes of twin-twin transfusion syndrome. Recently, favorable prognoses regarding morbidity and mortality in twins after selective laser photocoagulation of placental communicating vessels (SLPCV) have been described. But descriptions of this procedure in monochorionic triplet cases are limited. This is the case report of an experience of SLPCV applied to monochorionic triamniotic triplets with FFTS. Triplet A had polyhydramnios, while absent end-diastolic flow in the umbilical artery of triplet B, the triplet with anhydramnios, was persistent. Triplet C looked normal, vertical amniotic pocket and Doppler studies yielding normal results. At the beginning of the SLPCV procedure, feto-fetal hemorrhage, subsequent to the fetal death of the donor triplet, occurred. Both surviving cofetuses showed persistent bradycardia; and 1 fetus died while the other recovered from the fetal bradycardia. All vascular anastomoses between the 3 triplets could be identified and obliterated, requiring two trocars. Our fetoscopic observation revealed feto-fetal hemorrhage after demise of monochorionic triplet, which led to injury of other fetuses due to hypovolemia in an instant. In conclusion, SLPCV might be a valid option for FFTS in triplet cases, while further experience is required in order to evaluate the risks and benefits of this procedure in triplet cases.
Copyright (c) 2006 S. Karger AG, Basel.
R A Quintero, J M Martínez, C Bermúdez, J López, C Becerra
Fetoscopic demonstration of perimortem feto-fetal hemorrhage in twin-twin transfusion syndrome.
Ultrasound Obstet Gynecol. 2002 Dec;20(6):638-9. doi: 10.1046/j.1469-0705.2002.00859.x.
Abstract/Text
R Bajoria, L Y Wee, S Anwar, S Ward
Outcome of twin pregnancies complicated by single intrauterine death in relation to vascular anatomy of the monochorionic placenta.
Hum Reprod. 1999 Aug;14(8):2124-30.
Abstract/Text
The objective of this study was to determine the relationship between the type of placentation, vascular anatomy of the monochorionic (MC) placenta and the perinatal outcome of the surviving twin following a single intrauterine fetal death (IUFD). In this retrospective study, 92 twin pregnancies complicated by a single intrauterine death were identified from three tertiary referral centres [50 MC and 42 dichorionic (DC)]. Antenatal and neonatal data as well as information on the chorionicity, vascular anastomoses, and autopsy findings were also obtained. The percentage risk of IUFD (26 versus 2.4; P < 0.001), anaemia (51.4 versus 0; P < 0.001) and intracranial lesions at birth (46 versus 0; P < 0.001) was greater in MC than in DC twins. In MC twins without twin-twin transfusion syndrome (TTTS), perinatal mortality was higher in the group with superficial arterioarterial (AA)/venovenous (VV) channels than those with only multiple bidirectional arteriovenous (AV) anastomoses (12/15 versus 0/8; P < 0.001). However, in the TTTS pregnancies (n = 26), perinatal outcome of the surviving twin was dependent on whether the recipient (n = 16) or the donor twin (n = 10) died first. Incidence of IUFD (9/16 versus 0/10; P < 0.001), severe anaemia (7/7 versus 1/10; P < 0.001) and intracranial lesions at birth (6/7 versus 2/10; P < 0.001) was common in pregnancies where the recipient twin died first. In the TTTS group, unidirectional AV anastomotic channels were found in all but two placentae. In conclusion, this study suggests that the outcome of twin pregnancies complicated by IUFD is dependent on the type of vascular anastomoses and TTTS.
S Tanawattanacharoen, M J Taylor, E A Letsky, P M Cox, F M Cowan, N M Fisk
Intrauterine rescue transfusion in monochorionic multiple pregnancies with recent single intrauterine death.
Prenat Diagn. 2001 Apr;21(4):274-8. doi: 10.1002/pd.49.
Abstract/Text
To assess the role of fetal blood sampling and intrauterine transfusion in monochorionic (MC) multiple pregnancy complicated by single intrauterine death (IUD), we reviewed ten cases over a 4-year period in a tertiary referral centre which underwent fetal blood sampling within 24 h of death of its MC co-twin. Intrauterine rescue transfusion was performed in all seven anaemic fetuses (hematocrit; Hct < 30%) to raise the fetal Hct to > or = 40%. The rationale was to prevent death and/or brain injury. Two fetuses, which were severely acidaemic at blood sampling, died in utero within 24 h of the procedure. In two cases, the surviving twins manifested abnormal sonographic findings of the fetal brain 2-5 weeks later and underwent late termination. In two cases, the pregnancies continued uneventfully until delivery at 35 and 40 weeks' gestation with good neonatal outcome. In one case the co-twin delivered 1 week later at 29 weeks but died within 12 h. Fetuses without anaemia were not transfused and had normal clinical outcomes. We suggest that intrauterine rescue transfusion before the development of severe acidaemia in anaemic surviving MC co-twins may prevent fetal death, but does not necessarily prevent brain injury. Until its role becomes clearer, we recommend that its use be restricted to situations in which the parents and the local jurisdiction allow late termination as an option if brain injury subsequently manifests on ultrasound.
Copyright 2001 John Wiley & Sons, Ltd.
F L Mackie, A Rigby, R K Morris, M D Kilby
Prognosis of the co-twin following spontaneous single intrauterine fetal death in twin pregnancies: a systematic review and meta-analysis.
BJOG. 2019 Apr;126(5):569-578. doi: 10.1111/1471-0528.15530. Epub 2018 Nov 26.
Abstract/Text
BACKGROUND: Single intrauterine fetal death affects approximately 6% of twin pregnancies and can have serious sequelae for the surviving co-twin.
OBJECTIVES: Determine the prognosis of the surviving co-twin following spontaneous single intrauterine fetal death to aid counselling patients and highlight future research areas.
SEARCH STRATEGY: Medline, Embase, Web of Science, and Cochrane Library, from 1980 to June 2017.
SELECTION CRITERIA: Studies of five or more cases of spontaneous single intrauterine fetal death after 14 weeks gestation, in diamniotic twin pregnancies.
DATA COLLECTION AND ANALYSIS: Summary event rates were calculated and stratified by chorionicity. Monochorionic and dichorionic twins, and sub-groups, were compared by odds ratios.
MAIN RESULTS: In monochorionic twins, when single intrauterine fetal death occurred at less than 28 weeks' gestation, this significantly increased the rate of co-twin intrauterine fetal death [odds ratio (OR) 2.31, 95% confidence interval (CI) 1.02-5.25, I2 = 0.0%, 12 studies, 184 pregnancies] and neonatal death (OR 2.84, 95% CI 1.18-6.77, I2 = 0.0%, 10 studies, 117 pregnancies) compared with when the single intrauterine fetal death occurred at more than 28 weeks' gestation. Neonatal death in monochorionic twins was significantly higher if the pregnancy was complicated by fetal growth restriction (OR 4.83, 95% CI 1.14-20.47, I2 = 0.0%, six studies, 60 pregnancies) or preterm birth (OR 4.95, 95% CI 1.71-14.30, I2 = 0.0%, 11 studies, 124 pregnancies). Abnormal antenatal brain imaging was reported in 20.0% (95% CI 12.8-31.1, I2 = 21.9%, six studies, 116 pregnancies) of surviving monochorionic co-twins. The studies included in the meta-analysis demonstrated small study effects and possible selection bias.
CONCLUSIONS: Preterm birth was the commonest adverse outcome affecting 58.5 and 53.7% of monochorionic and dichorionic twin pregnancies. Outcomes regarding brain imaging and neurodevelopmental comorbidity are an important area for future research, but meta-analysis may be limited due to different methods of assessment.
TWEETABLE ABSTRACT: Preterm birth is the highest risk in single co-twin death. Abnormal antenatal brain imaging was found in 1/5 surviving MC twins.
© 2018 Royal College of Obstetricians and Gynaecologists.
Rika Sugibayashi, Katsusuke Ozawa, Masahiro Sumie, Seiji Wada, Yushi Ito, Haruhiko Sago
Forty cases of twin reversed arterial perfusion sequence treated with radio frequency ablation using the multistep coagulation method: a single-center experience.
Prenat Diagn. 2016 May;36(5):437-43. doi: 10.1002/pd.4800. Epub 2016 Mar 22.
Abstract/Text
OBJECTIVE: To report the pregnancy outcomes of patients with twin reversed arterial perfusion (TRAP) sequence treated by radiofrequency ablation (RFA).
METHODS: This was a retrospective study of TRAP sequences treated in a single center between March 2002 and February 2015. Forty patients underwent RFA with expandable tines through a multistep coagulation method between 15 and 26 gestational weeks. The primary outcome was neonatal survival to discharge.
RESULTS: The overall survival of the pump twin was 85%. The survival rates in monochorionic-monoamniotic (MCMA) pregnancies and monochorionic-diamniotic pregnancies were 66.7% (4/6) and 87.9% (29/33), respectively. One triplet was treated successfully and delivered at 36 weeks of gestation. One of 35 live births (2.9%) had preterm premature rupture of membranes less than 34 weeks, resulting in infant death. In five intrauterine pump twin deaths, two cases were MCMA twins with cord entanglement, and three cases were MCDA twins with acardius anceps.
CONCLUSIONS: Our study supports the effectiveness of RFA for TRAP sequence after 15 weeks of gestation. The presence of MCMA twins or acardius anceps is associated with a high risk of pump twin death after RFA. © 2016 John Wiley & Sons, Ltd.
© 2016 John Wiley & Sons, Ltd.
Maiko Wagata, Takeshi Murakoshi, Keisuke Ishii, Jin Muromoto, Jun Sasahara, Jun Murotsuki
Radiofrequency Ablation with an Internally Cooled Electrode for Twin Reversed Arterial Perfusion Sequence.
Fetal Diagn Ther. 2016 Mar 1;. doi: 10.1159/000442152. Epub 2016 Mar 1.
Abstract/Text
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.
© 2016 S. Karger AG, Basel.
Suresh Seshadri, Roopa R Shinde, Uma Ram
Intrafetal laser for midtrimester TRAP sequence-experience from a single center.
Prenat Diagn. 2020 Jun;40(7):885-891. doi: 10.1002/pd.5707. Epub 2020 Apr 26.
Abstract/Text
OBJECTIVE: To report our experience and evaluate outcomes in monochorionic pregnancies with Twin Reversed Arterial Perfusion sequence with intrafetal laser therapy.
METHODS: Retrospective review of records of all pregnancies with TRAP sequence treated by intrafetal laser therapy between 2011 January and 2015 December that were retrieved and analysed.
RESULTS: Electronic search of the scan database retrieved 57 cases of TRAP sequence during the study period, 7 triplets and 50 monochorionic twins. Intrafetal laser was done in 27 cases, 22 cases of twins and 5 cases of triplets. In the twins group, median gestational age at intervention was 22.5 weeks, the earliest done at 16.3 weeks. The median gestational age at delivery and birth weight was 37 weeks and 2.5 Kgs. The median procedure and delivery interval was 14 weeks. Live birth rate was 17/22 (77%) the pump survival rate was 16/22 (73%). Pregnancies with non-surviving pump were 5 in numbers (5/22). A repeat procedure was warranted in one case. In the triplet group, median gestational age at intervention, delivery and procedure delivery interval was 18, 35 and 17 weeks.
CONCLUSION: Intrafetal laser is simple, effective and the treatment of choice to interrupt the vascular supply to acardiac twin.
© 2020 John Wiley & Sons, Ltd.
M Tavares de Sousa, P Glosemeyer, A Diemert, C Bamberg, K Hecher
First-trimester intervention in twin reversed arterial perfusion sequence.
Ultrasound Obstet Gynecol. 2020 Jan;55(1):47-49. doi: 10.1002/uog.20860. Epub 2019 Dec 12.
Abstract/Text
OBJECTIVE: To report the outcome of monochorionic twins with twin reversed arterial perfusion (TRAP) sequence following interstitial laser therapy in the first trimester.
METHODS: This was a retrospective cohort study of all consecutive cases of TRAP that underwent interstitial laser therapy at ≤ 14 + 3 weeks' gestation between January 2014 and April 2016. Interstitial laser treatment was performed under ultrasound guidance using a 400-nm Nd:YAG laser fiber. Hospital records were reviewed to ascertain perinatal survival and morbidity.
RESULTS: Twelve monochorionic twin pregnancies underwent interstitial laser treatment of the umbilical artery of the acardiac fetus, at a median gestational age of 13 + 5 (interquartile range (IQR), 13 + 4 to 14 + 0) weeks. In all cases, one treatment was sufficient to achieve complete interruption of the perfusion of the acardiac twin. There were no procedure-related complications during or within 48 h after the procedure. In one (8.3%) case, intrauterine death of the pump twin occurred 2 weeks after the intervention. All other cases (91.7%) resulted in a live birth at a median gestational age of 39 + 6 (IQR, 37 + 1 to 41 + 2) weeks and with a median birth weight of 3370 (IQR, 2980-3480) g. No neonatal mortality or serious morbidity occurred.
CONCLUSIONS: Our results support the use of interstitial laser therapy in the first trimester of pregnancy complicated by TRAP sequence, showing a live birth rate of 92%. The results of a randomized controlled trial, evaluating early vs late intervention in pregnancy with TRAP sequence, are awaited. © 2019 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.
© 2019 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.
Hongmei Wang, Qian Zhou, Xietong Wang, Jia Song, Pengzheng Chen, Yanyun Wang, Lei Li, Hongyan Li
Influence of indications on perinatal outcomes after radio frequency ablation in complicated monochorionic pregnancies: a retrospective cohort study.
BMC Pregnancy Childbirth. 2021 Jan 9;21(1):41. doi: 10.1186/s12884-020-03530-6. Epub 2021 Jan 9.
Abstract/Text
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.
E Gratacós, E Carreras, J Becker, L Lewi, G Enríquez, J Perapoch, T Higueras, L Cabero, J Deprest
Prevalence of neurological damage in monochorionic twins with selective intrauterine growth restriction and intermittent absent or reversed end-diastolic umbilical artery flow.
Ultrasound Obstet Gynecol. 2004 Aug;24(2):159-63. doi: 10.1002/uog.1105.
Abstract/Text
OBJECTIVE: To assess the incidence of parenchymal lesions on early and late neonatal brain scans and its association with the presence or absence of intermittent absent or reversed end-diastolic umbilical artery flow velocity (A/REDV) in monochorionic twins complicated by selective intrauterine growth restriction (IUGR), as compared to dichorionic twins and monochorionic twins without selective IUGR.
METHODS: This was a prospective cohort study involving 42 monochorionic twins diagnosed with selective IUGR and managed expectantly. The presence or absence of intermittent A/REDV was recorded in all cases. This study group was compared to dichorionic twins (n = 29) and monochorionic twins without selective IUGR (n = 32) delivered at 26-34 weeks during the study period. All infants underwent an early neonatal brain scan (at or before the fourth day of postnatal life) and at least one follow-up scan during the first 28 days of postnatal life. Perinatal outcome and the incidence of neurological damage were compared between the study groups.
RESULTS: The incidence of intrauterine fetal death (IUD) and periventricular leukomalacia was significantly increased in monochorionic twins complicated with selective IUGR, as compared with the other study groups. Intermittent A/REDV was observed in 22/42 (52.4%) twin pairs, and was always present in the growth-restricted twin. The incidence of IUD (overall 9/44 (20.5%) vs. 0/40, P < 0.001; smaller twin 6/22 (27.3%) vs. 0/20, P < 0.05) and parenchymal brain damage (overall 7/35 (20.0%) vs. 2/40 (5.0%), P = 0.07; larger twin 7/19 (36.8%) vs. 1/20 (5.0%), P < 0.05) was significantly higher in pregnancies with intermittent A/REDV than in those without intermittent A/REDV. Brain damage usually occurred in the larger twin, irrespective of whether the smaller twin was liveborn or not.
CONCLUSIONS: The presence of intermittent A/REDV in monochorionic twins with selective IUGR identifies a subgroup with an elevated risk of intrauterine demise of the smaller twin and neurological damage in the larger twin; this latter finding is not restricted to cases with IUD of the cotwin.
Copyright 2004 ISUOG
E Gratacós, L Lewi, B Muñoz, R Acosta-Rojas, E Hernandez-Andrade, J M Martinez, E Carreras, J Deprest
A classification system for selective intrauterine growth restriction in monochorionic pregnancies according to umbilical artery Doppler flow in the smaller twin.
Ultrasound Obstet Gynecol. 2007 Jul;30(1):28-34. doi: 10.1002/uog.4046.
Abstract/Text
OBJECTIVES: To evaluate a classification of selective intrauterine growth restriction (sIUGR) in monochorionic (MC) twins based on the characteristics of umbilical artery (UA) Doppler flow in the smaller twin, in terms of association with clinical outcome and with the pattern of placental anastomoses.
METHODS: One hundred and thirty-four MC twins diagnosed with sIUGR at 18-26 weeks were classified as Type I (UA Doppler with positive diastolic flow, n = 39), Type II (persistent absent or reversed end-diastolic flow, n = 30) and Type III (intermittent absent or reversed end-diastolic flow, n = 65). Perinatal outcome, placental sharing and the pattern of anastomoses were compared with those in 76 uncomplicated MC twins.
RESULTS: Mean gestational age at delivery was 35.5 (range, 30-38) weeks in controls, 35.4 (range, 16-38) weeks in Type I, 30.7 (range, 27-40) weeks in Type II (P < 0.0001) and 31.6 (range, 23-39) weeks in Type III (P < 0.0001) pregnancies. Fetal weight discordance was significantly higher in Type II (38%) and Type III (36%) than in Type I (29%) (P < 0.0001) pregnancies. Deterioration of the growth-restricted fetus occurred in 90% of Type II cases, compared with 0% and 10.8% of Types I and III, respectively (P < 0.001). Unexpected intrauterine fetal death of the smaller twin occurred in 15.4% of Type III cases, compared with 2.6% and 0% of Types I and II respectively (P < 0.05). Parenchymal brain lesions in the larger twin were observed in 19.7% of Type III cases and less than 5% in the other groups (P < 0.05). Placental discordance (larger/smaller) was 1.3 in controls, compared with 1.8, 2.6 and 4.4 in Types I, II and III, respectively (P < 0.01). The proportion of cases with arterioarterial anastomoses > 2 mm in diameter was 55% in controls, 70% in Type I, 18% in Type II (P < 0.01) and 98% in Type III (P < 0.01).
CONCLUSION: sIUGR can be classified on the basis of umbilical artery Doppler into three types that correlate with different clinical behavior and different patterns of placental anastomoses. This classification may be of help in clinical decision-making and when comparing clinical studies.
E Gratacós, E Antolin, L Lewi, J M Martínez, E Hernandez-Andrade, R Acosta-Rojas, G Enríquez, L Cabero, J Deprest
Monochorionic twins with selective intrauterine growth restriction and intermittent absent or reversed end-diastolic flow (Type III): feasibility and perinatal outcome of fetoscopic placental laser coagulation.
Ultrasound Obstet Gynecol. 2008 Jun;31(6):669-75. doi: 10.1002/uog.5362.
Abstract/Text
OBJECTIVES: To assess the feasibility and impact on perinatal outcome of fetoscopic laser coagulation of placental anastomoses in monochorionic twins with selective intrauterine growth restriction (sIUGR) and intermittent absent or reversed end-diastolic flow (iAREDF) in the umbilical artery (Type III), in comparison with expectant management.
METHODS: This is a descriptive study of the outcome of 18 cases of monochorionic twins with Type III sIUGR treated with laser, and 31 pregnancies managed expectantly over the same period. All newborns underwent neonatal brain ultrasound scans. Perinatal outcome and the incidence of neurological damage were compared between the two groups.
RESULTS: Laser coagulation could be performed in only 88.9% (16/18) of cases owing to technical difficulties, and in 12.5% (2/16) a second procedure was required to achieve complete coagulation of the large artery-to-artery anastomosis. Mean gestational age at delivery was 31.0 (range, 26-33) weeks in the expectant management group and 32.6 (range, 23-38) weeks in the laser group (P = 0.32). Overall perinatal survival was 85.5% (53/62) and 63.9% (23/36), respectively (P = 0.02). Intrauterine demise of the smaller twin occurred in 19.4% (6/31) and 66.7% (12/18), respectively (P = 0.001), and was associated with death of the cotwin in 50% (3/6) and 0% (0/12) of these cases, respectively (P = 0.02). The prevalence of periventricular leukomalacia in the larger fetus was 4/28 (14.3%) in the expectant management group and 1/17 (5.9%) in the laser group (P = 0.63).
CONCLUSIONS: Laser coagulation in sIUGR-iAREDF pregnancies is technically difficult and not always feasible. Placental dichorionization significantly increases the proportion of fetuses with intrauterine death of the growth-restricted twin, but it protects the normal twin from its cotwin's death in the event of demise of the growth-restricted twin.
Keisuke Ishii, Takeshi Murakoshi, Yuichiro Takahashi, Takashi Shinno, Mitsuru Matsushita, Hiroo Naruse, Yuichi Torii, Masahiro Sumie, Masahiko Nakata
Perinatal outcome of monochorionic twins with selective intrauterine growth restriction and different types of umbilical artery Doppler under expectant management.
Fetal Diagn Ther. 2009;26(3):157-61. doi: 10.1159/000253880. Epub 2009 Oct 28.
Abstract/Text
OBJECTIVES: To evaluate the prognosis of monochorionic twins with selective intrauterine growth restriction (sIUGR), classified according to the type of umbilical artery Doppler, under expectant management.
METHODS: The outcome of 81 cases with isolated sIUGR was evaluated according to a classification based on umbilical artery (UA) Doppler diastolic flow in the IUGR twin (I: present, II: constantly absent/reverse, III: intermittently absent/reverse). Selective feticide was not considered due to legal constraints. Perinatal outcomes included perinatal death and neurological outcome at 6 months of age.
RESULTS: From 81 cases with the diagnosis of sIUGR, twin-twin transfusion was diagnosed in 18 cases. This left 63 cases, of which 23 were classified as type I (36.5%), 27 as type II (42.9%) and 13 as type III (20.6%). Intrauterine death occurred in 4.3% (1), 29.6% (8) and 15.4% (2) among IUGR twins, and 4.3% (1), 22.2% (6) and 0.0% (0) among larger twins. Neonatal death occurred in 0.0% (0), 18.5% (5) and 0.0% (0) among IUGR twins, and 0.0% (0), 11.1% (3) and 23.0% (3) among larger twins. Neurological abnormalities at 6 months were found in 4.3% (1), 14.8% (4) and 23.1% (3) in smaller twins and 0.0% (0), 11.1% (3) and 38.5% (5) in larger twins, respectively. Intact survival at 6 months was recorded in 91% (21), 37% (10) and 61% (8) in smaller twins and 95% (22), 55% (15) and 38% (5) in larger twins, respectively.
CONCLUSION: The outcome in monochorionic twins with sIUGR and abnormal umbilical artery Doppler is poor under expectant management. Normal Doppler seems to be associated with a good prognosis.
Keisuke Ishii, Seiji Wada, Mayumi Takano, Masahiko Nakata, Takeshi Murakoshi, Haruhiko Sago
Survival Rate without Brain Abnormalities on Postnatal Ultrasonography among Monochorionic Twins after Fetoscopic Laser Photocoagulation for Selective Intrauterine Growth Restriction with Concomitant Oligohydramnios.
Fetal Diagn Ther. 2019;45(1):21-27. doi: 10.1159/000486130. Epub 2018 Feb 20.
Abstract/Text
INTRODUCTION: We aimed to clarify the survival rate without brain abnormalities (BA) after fetoscopic laser photoco-agulation (FLP) for monochorionic diamniotic twin gestations (MCDA) with selective intrauterine growth restriction (sIUGR) accompanied by abnormal umbilical artery (UA) Doppler waveforms and isolated oligohydramnios in the sIUGR twin.
MATERIALS AND METHODS: This retrospective study included 52 cases that underwent FLP. The main outcome was survival rate without BA of the twins at age 28 days. BA was defined as severe intraventricular hemorrhage and periventricular leukomalacia on postnatal ultrasonography.
RESULTS: Median gestational age at FLP was 20 (16-24) weeks. Ten cases were classified as type III based on Doppler for the UA. For all cases, including 20 cases of anterior placenta, FLP was completed without major intraoperative complications. Amnioinfusion was required in 49 cases for better fetoscopic visualization. Fetal loss occurred in 29 sIUGR twins and two larger twins, whereas one larger twin experienced neonatal death. Survival rates without BA were 44% (n = 23) for sIUGR twins and 94% (n = 49) for the larger twins.
DISCUSSION: FLP for MCDA with sIUGR presenting with oligohydramnios in the sIUGR twin might be considered a prenatal treatment option.
© 2018 S. Karger AG, Basel.
I Couck, S Ponnet, J Deprest, R Devlieger, L De Catte, L Lewi
Outcome of monochorionic twin pregnancy with selective fetal growth restriction at 16, 20 or 30 weeks according to new Delphi consensus definition.
Ultrasound Obstet Gynecol. 2020 Dec;56(6):821-830. doi: 10.1002/uog.21975.
Abstract/Text
OBJECTIVES: To report the outcome of selective fetal growth restriction (sFGR) diagnosed according to the new Delphi consensus definition, and determine potential predictors of survival, in a cohort of unselected monochorionic diamniotic twin pregnancies.
METHODS: This was a retrospective study of monochorionic diamniotic twin pregnancies followed from the first trimester onward, which were diagnosed with sFGR at 16, 20 or 30 weeks' gestation. sFGR was defined according to the new Delphi consensus criteria as presence of either an estimated fetal weight (EFW) < 3rd centile in one twin or at least two of the following: EFW of one twin < 10th centile, abdominal circumference of one twin < 10th centile, EFW discordance ≥ 25% or umbilical artery pulsatility index of the smaller twin > 95th centile. The primary outcomes were the overall survival rate (up to day 28 after birth) and risk of loss of one or both twins. We further determined possible predictors of survival using uni- and multivariate generalized estimated equation modeling.
RESULTS: We analyzed 675 pregnancies, of which 177 (26%) were diagnosed with sFGR at 16, 20 or 30 weeks. The overall survival rate was 313/354 (88%) with 146/177 (82%) pregnancies resulting in survival of both twins, 21/177 (12%) in survival of one twin and 10/177 (6%) in loss of both twins. Subsequent twin anemia-polycythemia sequence (TAPS) developed in 6/177 (3%) and twin-twin transfusion syndrome (TTTS) in 17/177 (10%) pregnancies. All TAPS fetuses survived. The survival rate in sFGR pregnancies that subsequently developed TTTS was 65% (22/34), compared with 91% (279/308) in those with isolated sFGR (no subsequent TAPS or TTTS) (P < 0.001). The majority of sFGR cases were Type I (110/177 (62%)) and had a survival rate of 96% (212/220), as compared with a survival of 55% (12/22) in those with Type-II (P < 0.001) and 83% (55/66) in those with Type-III (P = 0.006) sFGR. The majority of sFGR pregnancies (130/177 (73%)) were first diagnosed at 16 or 20 weeks (early onset), with a survival rate of 85% (221/260), as compared with a survival of 98% (92/94) in sFGR first diagnosed at 30 weeks (late onset) (P = 0.04). A major anomaly in at least one twin was present in 28/177 (16%) sFGR cases. In these pregnancies, survival was 39/56 (70%), compared with 274/298 (92%) in those without an anomaly (P < 0.001). Subsequent development of TTTS (odds ratio (OR), 0.18 (95% CI, 0.06-0.52)), Type-II sFGR (OR, 0.06 (95% CI, 0.02-0.24)) and Type-III sFGR (OR, 0.21 (95% CI, 0.07-0.60)) and presence of a major anomaly in at least one twin (OR, 0.12 (95% CI, 0.04-0.34)), but not gestational age at first diagnosis, were independently associated with decreased survival.
CONCLUSIONS: Isolated sFGR is associated with a 90% survival rate in monochorionic diamniotic twin pregnancies. The subsequent development of TTTS, absent or reversed end-diastolic flow in the umbilical artery of the smaller twin and the presence of a major anomaly adversely affect survival in sFGR. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.
Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.
F Slaghekke, W J Kist, D Oepkes, S A Pasman, J M Middeldorp, F J Klumper, F J Walther, F P H A Vandenbussche, E Lopriore
Twin anemia-polycythemia sequence: diagnostic criteria, classification, perinatal management and outcome.
Fetal Diagn Ther. 2010;27(4):181-90. doi: 10.1159/000304512. Epub 2010 Mar 26.
Abstract/Text
Monochorionic twins share a single placenta with intertwin vascular anastomoses, allowing the transfer of blood from one fetus to the other and vice versa. These anastomoses are the essential anatomical substrate for the development of several complications, including twin-twin transfusion syndrome (TTTS) and twin anemia-polycythemia sequence (TAPS). TTTS and TAPS are both chronic forms of fetofetal transfusion. TTTS is characterized by the twin oligopolyhydramnios sequence, whereas TAPS is characterized by large intertwin hemoglobin differences in the absence of amniotic fluid discordances. TAPS may occur spontaneously in up to 5% of monochorionic twins and may also develop after incomplete laser treatment in TTTS cases. This review focuses on the pathogenesis, incidence, diagnostic criteria, management options and outcome in TAPS. In addition, we propose a classification system for antenatal and postnatal TAPS.
Copyright 2010 S. Karger AG, Basel.
E Lopriore, D Oepkes
Fetal and neonatal haematological complications in monochorionic twins.
Semin Fetal Neonatal Med. 2008 Aug;13(4):231-8. doi: 10.1016/j.siny.2008.02.002. Epub 2008 Mar 19.
Abstract/Text
Placental vascular anastomoses are almost invariably present in monochorionic (MC) placentas. These anastomoses are the essential anatomical substrate for the development of several haematological complications in MC twins, in particular twin-to-twin transfusion syndrome (TTTS). Several forms of TTTS have been described, including chronic TTTS, acute perimortem TTTS, twin anaemia-polycythaemia sequence, acute perinatal TTTS and twin reversed arterial perfusion sequence. A significant evolution in prenatal care strategies and management options for patients with TTTS has occurred during the last decade. In chronic TTTS, endoscopic laser ablation of communicating placental vessels has led to an increase in survival rates. This review analyzes the possible pathophysiologic mechanisms involved, discusses the latest findings in diagnosis, therapy and prognosis, and focuses on fetal and neonatal haematologic complications associated with the various forms of TTTS.
Léonardo Gucciardo, Liesbeth Lewi, Pascal Vaast, Marzena Debska, Luc De Catte, Tim Van Mieghem, Elisa Done, Roland Devlieger, Jan Deprest
Twin anemia polycythemia sequence from a prenatal perspective.
Prenat Diagn. 2010 May;30(5):438-42. doi: 10.1002/pd.2491.
Abstract/Text
OBJECTIVES: To describe the prevalence, management and outcome of spontaneous twin anemia polycythemia sequence (TAPS) diagnosed in the prenatal period.
METHOD: Retrospective analysis of 142 consecutive monochorionic twin pregnancies not diagnosed with twin to twin transfusion syndrome. TAPS cases were identified based on the presence of discordant middle cerebral artery peak systolic velocity (MCA-PSV) measurements and signs suggestive of a chronic intertwin transfusion imbalance: either an elevated reticulocyte count in the anemic twin or the presence of few small unidirectional anastomoses during fetoscopy or at postnatal placental examination.
RESULTS: Three cases were identified, giving an estimated prevalence of 2%. Prenatal interventions were tailored to the characteristics of each case and consisted of intrauterine transfusion and interruption of the shared circulation by cord coagulation or laser separation.
CONCLUSION: In monochorionic twin pregnancies, TAPS is an uncommon prenatal finding. Nonetheless, its incidence seems high enough to recommend screening for this disease by MCA-PSV measurements.
A Mabuchi, K Ishii, R Yamamoto, T Taguchi, M Murata, S Hayashi, N Mitsuda
Clinical characteristics of monochorionic twins with large hemoglobin level discordance at birth.
Ultrasound Obstet Gynecol. 2014 Sep;44(3):311-5. doi: 10.1002/uog.13343. Epub 2014 Jul 25.
Abstract/Text
OBJECTIVES: To evaluate neonatal outcomes and clinical characteristics of monochorionic diamniotic (MCDA) twins with a large intertwin hemoglobin (Hb) difference at birth.
METHODS: This was a retrospective cohort study of MCDA twin gestations delivered at Osaka Medical Center and Research Institute for Maternal and Child Health between 2003 and 2012. Cases of pregnancy termination, acardiac twins or intrauterine death were excluded. A large intertwin Hb difference at birth was defined as > 8.0 g/dL according to the postnatal criteria for twin anemia-polycythemia sequence (TAPS). The intertwin reticulocyte count ratio (RCR) was calculated by dividing the reticulocyte count of the anemic twin by that of the polycythemic twin. Cases with Hb differences were divided into two groups according to the RCR, TAPS when the RCR was > 1.7 and acute fetofetal hemorrhage (AFFH) when the RCR was ≤ 1.7. Neonatal outcomes were compared between the TAPS and AFFH groups.
RESULTS: During the study period, 432 MCDA twin pregnancies of a total of 532 born at our hospital were analyzed. There were 12 (2.8%) cases of a large intertwin Hb difference. The median gestational age at birth of these cases was 34 (range, 23-38) weeks, and all were delivered by Cesarean section. There were seven (1.6%) cases of TAPS and five (1.2%) of AFFH. The neonatal survival rate was 91.7%; in one pair of twins with TAPS neonatal death occurred. All (100%) cases with TAPS and two (40%) with AFFH required blood transfusion or partial-exchange transfusion for at least one infant.
CONCLUSIONS: Although the incidence of TAPS and AFFH may be low in MCDA twins, many affected neonates required treatment for hematological abnormalities. Delivery of MCDA twins via Cesarean section does not appear to prevent AFFH, despite the absence of labor.
Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd.
Tae Yokouchi, Takeshi Murakoshi, Takashi Mishima, Hiroko Yano, Madoka Ohashi, Takashi Suzuki, Takashi Shinno, Mitsuru Matsushita, Satoru Nakayama, Yuichi Torii
Incidence of spontaneous twin anemia-polycythemia sequence in monochorionic-diamniotic twin pregnancies: Single-center prospective study.
J Obstet Gynaecol Res. 2015 Jun;41(6):857-60. doi: 10.1111/jog.12641. Epub 2014 Dec 16.
Abstract/Text
AIM: The purpose of this study was to prospectively estimate the incidence of spontaneous twin anemia-polycythemia sequence (TAPS) in monochorionic-diamniotic twin pregnancies.
METHODS: We prospectively examined umbilical cord hemoglobin (Hb) and reticulocyte count of consecutive monochorionic-diamniotic twin pregnancies delivered at Seirei Hamamatsu General Hospital from December 2006 to September 2013. We excluded cases of twin-twin transfusion syndrome, intrauterine fetal demise, and missing data (Hb and reticulocyte count missing from the medical record). TAPS was diagnosed using the postnatal criteria of intertwin Hb difference >8.0 g/dL and reticulocyte count ratio >1.7. Acute feto-fetal hemorrhage was defined as Hb difference >7 g/dL and reticulocyte count ratio <1.7.
RESULTS: A total of 185 monochorionic-diamniotic twin pregnancies were included in this study. Three fulfilled the diagnostic criteria for postnatal TAPS, and one fulfilled the diagnostic criteria for acute feto-fetal hemorrhage.
CONCLUSION: The incidence of spontaneous TAPS in monochorionic-diamniotic twin pregnancies was 1.6% (3/185) at Seirei Hamamatsu General Hospital.
© 2014 The Authors. Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology.
Romaine Robyr, Liesbeth Lewi, Laurent J Salomon, Masami Yamamoto, Jean-Pierre Bernard, Jan Deprest, Yves Ville
Prevalence and management of late fetal complications following successful selective laser coagulation of chorionic plate anastomoses in twin-to-twin transfusion syndrome.
Am J Obstet Gynecol. 2006 Mar;194(3):796-803. doi: 10.1016/j.ajog.2005.08.069.
Abstract/Text
OBJECTIVE: This study was undertaken to report on the prevalence and management of late complications in twin-to-twin transfusion syndrome (TTTS) treated by laser therapy when both twins are alive 1 week after surgery.
STUDY DESIGN: A total of 151 consecutive TTTS cases were treated by selective fetoscopic laser therapy. Cases in which both twins were alive 1 week after surgery were followed up with ultrasound and Doppler examination, including middle-cerebral artery peak systolic velocity measurement (MCA-PSV).
RESULTS: In the 151 cases treated with laser, both twins were still alive 7 days after the procedure in 101 cases. Intrauterine death of 1 and both twins occurred in 7 and 1 cases, respectively. Recurrence of TTTS with the polyhydramnios-oligohydramnios sequence occurred in 14 (14%) cases. In another 13 (13%) cases, amniotic fluid remained normal in both sacs, but MCA-PSV increased above 1.5 MoM in 1 twin and decreased concomitantly below 0.8 MoM in the co-twin. This was related to anemia and polycythemia, respectively, and resulted from unidirectional feto-fetal blood transfusion, mainly from former recipients into former donors. Late complications were managed accordingly by repeat laser, amnioreduction, cord coagulation, intrauterine blood transfusion, or elective delivery.
CONCLUSION: MCA-PSV Doppler measurements are useful in the follow-up of double survivors to detect and manage late complications after selective laser therapy.
L S A Tollenaar, E Lopriore, J M Middeldorp, M C Haak, F J Klumper, D Oepkes, F Slaghekke
Improved prediction of twin anemia-polycythemia sequence by delta middle cerebral artery peak systolic velocity: new antenatal classification system.
Ultrasound Obstet Gynecol. 2019 Jun;53(6):788-793. doi: 10.1002/uog.20096. Epub 2019 May 6.
Abstract/Text
OBJECTIVES: To investigate the diagnostic accuracy of delta middle cerebral artery peak systolic velocity (MCA-PSV) > 0.5 multiples of the median (MoM) and compare its predictive value with that of the current MCA-PSV cut-off values of > 1.5 MoM in the donor and < 1.0 MoM in the recipient, for the diagnosis of twin anemia-polycythemia sequence (TAPS) in monochorionic twin pregnancy.
METHODS: This was a retrospective consecutive cohort study comprising all uncomplicated monochorionic twin pregnancies and twin pregnancies with a postnatal diagnosis of TAPS managed between 2003 and 2017 in the Dutch national referral center for fetal therapy. Cases with incomplete MCA-PSV Doppler measurements 1 week prior to delivery or with incomplete hemoglobin measurements within 1 day after birth were excluded. The postnatal diagnosis of TAPS was based on an intertwin hemoglobin difference > 8 g/dL and at least one of the following: reticulocyte count ratio > 1.7 or presence of minuscule anastomoses on the placental surface. We compared the predictive accuracy of the current diagnostic method using MCA-PSV cut-off values of > 1.5 MoM in the donor and < 1.0 MoM in the recipient with that of a new method based on intertwin difference in MCA-PSV > 0.5 MoM for prediction of TAPS.
RESULTS: In total, 45 uncomplicated and 35 TAPS monochorionic twin pregnancies were analyzed. The sensitivity and specificity of the cut-off MCA-PSV values (donor > 1.5 MoM, recipient < 1.0 MoM) to predict TAPS was 46% (95% CI, 30-62%) and 100% (95% CI, 92-100%), respectively; positive predictive value was 100% (95% CI, 81-100%) and negative predictive value 70% (95% CI, 58-80%). Delta MCA-PSV showed a sensitivity of 83% (95% CI, 67-92%) and a specificity of 100% (95% CI, 92-100%); the positive and negative predictive values were 100% (95% CI, 88-100%) and 88% (95% CI, 77-94%), respectively. Of the 35 cases with TAPS diagnosed postnatally, 13 twin pairs showed a delta MCA-PSV > 0.5 MoM but did not fulfill the cut-off MCA-PSV criteria. Of these 13 TAPS twins, nine donors and four recipients had normal MCA-PSV values. There was a high correlation between delta MCA-PSV and intertwin difference in hemoglobin level (R = 0.725, P < 0.01).
CONCLUSION: Delta MCA-PSV > 0.5 MoM has a greater diagnostic accuracy for predicting TAPS compared to the current MCA-PSV cut-off criteria. We therefore propose a new antenatal classification system for TAPS. In monochorionic twin pregnancies with delta MCA-PSV > 0.5 MoM on Doppler ultrasound, but normal MCA-PSV values in the donor or recipient, obstetricians should be aware of the therapeutic implications and neonatal morbidities associated with TAPS. © 2018 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.
© 2018 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.
L S A Tollenaar, F Slaghekke, L Lewi, Y Ville, M Lanna, A Weingertner, G Ryan, S Arévalo, A Khalil, C O Brock, P Klaritsch, K Hecher, G Gardener, E Bevilacqua, K V Kostyukov, M O Bahtiyar, M D Kilby, E Tiblad, D Oepkes, E Lopriore, Collaborators
Treatment and outcome of 370 cases with spontaneous or post-laser twin anemia-polycythemia sequence managed in 17 fetal therapy centers.
Ultrasound Obstet Gynecol. 2020 Sep;56(3):378-387. doi: 10.1002/uog.22042.
Abstract/Text
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.
© 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.
V Giorgione, F D'Antonio, A Manji, K Reed, A Khalil
Perinatal outcomes of pregnancies complicated by twin anemia-polycythemia sequence: a systematic review and meta-analysis.
Ultrasound Obstet Gynecol. 2021 Jan 11;. doi: 10.1002/uog.23585. Epub 2021 Jan 11.
Abstract/Text
OBJECTIVE: To report the perinatal outcome in monochorionic diamniotic (MC) twin pregnancies complicated by twin anemia polycythemia sequence (TAPS).
METHODS: Medline, Embase and Cochrane Library databases were searched. Inclusion criteria were non-anomalous MCDA twin pregnancies with a diagnosis of TAPS. The primary outcome was mortality; the secondary outcomes were morbidity and preterm birth (PTB). All these outcomes were stratified according to the type of TAPS (spontaneous or following laser treatment) and management option adopted (expectant, laser, intra-uterine transfusion [IUT] and selective reduction [SR]). Random effect meta-analyses of proportions were used to analyze the data.
RESULTS: Spontaneous and post-laser TAPS (506 pregnancies): IUD occurred in 5.32 (95% CI, 3.6-7.1) of spontaneous and in 10.2% (95% CI, 7.4-13.3) of post-laser TAPS, while the corresponding figures for NND were 4.0% (95% CI, 2.6-5.7) and 9.2% (95% CI, 6.6-12.3). Severe neonatal morbidity occurred in 29.3% (95% CI, 25.6-33.1) of twins after spontaneous and 33.3% (95% CI, 17.4-51.8) after post-laser TAPS, while the corresponding figures for 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 and all cases with post-laser TAPS (95% CI, 84.3-100). Iatrogenic PTB was more frequent than the spontaneous PTB in both groups. Outcome according to different management options (418 pregnancies): IUD occurred in 9.8% (95% CI, 4.3-17.1) of pregnancies 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, IUT and SR, respectively. Severe neonatal morbidity affected 27.3% (95% CI, 13.6-43.6) twins in the expectant management group, 28.7% (95% CI, 22.7-35.1) in the laser surgery group, 38.2% (95% CI 18.3-60.5) in the IUT group and 23.3% (95% CI 10.5-39.2) 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, IUT and SR, respectively.
CONCLUSIONS: The present meta-analysis provides pooled estimates of perinatal mortality, morbidity and preterm birth in twin pregnancies complicated by TAPS, stratified by the type of TAPS and according to different management options. Although a direct comparison could not be performed, the results from this systematic review suggest that spontaneous TAPS may have a better prognosis than post-Laser TAPS. No differences in terms of mortality and morbidity were observed comparing different management options for TAPS although these findings should be interpreted with caution in view of the limitations of the original studies. An individualized prenatal management, taking into account the severity of TAPS and gestational age, is currently the recommended strategy. This article is protected by copyright. All rights reserved.
This article is protected by copyright. All rights reserved.
Keisuke Ishii, Shusaku Hayashi, Aki Mabuchi, Takako Taguchi, Ryo Yamamoto, Masaharu Murata, Nobuaki Mitsuda
Therapy by laser equatorial placental dichorionization for early-onset spontaneous twin anemia-polycythemia sequence.
Fetal Diagn Ther. 2014;35(1):65-8. doi: 10.1159/000354985. Epub 2013 Sep 14.
Abstract/Text
We report a case of twin anemia-polycythemia sequence (TAPS) treated by fetoscopic laser equatorial placental dichorionization, also known as the 'Solomon technique', at 24 weeks of gestation. TAPS was present despite the absence of fetoscopically visualized chorionic anastomoses from the donor to the recipient twin. The goal of this procedure was to prevent post-laser TAPS in cases of twin-twin transfusion syndrome. The surgery and subsequent intrauterine blood transfusion to the donor twin could result in the survival of both twins without hematologic or neurological complications. Following the surgery, a placental injection test revealed no residual anastomoses. At present, laser therapy is not always feasible for TAPS, primarily because of its difficulty. However, laser therapy using the Solomon technique could be a viable approach for early-onset TAPS, especially in difficult situations in which undetectable vascular anastomoses related to TAPS are present.
Copyright © 2013 S. Karger AG, Basel.
F Slaghekke, R Favre, S H P Peeters, J M Middeldorp, A S Weingertner, E W van Zwet, F J Klumper, D Oepkes, E Lopriore
Laser surgery as a management option for twin anemia-polycythemia sequence.
Ultrasound Obstet Gynecol. 2014 Sep;44(3):304-10. doi: 10.1002/uog.13382. Epub 2014 Aug 4.
Abstract/Text
OBJECTIVE: To evaluate the effectiveness of laser treatment for antenatally detected twin anemia-polycythemia sequence (TAPS) compared with intrauterine transfusion or expectant management.
METHODS: All monochorionic twin pregnancies with TAPS managed between 2005 and 2013 in two European fetal therapy centers were evaluated. The outcomes of TAPS cases treated primarily with laser surgery were compared with the outcomes of cases managed expectantly or treated with intrauterine transfusion.
RESULTS: In this retrospective study 52 cases of TAPS were detected antenatally and were managed with either laser surgery (n=8; 15%) or intrauterine blood transfusion (n=17; 33%) or expectantly (n=27; 52%). Perinatal survival in the laser group was 94% (15/16) vs 85% (29/34) in the intrauterine-transfusion group and 83% (45/54) in the expectant-management group (P=0.30). The rates of severe neonatal morbidity in liveborn neonates in the laser, intrauterine-transfusion and expectant-management groups were 7% (1/15), 38% (12/32) and 24% (12/50), respectively (P=0.17). There was a significant reduction in respiratory distress syndrome in cases treated by laser. No severe postnatal hematological complications were detected in the laser group compared with 72% (23/32) in the intrauterine-transfusion group and 52% (26/50) in the expectant-management group (P<0.01). Median time between diagnosis and birth was 11 weeks in the laser group compared to 5 weeks after intrauterine transfusion and 8 weeks after expectant management (P<0.01). After injection of colored dye no residual anastomoses were found in the laser group.
CONCLUSIONS: Laser surgery for TAPS appears to improve perinatal outcome by prolonging pregnancy and reducing respiratory distress syndrome. Larger, adequately controlled studies are needed to reach firm conclusions on the optimal management of TAPS.
Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd.
