Feto-fetal Transfusion Syndrome Research Articles

Incidences of Feto-Fetal Transfusion Syndrome and Perinatal Outcomes in Triplet Gestations with Monochorionic Placentation

Introduction: This study aimed to determine the incidences of feto-fetal transfusion syndrome (FFTS) and perinatal outcomes in triplet gestations with monochorionic placentation. Materials and Methods: In this retrospective cohort study, we evaluated the incidences of FFTS and perinatal outcomes at 28 days of age in cases of triplet gestations with monochorionic placentation who visited our centers before 16 weeks of gestation and delivered over a period of 11 years. Results: In 41 triplet gestations (17 monochorionic triamniotic, 22 dichorionic triamniotic, 1 dichorionic diamniotic, and 1 monochorionic monoamniotic), the incidence of FFTS was 17.1%, and the median gestational age at FFTS diagnosis was 19 weeks. In 123 triplets, the incidences of fetal death and neonatal death at 28 days of age were 8.1 and 0.9%, respectively. None of the surviving infants had grade 3 or 4 intraventricular hemorrhage, while cystic periventricular leukomalacia occurred in 6 of 113 infants (5.3%). The incidence of poor outcomes (death or any major neurological complication at 28 days of age) was 13.8%. Discussion: Seventeen percent of triplet pregnancies with monochorionic placentation developed FFTS, and 14% had a poor outcome. Therefore, triplet gestations with monochorionic placentation should be followed carefully.

Методика Соломона при оперативном лечении синдрома фето-фетальной трансфузии

Методика Соломона при оперативном лечении синдрома фето-фетальной трансфузии

P15.02: Incidences of fetofetal transfusion syndrome and perinatal outcomes in triplet gestations with monochorionic placentation

P15.02: Incidences of fetofetal transfusion syndrome and perinatal outcomes in triplet gestations with monochorionic placentation

Fetofetal Transfusion Syndrome in Monochorionic-Triamniotic Triplets Treated with Fetoscopic Laser Ablation: Report of Two Cases and A Systematic Review

Objective This study aims to determine the clinical outcomes of monochorionic-triamniotic (MT) pregnancies complicated by severe fetofetal transfusion undergoing laser photocoagulation. Study Design We report two cases of MT triplets complicated by fetofetal transfusion syndrome (FFTS) and a systematic review classifying cases into different subtypes: MT with two donors and one recipient, MT with one donor and two recipients, MT with one donor, one recipient, and one unaffected triplet. The number of neonatal survivors was analyzed based on this classification as well as Quintero staging. Results A total of 26 cases of MT triples complicated by FFTS were analyzed. In 56% of the cases, the FFTS involved all three triplets, 50% of whom had an additional donor and 50% an additional recipient. Among the 24 cases that survived beyond 1 week after the procedure, the average gestational age of delivery was 29.6 weeks, and the average interval from procedure to delivery was 10.1 weeks. The overall neonatal survival rate was 71.7%, with demises occurring equally between donor and recipient triplets. Overall neonatal survival including survival of at least two fetuses occurred with equal frequency between the different groups. Conclusion Significant neonatal survival can be achieved in most cases of MT triplets with FFTS.

Osteopathic Care of a Twin Risk Pregnancy: Case Study

A 32 year old patient gravid with twins came in the 23th week of pregnancy; one of her fetus was small for date with polyhydramnion and a beginning feto-fetal transfusion syndrome. This is a very dangerous situation, in which one or both twins can die intrauterine because of the lack of nutrition and oxygen. One of the twins may become a donator and give all its nutrition to the other and won´t grow anymore itself. While the patient got continuous check-ups in the university clinic with ultrasound, she also got osteopathic treatments in short periods, first weekly and continuing with bigger pauses. This treatments were focussed on the uterus and its arterial nutrition and also the form of the uterus, to support the placenta of the twins to get as much oxygen as possible to nourish the babies. An additional focus was seeking for the healthy matrix of the babies intrauterine and if any osteopathic lesions could be found and get helped dissolved. The woman delivered healthy and equal weighted sons in the 38th week with section cesarean. The following case shows that an osteopathic treatment can effectively balance blood flow, growth and the well-being both of mother and children. A careful medical control and the ultrasound showed this effect.

Perinatal outcome after laser surgery for triplet gestations with feto-fetal transfusion syndrome

The objective of this study is to evaluate the outcomes of fetoscopic laser photocoagulation (FLP) for a triplet gestation with feto-fetal transfusion syndrome (FFTS). On the basis of chorionicity, perinatal outcome at 28 days in triplets with FFTS after FLP were evaluated. Fetoscopic laser photocoagulation was completed for all 16 cases including nine dichorionic triamniotic (DT) cases and seven monochorionic triamniotic (MT) cases. The placenta was located anteriorly in six cases. The median gestational age at surgery was 21 (16-25) weeks, and the median operation time was 51 (25-125) minutes. Several technical maneuvers to complete the procedure in MT, such as trocar assistance in two cases, intentional septostomy of the dividing membrane in one, and double uterine entry in one, were used. The median gestational age at delivery was 31 (23-34) weeks. Overall perinatal survival in DT was 74% and that of MT was 95%. All 16 cases resulted in at least one survival, whereas three neonates survived in 44% of DT cases and in 86% of MT cases. Two MT neonates suffered severe intraventricular hemorrhages. Fetoscopic laser photocoagulation for FFTS in MT as well as DT triplets seems a valuable treatment.

Fotocoagulación con láser argón en el síndrome de transfusión feto-fetal

Se comunica el primer caso de cirugía fetal a nivel nacional en una gestante primigesta de 27 semanas con el diagnóstico de síndrome de transfusión feto-fetal, con categoría Quintero III, realizado en el Hospital Nacional EsSalud Huancayo Ramiro Priale Priale, utilizándose la técnica de fotocoagulación con láser de argón, por vía transcutánea. El resultado postoperatorio fue exitoso, con sobrevida en ambos fetos, los cuales nacieron vía cesárea luego de 25 días de la fotocoagulación, por presentar rotura prematura de membranas.Palabras clave: Síndrome de transfusión feto-fetal, fotocoagulación con láser de argón.

444: Outcomes of laser photocoagulation for feto-fetal transfusion syndrome in dichorionic-triamniotic triplet gestations as compared to monochorionic-diamniotic twins

To compare the outcomes of dichorionic-triamniotic (DC,TA) triplet gestations with the outcomes of a paired cohort of monochorionic-diamniotic twin (MC,DA) gestations undergoing laser photocoagulation of placental anastomosis for treatment of feto-fetal transfusion syndrome.

Monochorionic Triplets Complicated by Fetofetal Transfusion Syndrome: A Case Series and Review of the Literature

Objective: To compare perinatal outcome in monochorionic (MC) triplets with twin-to-twin transfusion syndrome (TTTS) versus dichorionic (DC) triplets with TTTS. Study Design: Retrospective analysis of all triplets with TTTS treated at our center and all cases reported in the literature between 1990 and 2010. Survival and gestational age at birth of MC and DC triplets were compared and stratified by type of intervention. We excluded triplets with one or more fetal deaths <16 weeks’ gestation and those with one or more fetuses with congenital anomalies. Results: MC triplets were affected by TTTS in a total of 27 cases, and overall survival was 51% (38/75 fetuses) compared to 105 DC triplets with a survival of 76% (220/291 fetuses) (p < 0.05). Mean gestational age at birth in MC triplets was 28 weeks, compared to 31 weeks in DC triplets (p < 0.05). Perinatal survival of at least one fetus in MC triplet and DC triplet pregnancies was 70% (19/27) and 91% (96/105) (p < 0.05). In DC triplets, survival after laser therapy was significantly improved compared to expectant management, amniodrainage or selective feticide (p < 0.05). Conclusion: MC triplets with TTTS are at a considerably higher risk for perinatal mortality and preterm birth than DC triplets. The optimal strategy to manage MC triplets with TTTS, including the role of selective feticide and laser therapy of all anastomoses, is still to be established.

Fetal Anemia of Unknown Cause – A Diagnostic Challenge

To assess the spectrum of underlying diseases in cases of fetal anemia in which the cause was unknown at the time of first and second transfusion or thereafter. All patients who underwent intrauterine transfusion were identified in the perinatal databases of two tertiary referral centers for prenatal medicine and treatment between 2002 and June 2010. 82 fetuses received intrauterine transfusion in the study period. A total of 356 transfusions were performed in these patients. The causes of fetal anemia in our cohort were alloimmunization (32), parvovirus infection (23), feto-fetal transfusion syndrome (9), sacrococcygeal teratoma (2) and cytomegalovirus infection (1). In the remaining 15 cases, the cause of fetal anemia was unknown at the time of first and second transfusion, and could only be ascertained in the further course of pregnancy, in the postnatal period or was ultimately left in doubt. In all cases markedly elevated peak systolic velocities in the middle cerebral artery accurately predicted fetal anemia. The final diagnosis in these cases was fetomaternal hemorrhage (4), Blackfan-Diamond anemia (1), diffuse neonatal hemangiomatosis with chorangioma (1), kaposi-like hemangioendothelioma (1), elliptocytosis (1), neonatal hemochromatosis (1), mucopolysaccharidosis type VII (1) and in 5 cases the cause of fetal anemia remained unexplained. The latter 5 cases had an uneventful postnatal course and did not require further transfusions in infancy. In cases of fetal anemia with negative indirect Coombs test and TORCH serology, rare causes of anemia have to be considered. Fetal studies should therefore include reticulocyte count, parameters of hemolysis, peripheral blood smear and fetal liver function tests. Maternal studies should involve a search for fetal red cells using flow cytometry rather than Kleihauer-Betke test.

Inconsistent Terminology

We noticed some inconsistencies in the terminology used in the review article by Dudenhausen et al, which we wish to clarify. In twin pregnancies, a distinction is made—depending on placentation and zygosity—between dichorionic (two placentas) and monochorionic (one placenta) pregnancies and dizygous (non-identical/biovular) and monozygous (identical) twins. We make a plea for using the terms zygosity and chorionicity correctly. To monitor the pregnancy and antenatal care, determining zygosity is irrelevant and sonographically impossible (in dichorionic placentation); it is exclusively chorionicity that is important. A monochorionic twin pregnancy can develop only from monozygous twins, whereas a dichorionic pregnancy can, as Dudenhausen and Maier mentioned, develop from two different fertilized ova (dizygous) or a single ovum (monozygous) that has divided at a very early stage. The statement “monozygous twins have a thin membrane, dizygous twins have a thick membrane” is therefore incorrect. Monochorionic twins have a thin membrane, and dichorionic twins (which may be monozygous or dizygous) have a thick membrane. Diagnostic evaluation by ultrasonography can determine the zygosity with any degree of certainty therefore only in monochorionic twins, not in dichorionic twins (exception: if the twins are not the same sex). Further, we wish to point out that fetofetal transfusion syndrome (FFTS) with a stuck twin is not mild FFTS (Figure 2), but according to the criteria set out by Quintero et al. (1), it is severe FFTS.

Perinatal problems in multiple births.

Multiple pregnancies have become more common in the industrialized world because of rising maternal ages and advances in reproductive medicine. Selective literature review. Multiple pregnancy carries a higher risk of prematurity, intrauterine growth restriction, and prenatal death, as well as elevated risks to the mother including preeclampsia, diabetes, and hemorrhage during delivery. Genetic tests and ultrasonography are the most important tests for monitoring during pregnancy. Ultrasound aids in the detection of the feto-fetal transfusion syndrome and in the determination of zygosity. The care of women with multiple pregnancies requires the collaboration of specialists in prenatal medicine, obstetrics, and neonatology as well as a properly functioning integration of outpatient and inpatient care.

Triplets with feto-fetal transfusion syndrome treated with laser ablation: The USFetus experience

Objective. We sought to assess outcomes of triplets with feto-fetal transfusion syndrome (FFTS) treated with selective laser photocoagulation of communicating vessels (SLPCV).Study design. All twins and triplets with FFTS treated with SLPCV were analyzed. Triplets were classified as dichorionic–triamniotic (D/T) or monochorionic–triamniotic (M/T). In M/T triplets, SLPCV between FFTS affected recipient–donor pairs was performed first (step 1); SLPCV of remaining vascular communications was then attempted (step 2).Results. Forty-six of 692 (6.7%) gestations with FFTS treated with SLPCV were triplets; 40 (87%) were D/T, 6 (13%) were M/T. Overall perinatal survivorship in triplets versus twins were not different (73.9% vs. 75.1%, p = 0.757). SLPCV was achieved in 93% of D/T triplets. In the M/T triplets, step 1 was successful in all cases, and step 2 in half of cases. The D/T group delivered later in gestation than the M/T group (31.6 vs. 27.0 weeks, p = 0.049); no difference in overall perinatal survival was detected (75.8% vs. 61.1%, p = 0.248).Conclusion. Overall perinatal survival of triplets and twins with FFTS treated via SLPCV is similar. Significant surgical challenges were posed by monochorionic versus dichorionic triplets. Further studies of monochorionic triplets are required to ascertain perinatal survival post-SLPCV in this subset of triplets.

Feto–Fetal Transfusion Syndrome in Monochorionic Quadruplets

Endoscopic laser ablation of placental vessels is now the preferred treatment for severe feto-fetal transfusion syndrome in twin gestations, and has been well-documented in triplet gestations as well. Stage IV feto-fetal transfusion syndrome was diagnosed at 20.3 weeks of gestation between two of a set of monochorionic, tetramniotic quadruplets. Endoscopic laser ablation occurred at 20.4 weeks. Feto-fetal transfusion recurred at 22 weeks between the initial donor and the two previously unaffected fetuses. Delivery occurred at 24.9 weeks. The donor and one of the corecipients died shortly after birth. The sole survivor was doing well. Treatment of feto-fetal transfusion syndrome in higher-order gestations is challenging because of the increased pregnancy risks, the difficult angioarchitecture and the risk of recurrence.

Placental Laser Surgery for Severe Previable Feto-fetal Transfusion Syndrome in Triplet Gestation

Information on feto-fetal transfusion syndrome (FFTS) in higher-order multifetal gestation is limited. We report outcomes of 10 triplet pregnancies treated by fetoscopic laser occlusion of the chorioangiopagous vessels (FLOC). The study period was August 1992 to August 2008. Inclusion criteria were gestational age < or =25 weeks and ultrasound confirmation of monochorionicity in at least one twin set and FFTS. Treatment included FLOC, exit amnioreduction, and cerclage when indicated. Hospital records, placental pathology, neonatal course, and long term follow-up of the mother and infants were reviewed. There were eight triamnionic dichorionic and two triamnionic monochorionic triplets. Mean maternal age was 29.8 years, and five conceived following in vitro fertilization. FFTS stage at treatment was > or =II in all cases, at a mean gestational age 20.9 +/- 2.2 weeks. Two patients required immediate rescue cerclage, and all 10 had hypoproteinemia and anemia. Mean age at delivery was 31.2 +/- 3.4 weeks, with a mean birth weight 1568.4 +/- 498 g for the live-born fetuses. Twenty-three (77%) fetuses survived, with at least one fetus surviving in 9 (90%) cases. Cerebral ultrasound imaging and neurological examination were normal in all neonates, and clinical follow-up has remained normal at 67.5 +/- 56 months for the group. FLOC is feasible in dichorionic and monochorionic triplet pregnancy complicated by FFTS. Outcomes are comparable to our experience with twins, namely improved perinatal survival and neonatal morbidity when compared with alternative treatments.

Triplets with feto-fetal transfusion syndrome treated with laser ablation: The USFetus experience

We sought to assess outcomes of triplets with feto-fetal transfusion syndrome (FFTS) treated with selective laser photocoagulation of communicating vessels (SLPCV). All twins and triplets with FFTS treated with SLPCV were analyzed. Triplets were classified as dichorionic-triamniotic (D/T) or monochorionic-triamniotic (M/T). In M/T triplets, SLPCV between FFTS affected recipient-donor pairs was performed first (step 1); SLPCV of remaining vascular communications was then attempted (step 2). Forty-six of 692 (6.7%) gestations with FFTS treated with SLPCV were triplets; 40 (87%) were D/T, 6 (13%) were M/T. Overall perinatal survivorship in triplets versus twins were not different (73.9% vs. 75.1%, p = 0.757). SLPCV was achieved in 93% of D/T triplets. In the M/T triplets, step 1 was successful in all cases, and step 2 in half of cases. The D/T group delivered later in gestation than the M/T group (31.6 vs. 27.0 weeks, p = 0.049); no difference in overall perinatal survival was detected (75.8% vs. 61.1%, p = 0.248). Overall perinatal survival of triplets and twins with FFTS treated via SLPCV is similar. Significant surgical challenges were posed by monochorionic versus dichorionic triplets. Further studies of monochorionic triplets are required to ascertain perinatal survival post-SLPCV in this subset of triplets.

645: Triplets with feto-fetal transfusion syndrome treated with laser ablation: A multicenter study

Selective laser photocoagulation of communicating vessels (SLPCV) in triplet gestations complicated by feto-fetal transfusion syndrome (FFTS) poses unique challenges. We sought to investigate survival of triplets with FFTS treated with SLPCV according to chorionicity, and to compare overall survival rates with twins. All twin and triplet gestations with FFTS treated with SLPCV in Tampa (USF) and Los Angeles (USC) were included in the analysis. Overall survival rate was defined as total number of 30-day survivors divided by total number of fetuses. Statistical analysis was performed via Fisher′s exact test and chi-square with Yates correction. 47 of 735 (6.4%) gestations with FFTS treated with SLPCV were triplets. Of the 47 triplets (40 at USF, 7 at USC), 39 (83%) were dichorionic-triamniotic (D/T) and 8 (17%) were monochorionic-triamniotic (M/T). The triplet survival rates according to fetal status were 57.4% for the donor, 74.5% for the recipient, and 89.4% for the “singleton”. The overall survival rate in the D/T group was 76.1% (89/117), which was not statistically different from the M/T group (62.5%, 15/24, p=0.262). None of the triplets had persistent or reversed FFTS post SLPCV. The overall survival rate of twins (73.0%, 1005/1376) was similar to triplets (73.8%, 104/141, p=0.93). Despite the significant surgical challenges posed by triplets with FFTS treated with SLPCV, no significant differences in overall survival rates were identified according to chorionicity and as compared to twins.

Pseudoamniotic band syndrome: a rare complication of monochorionic twins with fetofetal transfusion syndrome treated by laser coagulation

The purpose of this study was to assess the incidence and risk factors of limb constriction defects that are related to pseudoamniotic band syndrome (PABS) after selective fetoscopic laser surgery (FLS) in fetofetal transfusion syndrome (FFTS). All consecutive cases of FFTS that were treated by selective FLS between 1999 and 2006 were examined prospectively for PABS at the time of delivery. Incidence and characteristics of PABS were reported. Univariate analysis was conducted to look for potential risk factors of developing PABS. The 438 consecutive FFTS cases were treated at 15-26 weeks of gestation; PABS developed in 8 cases (1.8 %). The affected twin was always the former recipient. The diagnosis was made prenatally in 2 of 8 cases (25%). All cases survived the perinatal period. PABS affected fetal leg, arm, and foot in 3, 4, and 1 cases, respectively. In 5 (62.5%) and 7 (87.5%) cases, PABS occurred after premature rupture of membranes and intrauterine death of the donor, respectively. In 4 cases (50%), there was both premature rupture of membranes (PROM) and intrauterine fetal death; in 3 cases (37.5%), there was intrauterine fetal death alone, and in 1 case (12.5%), there was PROM alone. In the remaining 430 cases, PROM occurred in 62 cases (14.4%) and 66 cases (15.3%) within and after 3 weeks after surgery, respectively. PROM was significantly more frequent within the group that was complicated with PABS than within the rest of the cohort (P = .05). No maternal, fetal, or perioperative risk factor could be identified. Awareness and targeted serial ultrasound evaluation in this high-risk group may improve prenatal diagnosis, counseling, and management of PABS after FLS.

Outcome of anaemic monochorionic single survivors following early intrauterine rescue transfusion in cases of feto‐fetal transfusion syndrome

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). 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. 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. In cases of FFTS with single anaemic survivors, early IUT could be offered following extensive counselling and close follow up.

OP15.04: Pseudo‐amniotic band syndrome: a rare complication of monochorionic twins with feto‐fetal transfusion syndrome treated by laser coagulation

The aim of the study was to assess the incidence and risk factors of limb constriction defects related to pseudoamniotic band syndrome (PABS) as a rare complication following selective fetoscopic laser surgery (FLS) in feto-fetal transfusion syndrome (FFTS). All consecutive cases of FFTS treated by selective FLS between 1999 and 2006 were prospectively examined for PABS at the time of delivery. The incidence and characteristics of PABS were reported. Univariate analysis was conducted to look for potential risk factors of developing PABS. 438 consecutive FFTS cases were treated at 15 to 26 weeks. PABS developed in eight cases (1.8%). The affected twin was always the former recipient. The diagnosis was made prenatally in two of eight cases (25%). All cases survived the perinatal period. PABS affected fetal leg, arm or foot. In five (62.5%) and seven (87.5%) cases, PABS occurred following premature rupture of membranes and intrauterine demise of the donor, respectively. No maternal, fetal or peri-operative risk factor could be identified. This complication is related to invasive procedure and is probably different in the physiopathology from the intrinsic malformative theory, suggesting that the anomalies and the fibrous bands have a common origin, caused by an anomaly of the developing germinal disc of the early embryo. The sequence of events in our series involved rupture of the amnion (5/8), fetal demise of the donor after laser fetoscopy (7/8) and prematurity (7/8). The latter is consistent with a particular role of membranes in this condition. Awareness and targeted serial ultrasound evaluation in this high-risk group may improve prenatal diagnosis, counseling and management of PABS following FLS.