Incidence Of Twin-twin Transfusion Syndrome Research Articles

Perinatal outcome of monochorionic diamniotic twin pregnancies complicated with isolated amniotic fluid volume abnormality of one twin less than 26 weeks of gestation.

To evaluate the incidence of twin-twin transfusion syndrome (TTTS) and the perinatal outcome at 28 days of age in monochorionic diamniotic (MCDA) pregnancies complicated with isolated polyhydramnios (I-Poly) and isolated oligohydramnios (I-Oligo) diagnosed < 26 weeks of gestation. This was a retrospective study of women with MCDA pregnancies diagnosed with I-Poly or I-Oligo before 26 weeks of gestation over a period of six years. The incidence of subsequent TTTS and neonatal outcome in terms of intact survival (IS) at 28 days of age were evaluated. Intact survival was defined as being alive without any neurological complications at 28 days of age. There were 30 cases of I-Poly and 53 of I-Oligo that were eligible as per the inclusion criteria. Subsequent TTTS were complicated in six (20.0%) of the I-Poly and 26 (49.0%) of the I-Oligo cases. Among subjects with I-Poly, 17 had spontaneously normalized amniotic fluid volume. Prolonged oligohydramnios until intrauterine death, delivery or the onset of emerging TTTS was noted in 16 cases of I-Oligo. Both the twins exhibited IS in 26 (86.7%) cases of I-Poly and 31 (58.4%) cases of I-Oligo. One-fifth of I-Poly and half of I-Oligo MCDA twins at < 26 weeks of gestation potentially develop TTTS. I-Oligo in particular should be regarded as a high-risk condition as neonatal IS is less than 60%.

Significance of Velamentous Cord Insertion for Twin-Twin Transfusion Syndrome

Introduction: The objective of this study was to evaluate the actual association between velamentous cord insertion (VCI) and twin-twin transfusion syndrome (TTTS) in the native cohort concerning the natural history of monochorionic twin pregnancies. Material and Methods: All monochorionic diamniotic twin pregnancies who received prenatal care from <16 weeks of gestation until delivery at our center between 2004 and 2013 were included in this retrospective cohort study. Macroscopically defined cord insertion site was recorded as velamentous, marginal, or central. The effects of VCI on TTTS and a composite of adverse outcomes, including abortion, death, and neurological morbidities ≤28 days of age, were evaluated with a multiple logistic regression model. Results: A total of 357 monochorionic diamniotic twin pregnancies were analyzed. VCI in both twins was noted in 2.5% of cases and VCI in at least one twin was noted in 22.1% of cases. The incidence of TTTS was 8.4%; the incidence of a composite of adverse outcomes in at least one twin was 9.8%. There was no correlation between VCI and TTTS as well as a composite of adverse outcomes. Discussion: VCI in monochorionic twin pregnancies was not a risk factor for TTTS and severe perinatal morbidities.

Perinatal outcome of monochorionic diamniotic twin pregnancies managed from early gestation at a single center

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. 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. 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%). 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.

Perinatal Outcome of Monoamniotic Twin Pregnancies

To study perinatal mortality and neonatal morbidity in a large cohort of monoamniotic twin pregnancies with special emphasis to the gestational age-specific mortality. The study included monoamniotic twin pregnancies delivered in 10 perinatal centers in the Netherlands between January 2000 and December 2007. A total of 98 monoamniotic pregnancies were included. The perinatal mortality rate (20 weeks of gestation through 28 days of life) was 19%; after exclusion of fetuses with lethal anomalies, the rate was 17%. After 32 weeks of gestation, only two pregnancies were complicated by perinatal mortality (4%). The incidence of twin-twin transfusion syndrome was 6%. The incidence of congenital heart anomalies and cerebral injury was 4% and 5%, respectively. The current incidence of perinatal mortality in monoamniotic twins is considerably lower than in previous decades, but it is still high and occurs throughout pregnancy. III.

Detection of chromosomal abnormalities, congenital abnormalities and transfusion syndrome in twins

To evaluate the outcome of screening for structural malformations in twins and the outcome of screening for twin-twin transfusion syndrome (TTTS) among monochorionic twins through a number of ultrasound scans from 12 weeks' gestation. Enrolled into this prospective multicenter observational study were women with twin pregnancies diagnosed before 14 + 6 gestational weeks. The monochorionic pregnancies were scanned every second week until 23 weeks in order to rule out early TTTS. All pregnancies had an anomaly scan in week 19 and fetal echocardiography in week 21 that was performed by specialists in fetal echocardiography. Zygosity was determined by DNA analysis in all twin pairs with the same sex. Among the 495 pregnancies the prenatal detection rate for severe structural abnormalities including chromosomal aneuploidies was 83% by the combination of a first-trimester nuchal translucency scan and the anomaly scan in week 19. The incidence of severe structural abnormalities was 2.6% and two-thirds of these anomalies were cardiac. There was no significant difference between the incidence in monozygotic and dizygotic twins, nor between twins conceived naturally or those conceived by assisted reproduction. The incidence of TTTS was 23% from 12 weeks until delivery, and all those monochorionic twin pregnancies that miscarried had signs of TTTS. Twin pregnancies have an increased risk of congenital malformations and one out of four monochorionic pregnancies develops TTTS. Ultrasound screening to assess chorionicity and follow-up of monochorionic pregnancies to detect signs of TTTS, as well as malformation screening, are therefore essential in the antenatal care of twin pregnancies.

Diagnosis, management and pregnancy outcomes of twin-twin transfusion syndrome

目的 探讨双胎输血综合征的临床诊断、处理及妊娠结局.方法回顾性分析十五年间18例双胎输血综合征(TTTS组)和620例非双胎输血综合征双胎(非TTTS组)的临床资料,比较两组的妊娠并发症、妊娠合并症和妊娠结局. 结果 (1)双胎输血综合征占双胎妊娠总数的2.8%,占单绒毛膜双胎的8.1%;(2)明确分期14例,引产10例,要求保留胎儿7例(Ⅱ期1例、Ⅲ期5例、Ⅳ期1例);3例经腹羊水减量,其中2例转为Ⅴ期后引产,1例胎儿镜下激光凝固胎盘血管交通支,获两活婴;(3)TTTS组辅助生育受孕明显低于非TTTS组(11.1%比40.0%,P＜0.05),胎盘早剥发生率明显高于非TTTS组(22.2%比1.3%,P＜0.05);(4)TTTS组终止妊娠孕周、胎儿平均出生体重显著低于非TTTS组(P＜0.01).TTTS组胎儿死亡、畸形和窒息的发生率分别为41.7%、16.7%和33.3%,显著高于非TTTS组的6.4%、1.9%和7.0%(P＜0.01). 结论 (1)双胎输血综合征严重影响胎儿预后;(2)明确双胎输血综合征的分期有助于临床处理和评估预后;(3)胎儿镜下激光凝固胎盘血管交通支术治疗双胎输血综合征有较好的应用前景。

Antenatal Detection of Arterio-Arterial Anastomoses by Doppler Placental Assessment in Monochorionic Twin Pregnancies

Objectives: To evaluate the reproducibility of Doppler antenatal detection of arterio-arterial anastomoses (AAA) in monochorionic (MC) twin pregnancies. Methods: Between October 2002 and February 2004, 21 MC diamniotic twin pregnancies and one dichorionic triamniotic triplet seen at the Twin Clinic at the University of Brescia were recruited. After routine ultrasonographic assessment, AAA were searched using Color or Power and spectral Doppler. The presence of AAA was confirmed postnatally by placental injection studies. Results: Data of 19 patients were available for the analysis. AAA were detected in 12 cases (63%) antenatally and in 16 (84.2%) at injection study. Sensitivity and specificity of Doppler for detecting AAA were 75 and 100%, respectively. Detection rates increased at advanced gestations and with anterior/fundal placentae. The incidence of twin-twin transfusion syndrome was higher in the group with no AAA detected in vivo compared to the group with AAA found with Doppler (28.5 vs. 16.6%), but the difference was not statistically significant (p = 0.5). Conclusion: This study confirmed the feasibility of AAA Doppler detection in vivo in MC pregnancies.

Twin-twin transfusion syndrome treated with serial amniocenteses.

To evaluate the treatment and neonatal outcome in pregnancies complicated by twin-twin transfusion syndrome (TTS). Twenty-four women with TTS were identified in the period 1993-99 among 34477 deliveries. We include a retrospective chart review of all twins with TTS. The overall incidence of TTS was 4.75% of all twin pregnancies. The mean gestational age at the time of diagnosing TTS was 23 weeks (range 17.6-38), and the mean gestational age at delivery was 34.6 weeks (range 23.1-38.3). Therapeutic amniocenteses was performed in 21 women. The total volume drained varied from 0.4 to 32.31 with a mean of 2.3 l. Overall perinatal mortality in TTS was 35.4%, as nine donor twins and eight recipient twins died. The main causes for mortality were intrauterine death and prematurity. Twin-twin transfusion syndrome is a severe complication in monochorionic diamniotic twin pregnancies, with high perinatal mortality and morbidity even though amnioreduction prolonged the pregnancies leading to better neonatal outcome.

Monoamniotic-versus diamniotic-monochorionic twin placentas: anastomoses and twin-twin transfusion syndrome

Objective The purpose of this study was to compare monoamniotic-monochorionic and diamniotic-monochorionic twin placentas and to estimate the incidence of twin-twin transfusion syndrome in monoamniotic-monochorionic twin pregnancies. Study design We analyzed the angioarchitecture and cord insertion distance in 24 monoamniotic-monochorionic and 200 diamniotic-monochorionic placentas. Results Compared with diamniotic-monochorionic placentas, monoamniotic-monochorionic placentas had significantly more arterioarterial anastomoses (20/20 vs 159/200, respectively; P = .013), significantly less opposite arteriovenous anastomoses (10/20 vs 165/200, respectively; P = .002), similar venovenous anastomoses (6/20 vs 46/200, respectively; P = .323), and arteriovenous anastomoses (20/20 vs 187/200 respectively; P = .279) and significantly shorter umbilical cord distances (median [±SD], 5.0±6.9 cm vs 17.5±6.8 cm; P<.001). Conclusion Monoamniotic-monochorionic and diamniotic-monochorionic placentas have different anastomotic patterns. The (virtually) 100% incidence of arterioarterial anastomoses in monoamniotic-monochorionic placentas explains the reason that twin-twin transfusion syndrome rarely occurs in monoamniotic-monochorionic twin pregnancies and predicts that twin-twin transfusion syndrome manifestations are approximately 5 times less often recognized in monoamniotic-monochorionic pregnancies than in diamniotic-monochorionic pregnancies.

Twin transfusion syndrome--diagnosis and prognosis

Twin-twin transfusion syndrome is a serious complication of monozygotic, monochorionic, diamniotic twins resulting from transplacental vascular communications. In this syndrome blood is thought to be shunted from one twin--donor, who develops anaemia, growth retardation and oligoamnios, to the other twin--recipient, who becomes plethoric, macrosomic and develops polyhydroamnios. The incidence of twin-twin transfusion syndrome ranges from 5-15% of all twin pregnancies. If this condition develops in the second trimester, it is usually associated with spontaneous abortion and death of one or both fetuses before viability. Developing the syndrome in the third trimester has better perinatal outcome. Mortality rates ranging from 56%-100%, depending on gestational age and severity of the syndrome. The ultrasound criterias for diagnosis, in this study, were the presence of twins of the same sex with discordant growth, with oligohydroamnios in one twin sac and polyhydroamnios in the other one, one placenta and thin membrane between twins. The present study shows clinical course of 14 cases and value of Doppler ultrasound to analyze the usefulness of umbilical artery blood flow velocimetry for predicting the risk of twin-twin transfusion syndrome. 14 twin pregnancies with twin-twin transfusion syndrome were diagnosed during the last four years period and prospectively followed. 9 cases were diagnosed before the completion od 28 weeks of gestation. The mean gestational age was 21.6 _+ 4.2 weeks at diagnosis and 23.2 +_ 3.6 weeks at delivery. 5 cases were diagnosed after 28 weeks of gestation. The mean gestational age in this group was 29.6 +_ 2.1 weeks at diagnosis and 33 +_ 3.3 weeks at delivery. The survival rate in this study was 29% (8/28). 9 cases ended in spontaneous abortion between 18th and 27th weeks of pregnancy (table 1) and 5 in premature labor (table 2). There were 7 intrauterine death (5 at admission and 2 few days after admission) and 13 neonatal deaths. Overall mortality rate was 71% (20/28). Up to 28th weeks mortality rate was 100% and after 28th weeks mortality rate was 20% (2/10). 9 cases had "stuck" twin phenomenon. The differences in the Doppler indexes from twin-twin transfusion syndrome cases significantly exceeded those without this syndrome. This difference seemed to predict the risk of twin-twin transfusion syndrome, but the number of cases is too small for general conclusions. Treatment regimens for twin-twin transfusion syndrome have included bed rest, tocolytic agents and serial amniocenthesis for decompression in some cases. Neither serial amniocenthesis nor tocolytic agents use were associated with an improved survival rate in our study. Twin-twin transfusion syndrome can be diagnosed early in second trimester of pregnancy, but the survival rate remains low with the current methods of treatment. Survival was related to gestational age at delivery and birth weight. Twin-twin transfusion syndrome diagnosed before 28th weeks of gestation represents one of the most lethal conditions in perinatal medicine today.

Incidence of intrauterine complications in monoamniotic twin gestation.

We compared the incidence of intrauterine complications, such as twin-twin transfusion syndrome, between monochorionic-monoamniotic (MM) and monochorionic-diamniotic (MD) twin gestations. We retrospectively evaluated a series of 11 MM and 211 MD twin gestations managed after 22 weeks' gestation at our hospitals. One MM twin gestation was diagnosed with twin-twin transfusion syndrome based on clinical presentation of polyhydramnios and hydrops. The incidence of twin-twin transfusion syndrome in MM twin gestations (9.1%) was not measurable different from that in the MD twin gestations (7.6%, p=0.09). There were no measurable differences in the incidence of other complications, such as growth discordance >25% or intrauterine fetal demise between the two groups. MM twin gestations should be kept under close management while carefully monitoring for any circulatory imbalance between the twins.