Normal Twin Research Articles

164: Midtrimester isolated polyhydramnios in monochorionic diamniotic multiple gestations

164: Midtrimester isolated polyhydramnios in monochorionic diamniotic multiple gestations

3D Ultrasonography to Evaluate Fetal Urinary Production Rates in Twin Gestation: Construction of a Normal Value Curve

The aim of this study was to assess fetal urinary production rates (FUPR) in twin gestations using 3D ultrasonography with VOCAL® (virtual organ computer-aided analysis) and to develop a curve of normal values for the target population. A cross-sectional study was performed in 30 normal twin pregnancies with gestational ages ranging from 20 to 34 weeks. FUPR was measured using a three-dimensional ultrasound (3D US) virtual organ computer-aided analysis (VOCAL) system. FUPR (ml/hour) was calculated during the filling phase using the equation UPR = (VFB(2) - VFB(1))/time. The values for UPR were plotted as a function of fetal biometry (biparietal diameter) to generate a nomogram. A total of 41 normal twin fetuses with gestational ages between 20 and 34 weeks were investigated. Eleven were excluded because of inadequate bladder contour image quality and/or the observation of micturition in one or both fetuses. Linear regression analysis of FUPR as a function of biparietal diameter (BPD) shows the normal range for UPR by fetal biometry and is expressed by the following equation: Ln(UPR) = -5.0121 + 0.0548 BPD (R(2) 0.3386, p value <.001). There was no statistically significant difference when the UPR was stratified by chorionicity. The use of biometric parameters to predict fetal FUPR seems to be useful. In twin pregnancies, BPD is the variable that is most closely related to FUPR. For each 1 mm increase in BPD, there is a 5% increase in FUPR. Chorionicity did not affect FUPR.

Gestational Sac Aspiration of Heterotopic Ectopic Pregnancy in a Cesarean Section Scar

Abstract Background: This article describes a case of heterotopic pregnancy that included a normal twin intrauterine pregnancy and one cesarean section (CS) scar pregnancy diagnosed at 6 weeks of gestation. Ultrasound-guided aspiration of the ectopic gestational sac was performed, and the concurrent twin intrauterine pregnancy (IUP) was preserved successfully. The patient was a 50-year-old woman with secondary infertility. Case: The patient underwent in vitro fertilization and embryo transfer using a donor-egg program to achieve pregnancy with her current partner. At 6-weeks' gestation, she underwent a transvaginal ultrasound scan (US) examination showing a viable twin IUP with a third gestational sac with viable embryo located low within the anterior wall of the uterus. The appearance was consistent with a cesarean scar ectopic pregnancy. This was confirmed on a subsequent US 1 week later. She desired to continue the intrauterine pregnancy. US-guided aspiration of the cesarean scar ectopic pregnancy was ...

Screening for Down syndrome in dichorionic twin pregnancies conceived by in vitro fertilization (IVF): a clinical pilot study to confirm the laboratory methods

The corrections necessary to estimate the risk for Down syndrome in twin pregnancies have been pointed out. We performed a nested controlled study to evaluate the validity of these corrections in dichorionic twins conceived by IVF. Detailed clinical data was collected from the medical records. Twins were matched with a contemporaneous cohort of spontaneously conceived singleton pregnancies that serve as reference in a 1 to 4 ratio. All patients had their entire obstetrical care at our Hospital. The Student t-test was used for group comparisons and a p-value <0.05 was considered significant. Nineteen sets of normal twins concordant in size and with appropriate weight for gestational age were matched with 80 normal and mature newborns. Significant differences between groups were found for maternal age, gestational age at delivery and newborn weight (all p < 0.01). No statistical differences were noted for the levels of the biochemical markers expressed as multiples of the median. However, a 15% closer approximation to the laboratory median for PAPP-A and a 10% closer approximation to the laboratory median for free β-hCG was evident in twins when compared to the reference group. These findings support the methods used to estimate the risk for Down syndrome in dichorionic twin pregnancies conceived after IVF. A future study with a larger sample size could confirm if the laboratory corrections done on the combined screening test improve the predictability of Down syndrome in dichorionic twin pregnancy conceived by IVF when compared to singleton pregnancies.

Longitudinal assessment of amniotic fluid volume in monoamniotic twin gestations

The aim of this study is to describe normal amniotic fluid volume through gestation in a cohort of normal monoamniotic (MA) twins. Our ultrasound database was queried for MA twin gestations from 2004 to 2011. Monochorionic twin pregnancies mimicking MA gestations, such as twin-twin transfusion syndrome, were excluded. Complicated MA gestations and higher-order multifetal gestations involving an MA pair were excluded. Thirty subjects were followed with serial amniotic fluid index (AFI) measurements from 15 to 32 weeks gestation. Using each AFI measurement as a unique data point, a quadratic regression model and a multi-level growth model were developed against gestational age (GA), providing a predicted AFI at each completed week, with a 95% confidence interval. The quadratic regression least squares and multi-level growth models yielded the same curve comparing the AFI to the GA. Figure 1 depicts the model with the 95% confidence interval for normal amniotic fluid volume by GA for normal MA twins. Table 2 shows the 5th, 50th, and 95th percentiles for AFI by week from 15 to 32 weeks. We have generated normative data for amniotic fluid volume across gestation in uncomplicated MA twins. This can be used as a reference when managing MA pregnancies.

P07.03: Prenatally diagnosed tracheal atresia in twin pregnancy

We present a rare case of prenatally diagnosed tracheal atresia in one of the fetuses of twin pregnancy. During routine 2nd trimester scan of otherwise normal dichorionic twin pregnancy, bilateral and uniform hyperechogenicity of fetal thorax, ascites, pulmonary hyperplasia, diaphragmatic eversion, mediastinal compression with large heart vessels, hydrops and polyhydramnios in one of the fetuses were noted leading us to working diagnosis of laryngeal atresia. Later an increase of ascites was observed and affected fetus died in utero at 31 weeks. The second twin was developing well and delivered by CS at 34 weeks (boy, 1700 g) due to spontaneous onset of delivery. The affected fetus (girl, 1440 g) was on autopsy diagnosed with tracheomalacia and tracheal atresia just above the level of anticipated branching into the bronchi. Supporting information can be found in the online version of this abstract Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Positional vertical opsoclonus: A transient phenomenon in normal healthy twins

Opsoclonus is characterized by rapid bursts of involuntary, multidirectional, saccades without an intersaccadic interval. Three types of opsoclonus that occur in infancy have been identified, 2 of which are associated with a systemic or neurologic condition. The third is a benign condition that occurs transiently in healthy neonates and preterm babies. We report a case of 2 healthy twins who presented with transient opsoclonus, which was confined only to the vertical plane and manifested only in a supine position. Opsoclonus disappeared when the cheek was tapped. These eye movements began at 3 months and completely resolved by 6 months of age.

Allotwinning in a molecular crystal: (1R,3S)-dimethyl 2-oxocyclohexane-1,3-dicarboxylate

Two polytypic modifications of (1R,3S)-dimethyl 2-oxocyclohexane-1,3-dicarboxylate intergrow to form allotwins. One phase shows monoclinic symmetry, Cc, while the other is orthorhombic Pmc21. The structures may be considered as two different modes of superstructure ordering of an underlying, disordered structure. Considered in the same metrically orthorhombic unit cell a = 37.8883, b = 4.7233, c = 11.6835 Å, the two can be conveniently distinguished by their non-standard centering, Cc being represented as Xc with the centering vectors (0 0 0); (½ 0 ½); (¼ ½ ¾); (¾ ½ ¼); and Pmc21 as Xmc21 with the centering vectors (0 0 0); (½ 0 0). The difference between the allotwin domains lies only in the relationship between next-nearest neighbors along the stacking direction 100 and hence the conformations and packing efficiencies are identical for both phases and all three domains. The stacking sequences for the two phases correspond to ABAB for the orthorhombic stacking and ABA'B'/AB'A'B for the two (equivalent) monoclinic stackings. The monoclinic phase dominates comprising ca 80% of the total volume. Within the monoclinic phase, the ratio between the two possible orientations is highly unbalanced (6:1) indicating relatively large domains. The allotwinning detected in this sample may appear exotic in molecular compounds, but we suggest that the rarity of such examples in the literature is a reflection of the paucity of software that can identify and handle such cases. It is easy to overlook the possibility that a complex diffraction pattern originates from allotwinning and assume that normal mono-component twinning is the cause. The underlying mechanism in this case is the formation of two-dimensional layers of molecules that allow for two equivalent, but in terms of absolute geometry, different, ways of stacking.

Perinatal outcome of monochorionic diamniotic twins with selective intrauterine growth restriction

To evaluate the perinatal outcome of three types of monochorionic diamniotic (MCDA) twins with selective intrauterine growth restriction (sIUGR). From January 2005 to June 2012, clinical data of 42 pairs of MCDA twins (84 fetuses) with sIUGR and 71 pairs of normal MCDA twins (142 fetuses) in the same period were analyzed retrospectively in the First Affiliated Hospital of Sun Yat-Sen University. Fetuses with sIUGR were classified into three groups based on umbilical artery Doppler flow.There were 25 cases of type I, 11 cases of type II and 6 cases of type III. The perinatal outcome was compared between sIUGR and normal MCDA twins, and among the three types of sIUGR as well. Perinatal outcomes included gestational age at delivery, rate of intrauterine fetal death (IUFD), birth weight, intertwin discordance of birth weight, neonatal death and survival rate at 6 months. (1) The gestational age of sIUGR at delivery was significantly earlier than the control group [(34±3), (36±2) weeks, respectively], and the rate of IUFD of both fetuses of sIUGR was significantly higher (4.8%, 0, respectively). In the sIUGR group, the average birth weight of large or small twins [(2130±350), (1520±400) g, respectively] was smaller than those in the control group [(2470±500), (2340±460) g, respectively]. The difference was statistically significant (P<0.05, P<0.01, respectively). The intertwin discordance of birth weight in sIUGR group was significantly larger (27.6%) than the control group (4.0%, P<0.01). (2) The gestational age at delivery in type II and type III [(34±5), (34±2) weeks, respectively] was significantly earlier than the control group (P<0.05). The rate of IUFD of both fetuses in type II (18%) was significantly higher than in type I (0) and the control group (0, P<0.05). In sIUGR group, the average birth weight of small twins in type I, type II and type III was (1640±430), (1330±310) and (1500±380) g respectively, all of which were significantly smaller than that in the control group (P<0.05). The average birth weight of small twins in type II was smaller than in type I and the difference was statistically significant (P<0.05). In sIUGR group, the intertwin discordance of birth weight in type I, type II and type III was 24.1%, 34.6%, 31.3% respectively, all of which were significantly larger than that in the control group (4.0%, P<0.05). There were no statistically significant differences of the intertwin discordance of birth weight among the three types of sIUGR (P>0.05). Survival rate at 6 months in type II (64%) was significantly lower than in type I (92%) and the control group (91.5%, P<0.01). The perinatal outcome of MCDA twins with sIUGR is poor. The outcome is different among the three types of sIUGR, and typeIIis the worst. Type II is associated with a high risk of intrauterine fetal demise. It is important to monitor the intrauterine situation closely.

Monozygotic twin discordant for Down syndrome: mos 47,XX,+21/46,XX and 46,XX

Monozygotic twins, developed from a single zygote, are almost identical in clinical phenotype and concordant karyotypes. Monozygotic twins with discordant karyotypes are thought to be quite rare. Here, we report monochorionic-diamniotic twins discordant for Down syndrome. On findings of prenatal ultrasonography, nuchal translucency thickness was different between twins, and suggested that one of the twins was at high risk for having chromosomal abnormalities including Down syndrome. The twins were monochorionic-diamniotic; therefore, chorionic villi sampling of the common placenta was performed. The karyotype of the chorionic villi cells was 46,XX, and pregnancy was maintained. After delivery, dysmorphic clinical features suggesting Down syndrome were found in one of the twins, while the other twin showed a morphologically normal appearance. Karyotypes of peripheral blood leukocytes were repeatedly normal in the dysmorphic twin; however, the karyotype of skin fibroblasts from the dysmorphic twin indicated Down syndrome mosaicism; 47,XX,+21[99]/46,XX[2]. The karyotype of skin fibroblasts from the morphologically normal twin was 46,XX. Monozygosity of the twins was confirmed by a short tandem repeat analysis using 16 polymorphic markers. A mitotic nondisjunction followed by the twinning would explain the discordant karyotypes between monozygotic twins.

Perinatal Outcomes in Preterm Growth-Restricted Twins: Effects of Gestational Age and Fetal Condition

To evaluate the perinatal outcome of intrauterine growth-restricted preterm twins and contribution of prematurity to morbidity and mortality. A case-control study of 211 preterm twins: 108 growth-restricted twins matched with 103 normal growth twins of the same gestational age. Mortality and morbidity rates were compared between groups. Fetal and overall perinatal mortality rates of growth-restricted fetuses were higher than normal growth ones. Respiratory distress syndrome incidence was lower and neurologic sequelae incidence higher in growth-restricted twins. No differences were observed between groups with respect to neonatal mortality, low Apgar score, neonatal intensive care unit admission, periventricular hemorrhage, sepsis, jaundice, and hematologic or metabolic disorders. Adverse perinatal outcomes of preterm twins complicated with intrauterine growth restriction are represented by a higher antepartum mortality rate, but once born alive, neonatal outcomes seem to be associated only with gestational age at birth, excluding a protective effect on lung maturation and a higher risk of long-term neurologic sequelae.

LABELING WHITE MATTER TRACTS IN HARDI BY FUSING MULTIPLE TRACT ATLASES WITH APPLICATIONS TO GENETICS.

Accurate identification of white matter structures and segmentation of fibers into tracts is important in neuroimaging and has many potential applications. Even so, it is not trivial because whole brain tractography generates hundreds of thousands of streamlines that include many false positive fibers. We developed and tested an automatic tract labeling algorithm to segment anatomically meaningful tracts from diffusion weighted images. Our multi-atlas method incorporates information from multiple hand-labeled fiber tract atlases. In validations, we showed that the method outperformed the standard ROI-based labeling using a deformable, parcellated atlas. Finally, we show a high-throughput application of the method to genetic population studies. We use the sub-voxel diffusion information from fibers in the clustered tracts based on 105-gradient HARDI scans of 86 young normal twins. The whole workflow shows promise for larger population studies in the future.

Anencephaly in twin pregnancy: a series of 6 cases

To report a series of cases of anencephaly in twin pregnancies and assess the prognosis of the normal twin. Retrospective study covering 4 years, at the CHU Campus in Lomé, assessing the sonographic aspects and management of cases of anencephaly in twin pregnancies. Anencephaly was found in 6 twin pregnancies. The mothers' mean age was 31 years and all had a very low socioeconomic status. All had drunk a plant infusion of an unknown chemical composition in early pregnancy. Mean gestational age at diagnosis was 25 weeks. Ultrasound performed in all cases showed that 5 cases involved monochorionic diamniotic placentas, and 1 case a dichorionic placenta. Both fetuses were alive at diagnosis in all cases: one had anencephaly and the other twin was normal. The average estimated weight of the anencephalic twin at diagnosis was 659 grams, and of the normal twin, 749 grams; growth was thus discordant. Hydramnios was noted in all cases. Expectant monitoring was instituted; both twins died before 30 weeks in 4 cases. Anencephaly in twin pregnancy is a rare occurrence. Ultrasound can be involved in the diagnosis and management.

Pregnancies in XY women: Is a weak myometrium cause of complications during pregnancy and delivery?

Abstract Two 46, XY women with Swyers syndrome: A 39 years old with a normal twin pregnancy and a 26 year old with a singleton pregnancy and uterine rupture in the 2nd trimester. A woman with Swyer syndrome carried a twin pregnancy and delivered by caesarean section, while another Swyer syndrome patient with a singleton showed uterine rupture gestation week 20. These results and the present literature with only about 20% vaginal deliveries may suggest that the uterus of the 46, XY women might be weak and unable to contract compared to uterine muscles in normal women due to its hypoplastic nature.

Bidirectional asynchronous arterial flow in monochorionic twins – a precursor to the twin reverse arterial perfusion sequence

Monozygotic twins are, as recently described in this journal, subject to many complications 1 including the twin reverse arterial perfusion sequence (TRAP), which has an incidence between 0.3 and 1%. Arrested cardiac development within the abnormal twin and failure of the heart due to reverse perfusion by the co-twin through placental vascular anastomoses, have been proposed as underlying etiologies 2. We describe a case that demonstrates aspects of the evolution of TRAP. A woman presented at 12 weeks of gestation with a monochorionic diamniotic gestation (single placental mass and the “T” sign). One fetus appeared normal with a crown–rump length (CRL) of 63.5 mm and normal nuchal translucency. The second fetus was smaller (CRL 47 mm) with nuchal edema (11.4 mm) and hydrops. The extremities appeared disproportionately small and the intracranial anatomy was abnormal. Umbilical and ductus-venosus Doppler images of the larger twin were normal, whereas a biphasic pattern was identified within the umbilical cord of the second twin; comprising two superimposed unsynchronized arterial waveforms of similar rate (160 bpm), indicating the presence of significant inter-twin transfusion. One week later both twins remained viable; the normal twin had grown appropriately while the other demonstrated minimal growth with worsening hydrops (nuchal edema now 16.4 mm). The bidirectional perfusion of this twin's umbilical cord now demonstrated heart rates that were discordant; the abnormal twin being bradycardic. By 14 weeks, the CRL of the abnormal twin was 65 mm; the other twin demonstrated normal growth. The abnormal fetus continued to demonstrate a bradycardia and bidirectional perfusion in its' cord (Figure 1). Given the increasing overall pregnancy loss rate with delayed co-twin demise, selective termination was performed at this stage. This was achieved using radiofrequency cord occlusion (Radionics Cooltip Probe, Valley Lab, Boulder, CO, USA) combined with amniocentesis (normal karyotype reported). Subsequent to this, the surviving fetus continued to develop normally and the pregnancy, complicated only by gestational diabetes, ended with a healthy infant delivered vaginally at 39 weeks (birthweight 3.2 kg). In TRAP, placental vascular anastamoses allow the torso of the dead twin to be perfused by the surviving “pump” twin. The increased cardiac load faced by this twin is partly dependent upon the size of the “acardiac mass” and accounts for the high mortality (50–70%) observed with TRAP. The etiology of TRAP remains poorly understood. The high rate of aneuploidy observed (30%) 3 has led to speculation that fertilization anomalies produce chromosomally discordant twins that are predisposed to the development of TRAP. Karyotypic discordance in monochorionic twins has been reported, however dizygosity is very rare with the data overwhelmingly supporting monozygosity. Indeed, genetic evaluation of TRAP cases has excluded the presence of fertilization disorders, including fertilization of either the first or second polar body, moreover suggesting that TRAP pregnancies are monozygous 4. Only the abnormal twin was karyotyped here. Although genetic confirmation of monozygosity was therefore not obtained, available data would suggest dizygosity to be very unlikely. Alternative hypotheses suggest that TRAP arises as the result of reversed twin-perfusion through vascular anastomoses 5. Several pathologies might contribute to such a process, including cardiac malformations 2 or severe growth discordance. This case lends support to the theory that in some cases, TRAP evolves as the result of circulatory inequalities that result in co-perfusion of one twin by the other with this progressing to complete reverse perfusion upon fetal demise – the hypothesized “cardiac regression sequence” 6.

Acardiac twin: Conservative management

Introduction: Acardiac twin is a rare anomaly occurring in 1 in 35,000 pregnancies. the outcome is fatal for the acardiac twin with a 50–75% mortality of the normal pump twin. Management options include conservative management, medical therapy, occlusion of connecting vessels and selective termination of the acardiac twin. the Management of a twin pregnancy complicated by an acardiac twin is a challenge because the continuous growth of the acardiac fetus is deleterious to the healthy pump twin leading to cardiac insufficiency, polyhydramnios, prematurity and even death of the normal twin. case report: We report three cases of acardiac twinning which presented with different manifestations, acardius acephalus, acardius myelocephalus and acardius amorphous. All the three cases were managed conservatively with

Velamentous insertion of the umbilical cord: intrapartum diagnosis

A report of velamentous insertion of the umbilical cord diagnosed during a normal twin delivery, a rare event with higher incidence in multiple pregnancies. Because it is generally asymptomatic, when the mother does not go into labor, pregnancy must be interrupted by performing a caesarean delivery. Previous vasa is a rare complication and can be lethal. Ultrasound is crucial for diagnosis.

Intrafetal Laser Ablation of Umbilical Vessels in Acardiac Twin with Successful Outcome

The incidence of acardiac twin (the preferred term is TRAP—Twin Reversed Arterial Perfusion sequence) is approximately 1:35,000 pregnancies. This is characterized by vascular anastomoses in combination with partial or complete lack of cardiac development in one of the twins. The poor outcome with increased morbidity and mortality (50–70 %) has been noted in the normal twin due to congestive heart failure, hydramnios, and preterm labor.

Three-dimensional HDlive rendering images of the TRAP sequence in the first trimester: reverse end-diastolic umbilical artery velocity in a pump twin with an adverse pregnancy outcome.

The twin reversed arterial perfusion (TRAP) sequence, also known as fetus acardius, occurs in 0.3 % of monozygotic twin gestations, which amounts to a frequency of about 1 per 35,000 deliveries [1, 2]. There have been only two reports on antenatal three-dimensional (3D) sonographic diagnosis of the TRAP sequence during pregnancy [3, 4]. The HDlive is a new surface render mode involving the use of skin-like colors, and ‘‘its system uses an adjustable light source, giving the operator the opportunity to create lighting and shadowing effects and thereby increasing depth perception’’ [5]. There have been four reports on fetal, placental, and umbilical cord ultrasound images using the 3D HDlive rendering mode [5–8]. Employing 3D HDlive with new skin-like colors, we can achieve a natural and anatomically realistic appearance of the embryo and fetus in utero. However, there has been no reports on 3D HDlive rendering displays of the TRAP sequence in the first trimester of pregnancy. There have been five reports on reverse end-diastolic velocity in umbilical artery velocimetry with an adverse pregnancy outcome at less than 14 weeks of gestation, which suggested that reverse end-diastolic umbilical artery velocity waveforms might be an ominous sign in early pregnancy [9–13]. However, there are no sonographic findings in the first trimester that can help to distinguish between pregnancies resulting in death of the pump twin from those that will survive until prophylactic intervention at 16–18 weeks in TRAP sequence cases [14]. In this report, we present our experience of a TRAP sequence reconstructed employing the 3D HDlive rendering mode, and discuss the reverse end-diastolic blood flow velocity waveform in the umbilical artery of a pump twin with an adverse pregnancy outcome in the first trimester. A 33-year-old pregnant Japanese woman, gravida 1, para 0, was referred to our ultrasound clinic because of a suspected TRAP sequence at 11 weeks and 6 days of gestation. The 2D sonography and the 3D surface rendering mode (Voluson E8, GE Healthcare, Milwaukee, WI, USA) showed a normal pump twin and small acardiac twin with acrania and absence of the heart and upper limbs (Fig. 1). The crown-rump length of the pump twin was 43.3 mm (consistent with the corresponding age), and no gross fetal anomaly was noted. The longitudinal distance between the upper pole and rump of the acardiac fetus was 27.6 mm. The 3D HDlive rendering mode provided anatomically realistic images for TRAP sequence diagnosis (Fig. 2). Color and pulsed Doppler sonography revealed a reverse end-diastolic umbilical artery velocity in the pump twin at 13 weeks and 1 day of gestation (Fig. 3a). There was a single-artery umbilical cord between the placenta and acardiac fetus, and a reversed tiny absent diastolic umbilical artery velocity was noted (Fig. 3b). Fetal demise of the pump twin was confirmed at 14 weeks’ gestation. Delivery C. Tenkumo H. Tanaka M. Ito E. Uketa N. Mori U. Hanaoka K. Kanenishi T. Hata (&) Department of Perinatology and Gynecology, Kagawa University School of Medicine, 1750-1 Ikenobe, Miki, Kagawa 761-0793, Japan e-mail: toshi28@med.kagawa-u.ac.jp

TRAP Sequence - An Interesting Entity in Twins

Twin reversed arterial perfusion (TRAP) sequence, is a rare malformation occurring in monozygotic multiple gestations. One well-developed normal (pump) twin and the other twin with absent cardiac structure (acardiac), who is hemodynamically dependent on the normal (pump) twin are characteristic of this syndrome. The acardiac twin develops multiple anomalies that make survival difficult. The prognosis of the pump twin is variable with mortality rate ranging from 50% to 70%. Complications that affect the prognosis of the pump twin include complications of congestive cardiac failure due to increased cardiac demand, prematurity secondary to preterm delivery, and polyhydramnios. Because of these complications prompt detection, follow-up, and treatment of this condition is very important. We report two cases of TRAP sequence that emphasizes the importance of gray-scale and color Doppler imaging in diagnosis, detection of poor prognostic features, follow-up, and management of TRAP sequence.