Reduction In Monochorionic Pregnancies Research Articles

Early detection of ischemic brain injuries by diffusion-weighted imaging after radiofrequency ablation for fetal reduction in monochorionic pregnancies.

This study aimedto investigate the additional advantages of magnetic resonance imaging (MRI), particularly diffusion-weighted imaging (DWI) over fetal ultrasound in the detection of acute ischemic cerebral injuries in complicated monochorionic (MC) pregnancies that underwent selective reduction by radiofrequency ablation (RFA). This prospective cohort study was conducted on 40 women with complicated MC pregnancies who were treated by RFA. Fetal brain imaging by DWI and conventional MRI was performed either in the early (within 10 days after RFA) or late phase (after 3-6 weeks) in the surviving fetuses to detect both acute and chronic ischemic injuries. The presence of anemia after RFA was also evaluated by Doppler ultrasound. Overall, 13 of the total 43 fetuses (30.23%) demonstrated MRI abnormalities with normal brain ultrasound results including germinal matrix hemorrhage (GMH), extensive cerebral ischemia, and mild ventriculomegaly. Although seven fetuses with GMH eventually survived, fetuses that demonstrated ischemic lesions and ventriculomegaly on MRI died in the uterus. The absence of abnormal cerebral lesions or anemia on ultrasound and Doppler exams does not necessarily rule out fetal brain ischemia. Performing early MRI, particularly DWI seems to be a reasonable option for detection of early intracranial ischemic changes and better management of complicated multiple pregnancies which were treated by RFA.

VP39.01: Assessment of the time course of postmortem fetal brain changes by DWI after radiofrequency ablation for fetal reduction in monochorionic pregnancies

VP39.01: Assessment of the time course of postmortem fetal brain changes by DWI after radiofrequency ablation for fetal reduction in monochorionic pregnancies

OC08.01: Early detection of brain ischemic lesions by diffusion weighted imaging after radiofrequency ablation for fetal reduction in monochorionic pregnancies

OC08.01: Early detection of brain ischemic lesions by diffusion weighted imaging after radiofrequency ablation for fetal reduction in monochorionic pregnancies

Outcome of radiofrequency ablation for selective fetal reduction before vs at or after 16 gestational weeks in complicated monochorionic pregnancy

To investigate whether gestational age at intervention (< or ≥ 16 weeks) and other factors affect the risk of loss of the cotwin after selective fetal reduction using radiofrequency ablation (RFA) in monochorionic (MC) pregnancy. This was a single-center retrospective analysis of 63 consecutive RFA procedures performed at our institution from January 2011 to October 2019 for selective fetal reduction in complicated MC pregnancies. Indications for RFA were twin reversed arterial perfusion sequence (13 cases), twin-to-twin transfusion syndrome (12 cases), twin anemia-polycythemia sequence (two cases), selective fetal growth restriction (10 cases), discordant anomalies (17 cases) and multifetal pregnancy reduction in triplets or quadruplets with a MC pair (nine cases). Twenty-six (41.3%) of these procedures were performed before and 37 (58.7%) after 16 weeks. Potential factors that could affect the risk of loss of the cotwin, including gestational age at RFA, order of multiple pregnancy, amnionicity, indication for RFA and number of ablation cycles, were assessed first by univariate analysis and then by multivariate analysis. There were 17 (27.0%) cotwin losses. Ablation cycles numbering four or more was the only factor among those investigated to be associated with loss of the cotwin after RFA (P = 0.035; odds ratio, 5.21), while the indication for RFA, order of multiple pregnancy, amnionicity and gestational age at RFA had no effect. Comparing RFA performed at < 16 vs ≥ 16 weeks, there was no difference in the rate of cotwin loss (23.1% vs 29.7%; P = 0.558) or preterm prelabor rupture of the membranes before 34 weeks (7.7% vs 5.4%; P = 0.853), or in the median gestational age at delivery (36.2 vs 37.3 weeks; P = 0.706). RFA is a promising tool for early selective fetal reduction in MC pregnancy before 16 weeks. Four or more ablation cycles is a major risk factor for cotwin loss. Careful assessment pre- and post-RFA, together with proficient operative skills to minimize the number of ablation cycles, are the mainstay to ensure that this procedure is effective and safe. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Clinical Outcomes after Selective Fetal Reduction of Complicated Monochorionic Twins with Radiofrequency Ablation and Bipolar Cord Coagulation

Aims: To review pregnancy outcomes, complication rates and neonatal neural development of selective termination procedures for complicated monochorionic (MC) twins. Methods: This was a retrospective review of the pregnancies that underwent selective reduction with radiofrequency ablation (RFA) and bipolar cord coagulation (BCC) in our institution. Results: Forty-eight cases underwent selective reduction with BCC and the remaining 45 with RFA. Overall survival was not statistically different between the RFA and BCC groups (71.1 and 62.5%, p = 0.379). With regard to the indications, the survival rates were not significantly different for twin to twin transfusion syndrome, twin reversed arterial perfusion, discordant anomalies and selective intrauterine growth restriction. Preterm premature rupture of membrane was not statistically different between the BCC and RFA groups (47.9 and 33.3%, p = 0.153). Five foetuses presented with abnormal middle cerebral artery-peak systolic velocity in the BCC group and 4 in the RFA group (p = 0.829). In the BCC group, neurological injury was detected in 2 neonates, presenting with cerebral dysplasia on MR scanning. In the RFA group, intracranial haemorrhage Grade III was detected in one neonate with cranial ultrasound (p = 0.607). Conclusions: Overall survival and complication rates following selective reduction in complicated MC twin pregnancies is similar irrespective of whether the reduction was performed using RFA or BCC. Key Message: It seems that selective reduction in MC pregnancies with RFA does not carry a significant decrease in the overall survival and complication rates than the cases with BCC. According to our data, neurodevelopmental impairment of the co-twins is relatively seldom after selective reduction.

Outcome following selective fetal reduction in monochorionic and dichorionic twin pregnancies discordant for structural, chromosomal and genetic disorders

To investigate the indications for offering selective fetal reduction in monochorionic (MC) and dichorionic (DC) twins and to correlate obstetric outcome with the antenatal procedure. All cases of MC and DC twins discordant for structural anomalies and for chromosomal/genetic abnormalities were included. Selective reductions performed for twin-to-twin transfusion syndrome or growth restriction were excluded. For DC twins, feticide was achieved using intracardiac injection of potassium chloride (KCl). For MC twins, bipolar cord occlusion (BCO), interstitial laser or radiofrequency ablation (RFA) was used. There were 121 twin pregnancies discordant for structural and chromosomal abnormalities. Only 88 (56 were MC twins and 32 were DC twins) had selective reduction. For both MC and DC twins, the leading indication for selective reduction was structural anomalies with CNS malformations the most common. For all MC fetal reduction techniques, the overall pregnancy loss rate (<24weeks) was 8.9% with RFA having the lowest procedure loss rate (7.7%). The preterm delivery rate was lowest with reduction in DC pregnancies. The live birth rates for MC twins were >87% and 100% for DC twins. Selective reduction in MC pregnancies carries an increased procedure-related and preterm delivery rate compared with DC pregnancies. The main indication for selective reduction was structural malformations, with a predominance of CNS anomalies.

P09.23: A clinical trial of ultrasound treatment for TRAP sequence

Objectives: Selective fetal reduction in monochorionic (MC) pregnancies requires vaso-occlusive procedures to ablate umbilical cord blood flow to achieve asystole of the targeted fetus. We describe the perinatal outcome of a large series of MC pregnancies following radiofrequency ablation (RFA). Methods: This was a prospective study at Queen Charlotte’s Hospital, London of all cases of selective fetal reduction in MC pregnancies using RFA between Jan 2008 and Dec 2011. Indications for fetal reduction included discordant structural anomaly, TRAP sequence, discordant aneuploidy, twin to twin transfusion syndrome, multifetal reduction (MFPR) in triplets or higher order MC pregnancies or fetal growth restriction (FGR). Outcomes investigated were: rupture of membranes (ROM) or miscarriage within 2 weeks of the procedure, preterm delivery, co-twin demise, brain injury, fetal and neonatal death. Statistics were calculated with SPSSv.19. Results: 84 cases of RFA were performed (31 for structural anomaly, 9 for TRAP, 20 for TTTS, 2 for aneuploidy, 11 for MFPR, 11 for FGR). The median gestation at RFA was 17.5 weeks (range 12.1–27.6 weeks). The overall live birth rate was 82%. PPROM and/or miscarriage within 2 weeks occurred in 3% of cases respectively. Co-twin IUD occurred in 13% of cases. The median gestation at delivery was 35 weeks (Range 14–41 weeks). The preterm (<37 weeks) live birth rate was 45%. The incidence of brain injury following the RFA was 4.5%. Neonatal death occurred in 1.2% of cases. The incidence of co-twin demise appeared greatest (19.2%) when the RFA was performed before 16 weeks compared to after 16 weeks (13.9%), although this did not reach significance (P = 0.082). There were no maternal complications. Conclusions: RFA is a safe technique for selective reduction in MC pregnancies and can be performed much earlier compared with other methods. The risk of co-twin demise appears greatest before 16 weeks gestation.

P09.22: Perinatal outcomes following radiofrequency ablation in monochorionic pregnancies

Objectives: Selective fetal reduction in monochorionic (MC) pregnancies requires vaso-occlusive procedures to ablate umbilical cord blood flow to achieve asystole of the targeted fetus. We describe the perinatal outcome of a large series of MC pregnancies following radiofrequency ablation (RFA). Methods: This was a prospective study at Queen Charlotte’s Hospital, London of all cases of selective fetal reduction in MC pregnancies using RFA between Jan 2008 and Dec 2011. Indications for fetal reduction included discordant structural anomaly, TRAP sequence, discordant aneuploidy, twin to twin transfusion syndrome, multifetal reduction (MFPR) in triplets or higher order MC pregnancies or fetal growth restriction (FGR). Outcomes investigated were: rupture of membranes (ROM) or miscarriage within 2 weeks of the procedure, preterm delivery, co-twin demise, brain injury, fetal and neonatal death. Statistics were calculated with SPSSv.19. Results: 84 cases of RFA were performed (31 for structural anomaly, 9 for TRAP, 20 for TTTS, 2 for aneuploidy, 11 for MFPR, 11 for FGR). The median gestation at RFA was 17.5 weeks (range 12.1–27.6 weeks). The overall live birth rate was 82%. PPROM and/or miscarriage within 2 weeks occurred in 3% of cases respectively. Co-twin IUD occurred in 13% of cases. The median gestation at delivery was 35 weeks (Range 14–41 weeks). The preterm (<37 weeks) live birth rate was 45%. The incidence of brain injury following the RFA was 4.5%. Neonatal death occurred in 1.2% of cases. The incidence of co-twin demise appeared greatest (19.2%) when the RFA was performed before 16 weeks compared to after 16 weeks (13.9%), although this did not reach significance (P = 0.082). There were no maternal complications. Conclusions: RFA is a safe technique for selective reduction in MC pregnancies and can be performed much earlier compared with other methods. The risk of co-twin demise appears greatest before 16 weeks gestation.