Serial Amniocenteses Research Articles

Minimally invasive management of RH alloimmunization: Can amniotic fluid deltaOD450 be replaced by Doppler studies? A prospective multicenter trial

FLUID DELTAOD450 BE REPLACED BY DOPPLER STUDIES? A PROSPECTIVE MULTICENTER TRIAL DICK OEPKES, GARETH SEAWARD, FRANK VANDENBUSSCHE, JOHN KINGDOM, RORY WINDRIM, JOSEPH BEYENE, HUMPHREY KANHAI, ARNE OHLSSON, GREG RYAN, FOR THE DIAMOND STUDY GROUP, Leiden University Medical Center, Dept. of Obstetrics, Leiden, Netherlands, Fetal Medicine Unit, Mount Sinai Hospital, Toronto, Ontario, Canada, Dept. of Paediatrics, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada OBJECTIVE: In pregnancies complicated by red cell alloimmunization, the fetus may suffer from progressive hemolytic anemia, leading to hydrops and death if untreated. The standard management is to select at risk patients on the basis of obstetric history and maternal serum antibody levels. Evaluation is done by ultrasound for signs of hydrops, and serial amniocentesis for bilirubin (DOD450) values. Recently, middle cerebral artery (MCA) peak systolic velocity measurements have been reported to reliably predict fetal anemia. Our aim was to compare the performances of MCA Doppler and amniotic fluid DOD450. STUDY DESIGN: Prospective, international multicenter study of a cohort of consecutive Rh-D, c, E and Fy alloimmunized pregnancies with titers of R64 and antigen-positive fetuses. Both tests were performed simultaneously in all patients, and compared with the ‘‘gold standard’’ of fetal or cord blood sampling (at birth) to assess the actual hemoglobin (Hgb). Abnormal DOD450 was defined as a value on Liley’s chart in zone 2c or 3. Severe anemia was defined as Hgb of R5 SD below the mean for gestational age. RESULTS: In a total of 164 pregnancies with 165 fetuses (one set of twins), 74 fetuses were found to be severely anemic. MCA Doppler correctly predicted severe anemia in 65/74 (88%, 95% confidence interval: 83-93), with a specificity of 82% (77-88), positive predictive value 80% (74-86), NPV 89% (85-94), likelihood ratio pos. 5.00 (3.18-7.90), LR neg. 0.15 (0.08-0.27). Amniotic fluid DOD450 had a sensitivity of 76% (69-82), specificity 77% (70-83), PPV 73% (66-80), NPV 80% (73-86), LR pos. 3.28 (2.21-4.88), LR neg. 0.32 (0.21-0.48). CONCLUSION: MCA peak velocity measurement showed better test characteristics in the prediction of severe fetal anemia than traditional amniotic fluid DOD450 assessment. In addition, MCA Doppler is a noninvasive technique. This study shows that MCA Doppler can safely replace amniotic fluid DOD450 in the management of Rh-alloimmunized pregnancies. S2 SMFM Abstracts

Twin‐to‐twin transfusion syndrome: treatment with endoscopic laser surgery or serial amnio‐reduction?

Twin‐to‐twin transfusion syndrome: treatment with endoscopic laser surgery or serial amnio‐reduction?

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.

Twin-twin transfusion syndrome treated with serial amniocenteses

Twin-twin transfusion syndrome treated with serial amniocenteses

Fetoscopic laser surgery versus serial amniodrainage in the management of severe twin-to-twin transfusion syndrome at midgestation. a randomized controlled trial

Monochorionic twin pregnancies complicated by severe twin-to-twin transfusion syndrome at midgestation can be treated by either serial amniocentesis amniodrainage with removal of large volumes of amniotic fluid or by selective endoscopic fetoscopic laser coagulation of the communicating vessels on the chorionic plate. We conducted a randomized controlled trial to compare the efficacy of these two methods of treatment.

Stage-based treatment of twin-twin transfusion syndrome

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, ≥8 cm; oligohydramnios maximum vertical pocket, ≤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. (Am J Obstet Gynecol 2003;188:1333-40.)

Treatment Options for the Twin–Twin Transfusion Syndrome: A Review

This article reviews the treatment options of the twin–twin transfusion syndrome (TTTS). No single therapy is associated with a uniformly improved outcome for the involved twins and success is primarily related to gestational age and severity at diagnosis. Treatment options for severe cases include digitalization, ligation of the umbilical cord, serial amniocenteses, septostomy, laser occlusion of placental vessels, and selective feticide. These modalities are associated with significant risks of complications, and variable results of fetal morbidity and mortality. Therefore, they should be considered when risks of withholding treatment clearly outweigh those associated with intervention.

Treatment options for the twin-twin transfusion syndrome: a review.

This article reviews the treatment options of the twin-twin transfusion syndrome (TTTS). No single therapy is associated with a uniformly improved outcome for the involved twins and success is primarily related to gestational age and severity at diagnosis. Treatment options for severe cases include digitalization, ligation of the umbilical cord, serial amniocenteses, septostomy, laser occlusion of placental vessels, and selective feticide. These modalities are associated with significant risks of complications, and variable results of fetal morbidity and mortality. Therefore, they should be considered when risks of withholding treatment clearly outweigh those associated with intervention.

Pregnancy complicated by chronic spinal cord injury and history of autonomic hyperreflexia

Background: Women with spinal cord injuries are at risk for autonomic hyperreflexia during labor. Case: A 36-year-old woman, gravida 4, para 2, abortus 1, with a spinal cord injury and a positive antibody screen result had had a previous pregnancy complicated by autonomic hyperreflexia during labor. Autonomic hyperreflexia did not occur during serial amniocenteses and fetal transfusions for isoimmunization or intrapartum. Conclusion: Intrauterine procedures and vaginal delivery were accomplished without autonomic hyperreflexia in this pregnancy. Intrauterine procedures and vaginal delivery might be done safely in women with histories of autonomic hyperreflexia.

Twin-to-twin transfusion syndrome: a review of 27 cases and the relationship between gestational age at diagnosis and serial amniocentesis on outcome

Objective: To review outcomes of twin-to-twin syndrome (TTTS) cases and to examine the relationship between gestational age at diagnosis and serial amniocentesis drainage on these outcomes. Methods: Charts were reviewed from a 5-year period. Charts with a diagnosis of TTTS and multiples with discordant growth, polyhydramnios, oligohydramnios, or intrauterine growth restriction were reviewed. Diagnosis of TTTS was confirmed by ultrasound and pathological examination. Cases with placental insufficiency or chromosomal, cardiac, or urinary tract abnormalities were excluded. Outcomes were: survival rates, gestational age at delivery, and birth weight. Results were analyzed using the χ 2 and t tests. Results: Overall survival rate was 71%. Mean gestational age at delivery was 27.8 weeks, and mean birth weight was 1,141 g. If diagnosis was made before 24 weeks of gestation, the survival rate was 50%; if it was made after 24 weeks of gestation, survival was 100%. If drainage was required, survival rate was 56%. If no drainage was required, survival was 100%. Conclusions: TTTS still is associated with significant morbidity and mortality. Other treatments, such as laser ablation, need to be investigated, particularly for the patients who present in the second trimester. Studies of long-term morbidity also are needed.

Red Blood Cell Alloimmunization: Principles and Management in Pregnancy

Despite significant advances in immunohematology, including the discovery of the Rhesus factor and the subsequent development of nationwide Rh immune globulin prophylaxis programs, the incidence of Rhesus alloimmunization is one to two per 1000 Rh-negative women. This is largely due to the lack of administration of Rh immune globulin in high risk situations. The identification of a sensitized pregnant patient requires an initial antibody screen with appropriate antibody titres and paternal red blood cell antigen pheno-typing. Fetuses, identified at high risk due to critical antibody titre levels, require invasive action with serial amniocenteses plus amniocyte antigen testing. Percutaneous umbilical blood sampling or intrauterine fetal transfusion may be dictated in severe situations.

ACARDIAC TWIN PREGNANCY WITH NEONATAL RESOLUTION OF DONOR TWIN CARDIOMYOPATHY

In Brief Background: Twin reverse arterial perfusion, as with acardiac fetuses, is a rare complication of multifetal pregnancy. Prognosis of the donor twin is guarded because of the high risk of cardiac failure, polyhydramnios, and preterm delivery. Case: A 40-year-old woman, gravida 4, para 3, was diagnosed at 19 weeks' gestation with a twin pregnancy complicated by an acardiac, acephalic fetus. Serial amniocenteses were done to decompress the hydramnios between 27 and 33 weeks. Ultrasonography showed ventricular septal hypertrophy in the donor twin at 27 weeks, and cesarean delivery was done at 33 weeks. The neonatal course was complicated by hypertrophic cardiomyopathy, which resolved without sequelae by 1 year of age. Conclusion: Antenatal sonographic monitoring of interventricular septal thickness can be a useful marker to predict neonatal cardiac sequelae. Hypertrophic cardiomyopathy in the surviving twin of an acardiac pregnancy is detectable with antenatal ultrasound and might spontaneously resolve neonatally.

Acardiac twin pregnancy with neonatal resolution of donor twin cardiomyopathy

Background: Twin reverse arterial perfusion, as with acardiac fetuses, is a rare complication of multifetal pregnancy. Prognosis of the donor twin is guarded because of the high risk of cardiac failure, polyhydramnios, and preterm delivery. Case: A 40-year-old woman, gravida 4, para 3, was diagnosed at 19 weeks’ gestation with a twin pregnancy complicated by an acardiac, acephalic fetus. Serial amniocenteses were done to decompress the hydramnios between 27 and 33 weeks. Ultrasonography showed ventricular septal hypertrophy in the donor twin at 27 weeks, and cesarean delivery was done at 33 weeks. The neonatal course was complicated by hypertrophic cardiomyopathy, which resolved without sequelae by 1 year of age. Conclusion: Antenatal sonographic monitoring of interventricular septal thickness can be a useful marker to predict neonatal cardiac sequelae.

Long term outcome of twin-twin transfusion syndrome

AIMSTo compare the perinatal mortality and morbidity of infants with twin-twin transfusion syndrome (TTTS) with those of gestation matched twin controls and to assess the neurodevelopmental outcome of surviving twins...

F44Serial amniocentesis in twin Transfusion syndrome

BackgroundThe aim of our study was to estimate the efficiacy of serial amniocentesis in cases of acute polyhydramnion in TTS.MethodThe study group consisted of 13 pairs of twins with sonographically confirmed hydramnios. After the examination patients were prepared for amnioreduction. During the procedure the excess of amniotic fluid was removed through the punction needle.ResultsThe mean gestational age was 24.3 ± 2.9 weeks in the range 22–29 weeks. In 6 cases polyhydramnion/oligohydramnion was found. The therapy of TTS was based mainly on serial amniocentesis.The mean gestational age during delivery was 27.6 ± 3 weeks. The mean interval between the diagnosis and delivery was 3.3 weeks. In all cases the deliveries were preterm. The mean donor weight was 730 ± 290 g and the mean recipient weight was 1145 ± 435 g. The difference between the recipients and donors was approximately 37%. In 7 cases we observed an intrauterine demise of one fetus. The 5th min Apgar score was 1 pt (median). When the analysis was performed after exclusion of stillborns, the median Apgar score for donors and recipients was 4 and 2 pt, respectively.ConclusionSerial amniocentesis are effective in significant prolongation of gestation (the mean interval between diagnosis and delivery 24 days). The improvement of perinatal outcomes in twin gestations complicated by TTS can be achieved by the combination of serial amniocentesis and the laser ablation.

Invasive versus non-invasive testing in red-cell alloimmunized pregnancies

Amniocentesis for amniotic fluid bilirubin levels is the most widely used test to predict the severity of fetal disease in red-cell alloimmunization. Many textbooks and guidelines recommend serial amniocentesis to monitor these pregnancies. However, the reliability of amniotic fluid bilirubin measurements has been questioned. Two strategies have been proposed by investigators. Some advocate liberal or primary use of fetal blood sampling, while others promote the use of non-invasive ultrasonography and Doppler. The purpose of this literature review is to examine the usefulness of amniocentesis, ultrasonography and Doppler to predict the degree of fetal hemolytic anemia. The evidence suggests that amniotic fluid bilirubin measurements are of limited value in the second trimester. Furthermore, critical appraisal of the very few prospective studies is hampered by limitations in design or insufficient data given by the authors. Many ultrasound and Doppler parameters have been proposed as useful indicators of fetal anemia. The most promising of these methods are Doppler assessment of umbilical venous and middle cerebral artery flow velocities. We speculate that the accuracy of these non-invasive tests may be good enough to incorporate them in management protocols, possibly replacing amniocentesis. Well-designed prospective studies are needed to prove this hypothesis.

Fetal and neonatal echocardiographic findings in twin-twin transfusion syndrome

Objective: The study’s aim was to analyze the type of cardiac involvement in fetuses or infants with twin-twin transfusion syndrome. Study Design: Seventeen pairs of monochorionic diamniotic twin fetuses with twin-twin transfusion syndrome underwent serial Doppler echocardiographic studies. Repeated decompressive amniocenteses were performed in all pregnancies. Results: No specific cardiac involvement was seen in donor twins in utero or after birth. All recipient twin fetuses showed variable degrees of biventricular hypertrophy and dilation with tricuspid regurgitation. These features were also evident in 45% of the recipient twin neonates. The fluid unbalance resolved with serial amniocenteses in 9 cases and in a further 2 after the death of the donor twin; in all 11 of these recipient twin fetuses there was some degree of improvement of the cardiac involvement, which became normal in all surviving recipient twin infants within 40 days to 6 months after birth. Conclusion: Features of cardiac hypertrophy with signs of a prehydropic or hydropic state develop during fetal life in recipient twins in twin-twin transfusion syndrome; this impairment is reversible with the resolution of the fluid imbalance or after delivery. (Am J Obstet Gynecol 1998;179:1056-62.)

Iatrogenic Monoamniotic Twins as a Complication of Therapeutic Amniocentesis

Background: Therapeutic amniocentesis has been accepted widely as a safe and efficacious way to treat the polyhydramnios-oligohydramnios sequence associated with twin–twin transfusion syndrome.Case: A 28-year-old woman, gravida 2, para 1, diagnosed with twin–twin transfusion syndrome at 28 weeks’ gestation was treated with serial amniocenteses. The dividing membrane was ruptured inadvertently during therapeutic amniocentesis, with subsequent complete disruption of the amniotic membrane. Iatrogenic monoamniotic twins with cord entanglement and knotting resulted.Conclusion: Creation of monoamniotic twins by disruption of the dividing membrane can be a complication of therapeutic amniocentesis for twin–twin transfusion syndrome. Such disruption may result in the same morbidity and mortality that are seen in naturally occurring monoamniotic twins.

IATROGENIC MONOAMNIOTIC TWINS AS A COMPLICATION OF THERAPEUTIC AMNIOCENTESIS

In Brief Background Therapeutic amniocentesis has been accepted widely as a safe and efficacious way to treat the polyhydramnios-oligohydramnios sequence associated with twin-twin transfusion syndrome. Case A 28-year-old woman, gravida 2, para 1, diagnosed with twin-twin transfusion syndrome at 28 weeks' gestation was treated with serial amniocenteses. The dividing membrane was ruptured inadvertently during therapeutic amniocentesis, with subsequent complete disruption of the amniotic membrane. Iatrogenic monoamniotic twins with cord entanglement and knotting resulted. Conclusion Creation of monoamniotic twins by disruption of the dividing membrane can be a complication of therapeutic amniocentesis for twin-twin transfusion syndrome. Such disruption may result in the same morbidity and mortality that are seen in naturally occurring monoamniotic twins. Complete disruption of the dividing membrane in diamniotic twin gestations can complicate therapeutic amniocentesis in twin-twin transfusion syndrome.

Antepartum and postpartum complications of twin-twin transfusion.

Twin-twin transfusion is a condition that was previously associated with close to a 100% perinatal mortality. Recent reports suggest that a survival rate of about 60% can be achieved with serial amniocentesis and modern neonatal care. However, it is now apparent that the survivors of this condition have multisystem complications that can result in neonatal mortality and long-term morbidity. Fourteen cases of twin-twin transfusion were examined to determine the antenatal findings that may predict the postnatal outcomes of these infants. The overall survival was 61% (17 of 28). The mean gestation at diagnosis was 23.0 weeks (range 18-34 weeks) and the mean gestation at delivery was 29.0 weeks (range 23-37 weeks). The mean number of amniocenteses was 2.9 and the average total volume of amniotic fluid removed was 6,114 mL. Different patterns of complications were seen in the donor and recipient twins. Hypertrophic cardiomyopathy affected 9 of the recipient twins. Anuria/oliguria was found in 4 of the donor twins and none of the recipients. Periventricular leukomalacia was found in 8 twins and 7 also had mild ventriculomegaly; of the surviving 17 twins, 5 had either periventricular leukomalacia, mild ventriculomegaly or both. Amniotic fluid leakage and perforation of the intervening membrane subsequent to serial amniocentesis were seen in 5 cases. Severe intrauterine growth retardation and abnormal cardiotocographs were a common feature. These complications directly resulted in neonatal mortality and long-term morbidity in the survivors. Not all complications were detected antenatally and the severity was not able to be anticipated.