Twin Reversed Arterial Perfusion Research Articles

Twin reversed arterial perfusion sequence in monochorionic diamniotic pregnancy: A rare occurrence

Twin reversed arterial perfusion is a rare complication occurring in monochorionic multifetal pregnancies. This condition is characterized by a malformed fetus being perfused by a normal twin through an artery-to-artery anastomosis in the reverse direction. Herein, we report a case of a multigravida female with a twin pregnancy at 27 weeks 5 days of gestation referred in view of twin pregnancy with the intra-uterine demise of one twin. Gray scale and color Doppler imaging revealed a monochorionic diamniotic pregnancy with a viable, normal twin, and an amorphously developed acardiac twin. The patient was monitored with weekly ultrasonography, echocardiography, and Doppler ultrasound examination to ascertain the well-being of the pump twin. She delivered a normal live baby at term and an acardius acephalus fetus. The perinatal mortality of the pump twin is significantly high. Therefore, it is necessary to diagnose this entity at an early gestational age through improved imaging techniques, so that timely intervention can be planned.

Intrauterine Treatment of Monochorionic Triamniotic Triplet Pregnancy with Twin Reverse Arterial Perfusion Sequence

Intrauterine Treatment of Monochorionic Triamniotic Triplet Pregnancy with Twin Reverse Arterial Perfusion Sequence

Fetal magnetic resonance imaging, ultrasound, and echocardiography findings in twin reversed arterial perfusion sequence.

Twin reversed arterial perfusion (TRAP) sequence is a rare complication of monochorionic multiple gestation pregnancies, in which the pump twin provides hemodynamic support to a nonviable co-twin (acardius). Fetal magnetic resonance imaging (MRI) is used to detect pump twin abnormalities, particularly brain ischemia, prior to fetal intervention to interrupt umbilical blood flow to the acardius. To summarize the imaging findings of TRAP sequence pregnancies in a large series. A single-center retrospective review was performed of all TRAP sequence pregnancies referred for fetal MRI (2004-2021). Fetal MRI, ultrasound, and echocardiography data were collected. Eighty-eight TRAP sequence pregnancies with MRI were included (mean gestational age, 19.8±2.8 weeks). Demise of the pump twin was noted in two pregnancies at the time of MRI. By MRI, 12% (10/86) of live pump twins had abnormalities, including 3% (3/86) with brain abnormalities and 9% (8/86) with extra-cranial abnormalities. By echocardiography, 7% (6/86) of pump twins had structural cardiac abnormalities. Three acardius morphological subtypes were identified by MRI: acephalus (55%, 48/88), anceps (39%, 34/88), and amorphous (7%, 6/88). The mean ultrasound acardiustopump twin ratioA/Pratio, calculated for each twin pair as the ratio of the acardius trunk (and head, if present) plus limb volume to the pump twin estimated fetal weight) differed among the three acardius subtypes (P=.03). The mean A/P ratio moderately correlated with pump twin cardiothoracic ratio and combined cardiac output (Pearson's r=0.45 and 0.48, respectively, both P<.001). Fetal MRI of TRAP sequence pregnancies found anomalies in a substantial number of pump twins. The three acardius subtypes differed in A/P ratio, which moderately correlated with the pump twin cardiothoracic ratio and combined cardiac output.

224 Umbilical cord occlusion of twin reversed arterial perfusion (TRAP) sequence: laser photocoagulation vs radiofrequency ablation

224 Umbilical cord occlusion of twin reversed arterial perfusion (TRAP) sequence: laser photocoagulation vs radiofrequency ablation

TRAP Sequence, Diagnosis, Treatment, and Outcome

TRAP Sequence, Diagnosis, Treatment, and Outcome

SFM Fetal Therapy Practice Guidelines: Fetal Interstitial Laser

AbstractFetal laser therapy was first used in complicated monochorionic pregnancies such as twin-to-twin transfusion syndrome or twin-reversed arterial perfusion sequence. There are some other less common indications such as amniotic band syndrome, chorioangiomas, lower urinary tract obstructions, sacrococcygeal teratomas, and fetal thoracic masses. These practice guidelines discuss the indications, contraindications, and risks of the procedure along with information for patients and draft consent form.

Outcome of Monochorionic Diamniotic Twins with Twin Reversed Arterial Perfusion Sequence: Interstitial Laser versus Endoscopic Cord Occlusion.

Twin reversed arterial perfusion sequence (TRAP) is a rare complication of monochorionic twins (MC). This study aimed to describe and compare the short- and long-term outcomes of MC pregnancies with the TRAP sequence treated with two different techniques: interstitial fetal laser (IFL) (n = 22) versus endoscopic cord occlusion (CO) (n = 24). The study population included 46 MC pregnancies with TRAP. Pregnancy loss within 2 weeks after the procedure occurred in 27% of cases (6/22) in the group treated with IFL and in 8% of cases (2/24) in the group treated with CO. The survival rate of the pump twin was 73% (16/22) in the IFL group and 83% (20/24) in the group treated with CO. The median gestational age at birth was 38 weeks in the group treated with IFL and 35 weeks in the group treated with CO. The rate of preterm birth before 34 weeks was 12.5% (2/16) in the group treated with IFL and 32% (7/22) in the group treated with CO. In the group treated with IFL, there were no cases of neurological disabilities reported by the parents compared to three cases in the CO group. IFL is associated with a higher risk of early pregnancy loss; however, if the pregnancy progresses, it is associated with lower risks of preterm birth and neurological disabilities in the survivors.

Perinatal outcomes of monochorionic triplet pregnancies: multicenter cohort study.

Monochorionic triplet pregnancies are extremely rare and information on these pregnancies and their complications are limited. We aimed to investigate the risk of early and late pregnancy complications, perinatal outcomes, and the timing and methods of fetal intervention in monochorionic triplet pregnancies. This was a multicenter retrospective cohort study including monochorionic triamniotic (MCTA) triplet pregnancies. The exclusion criteria were twins, or multiple pregnancies with higher order than triplets (e.g. quadruplets, quintuplets), and dichorionic or trichorionic triplet pregnancies. Data on maternal age, mode of conception, diagnosis of major fetal structural anomalies or aneuploidy, gestational age (GA) at diagnosis of anomalies, twin to twin transfusion syndrome (TTTS), twin anemia polycythemia syndrome (TAPS), twin reversed arterial perfusion sequence (TRAP), or selective fetal growth restriction (sFGR) were ascertained from the patient records. Data on antenatal interventions were collected, including selective (fetal) reduction (3 to 2 or 3 to 1), laser surgery, or any active fetal intervention (including amniodrainage). Finally, perinatal outcomes included livebirth, intrauterine demise (IUD), neonatal death (NND), perinatal death (PND) and termination of pregnancy (TOP). Neonatal data such as GA at birth, birthweight, neonatal intensive care unit (NICU) admission, and neonatal morbidity were also collected. In our cohort of MCTA triplet pregnancies (n=153 after excluding early miscarriages, TOP and loss to follow-up), the majority (90%) were managed expectantly. The incidence of fetal abnormalities and TRAP was 13.7% and 5.2%, respectively. The most common antenatal complication related to chorionicity was TTTS, which complicated just over a quarter (27.6%) of the pregnancies, followed by sFGR (16.4%), while TAPS (both spontaneous and post-laser) occurred in only 3.3%; no antenatal complication was recorded in 49.3% of pregnancies. Survival was largely associated with the development of these complications: 85.1%, 100% and 47.6% of pregnancies had at least one surviving newborn in those without antenatal complications, complicated by sFGR, or complicated by TTTS, respectively. The overall rates of preterm birth prior to 28 weeks and prior to 32 weeks' gestation were 14.5% and 49.2%, respectively. MCTA triplet pregnancies represent a challenge in counseling, surveillance and management as monochorionicity-related complications occur in almost half of these pregnancies, which negatively impact their perinatal outcomes. This article is protected by copyright. All rights reserved.

EP14.38: A case report on twin reverse arterial perfusion sequence

EP14.38: A case report on twin reverse arterial perfusion sequence

EP14.21: Outcome of TRAP Sequence: a single centre's experience in South China

EP14.21: Outcome of TRAP Sequence: a single centre's experience in South China

Overview of Swine Congenital Malformations Associated with Abnormal Twinning.

A review of congenital malformations in swine relating to abnormal twinning was carried out. The aim was to describe and estimate these defects. Among the recorded twins, the most common defect was the syncephalus thoracopagus or cephalothoracopagus. A couple of dicephali and diprosopus congenital anomalies were also registered. At last, some cases of thoraco-omphalopagus piglets were surveyed. There was also a report of an acardiac twin (hemiacardius acephalus) and a case of a conjoined parasitic twin. The pathogenetic mechanisms of this condition, frequently reported in veterinary practice, are discussed. The importance of embryonic imperfect twinning is commonly associated with dystocia.

The Management of Acardiac Twinning: Twin Reverse Arterial Perfusion Sequence – An International Survey

Introduction: The optimal approach and therapy method for the acardiac twin with a reverse arterial perfusion sequence has not yet been established. The aim of this study was to determine the clinical practice patterns among international fetal therapy units in their management of these cases. Methods: A survey was sent to fetal centers across the world via email between December 2020 and December 2021. Results: Responses were obtained from 77% contacted centers. The most frequent ultrasound variables used in the evaluation of twin reverse arterial perfusion sequence include echocardiographic assessment of the pump twin and umbilical artery Doppler waveforms in the acardiac and pump twins, in 90% and 80% of the centers, respectively. Most centers in Europe and Latin America propose an in utero intervention in all cases. Most centers in Europe and Latin America prefer interstitial laser ablation, whereas radiofrequency ablation (RFA) is preferred in North America. The earliest gestational age for an intervention is on mean 13 weeks in Europe, which is earlier than the other geographic areas (p = 0.001). Conclusions: Most centers agreed that antenatal evaluation should include echocardiography along with the UA Doppler waveform measurements, and the most frequently used interventions were interstitial laser ablation or RFA at a median between 14 and 26 weeks.

Management of twin reversed arterial perfusion sequence: eight cases over 13 years.

Twin reversed arterial perfusion (TRAP) sequence is a rare condition that affects primarily monozygotic monochorionic twin pregnancies in which a normal twin acts as a pump (donor) for an acardiac recipient (perfuse) twin. We report our experience over the last 13 years at a tertiary health care center. Descriptive, retrospective case series SETTING: Tertiary health care center PATIENTS AND METHODS: All TRAP cases managed between the years 2009 and 2022 at our Fetal Diagnosis and Therapy Center were included. Data recorded included demographic and clinical information which was used to generate descriptive data. Patients were managed by a multidisciplinary team with variable interventions. Survival of normal twin SAMPLE SIZE: Eight RESULTS: Eight pregnant women with TRAP syndrome were managed at our center during that period. One was monozygotic monochorionic and the others were monochorionic diamniotic. Median maternal age at presentation was 27 years and median gestational age at diagnosis was 23 weeks. All were diagnosed with ultrasound (US) imaging. Three were managed with bipolar ligation of the cord of the acardiac twin under general anesthesia, one US-guided (single port) and 2 fetoscopic (2 ports) with a median operative time of 39 minutes. The last five cases were managed with US-guided radiofrequency ablation (RFA) under local anesthesia, one needed 2 sessions, 1 week apart. The median duration of the RFA procedure was 23 minutes. There were no complications and all had viable normal babies born at a median of 32 weeks of gestation (6 C-section, 2 spontaneous membrane rupture). Acardiac twin cord ligation and RFA are feasible and safe options with excellent outcome for TRAP syndrome. RFA may be preferable owing to its less invasiveness under local anesthesia. None, given the rarity of the disease and the study design. None.

Twin reversed arterial perfusion sequence: A review of cases in the Philippines from 2000 to 2022

Twin reversed arterial perfusion (TRAP) sequence, or acardiac twinning, is a congenital anomaly associated with monochorionic twin pregnancies. It occurs when the cardiac system of one twin supplies blood for both twins. This congenital anomaly has been previously reported in several case reports from the Philippines. However, there is still limited information about its local epidemiology and management. This study reviewed the previous cases of TRAP sequence and discussed the diagnosis, management, and ways to improve care for pregnant patients affected by this condition. There were five reported cases of TRAP sequence from the Philippines. Ultrasonography was used in diagnosing the disease antenatally. Preterm birth was reported in 60% of the cases, while 80% were delivered via Cesarean section. The most common type of acardiac twinning in the Philippines was the acardius acephalus. The most common placentation observed in TRAP sequence cases was monochorionic, monoamnionic placenta (75%), two of which had arterio-arterial and veno-venous anastomoses. All donor twins in the Philippines were delivered alive, with only one (20%) neonatal death due to Pseudomonas infection. Only a few centers can perform minimally invasive fetal interventions; one center has been performing fetoscopic surgery in the Philippines since 2021. Thus, cases of TRAP sequence in the Philippines have only been managed through antenatal surveillance with serial ultrasound and high-risk prenatal care until their eventual delivery.

TRAP Sequence in an IVF Pregnancy Successfully Treated with Laser Coagulation: Case Report

TRAP Sequence in an IVF Pregnancy Successfully Treated with Laser Coagulation: Case Report

Placental recruitment after spontaneous single fetal demise in monochorionic diamniotic twin pregnancies

IntroductionThe incidence of single fetal demise in monochorionic diamniotic twin pregnancies is approximately 7.5%. In single fetal demise cases, the placental region of the demised fetus is almost infarcted or necrotic at the time of delivery. Further, it has been reported that in some cases, a surviving fetus uses all regions of the placenta after a single fetal demise. Thus, in the present study, we investigated the incidence and natural prognosis of placental recruitment in spontaneous single fetal demise cases over a period of 11 years. MethodsAll 306 monochorionic diamniotic twin pregnancies that were delivered between 2011 and 2021 in our institution were included in this retrospective cohort study. The placenta and umbilical cord were investigated, and the type of anastomosis was identified by color injection. Furthermore, the number and direction of arteriovenous anastomoses were recorded. ResultsThere were eight single fetal demise cases, excluding cases of twin-reversed arterial perfusion sequence and after fetoscopic laser photocoagulation. The placental region of six demised fetuses had an infarction or necrotic region. In two cases, an infarction or necrosis was not observed, and the surviving fetus used all regions of the placenta. DiscussionThe surviving fetus in monochorionic diamniotic twin pregnancies with superficial anastomoses can use all regions of the placenta, even after a spontaneous single fetal demise. Further studies are needed to determine the difference between such cases and in those in which only the localized regions of the placenta can be used.

Obstetric vascular Doppler velocimetry: clinical applications and overuses.

A safe and non-intrusive assessment of fetal health is not only crucial in low-risk gestations, but it is also the standard of care in high-risk pregnancies. Therefore, measuring blood flow across different vessels with non-invasive ultrasound methods has been accurately and painstakingly studied and published. Amongst these state-of-the-art techniques, umbilical artery (blood flow) Doppler velocimetry (UADV) has allowed for fetal well-being follow-ups and assess uteroplacental function, which obtains a more complete and clearer picture; particularly in regard to complicated pregnancies. Additionally, there are other modalities with diverse clinical applications that have emerged, including their clinical and research utilization in conditions such as fetal growth restriction (FGR), preeclampsia, fetal anemia, monochorionic twins vascular blood flow mismatch such as is in twin-to-twin transfusion syndrome, twin anemia polycythemia sequence, and twin reverse arterial perfusion sequence. Nevertheless, their applications regarding various other maternal-fetal diagnoses in the same way as premature births and/or multiple gestation surveillance have not been reported to hold strong clinical evidence. With that in regard, the purpose of this unique study was to give update of the multiple clinical applications of this very important obstetrical tool. Additionally, to review the pathophysiology as well as revisit their reported significant valid uses and occasional overuses. We also delved into quality control measures as related to the application of Doppler in obstetrics. Lastly, it is essential to look through and reflect on the future developments of this valuable, non-invasive, high-risk marvelous modern device.

From ferrocene to decasubstituted enantiopure ferrocene-1,1'-disulfoxide derivatives.

The functionalization of (R,R)-S,S'-di-tert-butylferrocene-1,1'-disulfoxide by deprotolithiation-electrophilic trapping sequences was studied towards polysubstituted, enantiopure derivatives for which the properties were determined. While the 2,2'-disubstituted ferrocene derivatives were obtained as expected, subsequent functionalization of the 2,2'-di(phenylthio) and 2,2'-bis(trimethylsilyl) derivatives occurred primarily at the 4- or 4,4'-positions. This unusual regioselectivity was discussed in detail in light of pKa values and structural data. The less sterically hindered 2,2'-difluorinated derivative yielded the expected 1,1',2,2',3,3'-hexasubstituted ferrocenes by the deprotometallation-trapping sequence. Further functionalization proved possible, leading to early examples of 1,1',2,2',3,3',4,4'-octa, nona and even decasubstituted ferrocenes. Some of the newly prepared ferrocene-1,1'-disulfoxides were tested as ligands for enantioselective catalysis and their electrochemical properties were investigated.

Comparaison de la mortalité fœtale et néonatale des grossesses gémellaires monochoriales monoamniotiques et monochoriales biamniotiques

ObjectivesTo compare the mortality of monochorionic-monoamniotic (MCMA) and monochorionic-biamniotic (MCBA) twin pregnancies, from 14weeks of gestation to 28th day of life, before and after exclusion of major congenital malformations. MethodsWe conducted a retrospective cohort study in two level 3 maternity units of the Hospices civils de Lyon (France) including all patients with a monochorionic twin pregnancy between January 2013 and December 2020. We excluded TRAP sequences and conjoined twins. ResultsA total of 38 MCMA and 658 MCBA pregnancies were included. We showed an increase in overall mortality in the MCMA group compared to the MCBA group (31.6% versus 16.4%, P=0.03) even after exclusion of major congenital malformations (20.3% versus 9.5%, P=0.01). The main cause of mortality found in the MCMA group was the occurrence of unexpected IUGR. ConclusionsMCMA pregnancies have a higher foetal and neonatal mortality rate than MCBA pregnancies even after exclusion of congenital malformations related to the occurrence of unexpected MFIU.

Twin reverse arterial perfusion: Timing of intervention.

Twin reverse arterial perfusion (TRAP) sequence is a severe anomaly in monochorionic twins where one twin has profound corporeal underdevelopment and acardia. The normal "pump" co-twin provides blood flow to the acardiac twin through placental anastomoses which may lead to cardiac failure and pump twin demise as well as preterm delivery from severe polyhydramnios. Treatments include radiofrequency ablation, bipolar cord coagulation, and intrafetal laser with each aimed at occluding blood flow to the acardiac twin. However, none of these modalities has proven superior in terms of either pump twin survival or minimization of complications, including preterm premature rupture of membranes, preterm birth, or unexpected co-twin demise. The optimal timing of treatment is also unknown, without clear indications for intervention versus expectant management. Very early treatment of TRAP (i.e., <16 weeks) has been proposed to reduce first-trimester demise; however, this approach remains experimental. Further investigation is required to determine the best treatment and timing of intervention for TRAP.