Twin-twin Transfusion Syndrome Research Articles

Fetal sex and the development of gestational diabetes mellitus in gravidae with multiple gestation pregnancies.

There is an increasing incidence of pregnancies with twin gestations. One outcome more likely to occur with multiple gestations is gestational diabetes mellitus. Studies have suggested that in singleton pregnancies, fetal sex may affect insulin resistance. However, the effects of fetal sex in twins and the development of gestational diabetes mellitus are unknown. We hypothesized that rates of gestational diabetes mellitus and degree of insulin resistance might vary in twin gestations based on the fetal sex pairing: male-male, male-female or female-female. We aimed to employ a large population-based database to ascertain any correlations between fetal sex and gestational diabetes mellitus in multifetal gestations. A two-hospital, single academic institution database comprised of over 39 000 participants with pregnancy data from August 2011 to January 2022 was employed. All twin deliveries of live-born neonates >24 weeks' gestational age from gravidae without preexisting diabetes or twin-twin transfusion syndrome were included. Entries were then grouped based on the fetal sex of the pairing. The presence or absence of gestational diabetes and type of gestational diabetes - diet-controlled (gestational diabetes mellitus classification A1) vs medication-controlled (gestational diabetes mellitus classification A2) - were identified. Statistical analysis was performed using a generalized linear mixed method, and a P-value ≤0.05 was considered statistically significant. We identified 1924 twin deliveries that met the inclusion criteria in our database (male-male =652; male-female = 638; female-female = 634). We found no association between fetal sex pairing and the development of gestational diabetes mellitus. There was a significant association between the fetal sex pairing and the type of gestational diabetes mellitus developed, with 32.0% of male-male twins, 33.3% of male-female twins and 58.3% of the female-female twin deliveries associated with medication-controlled gestational diabetes classification A2: male-female vs female-female (P = 0.05) and male-male vs female-female (P = 0.046). While gestational diabetes mellitus is of multifactorial origin, we found a significant association between the fetal sex pairing and the treatment needed for gravidae with twins who develop gestational diabetes mellitus. A higher proportion of female-female twins was associated with gestational diabetes classification A2 compared with male-female or male-male deliveries. Further research on the physiology driving this association is warranted.

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.

EP14.31: Laser treatment for twin–twin transfusion syndrome in a dizygotic monochorionic twins: case report and literature review

EP14.31: Laser treatment for twin–twin transfusion syndrome in a dizygotic monochorionic twins: case report and literature review

OC13.05: Intertwin imbalance of amniotic fluid aldosterone levels in monochorionic twins: insight into twin–twin transfusion syndrome

OC13.05: Intertwin imbalance of amniotic fluid aldosterone levels in monochorionic twins: insight into twin–twin transfusion syndrome

OC13.02: Quantifying early reduction in cardiovascular burden following fetoscopic placental laser photocoagulation in the twin–twin transfusion syndrome

OC13.02: Quantifying early reduction in cardiovascular burden following fetoscopic placental laser photocoagulation in the twin–twin transfusion syndrome

EP09.06: Changes in soluble levels of biomarkers before and after fetoscopic laser surgery in twin–twin transfusion syndrome

EP09.06: Changes in soluble levels of biomarkers before and after fetoscopic laser surgery in twin–twin transfusion syndrome

EP14.14: Maternal circulation in twin pregnancies with twin–twin transfusion syndrome

EP14.14: Maternal circulation in twin pregnancies with twin–twin transfusion syndrome

EP14.44: MCDA twin pregnancy: TAPS developed into twin–twin transfusion syndrome?

EP14.44: MCDA twin pregnancy: TAPS developed into twin–twin transfusion syndrome?

EP14.23: Cervical cerclage in women with short or dilated cervix before fetoscopic laser surgery for twin–twin transfusion syndrome

EP14.23: Cervical cerclage in women with short or dilated cervix before fetoscopic laser surgery for twin–twin transfusion syndrome

OP11.09: The outcomes and prognostic factors of stage 1 twin–twin transfusion syndrome following fetoscopic laser photocoagulation

OP11.09: The outcomes and prognostic factors of stage 1 twin–twin transfusion syndrome following fetoscopic laser photocoagulation

OP07.02: Fetoscopic laser surgery versus planned preterm delivery in the management of twin–twin transfusion syndrome presenting after 26 weeks of gestation

OP07.02: Fetoscopic laser surgery versus planned preterm delivery in the management of twin–twin transfusion syndrome presenting after 26 weeks of gestation

OP-10 Selective fetal reduction with intrafetal laser in twin-twin transfusion syndrome

OP-10 Selective fetal reduction with intrafetal laser in twin-twin transfusion syndrome

Managing Monoamniotic Twin Pregnancies.

Monoamniotic twins comprise a rare subset of twins at risk of unique and serious complications. In addition to the risks faced by all twins (premature birth, growth restriction), all monochorionic twins (twin-to-twin transfusion syndrome), and all monozygotic twins (congenital anomalies), monoamniotic twins face the unique risk of cord entanglement, in addition to a markedly increased risk of congenital anomalies. Early diagnosis, screening for fetal anomalies and surveillance for twin-twin transfusion syndrome are critical. After fetal viability, frequent fetal monitoring reduces the risk of intrauterine fetal demise.

Outcome following laser surgery of twin-twin transfusion syndrome complicated by selective fetal growth restriction: systematic review and meta-analysis.

The published literature reports mostly on the outcome of twin pregnancies complicated by twin-twin transfusion syndrome (TTTS) without considering whether the pregnancy is also complicated by another pathology, such as selective fetal growth restriction (sFGR). The aim of this systematic review was to report on the outcome of monochorionic diamniotic (MCDA) twin pregnancies undergoing laser surgery for TTTS that were complicated by sFGR and those not complicated by sFGR. MEDLINE, EMBASE and Cochrane databases were searched. The inclusion criteria were studies reporting on MCDA twin pregnancies with TTTS undergoing laser therapy that were complicated by sFGR and those not complicated by sFGR. The primary outcome was the overall fetal loss following laser surgery, defined as miscarriage and intrauterine death. The secondary outcomes included fetal loss within 24 h after laser surgery, survival at birth, preterm birth (PTB) prior to 32 weeks of gestation, PTB prior to 28 weeks, composite neonatal morbidity, neurological and respiratory morbidity, and survival free from neurological impairment. All outcomes were explored in the overall population of twin pregnancies complicated by sFGR vs those not complicated by sFGR in the setting of TTTS and in the donor and recipient twins separately. Random-effects meta-analysis was used to combine data and the results are reported as pooled odds ratios (OR) with 95% CI. Five studies (1710 MCDA twin pregnancies) were included in the qualitative synthesis and four in the meta-analysis. The overall risk of fetal loss after laser surgery was significantly higher in MCDA twin pregnancies with TTTS complicated by sFGR (20.90% vs 14.42%), with a pooled OR of 1.6 (95% CI, 1.3-1.9) (P < 0.001). The risk of fetal loss was significantly higher in MCDA twin pregnancies with TTTS and sFGR for the donor but not for the recipient twin. The rate of live twins was 79.1% (95% CI, 72.6-84.9%) in TTTS pregnancies with sFGR and 85.6% (95% CI, 81.0-89.6%) in those without sFGR (pooled OR, 0.6 (95% CI, 0.5-0.8)) (P < 0.001). There was no significant difference in the risk of PTB prior to 32 weeks of gestation (P = 0.308) or prior to 28 weeks (P = 0.310). Assessment of short- and long-term morbidity was affected by the small number of cases. There was no significant difference in the risk of composite (P = 0.506) or respiratory (P = 0.531) morbidity between twins complicated by TTTS with vs those without sFGR, while the risk of neurological morbidity was significantly higher in those with TTTS and sFGR (pooled OR, 1.8 (95% CI, 1.1-2.9)) (P = 0.034). The risk of neurological morbidity was significantly higher for the donor twin (pooled OR, 2.4 (95% CI, 1.1-5.2)) (P = 0.029) but not for the recipient twin (P = 0.361). Survival free from neurological impairment was observed in 70.8% (95% CI, 45.0-91.0%) of twin pregnancies with TTTS complicated by sFGR and in 75.8% (95% CI, 51.9-93.3%) of those not complicated by sFGR, with no difference between the two groups. sFGR in MCDA pregnancies with TTTS represents an additional risk factor for fetal loss following laser surgery. The findings of this meta-analysis may be useful for individualized risk assessment of twin pregnancy complicated by TTTS and tailored counseling of the parents prior to laser surgery. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Extracorporeal Membrane Oxygenation (ECMO): A Lifeline for Pregnant and Postpartum Women.

Extracorporeal membrane oxygenation (ECMO) is a life-saving technology that temporarily supports the heart and lungs in critical care situations. This review article examines the role of ECMO as a lifeline for pregnant and postpartum women facing severe maternal and fetal conditions. The review begins with an overview of the physiology and pathophysiology of ECMO, including its procedure and how it supports cardiopulmonary function. Unique considerations specific to pregnant and postpartum women, such as physiological changes during pregnancy, risks and complications associated with ECMO, and the need to balance maternal and fetal considerations, are discussed. The indications for ECMO in this population are explored, including common maternal indications such as cardiogenic shock, acute respiratory distress syndrome (ARDS), pulmonary embolism, and eclampsia, as well as fetal indications such as fetal distress, hypoxic-ischemic encephalopathy (HIE), and twin-to-twin transfusion syndrome (TTTS). The challenges and considerations in ECMO for pregnant and postpartum women, including ethical considerations and the decision-making process, are highlighted. The review further explores the multidisciplinary care and collaborative approach required, emphasizing the importance of a specialized ECMO team and collaboration between obstetricians, neonatologists, cardiologists, and other specialists. Additionally, patient selection, pre-ECMO assessment, and planning strategies are discussed. The review evaluates existing literature and studies on ECMO in pregnant and postpartum women, analyzing survival rates and maternal and fetal outcomes and comparing different ECMO modalities and strategies. Future directions and research opportunities are presented, including emerging technologies, areas for further research and clinical trials, and improved patient selection and management strategies. The conclusion emphasizes the importance of ECMO as a lifeline for pregnant and postpartum women and the potential impact on maternal and fetal health. The review highlights the need for ongoing research and advancements in ECMO to optimize outcomes and improve care for this unique and vulnerable patient population.

Management of Late Twin-to-Twin Transfusion Syndrome beyond 26 Weeks: Comparison between Fetoscopic Laser Therapy versus Traditional Management

Introduction: A proportion of monochorionic diamniotic (MCDA) twin pregnancies complicated by twin-to-twin transfusion syndrome (TTTS) can present after 26 weeks of gestation. The aim of this study was to compare perinatal outcomes of late TTTS treated by fetoscopic laser coagulation versus traditional management with amniodrainage and/or emergency preterm cesarean delivery (CD). Methods: Retrospective cohort from January 2012 to January 2023 of consecutive MCDA twin pregnancies complicated by TTTS after 26 weeks and evaluated in our referring centers. We analyzed perinatal outcomes of cases treated with fetoscopic laser surgery at our national referral fetal surgery center in Queretaro, Mexico, and compared them with those managed with traditional management (amniodrainage and/or emergency preterm CD). The primary outcome was survival at discharge and the secondary outcome was gestational age (GA) at birth. Results: Among the study population, 46 TTTS cases were treated by fetoscopy at 27⁺⁶ (26⁺⁰–31⁺⁰) weeks^+days and were compared with a group of 39 cases who underwent emergency preterm CD. In comparison to the group who underwent traditional management, the group treated by laser fetoscopy showed a significantly higher GA at birth (32⁺³ vs. 29⁺¹ weeks^+days, p < 0.001), lower frequency of preterm delivery below 37 weeks (91.3% vs. 100%, p = 0.06), 34 weeks (63.0% vs. 100%, p < 0.001), 32 weeks (50% vs. 74.4%, p = 0.02), or 30 weeks (28.3% vs. 53.8%, p = 0.01), and significantly higher perinatal survival (89.1% vs. 71.8%, p < 0.05 of at least one twin; and 65.2% vs. 38.5%, p = 0.01 of both twins, respectively). Conclusion: MCDA twins complicated with TTTS can be treated with fetoscopic laser surgery between 26 and 31 weeks of gestation, which is a feasible and safe option, and such cases are associated with a higher GA at birth and better perinatal survival than those managed with amniodrainage and/or emergency preterm CD.

Association of amnioinfusion volume at the time of surgery for twin-twin transfusion syndrome and latency to delivery.

To evaluate the impact of amnioinfusion and other peri-operative factors on pregnancy outcomes in the setting of Twin-twin transfusion syndrome (TTTS) treated via fetoscopic laser photocoagulation (FLP). Retrospective study of TTTS treated via FLP from 2010 to 2019. Pregnancies were grouped by amnioinfusion volume during FLP (<1L vs.≥1L). The primary outcome was latency from surgery to delivery. An amnioinfusion statistic (AIstat) was created for each surgery based on the volume of fluid infused and removed and the preoperative deepest vertical pocket. Regression analysis was planned to assess the association of AIstat with latency. Patients with amnioinfusion of ≥1L at the time of FLP had decreased latency from surgery to delivery (61±29.4 vs. 73±28.8days with amnioinfusion <1L, p<0.001) and increased preterm prelabor rupture of membranes (PPROM) <34weeks (44.7% vs. 33.5%, p=0.042). Amnioinfusion ≥1L was associated with an increased risk of delivery <32 weeks (aRR 2.6, 95% CI 1.5-4.5), 30 weeks (aRR 2.4, 95% CI 1.5-3.8), and 28weeks (aRR 1.9, 95% CI 1.1-2.3). Cox-proportional regression revealed that AIstat was inversely associated with latency (HR 1.1, 95% CI 1.1-1.2). Amnioinfusion ≥1L during FLP was associated with decreased latency after surgery and increased PPROM <34weeks.

Feasibility of fetoscopic laser coagulation in triplet pregnancy.

To report the experiences of triplet pregnancies complicated by twin-to-twin transfusion syndrome (TTTS) treated with fetoscopic laser coagulation at a single center. Herein, we conducted a retrospective analysis to investigate the management and perinatal outcomes of triplet pregnancies with TTTS treated at a single institution between 2017 and 2022. Seven of the 98 triplet pregnancies (7.1%) encountered were complicated by TTTS, and all were dichorionic triamniotic triplets. Of the seven triplet pregnancies complicated by TTTS, four were treated with fetoscopic laser coagulation at our center, at a median gestational age of 20 weeks. No procedure-related complications or maternal complications were observed. The survival rate was higher and perinatal outcomes were better in fetoscopic laser coagulation cases than in other management cases. Four donor and four recipient triplets survived, with a median gestational age of 33 weeks at delivery. Although there were no cases of poor neonatal outcomes, one case was diagnosed with white matter injury, suspected to be hypoxic-ischemic encephalopathy on postnatal investigation. Fetoscopic laser coagulation is a feasible treatment option for triplet TTTS, provided the attending specialists have extensive experience with this technique.

Detection of Twin Pregnancies using Fetal Phonocardiogram.

Fetal phonocardiogram (fPCG), or the electronic recording of fetal heart sounds, is a safe and easily available signal that can be used to monitor fetal wellbeing. In the proposed work an attempt is made to identify twin pregnancies using fPCG data recorded from the fetus with 1/3rd power in octave band filtered output as features to train K-Nearest Neighbor (KNN) and support vector machine (SVM) classifiers. The SVM classifier with the quadratic kernel is able to identify singletons and twins with a positive predictive value of 100% and 79.1% respectively. The KNN classifier with k=10 neighbors is able to identify singletons and twins with a positive predictive value of 100% and 81.8% respectively.Clinical Relevance: Identifying twin pregnancies from singleton is an essential clinical protocol followed during late pregnancy as there may be complications like twin-twin transfusion syndrome, selective fetal growth restriction, and preterm labor in twin pregnancy [1], [2]. Ultrasound imaging is the most commonly used technique for twin pregnancy detection, though it is often not affordable or available in rural or low-income populations. Utilization of fPCG in such circumstances has immense clinical potential.

Two Year Neurodevelopmental Outcome after Fetoscopic Laser Therapy for Twin-Twin Transfusion Syndrome: Comparison with Uncomplicated Monochorionic Diamniotic Twins.

Twin-twin Transfusion Syndrome (TTTS) represents a significant complication in monochorionic twin pregnancies, caused by an unbalanced shunting of blood through intertwin placental vascular anastomoses. Despite advances in fetoscopic laser surgery, TTTS is still associated with a high rate of cerebral injury. However, there are no studies comparing these pregnancies with uncomplicated monochorionic diamniotic (MCDA) twin pregnancies, establishing the baseline risk of neurodevelopmental impairment. The aim of this study is to evaluate the odds of neurodevelopmental impairment in MCDA twins who undergo fetoscopic laser surgery for twin-twin transfusion syndrome, in comparison to a cohort of uncomplicated MCDA twin pregnancies. This is a retrospective cohort study of children born from MCDA twin pregnancies at a single center between 2008 and 2019. A routine, standardized follow-up assessment was conducted at a minimum of 2 years after delivery. The primary outcome of this was a 2 year neurodevelopmental impairment. Neurological, motor, and cognitive development was assessed by using the revised Brunet-Lézine scale. 176 children met the enrolment criteria. Of these, 42 (24%; TTTS group) underwent fetoscopic laser surgery for TTTS during pregnancy, and 134 (76%; uncomplicated MCDA group) were uncomplicated MCDA pregnancies. The primary outcome was found in four children (9.52%) in the TTTS group and ten children (7.46%) in the uncomplicated MCDA group (p = 0.67, aOR 2.82, 95% CI 0.49-16.23). Major neurologic impairment was found in 2.38% after fetoscopic laser surgery and 1.49% in uncomplicated MCDA twins (p = 0.70, aOR 0.97, 95% CI 0.22-4.24). The data were adjusted by birth order, birth weight, and gestational age at birth. The outcome in MCDA twins who underwent fetoscopic laser surgery for TTTS is comparable to the outcome in uncomplicated MCDA twins. Our findings emphasize the need for long-term neurodevelopmental follow-ups in all children from monochorionic twin gestations.