Perfusão arterial reversa gemelar: revisão da literatura / Twin reverse arterial perfusion: literature review

A perfusão arterial reversa gemelar é uma anormalidade rara que pode ocorrer em gestações gemelares monocoriônicas. Consiste em uma alteração na circulação fetoplacentária, com desvio de sangue de um dos gemelares para o outro, por meio de anastomoses arterioarteriais e venovenosas na superfície placentária e anastomoses arteriovenosas em áreas de circulação placentária compartilhada. O feto bombeador pode desenvolver insuficiência cardíaca devido ao aumento do débito cardíaco, e o feto receptor, perfundido por sangue pobre em oxigênio por meio do fluxo reverso, é severamente malformado, incompatível com a vida extrauterina. Este artigo apresenta o caso de uma gestação gemelar monocoriônica diamniótica, com manejo clínico conservador. O objetivo é relatar um caso de complicação rara de gestações monozigóticas e revisar condutas para diagnóstico e manejo adequado.(AU)

Twin reverse arterial perfusion is a rare abnormality that can occur in monochorionic twin pregnancies. It consists of an alteration in the fetal-placental circulation, with blood diversion from one of the twins to the other, through arterio-arterial and veno- venous anastomosis on the placental surface and arterio-venous anastomosis in areas of shared placental circulation. The pumping fetus may develop heart failure due to increased cardiac output, and the recipient fetus, perfused by oxygen-poor blood through reverse flow, is severely malformed, incompatible with extrauterine life. This article presents the case of a monochorionic diamniotic twin pregnancy, with conservative clinical management. The objective is to report a case of rare complication of monozygotic pregnancies and review procedures for diagnosis and adequate management.(AU)

Screening of ultrasound markers for predicting selective fetal growth restriction in monochorionic twins at 11-13 + 6 weeks / 中华超声影像学杂志

Objective:To screen the ultrasound markers of predictive value at 11-13 + 6 weeks for selective fetal growth restriction (sFGR) in monochorionic (MC) twins. Methods:A retrospective analysis of MC twin pregnancies collected prospectively from June 2020 to December 2021 at Beijing Obstetrics and Gynecology Hospital, Capital Medical University, with standardized ultrasound examinations performed at 11-13 + 6 weeks.According to the expert consensus on the diagnostic criteria for sFGR, collected MC twin pregnancies were divided into sFGR group and control group (normal MC twin group). Maternal age, maternal history, mode of conception, the incidence of increased nuchal translucency (NT) thickness, NT discordance, crown-rump length (CRL) discordance, abnormal ductus venous Doppler waveform and abnormal umbilical cord insertion position were compared between the two groups, and those markers that differed between groups were further analyzed for screening early ultrasound markers that could be used to predict sFGR. Results:A total of 106 cases were included in the analysis, 30 cases in sFGR group and 76 cases in control group. ①Compared with control group, sFGR group had a higher incidence of low fetal birth weight (below the 10th and 3rd percentile) in both surviving cases, large birth weight discordance and a higher incidence of birth weight inconsistency (difference >25%) ( P<0.001). ②Compared with control group, the CRL discordance was larger in sFGR group [7.8% (3.8%, 9.2%) versus 3.8% (1.5%, 7.2%)] and the incidence of abnormal cord insertion position (33.3% versus 6.6%) was higher, the differences were statistically significant ( P=0.004 and <0.001, respectively), whereas the differences of NT discordance, incidence of increased NT and abnormal ductus venous Doppler waveform were not statistically significant (all P values >0.05). ③CRL discordance was a risk factor for sFGR ( OR=1.136, 95% CI=1.021-1.264), with an area under the ROC curve of 0.682 (95% CI=0.576-0.787) for predicting sFGR, the sensitivity and specificity were 0.567 and 0.737 at a cut-off value of 6.5%. Abnormal umbilical cord insertion position was a risk factor for sFGR ( OR=7.100, 95% CI=2.176-23.167) with a sensitivity of 0.333 and specificity of 0.934 for predicting sFGR. Conclusions:CRL discordance and abnormal cord insertion position are risk factors for the development of sFGR and are of value in predicting sFGR in MC twins.

Anastomosis placentarias en embarazos gemelares monocoriales: estudio mediante técnicas de inyección vascular y relación con complicaciones fetales / Placental anastomoses in monochorionic twin pregnancies: study using vascular injection techniques and relationship with fetal complications

RESUMEN Introducción. Los embarazos gemelares son clasificados en dos grupos: monocoriónico (MC) y dicoriónico (DC). Los gemelos MC tienen 5 a 6 veces más riesgo de tener un resultado perinatal adverso. Se publica el estudio de un grupo de 22 placentas de pacientes con embarazo gemelar monocoriónico que presentaron complicaciones como síndrome de transfusión feto-fetal (STFF), secuencia de anemia policitemia (TAPS), perfusión arterial reversa (TRAP) y restricción de crecimiento intrauterino selectivo (RCIU-s). Objetivo . Determinar los tipos de anastomosis predominantes en las placentas con síndrome de transfusión feto-fetal, secuencia de anemia policitemia, síndrome de perfusión arterial reversa y restricción de crecimiento selectivo. Metodología . Se aplicó la técnica de inyección vascular placentaria para el reconocimiento de las anastomosis. Resultados . El número medio de anastomosis por placenta en el STFF (que fue la complicación más severa) fue de 8,2 ± 2,2. Las anastomosis AV y VA predominaron en un 83%. Hubo signos de discordancia placentaria en 30% de las placentas, y un 40% de placentas presentaron cordón de inserción velamentosa. Conclusiones. Las anastomosis vasculares no solo están implicadas en la etiología de las principales patologías propias de gestaciones monocoriónicas, sino que también influyen en su manejo. Creemos que un adecuado estudio placentario de cada uno de estos casos mediante la técnica de inyección vascular placentaria sería indispensable en los centros que aspiran a desarrollar manejos diferenciados de terapia fetal para cada una de estas complicaciones.

ABSTRACT Introduction: Twin pregnancies are classified into two groups: monochorionic (MC) and dichorionic (DC). MC twins are 5 to 6 times more likely to have an adverse perinatal outcome. The study of a group of 22 placentas from patients with monochorionic twin pregnancy who presented with complications such as feto-fetal transfusion syndrome (FFTS), twin anemia polycythemia sequence (TAPS), twin reverse arterial perfusion syndrome (TRAP) and selective intrauterine growth restriction (sIUGR) is presented. Objective: To determine the predominant types of anastomoses in placentas with feto-fetal transfusion syndrome, twin anemia polycythemia sequence, reverse arterial perfusion syndrome and selective intrauterine growth restriction. Methodology: The placental injection technique was applied for the recognition of anastomoses. Results: The mean number of anastomoses per placenta in STFF, which was the most severe complication, was 8.2 ± 2.2. The AV and VA anastomoses predominated in 83%. There were signs of placental discordance in 30% of placentas, and 40% of placentas presented velamentous cord insertion. Conclusions: Vascular anastomoses are not only involved in the etiology of the main pathologies of monochorionic gestations, but also influence their management. We believe that an adequate placental study of each of these cases by means of the placental vascular injection technique would be essential in centers that aspire to develop differentiated fetal management for each of these complications.

Secuencia de perfusión arterial reversa en embarazo gemelar; coagulación de arteria nutricia. Reporte del primer caso en el país / Twin reversed arterial perfusion sequence; coagulation of the umbilical cord. A report on the first case in Uruguay / Seqüência reversa de perfusão arterial na gravidez gemelar; coagulação da artéria nutritiva. Relato do primeiro caso no país

Resumen: La secuencia de perfusión arterial reversa (TRAP) es una complicación muy poco frecuente y grave de los embarazos gemelares monocoriónicos. Generalmente ocurre cuando el corazón de un gemelo de apariencia normal sirve como bomba para uno o más gemelos dismórficos cuya cabeza, órganos torácicos y extremidades superiores no se desarrollan completamente o no se desarrollan en absoluto y, por lo tanto, carecen de actividad cardíaca. La arquitectura placentaria vascular anómala provoca un cambio en el flujo arterial hacia el gemelo acardíaco. Los mecanismos fisiopatológicos exactos que conducen a este fenómeno devastador no se conocen bien. Compartiremos el caso clínico de una paciente de 19 años, cursando un embarazo gemelar monocorial monoamniótico, en que realizamos diagnóstico de TRAPS, y realizamos la coagulación laser de la arteria nutricia del feto acárdico.

Abstract: Twin reversed arterial perfusion sequence (TRAPS) is rather an unusual and severe complication of monochorionic twin pregnancies. It usually occurs when the normal-appearance heart of a twin acts as a pump for one or more dysmorphic twins whose head, thoracic organs and upper limbs fail to totally develop or do not develop at all and thus, have no cardiac activity. The abnormal vascular architecture at the placenta changes the arterial flow towards the acardiac twin. The exact pathophysiological mechanisms that result in this devastating phenomenon are still unknown. The study presents the clinical case of a 19-year- old patient pregnant with monoamniotic, monochorionic twins and a diagnosis of TRAPS, treated by laser coagulation of the acardiac twin's umbilical cord.

Resumo: A seqüência reversa de perfusão arterial (TRAPS) é uma complicação muito rara e grave de gestações gemelares monocoriônicas. Geralmente ocorre quando o coração de um gêmeo de aparência normal serve como uma bomba para um ou mais gêmeos dismórficos cuja cabeça, órgãos torácicos e membros superiores não se desenvolvem totalmente ou não se desenvolvem e, portanto, não têm atividade cardíaca. A arquitetura vascular placentária anormal causa uma mudança no fluxo arterial para o gêmeo acardíaco. Os mecanismos fisiopatológicos exatos que levam a esse fenômeno devastador não são bem compreendidos. Descrevemos o caso clínico de uma paciente de 19 anos, portadora de gestação gemelar monocoriônica monoamniótica, na qual fizemos o diagnóstico de TRAPS e realizamos coagulação a laser da artéria nutritiva do feto acardíaco.

Secuencia de perfusión arterial reversa gemelar (TRAP): reporte de caso clínico de manejo expectante / Twin Reverse Arterial Perfusion Sequence (TRAP): clinical case report of expectant management

TRAP describe la perfusión crónica de un gemelo acardíaco por un gemelo de bomba a través de canales vasculares entrelazados permeables. La secuencia TRAP ocurre en 1 de cada 35.000 nacimientos o en 1 de cada 100 pares de gemelos monocigóticos. Se diagnostica mediante los hallazgos ecográficos de un feto de desarrollo normal y una masa amorfa con frecuencia con partes fetales perceptibles. El Doppler color revela el flujo sanguíneo reverso hacia el gemelo acardíaco dentro de la arteria umbilical lo que lleva a las complicaciones típicas del cuadro. El manejo expectante es razonable en ausencia de características pronósticas deficientes. El propósito de este artículo es revisar los aspectos básicos y el estado actual de esta condición, haciendo énfasis en el diagnóstico y el manejo expectante.

TRAP describes the chronic perfusion of an acardiac twin by a pump twin through permeable interlocking vascular channels. TRAP occurs in 1 in 35,000 births or 1 in 100 pairs of monozygotic twins. It is diagnosed by ultrasound findings of a normally developing fetus and an amorphous mass often with noticeable fetal parts. Color Doppler reveals the reverse blood flow to the acardiac twin within the umbilical artery, leading to typical complications of the condition. Expectant management is reasonable in the absence of poor prognostic characteristics. The purpose of this article is to review the basic aspects and current status of this condition, emphasizing the diagnosis and expectant management.

Effects of twin pregnancy chorionic properties on fetal outcomes: a comparative study

Background: Twins carry significant risks to both mothers and babies. The purpose of this study was to evaluate chorionicity and its impact on perinatal outcomes in twins.Methods: This prospective observational study was conducted in the department of obstetrics and gynecology, Government T. D. Medical College, Alappuzha, Kerala. A total of 106 cases of twin pregnancies were included in the prospective descriptive study. Based on the ultrasound results and methods of the postpartum pathologic examination of the placental membranes, the cases were divided into the twin group with monochorionic diamniotic (MCDA) and twin group with dichorionic diamniotic (DCDA group). The relationships of different chorionic properties and fetal outcomes were determined by comparing various fetal outcomes.Results: Among 106 twin pregnancies, 61.3% were DCDA twins, 38.7% were MCDA. Average maternal age of monochorionic twin was 25 and that of dichorionic twin was 27. Perinatal mortality of monochorionic twin was 14.7% when compared to 8.6% for dichorionic twin. The mean gestational age for monochorionic twin pregnancy was 34.78 weeks whereas it was 35.91 weeks for dichorionic pregnancy. Elective and emergency LSCS was done more for dichorionic twin pregnancies compared to monochorionic twin pregnancies. Low Apgar scores were seen in monochorionic twins compared to dichorionic twins.Conclusions: The incidence of fetal outcomes in the monochorionic group was inferior to those in the dichorionic group. The fetal outcomes may be improved by determining the chorionic properties in early pregnancy by using ultrasound and consequently planning for pregnancy monitoring and intervention.

Obstetric outcome in twin pregnancies complicated with single intrauterine fetal demise

Background: It has been reported that single intrauterine fetal death in twin pregnancy occurs in 3.7-6.8% all twin pregnancies. The objective of this study was to evaluate the maternal and fetal demographic features and feto-maternal outcomes in twin pregnancies complicated with single intrauterine fetal demise and evaluation of available management guidelines.Methods: This retrospective study was conducted at obstetrics and gynecology department of SGRRIM and HS, Dehradun, Uttarakhand between January 2015 and December 2019. There was a total of 182 twin deliveries at study hospital during this period and 35 of these cases were complicated with single intrauterine fetal demise. Maternal age, parity, chorionicity of twin gestation, gestational age at single intrauterine fetal demise, gestational age at delivery, mode of delivery, birth weight, Apgar Score at birth, neonatal intensive care unit stay of newborn,  maternal fibrinogen levels during pregnancy and delivery time and associated obstetric complications were analyzed in these cases of single intrauterine fetal demise with twin gestation. All monochorionic twin pregnancies were included in the study Group A and dichorionic twin in Group B.Results: The mean age of 32 patients included in study was 29.7±4.6 years. Twenty (62.5%) of these patients were dichorionic and 12 (37.5%) of these were monochorionic twin gestation. Single intrauterine fetal demise occurred in first trimester in 8 (25%) patients, during the second trimester 20 (62.5%) and 4 (12.5%) patients had third trimester single intrauterine fetal demise. Preterm deliveries occurred in 18 (56.3%) of patients and 8 (44.4%) of patients were of monochorionic and 10 (55.6%) of dichorionic twin patients. Among thirty-two patients, 11 (34.4%) patients had caesarean delivery and 21 (65.6%) patient had vaginal birth. No maternal or fetal mortality noted and none of the patients had maternal coagulation disorder.Conclusions: This study indicates that in cases of twin pregnancies with single fetal intrauterine demise with individualized management plan at higher centre and close maternal and fetal surveillance live fetus can be saved without any maternal risk.

Twin reversed arterial perfusion sequence: the heartless twin

To report a case of twin reversal arterial perfusion sequence and its management by means of laser coagulation of the vascular malformation in the placenta. Twin reversed arterial perfusion sequence is a rare form of twin to twin transfusion syndrome occurring primarily in Monochorionic monoamniotic twins. The prevalence is about 1 in 35,000 pregnancies. The significance of this condition is that there is a normal foetus and an acardiac foetus. The blood is shunted from the normal twin to the acardiac twin through vascular malformations in the placenta. The normal twin faces a high risk of both morbidity and mortality due to cardiac failure. A case of twin reversal arterial perfusion sequence diagnosed at 22 weeks following a target scan underwent laser photocoagulation and gave birth vaginally at 30 weeks without any complications. Early detection of this condition can lead to timely intervention and thereby improve the outcome. In Twin reversal arterial perfusion sequence, the normal or the pump twin has a high chance of mortality due to cardiac failure. As the size of the acardiac twin increases, there is a higher chance of mortality of the pump twin. There is a need for regular follow up with ultrasonography and foetal echocardiography along with early therapeutic interventions to ensure the survival of the normal twin. In our case, despite the large size of the acardiac twin, we had a successful pregnancy outcome for the normal twin due to timely intervention.

Twin-Twin transfusion syndrome: a case report

Twin to twin transfusion syndrome is a rare but serious complication of monochorionic twin pregnancy. It is characterized by the development of abnormal placental vascular communication from one foetus (donor) to the other foetus (recipient). If left untreated it led to high rates of perinatal morbidity and mortality due to its poorly understood etiology and difficulty in diagnosing and treatment. Authors report a case of twin to twin transfusion syndrome in 24 years old primigravida with gestational age of 18 weeks 5 days diagnosed on ultrasound.

Monochorionic monoamniotic live twin ectopic pregnancy: a rarity

The incidence of unilateral live twin ectopic pregnancy is approximately 1:1,25,000 but increased in last few decades due to increased use of fertility drugs for ovulation induction, superovulation and assisted reproductive technology. It is also associated with increased incidence of pelvic inflammatory diseases. Patient was 30 years old G3P2L2 who presented to OPD of this LLRM medical college, Meerut with complain of amenorrhoea of two and half months. Pelvic examination revealed tenderness in lower abdomen, left adnexal fullness and tenderness without any bleeding. On USG, left adnexal monochorionic monoamniotic ectopic twins with normal cardiac activity. Exploratory laparotomy followed by left sided salpingectomy was done and patient was discharged with satisfactory condition. This is a very rare case and PID is also among risk factors and may also cause twin ectopic pregnancy.

A rare case of fetus papyraceous presenting in monozygotic biamniotic twins

Fetus papyraceous or compresses is characteristic of compressed mummified, parchment like remains of dead twin retained in utero after intrauterine death in the second trimester. It is an uncommon finding and we report in a G2P1L1 with 22 weeks with Monozygoticbiamniotic twins with fetus papyraceous stuck to left upper segment followed up to 36 weeks. The mother was advised regular antenatal visits and frequent feto-maternal monitoring was done. Patient delivered a single live baby and a placenta with mummified fetus within it. The incidence of fetus papyraceous is about 1 in 17000 to 1 in 20000 pregnancies. Early diagnosis of this condition helps in monitoring the surviving fetus.

Parapagus dicephalus conjoined twin: a case report

A conjoined twin is a rare event. As per recent literature, 60% of conjoined twins are aborted spontaneously and hence true incidence of conjoined twin is approximately 1 in 200,000 live births. Classification is based upon site of attachment out of which parapagus with dicephalic variety is extremely rare (0.5% amongst reported cases). Author report a case of dicephalic twin born at 36 weeks of gestation to a multigravida mother in central India.

Ultrasonographic diagnosis of twins in two pregnant bitches: case report / Diagnóstico ultrassonográfico de gestação gemelar em duas cadelas: relato de caso

Multiple pregnancies in humans account for only 3% of pregnancies, 97-98% of which are twin pregnancies and the morbimortality is higher in the monochorionic twins when compared to dichorionic ones. The canine species is naturally multiparous, but the diagnosis of monochorionic twin pregnancy is not common. The objective of this report was to describe the ultrasonographic diagnosis of monochorionic twin pregnancies in two bitches [Pug (case 1) and Shih tzu (case 2)]. It was possible to verify the presence of one gestational vesicle containing two fetuses in each female by observing two heads or two bodies within the same placental site. These fetuses presented adequate viability and normal organogenesis. Their development was similar to the other fetuses. In case 1 they were stillborn and smaller than the other five live-born fetuses. The twins in case 2 were born alive, but they also appeared smaller when compared to the littermates. The gestational risks associated with this condition in pregnant bitches are still unknown, however, there are reports of fetal death in monochorionic pregnancies in this species. Therefore, ultrasonographic exam during pregnancy allows an early monochorionic diagnosis and monitoring the fetal viability could bring health benefits to both the female and the littermates.(AU)

As gestações múltiplas em humanos correspondem a apenas 3% das gestações, sendo 97-98% dessas gestações gemelares. Sabe-se que a morbimortalidade fetal é maior em gêmeos monocoriônicos do que nos dicoriônicos. A espécie canina é naturalmente multípara, mas o diagnóstico gestacional de gêmeos monocoriônicos não é comum. O objetivo deste relato é descrever o diagnóstico ultrassonográfico de gêmeos monocoriônicos em duas cadelas, sendo uma da raça Pug (caso 1) e outra da raça Shih-Tzu (caso 2). Foi possível verificar a presença de uma única vesícula gestacional contendo dois fetos em cada cadela, por meio da visibilização de duas cabeças ou de dois corpos dentro de uma mesma placenta. Esses fetos apresentavam viabilidade e organogênese adequadas e o grau de desenvolvimento era similar aos demais fetos da ninhada. No caso 1, os gêmeos nasceram mortos e de tamanho menor que os outros cinco fetos nascidos vivos. Os gêmeos do caso 2 nasceram vivos, mas também eram pequenos em relação aos irmãos da ninhada. Os riscos gestacionais associados a essa condição em cadelas ainda não são conhecidos, no entanto já existem relatos de morte fetal em gestação monocoriônica nessa espécie. Portanto, o exame ultrassonográfico durante a gestação permite um diagnóstico precoce da monocorionicidade, e a monitorização da viabilidade fetal pode trazer benefícios para a saúde da matriz, assim como para o restante da ninhada.(AU)

A rare case of dicephalous dibrachius dipus conjoined twins:case report

Conjoined twin is a rare complication seen in 1% of monochorionic monoamniotic twins and associated with severe morbidity and mortality. We are reporting a case of 30 years old second gravida referred to our tertiary care center at 35 weeks of gestation with ultra-sonographic diagnosis of dicephalus conjoined twin and further confirmed after caesarean delivery.

A Hospital Based Study On Neonatal Outcome In Monochorionic And Dichorionic Twin Pregnancies

Background: Twin pregnancies account for 2 to 4% of the total number of births. Twin pregnancies are associated with signicantly higher morbidity and mortality than are singleton pregnancies. Among the twin pregnancies, Dichorionic pregnancies occur in 70% of the total twin pregnancies. Monochorionic twins are at higher risk twins for perinatal complications. The objective of the present study is to analyze neonatal outcomes associated with Monochorionic and Dichorionic twin pregnancies. Material and Methods: The study was Retrospective and Hospital based study conducted in Tertiary Care Hospital in Mumbai in 2018. The sample size was 50 (N=50). The patients with maternal co-morbidities like DM or other systemic illness were excluded from the study. The patients were divided into two groups, viz. Monochorionic or Dichorionic twins. The maternal age and its association with Monochorionic and Dichorionic twin pregnancy are studied. The neonatal outcome in Monochorionic and Dichorionic twins were then analyzed in terms of Birth weight, NICU stay, Neonatal deaths, etc. Statistical analysis: The maternal age and the various neonatal outcomes in Monochorionic and Dichorionic twin pregnancy were recorded. The student t test was used to compare the difference in both groups. Results: The maternal age was almost similar in both Monochorionic and Dichorionic twin pregnancies. The mean Birth Weight was more in Dichorionic group (p < 0.05). The Neonatal Outcomes like IUFD, TTTS and Discordant growth were more common in Monochorionic group as compared to Dichorionic group. Conclusion and Recommendations: Twin pregnancy rates have increased in the past 25-30 years, particularly in developing countries. The reasons may be more advanced maternal age and increased use of assisted reproductive techniques. The neonatal mortality and morbidity in twin deliveries is high in Monochorionic pregnancy as compared to Dichorionic pregnancy. The early identication of chorionicity in early pregnancy is necessary to prevent neonatal complications.

Restricción de crecimiento intrauterina selectiva tipo III, en gemelos monocoriales: serie de casos y revisión de la literatura / Monochorionic twins with type III selective intrauterine growth restriction: case series and review of the literature

We present four cases of monochorionic twin pregnancies with diagnosis of type III selective intrauterine growth restriction, highlighting the ultrasonographic characteristics (evaluation of the umbilical artery intermittent reverse diastole and the superficial arterio-arterial anastomosis), its evolution during pregnancy and its follow-up during the first month of life.

Se presenta cuatro casos de gestaciones dobles monocoriales afectadas con restricción selectiva de crecimiento de tipo III, con énfasis en las características ecográficas (evaluación de la diástole intermitente reversa de la arteria umbilical y la anastomosis superficial arterio-arterial), evolución durante la gestación y seguimiento hasta el mes de vida.

Cerebroplacental blood flow redistribution in monochorionic-diamniotic twin pregnancies with selective fetal growth restriction / 中华超声影像学杂志

Objective@#To analyze the cerebroplacental blood flow distribution characteristics in monochorionic-diamniotic (MCDA) twin pregnancies with selective fetal growth restriction (sFGR), and investigate the relationship between co-twin cerebroplacental blood flow discordances and co-twin birth weight discordances (BWdisc).@*Methods@#The cerebroplacental blood flow distribution characteristics and their discordances were analyzed retrospectively in 52 MCDA twin pregnancies with normal growth (control group) and 52 with sFGR (case group), including the umbilical artery pulsatility index (UA-PI), middle cerebral artery peak systolic velocity (MCA-PSV), middle cerebral artery pulsatility index (MCA-PI), cerebroplacental ratio (CPR), and their discordances (UA-PIdisc, MCA-PSVdisc, MCA-PIdisc and CPRdisc).@*Results@#Compared to the control group, UA-PIdisc, MCA-PIdisc and CPRdisc increased significantly (all P<0.01). UA-PIdisc, MCA-PIdisc and CPRdisc were related positively to BWdisc as shown by correlation analyses (r=0.488, 0.414, 0.592; all P<0.001), and they had moderate predictive accuracy for sFGR with area under the curves of 0.743, 0.662 and 0.778, with sensitivity of 48.08%, 67.31% and 71.15%, and specificity of 92.31%, 59.62% and 78.85% (all P<0.01). Multivariate Logistic regression analyses showed that only CPRdisc were independently associated with sFGR (P<0.05).@*Conclusions@#More cerebroplacental blood flow discordances are observed in MCDA twin pregnancies with sFGR. Co-twin cerebroplacental blood flow discordance is related to BWdisc.

Secuencia TRAP: serie de casos en el Hospital Regional de Alta Especialidad de la Mujer de Tabasco / TRAP sequence: Series of cases in Hospital Regional de Alta Especialidad de la Mujer de Tabasco

Resumen OBJETIVO: Reportar, comparar y analizar el estado posnatal de pacientes con embarazo gemelar monocorial y determinar la incidencia de secuencia TRAP. MATERIALES Y MÉTODOS: Estudio retrospectivo y descriptivo de una serie de casos de pacientes con diagnóstico de embarazo múltiple monocorial atendidas entre 2014 y 2018 en el Hospital Regional de Alta Especialidad de la Mujer de Tabasco. Se incluyeron todas las pacientes con diagnóstico de secuencia de perfusión arterial reversa gemelar con finalización del embarazo y reporte del estado posnatal. Se determinó la incidencia y se excluyeron las pacientes con expedientes incompletos y embarazos no concluidos en el Hospital Regional. RESULTADOS: Se encontraron 6 casos de embarazo gemelar monocorial con secuencia TRAP. De los casos reportados, 5 fueron gemelar doble y 1 de alto orden fetal. Solo 1 de los 6 casos recibió tratamiento intraútero. En 4 casos el gemelo bomba supervivió sin complicaciones reportadas. La incidencia de secuencia TRAP de embarazos monocoriales de la muestra de estudio fue de 5.2%. CONCLUSIÓN: Se expusieron 6 casos tratados de diferentes maneras y con mejores resultados con la conducta conservadora porque en los 4 casos que no recibieron tratamiento los gemelos bomba no sufrieron descompensaciones cardiacas y supervivieron, a diferencia del único caso con tratamiento intra-útero en el que hubo complicaciones que llevaron a la terminación del embarazo en el segundo trimestre.

Abstract OBJECTIVE: Report, compare and analyze the postnatal status of patients with monochorionic twin pregnancy and determine the incidence of TRAP sequence. MATERIALS AND METHODS: A descriptive, retrospective, case series study of patients diagnosed with monochorionic multiple pregnancy attended at the High Specialty Regional Women's Hospital of Tabasco between 2014 and 2018 was carried out. The study included all patients with the diagnosis of TRAP sequence, reported postnatal outcomes and the incidence was determined. Patients with incomplete records and unfinished pregnancies were excluded. RESULTS: Six cases of twin reversed arterial perfusion were diagnosed, five of which were twin pregnancies and one was a higher order multiple pregnancy. Only one of the patients received intra-uterine treatment. The pump twin survived without complications in four of the six cases. CONCLUSION: Six treated cases were exposed in different ways and with better results with the conservative behavior because in the 4 cases that did not receive treatment, the twin pump did not suffer cardiac decompensation and survived, unlike the only case with intra-uterine treatment in which there were complications that led to termination of pregnancy in the second trimester.

Cirugía fetal láser en síndrome de transfusión feto feto y restricción selectiva del crecimiento intrauterino

Introduction: The monochorionic biamniotic twin pregnancy (MCBA) corresponds to approximately 15% of all twin pregnancies and an estimate of 10-15% develop complications proper of these types of pregnancies, such as selective intrauterine fetal growth restriction (IUGRs) and feto-fetal transfusion syndrome (FFTS). Laser fetal surgery allows treatment of these hemodynamic alterations of MCBA by fulguration of placental anastomoses, and it is currently considered the first-choice therapy for FFTS and some IUGR cases. Objectives: To highlight the general aspects of laser fetal surgery and to describe current evidence of its efficacy and safety in FFTS and IUGRs. Methods: Review of articles published during the last five years in indexed journals from the following databases: PUBMED, MEDLINE, EMBASE and Cochrane Library. Review papers, original papers, and systemic reviews were included. Classic relevant papers on fetal surgery history were also included. Results: By means of this nonsystematic review of the literature, 43 articles were considered for the present paper. Conclusion: This review evidences that laser fetal surgery improves the prognosis of FFTS fetuses. The use of this therapy in IUGRs cases has not improved survival.

Introducción. El embarazo gemelar monocorial biamniótico (MCBA) corresponde aproximadamente al 15% de los embarazos gemelares y, de estos, se estima que 10 a 15% desarrollan complicaciones propias de este tipo de embarazos, como la restricción selectiva del crecimiento intrauterino (RCIUS) y el síndrome de transfusión feto (STFF). La cirugía fetal láser permite tratar la causa de estas alteraciones hemodinámicas propias de los embarazos MCBA a través de la coagulación de las anastomosis placentarias, y es considerada actualmente la terapia de elección en el STFF y aplicable en algunos casos de RCIUS. Objetivos. Resaltar los aspectos generales de la cirugía fetal láser y describir la evidencia actual de la eficacia y seguridad de su uso en el STFF y la RCIUS. Metodología. Se realizó una búsqueda de la literatura de artículos publicados en revistas indexadas en las siguientes bases de datos: PUBMED, MEDLINE, EMBASE, Cochrane Library. Se incluyeron revisiones de tema, investigaciones originales y revisiones sistemáticas de la literatura, publicadas en los últimos 5 años. Además, se incluyen artículos clásicos relevantes en la historia de la cirugía fetal. Resultados. Producto de la revisión no sistemática de la literatura, se incluyeron 43 para la construcción de la presente revisión. Conclusiones. La presente revisión evidencia que la cirugía láser fetal mejora el pronóstico de los fetos con STFF. El uso de dicha terapia para los casos de restricción de crecimiento intrauterino selectivo no ha mejorado la sobrevida.

Manejo del síndrome de transfusión feto fetal en gestaciones gemelares monocoriales / Management of Fetal Fetus Transfusion Syndrome in Monochorionic Twin Gestations

El síndrome de transfusión feto fetal es una complicación grave de las gestaciones gemelares monocoriales. Su etiología se debe a la transfusión crónica de sangre del feto donante, al feto receptor, a través de las anastomosis vasculares entre los territorios placentarios de ambos. El cuadro clínico característico se evidencia en ambos fetos, receptor y donante, lo cual es consecuencia directa de las alteraciones en la volemia que padece cada uno. En el feto receptor se observa un polihidramnios relacionado con la poliuria derivada de un estado de hipervolemia constante, que acaba evolucionando hacia una insuficiencia cardiaca congestiva. En el feto donante el cuadro es inverso, caracterizado por oligoamnios, oliguria, crecimiento intrauterino retardado e hipovolemia, con tasas de mortalidad sin tratamiento de entre el 80-100% de los casos, que varían en función del grado de transfusión. El diagnóstico se basa en el estudio ecográfico exhaustivo de ambos fetos, procurando un diagnóstico precoz y un estadiaje correcto, ya que el pronóstico se verá muy influenciado por la actuación temprana. El tratamiento de elección es la coagulación láser de las anastomosis vasculares por fetoscopia, que se realiza idealmente entre la semana 18 y 26 de embarazo. El pronóstico es variable, en función de la disponibilidad de terapia fetal y de la edad gestacional en el momento del diagnóstico, siendo, en general, de muy mal pronóstico sin tratamiento efectivo(AU)

Twin-twin transfusion syndrome (TTTS) is one of the most serious complications of monochorionic multiple gestations. The etiology is due to a chronic blood transfusion from de donor twin to the recipient twin trough vascular anastomoses between both placenta territories. Main clinical presentation is present in both donor and recipient fetuses, as a direct consequence of a blood volume alteration in each one. The recipient twin shows polyhydramnios related to polyuria resulting from a state of constant fluid overload, finally evolving into congestive heart failure. In the donor twin, the clinical presentation is opposite and shows oligoamnios, oliguria, intrauterine retarded growth and hypovolemia. Untreated mortality rates are between 80-100 % of all cases, which may vary depending on the severity of the transfusion. Diagnoses is based on exhausting ultrasound examination of both fetuses, securing early diagnosis and correct staging, since prognosis will be greatly influenced by early actions. Fetoscopic laser ablation is generally the definitive treatment between 16 and 26 weeks of gestation. The prognosis is variable, depending on the availability of fetal therapy and gestational age at diagnosis. It is generally very poor prognosis without effective treatment(AU)