ABSTRACT
Objective:To investigate the prenatal genetic features and the factors influencing the prognosis of twin reversed arterial perfusion sequence (TRAPS) in monochorionic twin pregnancies.Methods:A total of 99 cases diagnosed with TRAPS by prenatal ultrasound in the First Affiliated Hospital of Sun Yat-sen University from July 1, 2007, to December 31, 2021, were included retrospectively. The prenatal genetic features of acardiac and pump twins were analyzed. Eighty-nine cases were followed up and divided into two groups: the expectation group ( n=45) and the intrauterine intervention group (all underwent radiofrequency ablation, n=44) and the pregnancy outcomes were compared between the two groups. After excluding eight cases without complete ultrasound data, the expectation group was further divided into two subgroups: the pump fetus survival ( n=28) and the pump fetus death groups ( n=9), and the survival subgroup was divided into the spontaneous arrest group ( n=16) and coexistence group ( n=12) according to whether or not the blood flow stopped spontaneously.The relationship between ultrasonic indexes and pregnancy outcome was compared between the groups. Chi-square test (or Fisher's exact test), univariate logistic regression analysis and receiver operating characteristic (ROC) curve were used to analyze the relationship between the estimated acardiac to pump twin weight ratio (A/P Wt) and the pregnancy outcome of the pump twin in the expectation group. Results:(1) The median gestational age at diagnosis of the 99 TRAPS cases was 16.4 weeks (13.3- 21.3 weeks) and 32% (32/99) were diagnosed in the first trimester. Most of the cases were monochorionic diamniotic pregnancies (72/99, 73%). The survival rate of the pump twins was 71% (63/89). (2) Chromosome karyotyping and/or chromosomal microarray analysis was performed in 19 acardiac twins and 82 pump twins. The detection rate of genetic abnormalities in the acardiac twins was higher than that in the pump twins [4/19 vs 5% (4/82), Fisher's exact test, P=0.039]. Chromosomal microarray analysis was performed in 54 pump twins with normal karyotypes and the results showed three (6%) with genetic abnormalities. (3) In the expectation group, the area under ROC curve for the prenatal A/P Wt were 0.913 in predicting pump twin death and 0.807 in predicting spontaneous cessation of blood flow in the cardiac twin, and the cut-off values were 0.24 (sensitivity: 88.9%, specificity: 96.4%) and 0.11 (sensitivity: 75.0%, specificity: 81.3%), respectively. The survival rate of pump twins with abnormal cardiac function after intrauterine intervention was higher than that of the expectant group [72% (18/25) vs 3/11, Fisher's exact test, P=0.025]. Conclusions:TRAPS can be diagnosed in the first trimester and commonly occur in monochorionic diamniotic pregnancies. The detection rate of genetic abnormalities in the acardiac twins is higher than that in the pump twins. Prenatal A/P Wt>0.24 indicates the death of the pump twin and prenatal A/P Wt≤0.11 suggests a high possibility of spontaneous cessation of blood flow in the acardiac twin. Radiofrequency ablation is an effective method for improving the prognosis of the pump twin with cardiac dysfunction.
ABSTRACT
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.
Subject(s)
Female , Adult , Fetus , Perfusion , Twins , BloodABSTRACT
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.
ABSTRACT
Twin reversed arterial perfusion sequence is a complication of monochorionic twin pregnancies in which one twin that exhibits lethal anomalies, including acardia, is perfused by the other 'pump' twin via anastomoses between placental arteries. This results in growth and characteristic anomalies of the acardiac twin, and possible heart failure of the pump twin. The exact pathophysiological mechanisms that lead to this devastating phenomenon are not well known. It occurs in about 1% of monochorionic pregnancies and in one out of 35 000 pregnancies. Mortality is usually due to anemia and cardiac complications which can lead to cardiac failure, appear early during pregnancy and cause the death of the pump twin. We report a case of twin reversed arterial perfusion in a 28-year-old patient with 12 weeks monochorionic-diamniotic pregnancy that was referred for absent cardiac activity in one twin. Ultrasound showed an acardiac twin with flow reversal seen in the umbilical artery and umbilical vein and a normal second twin. At 28 weeks an emergency cesarean section was done due preterm labor and transverse situation of the second twin. The first twin was malformed and the second twin died two days later due to complications of prematurity. Accurate prenatal diagnosis of twin reversed arterial perfusion sequence is essential to improve the prognosis of this rare entity.
La secuencia de perfusión arterial reversa en gemelos es una complicación del embarazo gemelar monocoriónico, en la que un gemelo muestra anomalías mortales, incluyendo acardia, y es perfundido por el otro gemelo 'bomba' a través de anastomosis arteriales placentarias, produciendo el crecimiento y las anomalías características del gemelo acárdico, con posible insuficiencia cardíaca en el gemelo bomba. Los mecanismos fisiopatológicos exactos que conducen a este fenómeno devastador no son bien conocidos. Ocurre en aproximadamente 1% de los embarazos monocoriónicos y en 1 de cada 35 000 embarazos. La mortalidad se debe generalmente a anemia y complicaciones cardíacas que pueden conducir a insuficiencia cardíaca, que aparecen temprano durante el embarazo y causan la muerte del gemelo bomba. Se presenta un caso de perfusión arterial reversa en gemelos en paciente de 28 años de edad con un embarazo monocoriónicodiamniótico de 12 semanas quien fue referida por ausencia de actividad cardíaca de uno de los gemelos. La ecografía mostró un gemelo acárdico con reversión de flujo visto en arteria-vena umbilical y un segundo gemelo normal. A las 28 semanas se realizó una cesárea de emergencia debido a parto pretérmino y situación transversa del segundo gemelo, obteniendo el primer gemelo marcadamente malformado y un segundo gemelo vivo que murió dos días después de las complicaciones de la prematuridad. El diagnóstico prenatal exacto secuencia de perfusión arterial reversa en gemelos es esencial para mejorar el pronóstico de esta rara entidad.
ABSTRACT
Objective To explore the characteristics of prenatal ultrasound image of triplet pregnancy complicated by twin reversed arterial perfusion sequence (TRAPS) and improve early diagnosis of this rare fetal malformation. Methods Compare the ultrasound and pathological findings of 6 cases of triplet pregnancy with TRAPS fetus by prenatal ultrasound diagnosis and postnatal diagnosis from April 2001 to April 2017 in Hubei Maternal and Child Health Hospital, and summarize the characteristics of prenatal ultrasound images of TRAPS fetus. Results Sonographic findings of the six triplet pregnancy were as follows: (1) Acardiac fetus: all acardias were absence of heart and beat, with hypogenetic lower limbs, five with skin edema and lymphoedema, five were absence of fetal head while one with stunted head, one with hypogenetic upper limb, four with spin and abdominal cavity, four acardias had single umbilical artery and were supplied by umbilical artery draining towards the fetus, two cases showed no blood flow in umbilical artery and fetal body. (2) Pump fetus: all of the six cases with normal anatomical structure, two showed normal amniotic fluid volume while four showed polyhydramnios, three cases had prenatal cardiac dysfunction (one case survived, two cases of intrauterine demise). (3) The third fetal of the triplets (TRAP co-twin ): during the Prenatal ultrasound follow-up five fetus had normal morphology with normal heart function, one fetal with multiple malformations. Prognosis of the triplet pregnancy: one triplet cesarean delivery two normal boys, five triplets were of poor prognosis (four pump fetus of intrauterine demise, one pump fetal of premature death: one TRAP co-twin of intrauterine demise, two TRAP co-twins of premature death, two TRAP co-twins of induced labor), four acardia twins of intrauterine spontaneous blood blocking, two still birth. Fetal chorionic and amniotic membrane: four cases were dichorionic triamniotic triplet pregnancy, one case was monochorionic triamniotic triplet gestation, one case was monochorionic diamniotic triplet pregnancy. Six cases were confirmed by pathologic anatomy. Conclusion Triplet pregnancy complicated by TRAPS is a rare and severe multiple pregnancy complication, with its characteristic acoustic image characteristics, combined with color doppler, prenatal ultrasound has a high diagnostic value.
ABSTRACT
Abnormal placental vascular anastomoses in monochorionic twins can give rise to a rare congenital anomaly known as Acardiac twin. With the advancement of antenatal care and ultrasonography many such cases are diagnosed early. However, in underdeveloped country like Nepal where early antenatal care coverage rate is low such cases may be diagnosed late. I report one such case of Acardiac acepahalus twin diagnosed during delivery.
ABSTRACT
In general, twin pregnancy represents a high-risk pregnancy. The monozygous twin of all twin pregnancy is a real challenge for the obstetrician due to the severe complications that may arise during its development. An extremely uncommon, severe complication of monozygous twin pregnancy, which we recently experienced in Soonchunhyang University Cheonan Hospital, was a monochorionic diamniotic twin pregnancy with acardiac twin-twin reversed arterial perfusion sequence. An acardiac twin presented no heart, underdeveloped inferior part of the body, being transfused by the other fetus (pumping twin) by umbilical vessels. We report a 33-year-old pregnant woman, with a history of in vitro fertilization-embryo transfer in the second pregnancy, who presented with generalized edema, abdominal discomfort, and high blood pressure at 33 weeks' gestation. By ultrasonography, one of the babies is normally developed but in the other baby, head, upper extremities, and cardiac activity cannot be detected. The pumping twin was cardiomegaly, polyhydramnios, absent diastolic wave on the umbilical artery, and small for gestational age. We decided to terminate the pregnancy by primary cesarean section after administration of corticosteroids. The comprehension of this case is compulsory in order to provide maximum survival opportunity to the viable baby.
Subject(s)
Adult , Female , Humans , Pregnancy , Adrenal Cortex Hormones , Cardiomegaly , Cesarean Section , Comprehension , Edema , Fetus , Gestational Age , Head , Heart , Hypertension , In Vitro Techniques , Perfusion , Polyhydramnios , Pregnancy, High-Risk , Pregnancy, Twin , Pregnant Women , Twins , Ultrasonography , Umbilical Arteries , Upper ExtremityABSTRACT
Se presenta el caso de una gestante de 27 semanas de edad gestacional referida a nuestro servicio por presentar una gestación gemelar monocoriónica complicada con secuencia arterial reversa (TRAP). Se realizó una intervención de fetoscopia y coagulación bipolar del gemelo acárdico, con un resultado favorable.
A case of a pregnant woman referred to our center at 27 weeks of gestational age for twin reversed arterial perfusion (TRAP) sequence is reported. Fetoscopy and bipolar coagulation of the umbilical cord of the acardiac twin was performed with successful outcome.
ABSTRACT
El embarazo ectópico es la gestación que se anida fuera del endometrio que recubre la cavidad uterina. Se estima una incidencia de 0,94 a 2,6% de todas las gestaciones. Su localización en cicatriz uterina de cesárea previa (0,15%) -una rara presentación de esta patología- representa 6,15% de los casos de embarazo ectópico que ocurren en mujeres con antecedente de cesárea. En el presente artículo se analiza el caso de una paciente de 28 años, gesta 5, para 0412, con antecedente de 3 cesáreas, que acudió al Hospital Nacional Docente Materno Infantil (HONADOMANI) San Bartolomé en febrero 2013 con diagnóstico de embarazo ectópico localizado en cicatriz uterina por cesárea previa, por ecografía transvaginal, y que fue resuelto exitosamente mediante manejo laparoscópico. El embarazo ectópico localizado en la zona de cicatriz uterina por cesárea previa, aunque raro, va en aumento debido al incremento de la tasa de cesáreas. La ultrasonografía transvaginal es crucial para su diagnóstico, y actualmente no existe un consenso o guía clínica que nos oriente en su manejo.
Ectopic pregnancy is a gestation that nests outside of the uterus endometrial lining. Incidence is estimated at 0.94-2.6% of all pregnancies. Its location in a previous cesarean section uterine scar is a rare (0.15%) presentation of this disease, accounting for 6.15% of ectopic pregnancy cases occurring in women with previous cesarean section. A case of a 28 year-old woman G: 5 P: 0412, with history of 3 cesarean sections was hospitalized in Hospital Nacional Docente Materno Infantil (HONADOMANI) San Bartolomé in February 2013 because of transvaginal ultrasound diagnosis of ectopic pregnancy located in previous uterine cesarean scar; it was successfully resolved by laparoscopic management. Cases of ectopic pregnancy located in the uterine scar from previous cesarean are increasing due to the rising cesarean section rate. Transvaginal ultrasonography is crucial for diagnosis. There is no current consensus or guidelines for its management.
ABSTRACT
Acardiac twin is a rare anomaly that occurs 1% in monochorionic twins and 1 in 35,000 pregnancies overall. Acardiac twin, also known as twin-reversed arterial perfusion (TRAP) sequence, involves a "pump" or donor twin perfusing a recipient or "acardiac" twin through vascular (usually arterial-arterial and venous-venous) anastomoses. Perinatal mortality rate for the pump twin has been reported to be 50~75%, mainly as a result of polyhydramnios, preterm labor, and congestive heart failure. Therefore, occlusion of the circulation to the acardiac twin has been recommended to improve perinatal outcome of the pump twin. Radiofrequency ablation of the acardiac twin effectively protects the pump twin from high-output cardiac failure and death. We report our experience in the treatment of patients with TRAP sequence using radio frequency ablation to stop perfusion to the acardiac twin.
Subject(s)
Female , Humans , Pregnancy , Fetus , Heart Failure , Obstetric Labor, Premature , Perfusion , Perinatal Mortality , Polyhydramnios , Pregnancy, Twin , Tissue Donors , Umbilical CordABSTRACT
Objective To investigate the value of prenatal ultrasound in diagnosis and treatment of twin reverse arterial perfusion (TRAP) syndrome. Methods A retrospective study was performed in 5 TRAP cases, including ultrasound images, clinical data and pregnancy outcomes. The sonographic characteristics were summarized. Results Five TRAP cases were diagnosed during 13 to 28 weeks' gestation and confirmed after birth. Color Doppler unltrasonography revealed retrograde umbilical artery perfusion towards acardiac twin. Two of 5 cases ended up in induced abortion, 1 in spontaneous abortion, 1 was delivered at 37 weeks' gestation after ultrasound-guided feticide of the acardiac twin and 1 was monitored closely with ultrasound and delivered alive at 32~(+4) weeks' gestation. Conclusion Prenatal ultrasonography has great applicative value for TRAP syndrome in early diagnosis, choosing optimal treatment and prognosis assessment.
ABSTRACT
Twin reversed arterial perfusion (TRAP) sequence is a unique complication of monochorionic twinning, in which normal pump or donor twin paradoxically perfuses the recipient or acardiac twin through arterial- arterial anastomoses. This results in reversed flow of poorly oxygenated blood through the recipient twin and is usually associated with partial or complete lack of heart development. The pump twin has a mortality rate of 50% as a result of high-output heart failure, preterm labor, and polyhydramnios. We present here a case of twin reversed arterial perfusion (TRAP) sequence complicated by severe polyhydramnios during the second trimester. The blood supply to acardiac twin was interrupted successfully at 25 weeks of gestation by injecting 1.5 mL of absolute alcohol into the intra-abdominal portion of the single umbilical artery, under ultrasound guidance. Serial ultrasound showed normal growth and normal amniotic fluid volume in normal pump twin, but arrest of growth in femur length and decrease in amniotic fluid volume in acardiac twin. The normal pump twin was delivered at 384 weeks of gestation and had uneventful neonatal course.
Subject(s)
Female , Humans , Pregnancy , Amniotic Fluid , Ethanol , Femur , Heart , Heart Failure , Mortality , Obstetric Labor, Premature , Oxygen , Perfusion , Polyhydramnios , Pregnancy Trimester, Second , Single Umbilical Artery , Tissue Donors , UltrasonographyABSTRACT
It is important to consider the fetal, uteroplacental, and maternal issues when choosing anesthetic technique for fetal surgery. The twin reversed arterial perfusion (TRAP) sequence, or the acardiac anomaly, occurs in 1:100 monozygous multiple pregnancies and in 1:35,000 births. The TRAP sequence is characterized by placental vascular arterio-arterial anastomosis between twin fetuses, one an acardiac/acephalic twin that receives its blood flow from the normal pumping twin, thereby endangering the normal twin by high output cardiac failure. The acardiac twin is nonviable, and perinatal mortality in the pump cotwin exceeds 50% because of cardiac failure and prematurity. This can be managed by fetal surgery. We report on a patient with a 26-wk gestation complicated by an acardiac/acephalic fetus anesthetized for surgical umbilical cord ligation.
Subject(s)
Female , Humans , Pregnancy , Anesthesia , Fetus , Heart Failure , Ligation , Parturition , Perfusion , Perinatal Mortality , Pregnancy, Multiple , Umbilical CordABSTRACT
Twin reversed arterial perfusion (TRAP) sequence is a rare specific anomaly of twin gestation with fused placenta and umbilical anastomosis. This syndrome occurs once in about 34,600 births and reported first by Beneditti in 1533. We report on prenatal diagnosis of a case of TRAP sequence with color Doppler sonography, this case is presented with a brief review of the literature.