Síndrome de transfusão feto-fetal: revisão de literatura / Twin-twin transfusion syndrome: a literature review

A síndrome de transfusão feto-fetal é uma complicação das gestações gemelares monocoriônicas. Além de ocorrer comumente no segundo trimestre, apresenta elevada morbimortalidade fetal e neonatal, e taxas de incidência que variam de 10 a 15% dentre todas as gravidezes monocoriônicas. O objetivo deste estudo é realizar uma revisão de literatura a partir de levantamento bibliográfico acerca dos principais aspectos epidemiológicos, clínicos e terapêuticos da STFF. A base de dados PubMed foi consultada, uma vez que os termos de pesquisa utilizados foram "síndrome de transfusão feto-fetal", "diagnóstico" e "tratamento". Obtiveram-se sessenta e oito artigos de revisão de literatura e/ou revisão sistemática, sendo que apenas vinte e nove foram selecionados após aplicação dos critérios de elegibilidade. Em relação à fisiopatologia, a síndrome é explicada pela transferência sanguínea direta entre os fetos gemelares através de anastomoses arteriovenosas placentárias, conceitualmente determinando a existência de um feto receptor e outro doador. Embora as gestantes comumente se apresentam assintomáticas, as repercussões clínicas fetais costumam ser graves. O diagnóstico é exclusivamente ultrassonográfico e deve ser feito o mais precocemente possível, ressaltando-se a importância da detecção da corionicidade da gestação gemelar, além de acompanhamento ultrassonográfico seriado para rastreio do desenvolvimento da síndrome. Apesar de ainda não haver protocolo de tratamento bem estabelecido, a ablação dos vasos placentários a laser é tida como o padrão-ouro dentre as opções terapêuticas disponíveis. Apresenta elevada taxa de sobrevida de pelo menos um dos fetos e baixos índices de sequelas neurológicas neonatais, podendo ser realizada somente até a 26ª semana de gestação.

Twin-twin transfusion syndrome is a complication of monochorionic twin pregnancies. In addition to commonly occurring in the second trimester, it has high fetal and neonatal morbidity and mortality and incidence rates ranging from 10 to 15% among all monochorionic pregnancies. This study aims to perform a literature review based on a bibliographic survey about the main epidemiological, clinical and therapeutic aspects of TTTS. The PubMed database was consulted, as the search terms used were "twin-twin transfusion syndrome", "diagnosis", and "treatment". Sixty-eight literature review and systematic review articles were obtained, and only twenty-nine were selected after applying the eligibility criteria. About the pathophysiology, the syndrome is explained by direct blood transfer between the twin fetuses through placental arteriovenous anastomoses, determining the existence of a recipient fetus and another donor. Although pregnant women are usually asymptomatic, the clinical fetal repercussions are often severe. Diagnosis is exclusively ultrasonographic and must be made as early as possible, emphasizing the importance of detecting chorionicity in twin pregnancy, in addition to serial ultrasonographic follow-up to track the development of the syndrome. Although there is still no well-established treatment protocol, endoscopic laser ablation of vascular anastomoses is considered the gold standard among the available therapeutic options. It has a high survival rate for at least one of the fetuses and low rates of neonatal neurological sequelae and can only be performed until the 26th week of pregnancy.

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.

The advantage by MRI of brain lesions after fetoscopic selective laser coagulation for twin-twin transfusion syndrome / 实用放射学杂志

Objective To demonstrate that MRI is more advantageous than ultrasound in the detection of ischemic cerebral lesions precisely in twin-twin transfusion syndrome(TTTS)fetus following fetoscopic selective laser coagulation(SLCPV).Methods The fetus with TTTS treated by SLCPV were collected.All fetuses underwent brain MRI within 1-5 days after the procedure and a follow-up MRI at 29-32 weeks'gestation.All fetuses also had frequent ultrasound evaluation until delivery.Results Twenty-five pregnancies with TTTS were included in the study.Six pregnancies resulted in survival of only one twin after the procedure(Group A),while the other 19 pregnancies resulted in the survival of both twins(Group B),as assessed at the time of initial MRI.Two fetus in Group A and three in Group B had evidence of bleeding in lateral ventricle.Two fetus in Group B had actue brain ischemia.One fetus in Group B had appeared brain atrophy and choosed to terminate pregnancy.Conclusion MRI can make a clearer diagnosis of cerebral damage of TTTS fetus in a short period after SLCPV.

Progress in diagnosis and treatment of twin-twin transfusion syndrome / 中华实用儿科临床杂志

Twin-twin transfusion syndrome is the specific complication in monochorionic diamnionic twin pregnancy with the higher morbidity and mortality.Now,the progress in the clinical manifestation,complications,diagnosis and treatment of the twin-twin transfusion syndrome are introduced,in order to arouse clinicians to put importance on the diagnosis of chorion and amnion,specially monochorion,and provide help for the early management and intervention of twin pregnancy.

Rapid initiation of fetal therapy services with a system of learner-centred training under proctorship: the National University Hospital (Singapore) experience

<p><b>INTRODUCTION</b>Management of complicated monochorionic twins and certain intrauterine structural anomalies is a pressing challenge in communities that still lack advanced fetal therapy. We describe our efforts to rapidly initiate selective feticide using radiofrequency ablation (RFA) and selective fetoscopic laser photocoagulation (SFLP) for twin-to-twin transfusion syndrome (TTTS), and present the latter as a potential model for aspiring fetal therapy units.</p><p><b>METHODS</b>Five pregnancies with fetal complications were identified for RFA. Three pregnancies with Stage II TTTS were selected for SFLP. While RFA techniques utilising ultrasonography skills were quickly mastered, SFLP required stepwise technical learning with an overseas-based proctor, who provided real-time hands-off supervision.</p><p><b>RESULTS</b>All co-twins were live-born following selective feticide; one singleton pregnancy was lost. Fetoscopy techniques were learned in a stepwise manner and procedures were performed by a novice team of surgeons under proctorship. Dichorionisation was completed in only one patient. Five of six twins were live-born near term. One pregnancy developed twin anaemia-polycythaemia sequence, while another was complicated by co-twin demise.</p><p><b>DISCUSSION</b>Proctor-supervised directed learning facilitated the rapid provision of basic fetal therapy services by our unit. While traditional apprenticeship is important for building individual expertise, this system is complementary and may benefit other small units committed to providing these services.</p>

Manejo del síndrome de transfusión feto fetal en gestaciones gemelares monocoriales / Management of twin-twin 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 evoluciona 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 80-100 por ciento 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, 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; al ser, en general, de muy mal pronóstico sin tratamiento efectivo(AU)

Twin-twin transfusion syndrome is one of the most serious complications of monochorionic multiple gestations. Its etiology is due to a chronic blood transfusion from de donor twin to the recipient twin through the vascular anastomoses between the placental territories of both fetuses. The characteristic clinical presentation appears in both donor and recipient fetuses, as a direct consequence of altered volemia in each one. Polyhydramnios related to polyuria resulting from a state of constant hypervolemia is observed in the recipient twin, finally evolving into congestive heart failure. The clinical presentation in the donor twin is reversed and characterized by oligoamnios, oliguria, retarded intrauterine growth and hypovolemia, with untreated mortality rates ranging 80-100 percent of all cases, which may vary depending on the severity of the transfusion. The diagnosis is based on exhaustive echographic examination of both fetuses to make an early diagnosis and correct staging, since the prognosis depends very much on early action. The treatment of choice is fetoscopic laser coagulation of vascular anastomoses between 18 and 26 weeks of gestation. The prognosis is variable, depending on the availability of fetal therapy and the gestational age at diagnosis, being prognosis generally very poor without an effective treatment(AU)

Mirror Syndrome after Fetoscopic Laser Treatment - A Case Report / Síndrome do espelho após tratamento laser por fetoscopia - caso clínico

Abstract Mirror syndrome is a rare disease with unknown pathophysiology that can be present in different diseases that can cause fetal hydrops. The prognosis is usually bad with a high perinatal mortality. We report an unusual form of mirror syndrome that manifested itself only after a successful treatment for fetal hydrops (caused by twin-twin transfusion syndrome, in Quinteros stage IV) was performed. This syndrome was controlled by medical treatment, and despite the usually bad prognosis seen in these cases, we could extend the pregnancy from the 23rd to the 34th week of gestation, resulting in the birth of 2 live infants.

Resumo A síndrome do espelho é uma doença rara, de fisiopatologia desconhecida, que se manifesta em situações obstétricas responsáveis pela presença de hidrópsia fetal. Habitualmente o prognóstico é reservado, uma vez que se associa a elevadas taxas de mortalidade perinatal. O presente caso clínico trata de uma situação de síndrome do espelho que se manifestou, atipicamente, após o tratamento eficaz para a hidrópsia fetal associada à síndrome de transfusão feto-fetal. Apesar do mau prognóstico associado a estas situações, conseguiu-se controlar a situação apenas com tratamento médico e, desta forma, prolongar a gravidez durante 12 semanas.

Resultados perinatales en el síndrome de transfusión feto fetal manejados con la técnica de Solomon: revisión de la literatura / Perinatal outcomes in fetal-fetal transfusion syndrome managed with the Solomon technique: literature review

INTRODUCCIÓN: Entre 15-20% de los embarazos gemelares monocoriales biamnióticos se complican con el síndrome de transfusión feto/fetal el cual se asocia con mortalidad superior a 90% y morbilidad significativa en el 50% del gemelo sobreviviente. La técnica láser que coagula la superficie de la placa coriónica entre los principales canales a lo largo del ecuador (técnica de Solomon), se ha sugerido para disminuir la recurrencia, prevenir complicaciones secundarias sin incrementar resultados adversos. Métodos: REVISIÓN de la literatura existente en las bases de datos MEDLINE, EBSCO, OVID, PROQUEST, COCHRANE, Lilacs, SciELO, desde el año 2000 al 2015. Se incluyeron los artículos de revisión e investigaciones originales que compararon la técnica estándar de fotocoagulación secuencial con láser y la técnica de Solomon, el resultado primario fue la reducción de la incidencia Secuencia Anemia Policitemia, recurrencia del síndrome de transfusión feto/fetal, mortalidad perinatal y morbilidad neonatal severa. RESULTADOS: Se encontraron 200 artículos, se seleccionaron seis: 1 ensayo clínico y su análisis secundario, 2 estudios de cohorte retrospectivos, 1 revisión sistemática y un estudio que compara los resultados del neurodesarrollo. Los estudios sugieren una mejoría en la sobrevida de algunos de los fetos con la técnica Solomon, menor recurrencia del síndrome de transfusión feto/fetal y Secuencia Anemia Policitemia, sin la presencia de eventos adversos. CONCLUSIÓN: La técnica de Solomon mejora la sobrevida de algunos gemelos, sin embargo no puede concluirse que haya mejoría en la mortalidad pues los estudios no tienen el suficiente poder para determinarlo.

INTRODUCTION: Between 15 to 20% of monochorionic diamniotic twin pregnancies are complicated by the twin-twin transfusion syndrome. It has a mortality greater than 90% and a significant morbidity, 50% in the surviving twin. The Solomon technique (laser photocoagulation of the main vascular channels of the chorio-nic plate surface along the entire vascular equator) has been suggested to reduce the recurrence, and pre-vent secondary complications without increasing adverse results. METHODS: Systematic review of electronic searches of the literature from 2000 to 2015 (MEDLINE, EBSCO, OVID, PROQUEST, COCHRANE, Lilacs, and SciELO). We included review articles and original investigations comparing the standard photocoagulation technique with laser ablation against the Solomon technique. The primary results were reduction of Anemia Polycythemia Sequence incidence, twin-twin transfusion syndrome recurrence, perinatal mortality and severe neonatal morbidity. RESULTS: Of 200 articles, we selected six: one clinical essay and its secondary analysis, two retrospective cohort studies, one systematic review and a study comparing neurodeve-lopmental outcomes. The studies suggested a survival improvement in some fetuses using the Solomon technique, less twin-twin transfusion syndrome recurrence and Anemia Polycythemia Sequence without the presence of adverse effects. CONCLUSION: Solomon technique improves the survival of some twins, although we cannot conclude there is mortality improvement, because the studies do not have enough power to determine that.

A Case of Spontaneous Twin Anemia-Polycythemia Sequence

Twin anemia-polycythemia sequence (TAPS) is characterized by the transfer of blood via intertwin vascular anastomoses in a single placenta. It differs from twin-twin transfusion syndrome (TTTS) in that amniotic fluid levels remain normal during pregnancy. Since the concept of TAPS was first introduced in 2007, some cases have been reported abroad, but no such a case has been reported in Korea. Here, we report the first case of spontaneous TAPS in Korea.

Síndrome de transfusión feto-fetal (STFF)

Objetivos: Revisar el síndrome de transfusión feto fetal (STFF) en relación al diagnóstico, tratamiento y resultados comparativos de sobrevivencia y complicaciones por las técnicas utilizadas, y la situación actual del manejo de esta complicación en el Perú. Métodos: Se revisó publicaciones en fuentes bibliográficas especializadas y se analizó la experiencia en Perú y Chile sobre el manejo del síndrome. Resultados: El STFF es una complicación poco frecuente en el embarazo gemelar monocoriónico, pero con alta repercusión en la salud de ambos fetos. Existe evidencia científica clara de que el tratamiento de elección en casos severos (Quintero I-IV) es la coagulación láser de las anastomosis superficiales y profundas mediante fetoscopia entre las 18 y 26 semanas de gestación. En el Perú se presentan alrededor de 140 casos al año, siendo necesaria la implementación de esta técnica. Conclusiones: El tratamiento de elección en casos severos de STFF es la coagulación láser de las anastomosis superficiales y profundas mediante fetoscopia entre las 18 y 26 semanas de gestación. Es necesaria la implementación de esta técnica en el Perú.

Objectives: To review twin-twin transfusion syndrome (mS) comparative results by techniques used in regards to diagnosis, treatment, survival and complications, as well as current management of this complication in Peru. Methods: Articles published in specialized bibliographic sources were revised, and experience in Peru and Chile on management of this syndrome was analyzed. Results: ms is an uncommon complication of monochorionic twin pregnancy with major repercussion on the health of both fetuses. Treatment of choice of severe cases (Quintero I-IV) is fetoscopic laser photocoagulation of superficial and deep anastomoses at 18-26 weeks of pregnancy. About 140 cases per year occur in Peru and implementation ofthis technique is necessary. Conclusions: Elective treatment of severe cases of ms is fetoscopic laser photocoagulation of superficial and deep anastomoses between 18-26 weeks of gestation. This technique should be implemented in Peru.

Complicaciones feto-neonatales del embarazo múltiple. Análisis embriológico

Objetivo: Analizar las características epidemiológicas y complicaciones feto/neonatales del embarazo múltiple en el Hospital Militar de Maracaibo. Métodos: Estudio descriptivo y retrospectivo en pacientes ingresadas con embarazo múltiple desde el 01 de enero de 1998 al 30 de mayo de 2013. Se registró edad materna, presentación, tipo de parto, motivo de interrupción del embarazo, corionicidad, complicaciones feto/neonatales, peso y anomalías congénitas. Resultados: De 2 469 embarazadas ingresadas para parto, 31 (1,26 %) fueron múltiples o 1/80 nacimientos. Edad materna promedio 28 años, presentación fetal más frecuente cefálica-podálica en 12 (38,7 %) y se realizó cesárea en 27 (87,1 %) pacientes. La indicación de interrupción del embarazo más frecuente fue la electiva en 12 (38,7 %) y prematuridad en 11 (35,5 %). Se obtuvieron 62 productos y la mortalidad fue 17,7%, con 11 muertes fetales y/o perinatales, de estas 8 (72,7 %) fueron por causa de la monocorionicidad (P < 0,05) y sus consecuencias, en 5 (45,46 %) fetos fue por síndrome de transfusión intergemelar. Se diagnosticó restricción del crecimiento intrauterino en 13 (20,9 %) y en 26 (42 %) crecimiento fetal discordante moderado o severo. En 8 (8,1 %) neonatos se observaron anomalías congénitas predominantemente osteomusculares Conclusión: El embarazo múltiple tiene una elevada morbimortalidad fetal y neonatal dependiente principalmente de las complicaciones derivadas de la corionicidad, amniocidad, prematuridad y de la posibilidad de anomalías congénitas. Realizar el diagnóstico temprano de la corionicidad permite planificar medidas de vigilancia prenatal y garantizar la mejor calidad de vida materno feto/neonatal.

Objective: To analyze epidemiological characteristics and fetal/neonatal complications of twin pregnancy at the Military Hospital of Maracaibo. Methods: A descriptive and retrospective study of patients admitted with twin pregnancies, from January 1st, 1998 to May 30th, 2013. Maternal age, fetal presentations, mode of delivery, reason for interruption of the pregnancy, chorionicity, fetal/neonatal complications, weight and congenital anomalies were registered. Results: There were 31 (1.26 %) twin deliveries (or 1/80) in 2 469 pregnant woman admitted for delivery. Average maternal age was 28. The most common fetal presentation was vertex-breech in 12 (38.7 %) and in 27 (87.1 %) patients cesarean section was performed. The most common indication of pregnancy interruption were the elective delivery in 12 (38.7 %) and prematurity in 11 (35.5 %). 62 fetuses were obtained and mortality was 17.7 % with 11 stillbirth and/or perinatal death, in 8 (72.7 %) were due to monochorionicity (P< 0.05) and its consequences, of these 5 (45.46 %) were for twin-twin transfusion syndrome. Intrauterine growth restriction in 13 babies (20,9 %) and mild or severe discordant fetal growth in 26 (42 %). Congenital anomalies were observed in 8 fetuses (8.1 %) with a musculoskeletal predominance. Conclusion: Multiple pregnancy has high fetal/neonatal morbimortality which is principally dependent of the complications derived from the chorionicity, amnionicity, prematurity and the possibility of congenital anomalies. An early diagnose of the chorionicity allows the planning of antenatal care and guaranteeing the improvement of the mother and fetal/neonatal life and health.

Desenlaces materno-fetales de los embarazos atendidos en el Hospital Universitario de Santander, Bucaramanga (Colombia), 2007-2011. Estudio de cohorte / Maternal and foetal outcomes in twin pregnancies seen at Hospital Universitario de Santander, Bucaramanga (Colombia), 2007-2011. A cohort study

Los embarazos gemelares implican mayor riesgo de complicaciones materno-fetales que los embarazos únicos, particularmente en los monocoriales. El objetivo del trabajo fue describir las características clínicas y los desenlaces materno-fetales, por tipo de placenta (monocorial o bicorial), de los embarazos gemelares atendidos en el Hospital Universitario de Santander (HUS), institución de tercer nivel de complejidad localizada en Bucaramanga (Colombia). Materiales y métodos: estudio descriptivo de cohorte, se incluyeron las pacientes que terminaron un embarazo gemelar entre 2007 y 2011 en el HUS, hospital general de referencia de la región centro-oriental del país. Muestreo consecutivo. Se evaluó la edad gestacional en la primera consulta al hospital, los hallazgos clínicos en la evaluación inicial, la terminación del parto y los resultados perinatales. Se hace análisis descriptivo por tipo de corionicidad. Resultados: se incluyeron un total de 248 gestantes con embarazo gemelar en el periodo de estudio. La mediana de la edad gestacional en la primera atención en el hospital en fue de 34 semanas. Al ingreso, 127 (51,2 %) pacientes se diagnosticaron con embarazo monocorial, pero solo en dos terceras partes coincidió el diagnóstico prenatal de corionicidad con el del posparto. Se diagnosticó RCIU con más frecuencia en embarazos monocoriales que en bicoriales (22,3 vs. 7,5 %), y el doppler se encontró alterado con mayor frecuencia en fetos de embarazo monocorial (7,8 vs. 1,1 %). Los neonatos > 24 semanas de edad gestacional de embarazo monocorial pesaron, en promedio, 109 g (IC 95 %: 34-184) menos que los bicoriales. Conclusiones: los resultados de este estudio sugieren un problema de salud pública en este grupo de pacientes, con inicio tardío de control prenatal, de remisión tardía a centros especializados y capacidad insuficiente para definir corionicidad. Se requiere plantear estrategias de atención que incluyan considerar los embarazos gemelares como alto riesgo y garantizar la atención oportuna y adecuada, orientada por una guía de cuidado diferencial para este grupo de gestantes...

Twin pregnancies, especially monochorionic placentations, are associated with a higher rate of maternal and foetal complications when compared to singleton pregnancies. The objective of this work was to describe the clinical characteristics and the maternal and foetal outcomes according to the type of placentation (monochorial or dichorial) of twin pregnancies delivered at Hospital Universitario de Santander (HUS), a level III institution located in Bucaramanga, Colombia. Materials and methods: Descriptive cohort study. The cohort consisted of patients delivered of a twin pregnancy between 2007 and 2011 at the HUS, a general referral hospital for the central-eastern region of the country. The assessment included gestational age at the time of initial presentation to the hospital, clinical findings during the initial assessment, delivery completion, and perinatal results. Descriptive analysis by chorionicity type. Results: A total of 248 women with a twin pregnancy during the study period were included. The mean gestational age on the first visit to the hospital was 34 weeks. On admission, 127 patients (51.2%) were diagnosed with a monochorionic pregnancy, but only in two thirds of the cases was the prenatal chorionicity diagnosis consistent with the post-partum finding. IUGR was diagnosed more frequently in monochorionic than in dichorionic pregnancies (22.3% v. 7.5%) and abnormal Doppler findings were more frequent in monochorionic foetuses (7.8% v. 1.1%). Neonates > 24 of gestational age in monochorionic pregnancies weigh in average 109 gr (IC 95%: 34-184) less than dichorionic twins. Conclusions: The results of this study suggest a public health problem in this group of patients who come late for their prenatal visits and are late referrals to specialized centres, when there is already a limited ability to determine chorionicity. There is a need to develop care strategies in which twin pregnancies are included as a high-risk condition, and to ensure timely and adequate care provision in accordance with differential care guidelines for this group of pregnant women...

Comparative study of twin-twin transfusion syndrome and twin anemia-polycythemia sequence / 国际儿科学杂志

In monozygotic monochorionic diamnionic twin pregnancy,twin-twin transfusion syndrome is one of the most serious complications and often exhibit twin growth not well proportioned, abnormal amniotic fluid volume and other complications.Twin anemia-polycythemia sequence is a special type of Twin-twin transfusion syndrome, and both have great difference in clinical manifestations, diagnosis and prognosis of neonatal stages.This article compares with the pathogenesis, diagnostic criteria, treatment methods and prognosis of these two diseases.

Síndrome de transfusão feto-fetal, diagnóstico e tratamento: relato de caso / Twin-twin transfusion syndrome, diagnosis and treatment: case report

Objetivo: relatar um caso de síndrome de transfusão feto-fetal (STFF), demonstrando a importância do correto eprecoce diagnóstico ultrassonográfico e quando necessário a indicação da fotocoagulação a laser fetoscópica(FCLF) como melhor conduta terapêutica. Relato do caso: mulher 18 anos, secundigesta, gestação gemelarmonocoriônica diamniótica com diagnóstico ultrassonográfico tardio de STFF, devido não realização de prénatal.Realizados dois procedimentos de amniodrenagem como medida paliativa, evoluindo para partoprematuro no oitavo dia de internação. Um dos gêmeos evoluiu a óbito na UTI neonatal. Considerações finais:percebe-se a necessidade de uma melhor assistência pré-natal, treinamento dos profissionais médicos para arealização do diagnóstico ultrassonográfico correto e de investimentos em centros de Medicina fetal no Parápara tratamento adequado

Objective: to report a case of twin-twin transfusion syndrome (TTTS), demonstrating the importance of correctand early ultrasound diagnosis and when necessary the indication of laser photocoagulation fetoscópica (FCLF)as the best therapeutic approach. Case report: 18 years woman, in her second, diamniótica monochorionic twinpregnancy with late diagnosis of TTTS, because failure to carry out prenatal care. Evolved into premature laborafter cesarean with indication of two procedures amniodrenagem. After a cesarean section withoutcomplications was death of the twins in the NICU. Final considerations: we perceive the need to support theadequacy of prenatal care, training of medical professionals to perform the correct ultrasound diagnosis andinvestments in fetal medicine centers in Pará.

Neonatal Mortality and Morbidity of Twin-Twin Transfusion Syndrome

PURPOSE: This study was aimed to evaluate the neonatal mortality and morbidity of infants affected by twin-twin transfusion syndrome (TTTS) compared to the control twins matched for gestational age. Also the perinatal outcomes of donor parts of TTTS twins with their counterpart recipients were compared. METHODS: A retrospective case-control study was conducted from infants born at Seoul National University Children's Hospital and Seoul National University Bundang Hospital between April 2005 and July 2011. Eighteen pairs of TTTS infants were allocated to the TTTS group. The control group consisted of 36 pairs of twin infants unaffected by TTTS who were matched for gestational age. Neonatal deaths and morbidities were recorded. RESULTS: The mortality in TTTS group was significantly higher than control group (27.8% vs. 4.2%, P=0.001). The incidence of acute renal failure (41.2% vs. 9.7%, P or =2 intraventricular hemorrhage (33.3% vs. 11.1%, P=0.012) and grade > or =2 periventricular leukomalacia (24.2% vs. 2.8%, P=0.001) were significantly higher in TTTS group than control group. There was no significant difference in mortality and morbidities between donors and recipients except significantly higher incidence of acute renal failure in donors (70.6% vs. 11.8%, P=0.001). CONCLUSION: Twin infants affected by TTTS have higher risk of neonatal death and several severe morbidities. These results indicate that alert monitoring and checking about possible morbidities are very important in newborns with TTTS and early intervention is critical for improving the overall outcome of the affected infants.

Assessment of right ventricular function in recipient fetus of twin-twin transfusion syndrome with two-dimensional strain imaging / 中华超声影像学杂志

Objective To evaluate the value of two-dimensional strain imaging in assessing right ventricular function of recipient fetus in TTTS pregnancies.Methods Sixteen TTTS pregnancies and 19 normal monochorionic diamniotic pregnancies(controls) were included.Doppler studies of the umbilical artery,umbilical vein,ductus venosus,middle cerebral artery,atrioventricular valve and semilunar value were recorded in both fetus,and myocardial performance index of both ventricles was calculated.Longitudinal peak systolic strain of right ventricular were calculated and compared between recipient fetus and other fetus.Results Cardiothoracic ratio and myocardial performance index of right ventricular showed significant differences between recipient fetus and controls.Right ventricular strain was decreased in recipient fetus compared with controls.Conclusions Two-dimensional strain imaging can be used to evaluate right ventricular myocardial function in the recipient fetus of TTTS.

Selective fetoscopic laser photocoagulation of superficial placental anastomoses for the treatment of severe twin-twin transfusion syndrome

OBJECTIVE: To report our initial institutional experience with fetoscopic laser photocoagulation of placental anastomoses in severe twin-twin transfusion syndrome using a 1.0 mm endoscope. METHODS: Between July 2006 and June 2008, 19 monochorionic diamniotic twin pregnancies complicated by severe TTTS (Quintero stages III and IV) underwent fetoscopic laser therapy. Perinatal data were prospectively collected and compared according to the Quintero stages. RESULTS: Nine patients were classified as stage III and ten as stage IV. The Mean gestational ages at diagnosis and procedure were 20 (range: 17-25) and 22.0 (range: 19.0-26.0) weeks, respectively, with no statistical difference between the two groups. Preterm premature rupture of the membranes occurred in two cases (10.5 percent), and spontaneous preterm delivery in eight (42.1 percent). Overall mean gestational age at delivery was 32.1 (range: 26.0-38.0) weeks. Prematurity was more severe in stage IV patients (p<0.01). Among all cases, the overall survival rate was 52.6 percent, and the percentages of pregnancies with survival of both babies and at least one twin were 26.3 percent and 78.9 percent, respectively. In the case of stage III patients, the overall survival rate was 61.1 percent. Of the stage III pregnancies, 33.3 percent resulted in both babies surviving, and 88.9 percent of these pregnancies resulted in at least one surviving twin. For stage IV, as the corresponding statistics were 45.0 percent, 20.0 percent and 70.0 percent respectively. CONCLUSIONS: Our initial institutional experience with 1.0 mm fetoscopic laser therapy for severe TTTS showed results similar to those reported in the literature for larger endoscopes.

Twin-twin transfusion syndrome; TTTS / 대한산부인과학회지

Twin-twin transfusion syndrome (TTTS) is a complex cardiovascular disease affecting monochorionic (MC) twin pregnancies, and has a high perinatal mortality rate. Its pathogenesis remains poorly understood, but TTTS involves unbalanced transfusion of blood from a donor to a recipient along one or more placental arteriovenous anastomosis in absence of adequate compensatory superficial counter-transfusion. Recent data demonstrated laser ablation to be better than amnioreduction, especially when the condition develops before 26 weeks of gestation.

A Case of Severe Neonatal Hypertension in Twin-Twin Transfusion Syndrome

Twin-twin transfusion syndrome is attributed to an unbalanced blood flow between the donor and the recipient twin, but the exact pathophysiology remains incompletely understood. Despite active prenatal management, fetal twin-twin transfusion syndrome is still associated with a substantial residual perinatal mortality and morbidity. The donor twin progressively becomes anemic, growth restricted, oliguric and has oligohydramnios, where as the recipient becomes plethoric, polyuric and has polyhydramnios and in the most severe cases develops cardiomegaly, congestive heart failure and hypertension. We report a case of severe systemic hypertension developed in recipient twin.

Perinatal Outcomes of Twin-Twin Transfusion Syndrome according to Clinical Stage based on Sonographic findings / 대한산부인과학회지

OBJECTIVE: After classifing the twin-twin transfusion syndrome (TTTS) according to clinical stage by Quintero, we reviewed effectiveness and usefulness of clinical stage by Quintero in diagnosis and treatment of TTTS. METHODS: Twelve cases (16%) were diagnosed as TTTS among 75 examples (31.3%) of monochorionic twin pregnancy out of 240 cases of twin pregnancy born in our hospital between Mach 2000 and June 2004. For TTTS, the clinical stage was decided at the time of initial diagnosis, and any changes of it were observed according to the developments of pregnancy. Neonate was regarded as alive when 5 minutes Apgar score was above 7 after birth. Also we observed the vascular anastomosis of placenta, and classified the method of treatments and its results according to each clinical stage. RESULTS: Two cases were classified into the clinical stage 1 through 4 each, and 4 cases in the clinical stage 5. The higher the clinical stage, the shorter the duration between diagnosis and delivery (p<0.05). In cases of both survivors, compared to no survivors, the interval between diagnosis and delivery were long (p<0.05). In the clinical stage 4 and 5, we found many cases that didn't have placental vascular anastomosis between artery and artery, and in this case, there revealed poor perinatal outcomes. For 4 cases that fell in the clinical stage 1 and 2 and 4, we performed amnioreduction and for one case in the clinical stage 2, we did amnioseptostomy at the same time. In 4 cases with amnioreduction or amnioseptostomy, survival rate was 38%. CONCLUSION: The clinical classification system of TTTS by ultrasound would be helpful for planning treatments and also for predicting the outcomes.