Fetal Hemodynamic Responses to Arterial Occlusion of Acardiac Twins.

The objective of this study was to comprehensively assess fetal hemodynamic adaptions to occlusive procedures. Twin pregnancies complicated with acardiac twin and hydrops fetalis of the pump twin were recruited. The occlusive procedures - either alcoholization, radiofrequency ablation, coil embolization or occlusive glue - were performed under ultrasound guidance. Various hemodynamic parameters were assessed before, shortly after, then every 6 h for 48 h and 2-4 weeks after the procedures. Seven pregnancies were recruited. The median (range) gestational age of intervention was 21 (17-26) weeks of gestation. Before the procedures, all cases showed normal cardiac function. Just after the procedures, all cases showed an increase in Tei index and isovolumic relaxation time but returned to preocclusion levels within 6-48 h, except for two cases that were persistently high. Increased preload and poor shortening fraction were observed in two cases, leading to heart failure, with one recovery and one death in utero. Five out of the seven cases got through the critical period with a gradual return to normal hemodynamics, ending with the disappearance of hydrops and successful outcomes. It was concluded that the occlusive procedure could aggravate the overworked heart, leading to heart failure. Preocclusion preload index and Tei index may predict risk of heart failure due to the occlusion. This small series strongly suggests that the occlusion should be performed before the deterioration of cardiac function.

Complex multigestational anomalies.

The increase in multiple gestation pregnancies has resulted in significant health care implications for both mother and child. Our ability to diagnose and intervene on an at-risk multi-gestation pregnancy has dramatically improved. It is important for the pediatric surgeon to be equipped with a basic fund of knowledge concerning these pregnancies. An understanding of amnionicity and chorionicity will equip the practitioner with the ability to identify which pregnancies are at risk for specific complications. This article highlights multi-gestation pregnancies that are monochorionic (single shared placenta) and can be complicated by twin-twin transfusion syndrome (TTTS), twin reversed arterial perfusion (TRAP) sequence, twin anemia polycythemia sequence (TAPS), or selective fetal intrauterine growth restriction (sIUGR). The risk of fetal demise is significant in these pregnancies. Understanding recommended surveillance and warning signs can alert surgeons to developing complications. Specialized fetal care centers possess the ability to intervene on these pregnancies in utero.

Case Report of Autopsy and Placental Examination After Radiofrequency Ablation of an Acardiac Twin.

We report the autopsy and placental findings in a monochorionic twin gestation complicated by twin reversed arterial perfusion (TRAP) sequence. Radiofrequency ablation (RFA) was performed at 24 weeks gestation to abort the acardiac fetus, and vaginal delivery of the co-twin and acardiac fetus occurred at 33 weeks gestation. An autopsy of the acardiac fetus revealed multiple congenital anomalies including complete absence of the upper extremities and poor development of the skull and facial structures. In contrast to the upper body, the lower half of the body, although malformed, was more developed. The monochorionic twin placenta showed velamentous, atrophied, proximal artery-artery and vein-vein intertwin vascular connections which essentially bypassed the placental parenchyma for the acardiac fetus. Ink injection and histologic examination confirmed thrombosis of these critical intertwin vascular connections after RFA. This report highlights the fetal and placental anatomy of TRAP sequence and stresses the importance of placental examination after fetal surgical techniques.

Fetoscopia y coagulación bipolar selectiva en una gestación gemelar complicada con secuencia arterial reversa: a propósito del primer caso en el Perú

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.

Manejo laparoscópico de embarazo ectópico en cicatriz uterina por cesárea previa: reporte de un caso

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.

Examination of the twin placenta.

Twin birth rates have increased dramatically over the past three decades, and twins currently account for 3% of all pregnancies. Twin pregnancies of any type are at risk for prematurity. In addition, monochorionic twin pregnancies (25-30% of all twin pregnancies) are predisposed to a specific set of complications, including twin-to-twin transfusion syndrome (TTTS), twin reversed arterial perfusion syndrome (TRAP), malformations, and intertwin growth discordance. This article reviews the basic mechanisms underlying the twinning process, the relationship between zygosity and chorionicity, and the various types of twinning. We describe the major complications of monochorionic twinning in association with their reported placental characteristics (or lack thereof). Finally, a rational, evidence-based approach to examination of the twin placenta is presented. It is essential for the pathologist to understand the value, strengths, and limitations of examination of the twin placenta in order to provide a meaningful clinicopathological correlation in complicated (monochorionic) twin pregnancies.

A case of acardiac twin pregnancy with fetus survival after successful radiofrequency ablation of umbilical cord / 대한산부인과학회지

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.

Successful Management with Intra-abdominal Alcohol Ablation of Acardiac Twin and Amniodrainage in Twin Reversed Arterial Perfusion Sequence with Severe Polyhydramnios / 대한산부인과학회잡지

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.

Three Cases of Acardiac Twin / 대한산부인과학회잡지

No abstract available.

Prenatal Diagnosis of TRAP sequence: A Case REport -Usefulness of Color Doppler Sonography- / 대한주산의학회잡지

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.