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PubMedDate not supplied

[Twin pregnancies with fetofetal transfusion syndrome].

During an observation period of 10 years 30 cases (11%) of twin transfusion syndrome were observed in a collective of 286 twin pregnancies at the University Women's Clinic Heidelberg. Typical symptoms of a twin transfusion syndrome as polyhydramnios, hydrops fetalis, polyserositis, disparity in fetal growth of the twins and pathological CTGs were examined for their diagnostic and prognostic values. A difference in birth weight of more than 25% was noted in only 28% of cases (range 2-58). A polyhydramnios was diagnosed in 63% of cases, an acute form in 30%. Eight of the nine pregnancies with an acute hydramnios ended in an abortion or intrauterine death up to 28 weeks of gestation. Amniocentesis for reduction of the excessive amount of amniotic fluid had no positive therapeutic effect. Eight of the pregnancies, in which a hydramnios had been detected, were further complicated by a hydrops fetalis (23%). Typical sinusoidal CTGs were registered in only 3 cases. Intrauterine fetal mortality respectively abortion up to 28 weeks of gestation was noted in 6 patients (12/60; 20%). Fetal mortality after 28 weeks of gestation occurred in 9/60 cases (15%). Four infants died more than 7 days post partum (7%). The fetal malformation rate was determined in our collective with 7% (4/60 fetuses). No chromosomal abnormalities were observed. The data collected show the prognostic relevance of the parameters analysed and reveal the cases in which a therapy might be effective. Ultrasonographic scanning of fetal activity or doppler flow measurements are further diagnostic procedures that can be employed in surveillance of risk pregnancies with twin transfusion syndrome. Also umbilical cord puncturing under direct ultrasonographic monitoring is of certain diagnostic and therapeutic value.

Cardiotocography↗
PubMed1995

[Prenatal management of fetofetal transfusion syndrome].

The twin-twin transfusion syndrome is a rare but severe complication in monozygotic twins. A total of 172 twin pregnancies were investigated in our hospital between January 1990 and August 1993. The patients were divided into 4 groups: Group I: Normal twin pregnancy, treatment only in our hospital. Group II: Twin-twin transfusion syndrome, treatment only in our hospital. Group III: Normal twin pregnancy, delivery in another hospital. Group IV: Twin-twin transfusion syndrome, after treatment and therapy delivery in another hospital. These cases were analysed concerning prenatal management and perinatal outcome. The perinatal mortality rate in group I-IV was 17%, 58%, 18% and 60%, respectively. A benefit of aggressive amniocentesis in case of polyhydramnios, administration of digoxin and timing of labour could be demonstrated.

Adult↗
PubMed2005

Management of fetofetal transfusion syndrome.

Feto-fetal transfusion syndrome contributes heavily to high rates of perinatal mortality and morbidity in monochorionic multiple pregnancies. Its prenatal management has been controversial for at least 25 years. We review the recent literature in order to present the basis for a pragmatic reappraisal of the management of this condition. Laser surgery of the chorionic plate inter-twin anastomoses is the best first-line treatment when the syndrome develops before 26 weeks' gestation. Survival (including quality of survival) and gestational age at delivery are improved when compared to serial amnioreduction. Second-line treatment options include repeat-laser, intra-uterine blood transfusion, serial amnioreduction, selective feticide using bipolar cord coagulation or elective delivery, depending upon gestational age and the severity of the disease and its complications. We have found that fetoscopic placental surgery has proven itself over simplicity of amnioreduction. There is no evidence that treatment should be customized according to the stage of the disease at diagnosis. Early recognition of the syndrome through fortnightly serial ultrasound follow-up of all monochorionic pregnancies should ensure timely referral and make up for geographical constraints. Laser surgery should now be available in fetal medicine units that are managing at least 20 cases per year.

Decision Trees↗
PubMedDate not supplied

[Maternal and fetal digoxin level in fetofetal transfusion syndrome (FFTS)].

BACKGROUND: Even though invasive intrauterine techniques for the treatment of TTTS such as punction of amniotic fluid and laser coagulation of placental vascular anastomoses are established methods in specialized centers, invasive methods are not always sufficiently successful. In conservative treatment of TTTS oral or intravenous maternal digoxin therapy in order to improve fetal cardiac insufficiency in combination with or after failure of invasive techniques is an useful method. PATIENTS AND METHODS: We investigated 12 TTTS pregnancies and 4 singleton pregnancies, which had been treated by maternal digoxin treatment for TTTS or arrhythmias, respectively. At birth, which was performed by means of caesarian section, venous cord blood samples of the newborns and venous maternal blood samples were collected, centrifugated and stored at minus 20 degrees C. Digoxin determinations were performed by radioimmunoassay. RESULTS: Fetal digoxin levels varied between 0.38 and 1.73 ng/ml, maternal levels ranged from 0.97 to 3.23 ng/ml. The fetomaternal digoxin gradient reached a mean of 0.56 (range 0.35 to 1.09). Donator and acceptor gradients were comparable and increased with birth weight or gestational week, respectively. CONCLUSIONS: In cases of pregnancies with TTTS a relatively high maternal digoxin level is necessary, especially during early gestational weeks, in order to reach therapeutical levels in the fetal circulation. Too low dosages might be responsible for unfavourable results in digoxin treatment of TTTS. Whether the maturation of placental villi during gestation could be the reason for increasing digoxin gradients requires further investigations.

Administration, Oral↗
PubMed1989

Perinatal outcome in very preterm births with twin-twin transfusion syndrome.

We retrospectively studied 48 pairs of twin gestations delivered between 24 and 28 weeks' gestation from 1975 to 1986 at Vanderbilt University Medical Center. The incidence of fetofetal transfusion syndrome was 20%, more than double the incidence previously reported in large series of twin deliveries that encompassed a wider gestational age range. The overall mortality was 55%, and mortality for the fetofetal transfusion group was 70%, whereas a subset of the fetofetal transfusion group, those without weight discordancy, had a mortality rate of 75%. Our findings suggest that traditional reliance on ultrasonographic criteria for diagnosis of fetofetal transfusion will not detect 40% of such cases. The poor outcome data suggest a need for innovative approaches to diagnosis and treatment.

Birth Weight↗
PubMed1997

Twin-twin transfusion syndrome. Three possible pathophysiologic mechanisms.

OBJECTIVE: To propose a classification of twin-twin transfusion syndrome based upon three categories of placental anastomotic patterns. STUDY DESIGN: A mathematical model developed to compute fetal blood volume in monochorionic twins combines fetoplacental circulation with net fetofetal transfusion along placental anastomoses. We included (1) unequal cotyledonic sharing, assuming that smaller fractions cause smaller twins with lower blood pressure, and (2) significantly decreasing anastomotic resistance, combining Poiseuille's law with placental anastomotic growth. Fetoplacental compensatory mechanisms were not studied. RESULTS: First, unidirectional arteriovenous anastomoses produce steadily increasing fetal discordance by small anastomotic blood flow. Second, arteriovenous plus compensating anastomoses (venoarterial, arterioarterial, venovenous) produce fetal discordance followed by a dynamic steady state of minimal net fetofetal transfusion and large anastomotic flow. This circumstance mitigates further discordant growth. Third, unequal cotyledonic sharing plus superficial compensating anastomoses (arterioarterial, venovenous) produce fetal discordance followed by a steady state of equal fetal growth and small anastomotic flow. The model predictions include spontaneous disappearance and reversal of discordance. Serial measurement of fetal growth patterns and anastomotic flow could identify the syndrome's underlying pathophysiology. CONCLUSION: Testing the model predictions by relating clinical presentation with placental anatomy could increase our understanding and direct diagnostic and therapeutic strategies to match the underlying placental anatomy.

Arteriovenous Anastomosis↗
PubMed2007

Deep-hidden anastomoses in monochorionic twin placentae are harmless.

OBJECTIVES: Our objective was to identify the clinical consequences of deep-hidden anastomoses that occur underneath the placental surface. METHODS: Twelve placentae that underwent intrauterine laser ablation of placental anastomoses for twin-twin transfusion syndrome (TTTS) and 14 non-TTTS controls were investigated for deep-hidden anastomoses. Additionally, we investigated the inter-twin haemoglobin differences as an indicator for fetofetal transfusion. Placentae were divided into four groups: TTTS placentae without residual chorionic-plate anastomoses without deep-hidden anastomoses (group 1) and with deep-hidden anastomoses (group 2), and non-TTTS placentae with chorionic-plate anastomoses without deep-hidden anastomoses (group 3) and with deep-hidden anastomoses (group 4). RESULTS: Deep-hidden anastomoses were identified in 58% (7/12) of the TTTS placentae after laser surgery and in 64% (9/14) of the non-TTTS placentae. Groups 1 and 2 had equal inter-twin haemoglobin differences: medians 1.4 and 1.2 gr/dL, respectively (p = 0.48). In group 3, the median inter-twin haemoglobin difference without deep-hidden anastomoses was 2.6 gr/dL (group 3) and with deep-hidden anastomoses (group 4) it was 5.1 gr/dL (p = 0.26). CONCLUSION: Both comparisons imply that deep-hidden anastomoses did not cause any additional increase in Hb difference. In conclusion, haematological and additional hemodynamical analysis show that deep-hidden anastomoses are likely to occur without any clinical consequences.

Female↗
PubMed1995

Preliminary experience with endoscopic laser surgery for severe twin-twin transfusion syndrome.

BACKGROUND: In monozygotic twin pregnancies, there are placental vascular communications between the two fetuses. In 15 percent of such pregnancies there is an imbalance in net blood flow between the twins, resulting in the twin-twin transfusion syndrome. The recipient twin may have severe hydramnios during the second trimester of pregnancy, and there is a high risk of perinatal death and cerebral palsy in survivors. This condition can now be treated by endoscopic coagulation of the vascular anastomoses responsible for fetofetal transfusion with a neodymium:yttrium-aluminum-garnet (Nd: YAG) laser. METHODS: We performed intrauterine surgery in 45 pregnant women carrying twins at 15 to 28 weeks of gestation (median, 21); in each case there was severe hydramnios in one fetus due to the twin-twin transfusion syndrome. With the use of local anesthesia and continuous ultrasound visualization, a rigid fetoscope 2 mm in diameter, housed in a 2.7-mm cannula, was introduced transabdominally into the amniotic cavity of the recipient twin. A systematic search was made for all vessels approaching or crossing the membrane between the twins, and these were coagulated with an Nd:YAG laser by means of a fiber in the side arm of the cannula. RESULTS: Coagulation of the communicating vessels was successful in all cases. The total number of fetuses who survived to delivery was 48 (53 percent), and the number of pregnancies with at least 1 survivor was 32 (71 percent). Among the live-born infants, the median gestational age at delivery was 35 weeks (range, 25 to 40), and the median birth weight was 2098 g (range, 550 to 4252). The median interval between the endoscopic laser procedure and delivery was 14 weeks (range, 0 to 21). All the survivors were developing normally at a median age of 12 months (range, 2 to 24). CONCLUSIONS: Our preliminary experience suggests that the twin-twin transfusion syndrome can be treated effectively by endoscopic laser coagulation of the communicating placental vessels.

Endoscopy↗