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PubMed2004

Modeling a hydropic recipient twin in twin-twin transfusion syndrome.

We developed a mathematical model of twin-twin transfusion syndrome (TTTS) that includes a hydropic recipient twin, adding interstitial and intracellular fluid compartments, fetal congestive cardiac failure, and the dynamics of renin-angiotensin system (RAS) mediators to our previous TTTS model. Ten differential equations for each twin, coupled by the net fetofetal transfusion of blood and blood components, i.e., colloids, osmoles, and RAS mediators, describe the development of fetal arterial and venous blood volumes, blood osmolality and colloid osmotic pressure (COP), interstitial fluid volume and COP, intracellular fluid volume, amniotic fluid volume and osmolality, and RAS mediator concentration. We included varying placental anastomoses, placental sharing, and amnionicity. The 20 differential equations were solved numerically from 0 to 40 wk with a 0.6-s time step. Consistent with clinical experience, model predictions are as follows. Unidirectional arteriovenous anastomoses and arteriovenous anastomoses inadequately compensated by oppositely directed anastomoses cause severe TTTS that includes a hydropic recipient. Adequately compensated arteriovenous anastomoses simulated TTTS without hydrops. The probability that oppositely directed anastomoses prevent onset of a hydropic recipient after TTTS onset, i.e., the largest interval between onset of TTTS and onset of hydrops in the recipient, was best for a venovenous anastomosis, closely followed by an arterioarterial and finally an oppositely directed arteriovenous anastomosis. Hydropic recipients have decreased amniotic fluid volume. Unequal placental sharing and amnionicity modify hydrops onset. In conclusion, our model simulates a sequence of events that results in a hydropic recipient twin in severe TTTS. The model may allow an assessment of the efficacy of current therapeutic interventions for TTTS cases that include a hydropic recipient twin.

Adult↗

PubMedDate not supplied

Fetal and neonatal hypertension in twin-twin transfusion syndrome: a case report.

We report a case of fetal systemic hypertension. This occurred in an ex-donor twin soon after coagulation of chorionic vessels and amniodrainage performed for severe twin-twin transfusion syndrome during the 2nd trimester of pregnancy. Systemic hypertension was suspected because of a high systolic velocity through the tricuspid valve, and Bernoulli's equation was used to estimate the right intraventricular pressure. As both pulmonary arteries and ductus arteriosus were normal, the pressure in the aorta was considered to be equal to that in the right ventricle (60 mm Hg). Fetal systemic hypertension could have happened either because of a dramatic increase in placental resistances in the territory of the ex-donor twin or by reversal of the fetofetal transfusion pathological process.

Adult↗

PubMed1999

Acute intrapartum fetoplacental transfusion in monochorionic twin pregnancy.

BACKGROUND: The risk of antenatal fetofetal transfusion in monochorionic twin pregnancies has been noted, but possible acute intrapartum transfusion has not been studied extensively. Acute fetoplacental transfusion after the birth of the first twin can be disastrous to the second twin, so it deserves description. CASES: We present three cases of acute intrapartum fetoplacental transfusion after successful deliveries of first twins. After the births of their cotwins, the second twins rapidly deteriorated and were born severely hypovolemic and anemic. CONCLUSION: The risk of acute intrapartum transfusion should be kept in mind when planning delivery of monochorionic twins.

Acute Disease↗

PubMed1977

IgG deficiency in association with placental oedema.

Deficiency of the immunoglobulin C (IgG) in the human newborn is rare in the absence of maternal hypogammaglobulinaemia. Low concentrations of IgG in cord blood were found in 3 conditions--the donor twin in the fetofetal transfusion syndrome, hydrops fetalis and congenital hepatic disease. These were all associated with placental oedema. It is suggested that the oedema may be responsible for a disturbance in maternofetal placental transfer.

Dysgammaglobulinemia↗

PubMed2005

Simulation of therapy in a model of a nonhydropic and hydropic recipient in twin-twin transfusion syndrome.

OBJECTIVE: This study was undertaken to model the sequence of events that occurs after amnioreduction, laser therapy, and digoxin administration in twin-twin transfusion syndrome (TTTS) with and without a hydropic recipient twin. STUDY DESIGN: We added amnioreduction, laser therapy, and digoxin administration to our mathematical TTTS model and simulated combinations of these therapies. RESULTS: With a nonhydropic recipient, simulated amnioreduction delays the onset of hydrops. Conversely, with a hydropic recipient, amnioreduction aggravates the degree of hydrops. Furthermore, amnioreduction increases the transplacental fluid flow and may temporarily cause a hydropic donor. Laser therapy terminates the cause of recipient hydrops. Digoxin reduces the degree of recipient hydrops, but increases arteriovenous fetofetal transfusion. CONCLUSION: Laser therapy is superior in TTTS with a hydropic recipient, because simulated amnioreduction aggravates the recipient's cardiovascular status. Digoxin benefits a hydropic recipient but slightly worsens the donor's condition. Therefore, TTTS presenting with a hydropic recipient prior to fetal viability (approximately 26 weeks) may be best treated with laser therapy, whereas more advanced gestations may be offered digoxin administration plus amnioreduction, to delay the progression of TTTS.

Cardiotonic Agents↗

PubMed2001

Amniotic fluid and hemodynamic model in monochorionic twin pregnancies and twin-twin transfusion syndrome.

We developed a mathematical model of monochorionic twin pregnancies and twin-twin transfusion syndrome (TTTS), combining both fetal fluid dynamics and fetoplacental growth and circulation alterations and assuming that transplacental fluid flow from mother to fetus accounts for normal fetal and amniotic fluid volumes. Ten coupled differential equations, describing fetal total body and amniotic fluid volumes, their osmolalities, and fetal blood colloid osmotic pressure, for both donor and recipient twins, were solved numerically. Amniotic flows are controlled by fetal plasma osmolality and hydrostatic and colloid osmotic pressures. We included varying placental anastomoses and placental sharing of the circulations. Consistent with clinical experience, model predictions are: fetofetal transfusion from unidirectional arteriovenous anastomoses cause oligo-polyhydramnios, a normal size recipient but hypovolemic donor; compensating oppositely directed deep and superficial anastomoses moderate discordant development; and anhydramnios results from mild and severe TTTS, where milder forms may even present earlier in gestation than severe TTTS. Unequal placental circulatory sharing may exacerbate discordant development. In conclusion, our model simulates a wide variety of realistic manifestations of amniotic fluid volume and fetal growth in TTTS related to placental angioarchitecture. The model may allow an assessment of the efficacy of current therapeutic interventions for TTTS.

Amniotic Fluid↗

PubMed2004

[First trimester ultrasound screening for structural and chromosomal anomalies in multiple pregnancy].

AIM OF THE STUDY: To assess the feasibility of first trimester ultrasound screening for structural and chromosomal fetal anomalies in multiple gestations. METHODS: An observational prospective follow up study was carried out in 32 cases of multiple pregnancies. Two scans were scheduled in each case--the first, between 6-9 weeks of gestation (w.g.) and the second, between 11-14 w.g. The aim was assessment of fetal number, viability, chorionicity/amnionicity and fetal biometry. In addition, nuchal translucency [NT] measurement, assessment of risk for chromosomal anomalies and fetal anatomy survey were always performed. Increased NT > or = 95 percentile and/or detection of structural anomaly were considered indications for invasive prenatal diagnosis and fetal karyotyping. Selective fetocide was considered in cases of chromosomal or structural anomalies and in high-order multiple gestations (> or = 3 fetuses). Pregnancy outcome was ascertained by the physical examination of the fetuses, placentas and membranes postpartum, the hospital records, the referring physicians or the parents. RESULTS: From 32 cases of multiple pregnancies included in the study, 28 were twins, and 4--triplets. 68% (19/28) of the twin pregnancies were bichorionic-biamniotic [Bi-Bi], 25% (7/28)--monochorionic-biamniotic [Mo-Bi] and 7% (2/28)--monochorionic-monoamniotic [Mo-Mo]. 4 cases of increased NT in one of the twins (1--associated with trisomy 21) were observed, as well as 2 cases of structural fetal anomalies (1--discordant for exencephaly, and 1--with conjoint twins), 2 cases of feto-fetal transfusion syndrome that developed in the second trimester (1--associated with increased NT between 11-14 w.g.), 1 case of TRAP syndrome [twin-reversed arterial perfusion] and 1 case of cord entanglement in monoamniotic twins. In addition, there were 4 cases of a vanishing twin in the first trimester, and in 2 other cases spontaneous miscarriage of both twins occurred before 24 w.g. In two of the triplet pregnancies selective fetocide was performed, one was successfully delivered at 33 w.g. and in the last case the parents chose to terminate the pregnancy. CONCLUSIONS: First trimester ultrasound is a method of choice for detection of major structural fetal anomalies in multiple gestations. Increased NT between 11-14 w.g. in multiple pregnancies is a useful screening tool for detection of chromosomal fetal anomalies, while in monochorionic twins its presence might predict the development of fetofetal transfusion syndrome. First trimester selective fetocide in high-order multiple gestations or in affected twins is one of the options in pregnancy management.

Abortion, Missed↗

PubMed2004

Modelling the influence of amnionicity on the severity of twin-twin transfusion syndrome in monochorionic twin pregnancies.

Clinical treatment for diamniotic-monochorionic twin-twin transfusion syndrome (TTTS) may include conversion of diamniotic pregnancies to a monoamniotic-monochorionic state by disrupting the amnion septum. We sought to test the underlying hypothesis, i.e. that a monoamniotic state reduces the severity of TTTS. With use of our previously developed mathematical model of two equal fetoplacental circulatory units connected by various sizes and types of placental anastomoses, we compared the haemodynamic and amniotic fluid dynamics of monoamniotic and diamniotic twins that develop TTTS. We used three anastomotic patterns that produce severe, moderate or mild forms of TTTS, respectively, in our diamniotic-monochorionic twin model. Monoamnionicity was modelled by adding the two amniotic fluid volumes and using the volume-averaged amniotic fluid osmolality. The results were as follows: for severe TTTS, small differences develop between diamniotic and monoamniotic donor twins in fetal urine production, swallowed volume, blood volume, blood pressures, net fetofetal transfusion, and blood and amniotic fluid osmolality. However, the circulatory imbalance between the monoamniotic twins deteriorates similar to that of diamniotic twins. The pathophysiological differences tend to disappear for milder TTTS. In conclusion, our model suggests that the uncommon finding of TTTS in monoamniotic twins is not due to the presence of a single amniotic sac. Rather, clinically significant differences in anastomotic patterns and the delayed or lack of identification of manifestations in monoamniotic twins account for the reduced rate of TTTS diagnosis. Based on these results we expect the clinical disruption of the amnion septum in diamniotic-monochorionic TTTS pregnancies to have only minimal benefits.

Amnion↗

PubMed1997

Velamentous cord insertion in monochorionic twin gestation. An added risk factor.

OBJECTIVE: To study the effects of umbilical cord insertion combinations on outcomes in monochorionic (MC) twin placentas. STUDY DESIGN: Sixty consecutive MC placentas were analyzed by cord insertion patterns with regard to growth discordance, placental parenchymal sharing, types and patterns of intertwin vascular anastomoses, perinatal mortality and frequency of fetofetal transfusion. Cord insertions were classified as central/eccentric (CEN) or velamentous/marginal (VEL). RESULTS: Forty-five percent of the twins had VEL insertions. The CEN/VEL combination was found in 53% of pairs. The CEN/VEL group had the highest rates of growth discordance > 20%, unequal placental parenchymal sharing, uncompensated anastomoses and perinatal demise. CONCLUSION: VEL cord insertion and the CEN/VEL combination are indicators of high-risk subgroups within MC twins. VEL cord insertions can be diagnosed by ultrasound, identifying these high-risk groups.

Diseases in Twins↗

PubMed1976

Serum immunoglobulins in multiple pregnancy.

The concentrations of immunoglobulins (Ig) G.A.M. and E were determined in paired umbilical cord and maternal sera in 50 twin pregnancies. Mean IgG levels were higher in cord than maternal sera and in most cases the cord IgG level related more closely to that of the other twin than to either maternal level or birthweight, and was in the range for singletons of the same gestational age. The three cases of fetofetal transfusion syndrome were exceptional in the large difference between IgG concentrations in recipient and donor twins. The discrepancy was much greater than that found between the levels of proteins produced by the fetus, suggesting a disturbance in maternofetal placental transfer. IgM was detected in all cord sera, with one exception, and the level was not related to order of birth. IgA was detected in 16% of cord sera, 13% in sera from first borns. IgE was detected in only 8% of cord sera and there was no evidence of placental transfer.

Female↗

PubMed1998

Fetal biometry and outcome in monochorionic vs. dichorionic twin pregnancies; a retrospective cross-sectional matched-control study.

Fetal biometry, amniotic fluid volume distribution and perinatal outcome were determined in a retrospective, cross-sectional matched-control study design, including 20 monochorionic (MC) twin pregnancies and 20 dichorionic (DC) twin pregnancies (historic controls). Intertwin differences for fetal abdominal circumference were larger in the MC subset than in the DC subset. Fetofetal transfusion syndrome, based upon a combination of oligohydramnios in one sac and polyhydramnios in the other sac, existed in 40% (8 of 20) of the MC twin pregnancies, but in none of the DC twin pregnancies. Mean gestational age at delivery was significantly shorter in the MC subset (30.9 weeks) than in the DC subset (34.3 weeks). The perinatal death rate was significantly higher in MC twin pregnancies (50%) than in DC twin pregnancies (15%). No differences were established for intertwin weight estimates by ultrasound and birth weight between both subsets. The poor perinatal outcome in monochorionicity is mainly a result of the degree of premature delivery.

Amniotic Fluid↗

PubMed1988

Intrauterine death of a single fetus in twin pregnancies.

The paper reports on nine twin pregnancies in the years 1982-1987 with the intrauterine death of a single fetus. The incidence of 0.10% is consistent with that reported in other comparable studies. Evaluation of the causes of death shows a preponderance of asphyxia. A fetofetal transfusion syndrome occurred in 4 cases. Eight of the pregnancies were terminated by caesarean section. One of the surviving children died in the neonatal period. The course of the neonatal period in the other babies was determined mainly by the state of maturity. No increased maternal morbidity was observed. On the basis of this and other experience described in the literature, some general guidelines are proposed for the management of the further pregnancy and delivery in such high-risk cases.

Adult↗

PubMed1965