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The chk1 pathway is required to prevent mitosis following cell-cycle arrest at 'start'.

BACKGROUND: The G2-M-phase transition is controlled by cell-cycle checkpoint pathways which inhibit mitosis if previous events are incomplete or if the DNA is damaged. Genetic analyses in yeast have defined two related, but distinct, pathways which prevent mitosis--one which acts when S phase is inhibited, and one which acts when the DNA is damaged. In the fission yeast Schizosaccharomyces pombe, many of the gene products involved have been identified. Six 'radiation checkpoint' (rad) gene products are required for both the S-M and DNA-damage checkpoints, whereas Chk1, a putative protein kinase, is required only for the DNA-damage checkpoint and not for the S-M checkpoint following the inhibition of DNA synthesis. RESULTS: We have genetically defined a third mitotic control checkpoint pathway in fission yeast which prevents mitosis when passage through 'start' (the commitment point in G1) is compromized. In cycling cells arrested at start, mitosis is prevented by a Chk1-dependent pathway. In the absence of Chk1, G1 cells attempt an abortive mitosis with a 1C DNA content without entering S phase. Similar results are seen in the absence of Rad17, a typical example of a rad gene product. CONCLUSIONS: Genetic dissection of checkpoints in logarithmically growing fission yeast has identified a pathway that couples mitosis to correct passage through start. This pathway is related to the DNA-structure check-points which ensure that mitosis is dependent on the completion of replication and the integrity of the DNA. We propose that all three mitotic control checkpoints monitor distinct DNA or protein structures at different stages in the cell cycle.

Cell Cycle↗

Consequences of antenatal diagnosis for pediatric surgery.

Based on an increase from 6000 ultrasound examinations done at the First University Gynecological Hospital of Munich in 1969 to more than 13,000 in 1982, and on an increased rate of antenatally diagnosed malformation, the accuracy of antenatal ultrasound diagnosis was investigated. It turned out that correct diagnosis could be made in over 80% of cases. However, this was incomplete in approximately 40% of the cases, since associated malformations of the gastrico-intestinal tract, congenital heart disease, myelomeningocele in correctly diagnosed hydrocephalus, and others were not recognized. False-positive results were found in 17.5% of cases, false-negative ones in 12.7%. Because of the uncertainty of antenatal diagnosis and ignorance of many physiological parameters, intrauterine surgical treatment cannot be advocated at present. Intrauterine measures are still confined to punctures, administration of drugs, and diagnostic procedures. Further consequences such as termination of pregnancy, psychological aspects, and possible development of intrauterine therapy are discussed.

Abortion, Induced↗

Contragestion by antiprogestin: a new approach to human fertility control.

The steroidal derivative RU 486 (17 beta-hydroxy-11 beta-(4-dimethylaminophenyl 1)-17 alpha (prop-1-ynyl)-estra-4,9-dien-3-one) is the first potent antiprogestin. Acting reversibly at the molecular level of receptor binding, it interrupts progesterone action definitively if the target cell dynamics are irreversibly disrupted. Its preferred target cells are those of the uterine decidualized mucosa and uterine cervix, and increased myometrial contractility facilitates the termination of pregnancy. Luteolysis is secondary to the decrease in chorionic gonadotropin, itself brought about by secondary alteration or detachment of the trophoblast. Clinical results so far indicate that RU 486 can be a very efficient and safe contragestive agent, especially for the medical termination of early pregnancy or as a postcoital menses inducer or menstrual regulator. Incomplete expulsion is sometimes noted at present when RU 486 is given alone but this may not happen when efficient form(s) of administration are used and/or when uterotonics are added. When a small amount of prostaglandin (which by itself would be inefficient) is given at the end of treatment with RU 486, the results are highly satisfactory. The antiprogestin RU 486 does not expose women to hormones continuously. Based on a dual concept, physiological and molecular, it may be typical of the second generation of agents required to achieve safe and effective control of human fertility.

Abortifacient Agents↗

Placental oxidative stress: from miscarriage to preeclampsia.

OBJECTIVE: To review the role of oxidative stress in two common placental-related disorders of pregnancy, miscarriage and preeclampsia. METHODS: Review of published literature. RESULTS: Miscarriage and preeclampsia manifest at contrasting stages of pregnancy, yet both have their roots in deficient trophoblast invasion during early gestation. Early after implantation, endovascular trophoblast cells migrate down the lumens of spiral arteries, and are associated with their physiological conversion into flaccid conduits. Initially these cells occlude the arteries, limiting maternal blood flow into the placenta. The embryo therefore develops in a low oxygen environment, protecting differentiating cells from damaging free radicals. Once embryogenesis is complete, the maternal intervillous circulation becomes fully established, and intraplacental oxygen concentration rises threefold. Onset of the circulation is normally a progressive periphery-center phenomenon, and high levels of oxidative stress in the periphery may induce formation of the chorion laeve. If trophoblast invasion is severely impaired, plugging of the spiral arteries is incomplete, and onset of the maternal intervillous circulation is premature and widespread throughout the placenta. Syncytiotrophoblastic oxidative damage is extensive, and likely a major contributory factor to miscarriage. Between these two extremes will be found differing degrees of trophoblast invasion compatible with ongoing pregnancy but resulting in deficient conversion of the spiral arteries and an ischemia-reperfusion-type phenomenon. Placental perfusion will be impaired to a greater or lesser extent, generating commensurate placental oxidative stress that is a major contributory factor to preeclampsia. CONCLUSION: Miscarriage, missed miscarriage, and early- and late-onset preeclampsia represent a spectrum of disorders secondary to deficient trophoblast invasion.

Abortion, Spontaneous↗

Motherhood lost: cultural dimensions of miscarriage and stillbirth in America.

Despite the frequency of incompleted pregnancies (an estimated 20-30% of all pregnancies), a veil of silence surrounds pregnancy loss in our culture. In the last fifteen years organizations have sprung up throughout the United States which protest the cultural denial of perinatal loss and seek to define a miscarriage or stillbirth as a legitimate source of grief. Participants in support groups are for the most part members of the white middle class and cannot be taken to represent 'American society' but because they are organized and vocal, members of such groups hold the potential for significantly changing the way miscarriage and stillbirth are treated in American society. This article explores a number of recurrent themes observed among participants of pregnancy loss support groups: the angst of an incompleted rite of passage; the struggle for defining the embryo, fetus, or neonate as a 'child' and of oneself as a 'parent'; the search for and attribution of meaning to a seemingly unexplainable event; and the link between changing attitudes towards birth, death, and personhood. The impact of new technologies on the experience of pregnancy and consequentially on the experience of pregnancy loss is also explored. Most prior studies of pregnancy loss have been quantitative and have focused on the individual. The anthropological approach, with its emphasis on the cultural construction of meanings and special understanding of ritual process adds an important dimension to this area of research.

Abortion, Spontaneous↗

Laparoscopic pelvic lymphadenectomy in an anatomical model: results of an experimental comparative trial.

OBJECTIVES: The aim of this paper was to compare the accuracy of laparoscopic versus open pelvic lymphadenectomy in an experimental trial. STUDY DESIGN: We performed unilateral laparoscopy pelvic lymphadenectomy (LPL) in 33 non-embalmed cadavers between the external iliac vein, the obliterated umbilical artery and the obturator nerve. Then a laparotomy was performed to inspect the LPL limits, look for laparoscopic complications and finally realize a controlateral lymphadenectomy. The LPL side was randomly decided. A pathologist counted the number of lymph nodes collected with both techniques. We compared the number of retrieved lymph nodes, the completeness of the dissection and the complication rate with those two procedures. Student's t-test, chi 2-test and non-parametric tests were used when appropriate. RESULTS: No dissection had to be aborted. One hundred and twelve nodes were removed laparoscopically (mean, 3.73; S.E., 2.9) and 84 at laparotomy (mean, 2.77; S.E., 2.06). There was no significant difference in the number of nodes retrieved with both procedures. Effectiveness of laparoscopy was not significantly different in the first ten procedures, in the second ten or in the last ten LPL. Residual tissue was observed after LPL in 13.3% of the procedures whereas all open lymphadenectomies were complete. LPL sensitivity reached at least 86% in this paper. Failures were more frequent at the beginning of the study (50% among the first ten dissections), in obese subjects or in subjects with prior history of laparotomy (but the difference was not significant). Two venous injuries occurred during LPL (6.7%). Complication rates for the two techniques were not significantly different. However, the LPL complication rate was higher at the beginning of the study and increased significantly in subjects with prior history of laparotomy (P < 0.05). CONCLUSIONS: This randomized study shows that LPL and laparotomy have similar effectiveness. Incomplete dissections and complications are more frequent in obese subjects or in case of prior history of laparotomy. Fifteen procedures seems necessary to learn the technique and provide constant and safe results in routine practice.

Aged↗

Urethral syndrome and associated risk factors related to obstetrics and gynecology.

OBJECTIVE: To evaluate the risk factors related to gynecology and obstetrics, and the incidence of urethral syndrome in our gynecological practice. STUDY DESIGN: The study comprised 35 patients without urinary tract infection who admitted to our department of gynecology with the complaints of recurrent urinary irritation symptoms, sensation of incomplete emptying and burning sensation during urination after sexual intercourse. A total of 200 women served as controls. RESULTS: We found urethral syndrome in 15% of patients. The incidence of grandmultiparity and the delivery without episiotomy were significantly higher in the study group than controls using univariate analysis. Considering logistic regression analysis, we found that grandmultiparity, two or more abortus, hospital delivery, delivery without episiotomy and pelvic relaxation were risk factors for the urethral syndrome. CONCLUSION: Although urethral syndrome is often detected in gynecological practice, it has not yet been reached utmost importance. Grandmultiparity and delivery without episiotomy are the major risk factors accompanying urethral syndrome.

Abortion, Induced↗

Reported management of early-pregnancy bleeding and miscarriage by general practitioners in Victoria.

OBJECTIVES: To describe the management of early-pregnancy bleeding and miscarriage reported by general practitioners in Victoria. DESIGN, SETTING, AND PARTICIPANTS: Self-administered, mailed survey of a stratified random sample of GPs in Victoria. Responses weighted by strata to reflect GP population. MAIN OUTCOME MEASURES: Reported management in referral; investigation (especially ultrasound); expectant versus interventional management; and prevention of rhesus iso-immunisation RESULTS: 382 of 621 eligible GPs responded (response rate, 62%). GPs' reported referral was more likely if the patient had painful bleeding (55%) or if the pregnancy was not viable (77%). Ultrasound strongly influenced the assessment of bleeding. Two-thirds of doctors (262/369; 66%) would routinely order ultrasound for painless bleeding, and 328/369 (84%) for painful bleeding. Expectant management was recommended by 15/353 (4%) for incomplete miscarriage with light bleeding and by 6/351 (2%) when bleeding was heavy. Some GPs are uncertain of the indications for anti-D prophylaxis, including instrumentation of the uterus, for which 261/337 (77%) said they would routinely offer anti-D. There was less agreement about anti-D after threatened miscarriage, for which 213/353 (57%) said they offered the injection. CONCLUSIONS: GPs need a working knowledge of the management of early-pregnancy bleeding, and can probably encourage more rational management. There are significant areas where GPs are uncertain, often reflecting uncertainty elsewhere, and some areas where a minority of GPs are not aware of essential requirements.

Abortion, Spontaneous↗

Hysteroscopic metroplasty.

Between February 1990 and June 1993 40 patients underwent hysteroscopic metroplasty for septate uterus. Twenty-six patients had previous miscarriages (65%) and fourteen were infertile (35%). Hysteroscopic section of uterine septa was performed by means of Hamou resectoscope with sorbitol-mannitol solution as distending medium. Surgical outcome was excellent without intraoperative and postoperative morbidity. After 40-60 days the uterine cavity was completely epithelialized without intrauterine adhesions in all the cases. One patient had incomplete septum section that required a second procedure. Postoperative reproductive outcome was evaluated in 26 patients: the cumulative pregnancy and birth rate was 73% and 86%, respectively. Five patients delivered by cesarean section (39%). In the infertile group the pregnancy and birth rate was much lower (44% and 75%, respectively) than in previous miscarriage group (88% and 91%, respectively). Infertile patients do not seem to be cured by hysteroscopic metroplasty; however, in these cases the endoscopic operation should be performed, because it may prevent subsequent miscarriage. Hysteroscopic metroplasty by means of Hamou resectoscope is a very successful, quick, simple and safe procedure that may replace abdominal metroplasty.

Abortion, Spontaneous↗

Transcervical hysteroscopic myomectomy: long-term effects on abnormal uterine bleeding.

OBJECTIVE: To evaluate the effectiveness of hysteroscopic myomectomy in the treatment of symptomatic submucous leiomyomas and long-term outcomes. STUDY DESIGN: A total of 107 patients with abnormal uterine bleeding (n = 84) and/or infertility (n = 23) were submitted to hysteroscopic resection. MAIN OUTCOME MEASURES: control of menorrhagia and reproductive outcome. RESULTS: Abnormal uterine bleeding was controlled in 68 out of 84 patients with one procedure; 15 needed a second procedure for incomplete resection. Five patients had menorrhagic pathology relapse. Among 23 patients with associated infertility pregnancy was achieved in eight cases, seven went to term and one miscarried; one patient needed a second procedure. The mean follow-up was 36 months (24-60). Three patients were lost at follow-up. CONCLUSIONS: Transcervical hysteroscopic resection of submucous myomas is effective for control of abnormal uterine bleeding. Further studies are needed to define the value of such procedure in the treatment of infertility. Short and long-term results are strictly correlated to the possibility of obtaining a complete resection, which is conditioned by degree (0, 1, 2) and number of myomas.

Abortion, Spontaneous↗

On the assessment of the growth patterns in human fetal limbs: longitudinal measurements and allometric analysis.

The total length (TL) and length of the ossified part (OL) of some long bones of the upper (humerus, ulna, radius) and lower limb (femur, tibia, fibula) were evaluated in 58 aborted human fetuses (crown-rump length, CRL, between 38 and 116 mm, developmental age from 8 to 14 weeks). The specimens, without any detectable malformation, were cleared and double-stained with alcian blue and alizarin red S to obtain a differential detection of the ossified part within the comprehensive outline between the cartilaginous epiphyses. The correlation between the values of TL and OL and those of CRL emphasized that the systematic OL measurement in limb long bones correlated better than TL with development age, since OL increased faster than TL. TL and OL also correlated with the CRL by bivariate allometry (ln y = ln a + b ln x) and the data obtained showed that they grew with positive allometry. The comparison between the cumulative values of the bones examined in each limb showed that both TL and OL grew relatively faster in the lower limb than the upper; the greatest growth rate was found for OL in the lower limb. These results many provide a tool for a comprehensive assessment of long bone growth patterns and may be useful in determining fetal growth even in incomplete specimens, in which one or some long bones can still be measured.

Embryonic and Fetal Development↗

"Incessant ovulation" and ovarian cancer.

A case-control study of 150 ovarian cancer patients under the age of 50 and individually matched controls was done to study the influence of fertility and oral contraceptive use on the risk of ovarian cancer. The risk decreased with increasing numbers of live births, with increasing numbers of incomplete pregnancies, and with the use of oral contraceptives. These three factors can be amalgamated into a single index of protection--"protected time"--by considering them all as periods of anovulation. The complement of protected time--viz., "ovulatory age", the period between menarche and diagnosis of ovarian cancer (or cessation of menses) minus "protected time"--was strongly related to risk of ovarian cancer. Other factors found to be associated with increased ovarian cancer risk were obesity, cervical polyps, and gallbladder disease. Women who had an "immediate" intolerance to oral contraceptive use had a fourfold increased risk of ovarian cancer. 7 patients, but no controls, could recall a family history of ovarian cancer.

Abortion, Spontaneous↗

Unusual sequence of immunoglobulin L-chain rearrangements in a gamma heavy chain disease patient.

Patients with gamma heavy chain disease (gamma-HCD) generally produce incomplete immunoglobulin (Ig) gamma-heavy chains (gamma-HCD protein) which cannot associate with light chains (IgL). In most patients Bence Jones proteins (BJP) are not observed. However, in the 61-year-old patient WIN we found gamma l-HCD proteins and lambda BJP in serum and urine. WIN gamma l-HCD protein does not carry the Ig Fd region, has a molecular weight of 33.5 kDa, and the seven N-terminal amino acid residues are not translated from any of the known immunoglobulin heavy chain (IgH) gene sequences. These residues are followed by the C gamma l-hinge region. In DNA from peripheral blood lymphocytes of patient WIN we found bands representing dominant rearrangements in one of the two alleles of the IgH, Ig kappa and Ig lambda locus. Taken together, the data from protein and DNA analysis strongly suggest, albeit do not formally prove, that one dominant B-cell clone which carries a rearranged and a non-rearranged allele of each Ig locus produces gamma-HCD protein and lambda BJP. The productive lambda-gene rearrangement in this clone thus has not been preceded by abortive rearrangements in both kappa-locus alleles. Lymphocytes with an unusual sequence of IgL-chain gene activation seem to be involved in the case of gamma-HCD described here.

Amino Acid Sequence↗

Voluntary interruption of pregnancy with mifepristone (RU 486) and a prostaglandin analogue. A large-scale French experience.

In 2115 women seeking voluntary termination of pregnancy after 49 days of amenorrhea or less, we studied the effect of a single 600-mg dose of mifepristone (RU 486), followed 36 to 48 hours later by the administration of one of two prostaglandin analogues, either gemeprost (1 mg by vaginal suppository) or sulprostone (0.25, 0.375, or 0.5 mg by intramuscular injection). The women were monitored for four hours after prostaglandin administration. Efficacy was indicated by the complete expulsion of the conceptus without the need of an additional procedure. All other results were considered failures, and the pregnancy was then terminated by a surgical method. The overall efficacy rate was 96.0 percent (95 percent confidence interval, 95.0 to 96.8). The failures included persisting pregnancies (1.0 percent), incomplete expulsions (2.1 percent), and the need for hemostatic procedure (0.9 percent). The mean time to expulsion was significantly shorter when sulprostone was given in the high dose (4.5 hours) than when it was given in the two lower doses (13.1 and 19.3 hours) or when gemeprost was given (22.7 hours). The mean duration of uterine bleeding was 8.9 days (range, 1 to 35); one woman received a blood transfusion. Most women had transient abdominal pain after receiving prostaglandin, but there were few other side effects. We conclude that the administration of mifepristone followed by a small dose of a prostaglandin analogue is an effective and safe method for the early termination of pregnancy.

Abortifacient Agents↗

Fetal programming: the perspective of single and twin pregnancies.

Multiple pregnancy is associated with increased risk of adverse consequences for both mother and fetus(es), including increased rates of maternal hypertension and pre-eclampsia, spontaneous abortion, Caesarean delivery, low birthweight, birth prematurity, perinatal mortality, admission to neonatal intensive care and extended length of care, respiratory distress, cerebral palsy, developmental delay, contact with disability services and mortality to age 5 years. Premature birth, which affects 97% of triplets and 53.3% of twins in Australia, is not the sole factor involved. The rate of multiple pregnancy in Australia is 1.7%. This compares to 22.1% for pregnancies resulting from assisted reproduction technology (ART). As a result, 21.8% of babies born from ART are from a multiple pregnancy, in comparison to the USA where the majority of babies born from ART are from a multiple pregnancy. Additionally, the population rate of multiple births is rising due to the more frequent use of ART and continued multi-embryo transfers, which is operating against a background of rising implantation rates within ART clinics. Twins have been of interest from a programming perspective. However, analysis of associations between crude birthweight and subsequent metabolic risk factors or mortality in adulthood from chronic disease indicate that adaptations in pregnancy to support multi-fetal growth are not identical to fetal growth restriction in singleton pregnancies. Indeed, the process of 'maternal constraint' is incompletely understood and confounds such comparisons. From a programming perspective, it is a challenge to identify in twin pregnancies the transition from physiological adaptation to pathological growth restriction. Growth disparity between twins has been more illuminating of subtle adverse effects for the smaller of twin pairs in both blood pressure and insulin resistance in adulthood. Interestingly, these effects can be observed in both dizygotic and to a lesser degree in monozygotic twins, which indicates a role for both genetic and environmental factors in these measures. This suggests that, consistent with experimental studies in other species, the relationship between impaired growth in utero and chronic disease in later life is not simply mediated by a common genetic pathway.

Australia↗

Donor and recipient outcomes in right lobe adult living donor liver transplantation.

Severe donor organ shortage has provided the impetus for adult living donor liver transplantation (ALDLT). Despite rapid implementation and expansion of the procedure, outcome analysis of ALDLT is still incomplete. This study analyzed both donor and recipient outcomes after ALDLT at a single center. ALDLT performed at UCLA between August 1999 and November 2001 were reviewed retrospectively. Twenty recipients (14 men and 6 women) with a mean age of 48.8 +/- 9.7 (29 to 66) years underwent right lobe ALDLT. By computed tomograpy (CT), graft/recipient weight ratio (GRWR) was 1.3 +/- 0.3 (1 to 2.2). Overall 1-year patient and graft survival rates were 95% and 85%, respectively. One recipient died of heart failure with normal liver function 5 months after transplantation. Three grafts (14%) were lost and all three patients underwent successful cadaveric retransplantation. Complications were classified according to the Clavien grading system with all but 3 recipients encountering at least one complication. Nine (45%) had grade 1 (minor), 10 (50%) had grade 2 (potentially life threatening without residual disease/disability), 3 (14%) had grade 4A (retransplantation) and one grade 4B (death). Right lobectomy for living donation was performed in 20 patients (12 men, 8 women). Residual left lobe volumes were 36 +/- 5.3 (23.9 to 47.9)% of total donor liver volume. No donor required intensive care unit admission and median hospital stay was 7.5 (6 to 14) days. One donor was aborted after intraoperative biopsy showed > 50% macrovesicular steatosis. No donor mortality or long-term complications were encountered. Five grade 1 minor complications, by Clavien Classification, occurred in 4 of 20 (20%) donors. ALDLT using right lobe grafts is an effective procedure to expand a severely depleted donor, but is associated with a high complication rate despite good survival outcomes. Continuous standardized reporting of ALDLT outcomes is required to allow successful and safe implementation of the procedure.

Adult↗

First-trimester, three-dimensional transvaginal ultrasound volumetry in normal pregnancies and spontaneous miscarriages.

OBJECTIVE: The aim of this study was to perform three-dimensional ultrasound volumetry of intrauterine contents in cases of normal and failed pregnancies and correlate these with conventional two-dimensional measurements. METHODS: This was a cross-sectional observational study. Three-dimensional volumetric data were collected from a total of 111 patients with first-trimester singleton pregnancies together with conventional two-dimensional measurements. A single investigator performed all ultrasound scans and volume measurements. RESULTS: Among 111 participants, 30 had an ongoing pregnancy and 81 had a miscarriage (anembryonic pregnancy 30, missed miscarriage 30, and incomplete miscarriage 21). There were no significant differences in age, parity, or gestational age between groups. A positive linear correlation was demonstrable between the crown-rump length and gestational sac volume in normal pregnancies (r = 0.962) and between gestational sac volume and gestational age, but the correlation was weaker in cases of missed miscarriage (r = 0.561). The volume of the retained products of conception as measured by three-dimensional ultrasound volumetry in cases of incomplete miscarriage also showed a strong linear correlation (r = 0.938) to their maximum anterior-posterior diameter. There was an exponential correlation between the mean gestational sac diameter and gestational sac volume and the crown-rump length and embryonic volume in cases of both normal and failed pregnancies. The mean gestational sac diameter:crown-rump length ratio (P = 0.008) and gestational sac volume:embryonic volume ratio (P = 0.023) in missed miscarriages were significantly higher than those in ongoing pregnancies. CONCLUSION: Three-dimensional ultrasound volumetry of intrauterine contents in normal and failed pregnancies correlates well with conventional two-dimensional measurements. Volumetric assessment does not seem to improve the diagnosis of miscarriage. However, its potential to predict pregnancies that will fail and determine the appropriate management regime for individual patients merits further research.

Abortion, Spontaneous↗

Fetal urine and amniotic fluid in monochorionic twins with twin-twin transfusion syndrome: simulations of therapy.

OBJECTIVE: Therapy for twin-twin transfusion syndrome includes amnioreduction, septostomy, and laser ablation, but there is no accepted standard of care. Mechanisms for the reported improvement in survival are incompletely understood. We sought to model the mechanisms and predict the response of varying severities of twin-twin transfusion syndrome and placental angioarchitectures to current therapies to determine optimal clinical interventions. STUDY DESIGN: We used our mathematic model of twin-twin transfusion syndrome that predicts fetal and amniotic fluid abnormalities that are related to the placental angioarchitecture. Amnioreduction was modeled as reduction in amniotic fluid volume; septostomy was modeled as the merging of donor and recipient amniotic fluid, and laser ablation was modeled as the cessation of all placental anastomotic blood flows. RESULTS: Amnioreduction reduces amniotic fluid pressure, which improves transplacental fluid flow from mother to fetus and increases both donor and recipient blood volume. However, net arteriovenous transfusion increases, because of increased donor arterial pressure, which negates, in part, the benefit of amnioreduction. Septostomy allows amniotic fluid to be swallowed by the donor, with minimal effects on donor growth and blood volume. Laser ablation eliminates anastomotic exchange of blood and reduces discordant fetal growth. CONCLUSION: Amnioreduction may be effective in milder twin-twin transfusion syndrome pregnancies but ineffective in severe cases. Septostomy is unlikely to offer significant therapeutic efficacy. Laser ablation is equally effective in mild and severe twin-twin transfusion syndrome but has a higher spontaneous abortion rate than amnioreduction. The model indicates improved outcomes with the use of amnioreduction in mild twin-twin transfusion syndrome cases and with laser ablation in severe cases.

Amniocentesis↗