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PubMedDate not supplied

Management of a case of twin-to-twin transfusion syndrome by a combined surgical approach.

OBJECTIVE: The management of a case of severe twin-to-twin transfusion syndrome at 24 weeks of gestation is presented, using a combined surgical and medical approach. METHODS: Operative fetoscopy was used to coagulate placental vessels crossing the intertwin membranes. Repeated intrauterine transfusions were used to correct recurrent anemia in the donor twin. Selective three-dimensional placental angiography and directed histological analysis were used to study the placenta after delivery. RESULTS: Resolution of twin-to-twin transfusion syndrome was obtained by coagulation of placental anastomoses, but was followed by recurrent anemia in the donor twin. This was successfully treated by serial intrauterine blood transfusions, and 2 healthy twins were delivered at 31 weeks of gestation. One artery-to-vein anastomosis was demonstrated to be the only communication left between the two circulations. CONCLUSIONS: This case illustrates the limitations of placental surgery in twin-to-twin transfusion syndrome and highlights the need for ultrasound and Doppler follow-up of these high-risk fetuses to indicate further treatment. Placental anastomoses can be overlooked by macroscopic examination and injection technique, but can be demonstrated by placental angiography.

Adult↗
PubMedDate not supplied

Diagnosis, pathophysiology, and treatment of chronic twin-to-twin transfusion syndrome.

The discovery of a 'stuck twin' during an ultrasound examination has often been equated with twin-to-twin transfusion based to a great extent on postnatal confirmation of discordant fetal size and hemoglobin concentration. However, the diagnosis of twin-to-twin transfusion cannot be made with certainty after birth since virtually all monochorionic gestations have placental anastomoses and there are many causes of growth deficiency and abnormal hemoglobin concentration. The purpose of this study is to investigate the pathophysiology of chronic twin-to-twin transfusion syndrome and apply the findings to the development of a management algorithm. In 42 twin gestations with stuck twin associated with acute hydramnios, we performed targeted ultrasound cordocentesis in each fetus and therapeutic amniocentesis. The diagnosis of chronic twin-to-twin transfusion syndrome required: sonographic evidence of monochorionicity; rapid reaccumulation of fluid after amniocentesis; discordant fetal size, and divergent fetal hematocrit measurements with at least one above or below the 95% confidence interval for gestational age. These criteria were met in 20 of 42 (48%) pregnancies. The mean gestation was 23.8 +/- 2 weeks (range 21-27 weeks). In 4 pregnancies, the transfer of adult RBCs from the donor to the recipient was documented. Monochorionicity was confirmed in all postnatally. All recipients had polycythemia and hyperproteinemia. Hydrops developed only in the recipient twin (6 of 20) and was associated with an elevated umbilical venous pressure. All pregnancies were treated with aggressive serial therapeutic amniocenteses. There was no objective evidence that amniocentesis altered the magnitude of the shunt.(ABSTRACT TRUNCATED AT 250 WORDS)

Amniocentesis↗