a systematic approach to the diagnosis and management of mc twin complications · 2015-07-03 ·...
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A systematic approach to the diagnosis and management of MC
twin complicationsEduard&Gratacós
BCNatal'and'Fetal'i+D,'Hospital'Clínic'and'Hospital'Sant'Joan'de'Deu,'University'of'Barcelona,'Spainwww.fetalmedicinebarcelona.org
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1. Diagnosis and pregnancy management
2. The main syndromes
3. Differential diagnosis algorithm
4. Main principles for management
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1. Diagnosis and pregnancy management
2. The main syndromes
3. Differential diagnosis algorithm
4. Main principles for management
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4/5 DICHORIONIC15-20/1000
1/5 MONOCHORIONIC4-5/1000
TWIN PREGNANCY
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Diagnosis chorionicity < 14 w
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TWIN PREGNANCY
4/5DC twins
1/5MC twins
IUGRMalformation
TTS -TAPS sIUGR
-Dizygotic-Mono (early
split)
Independent placenta
Isolated systems
Monozygotic(late split)
Shared placenta
Vascular-connected systems
MC: neurologic morbidity x4-5
Complication rate: 1 in 3 Acosta 2008, Lewi 2009
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MC and DC discordant twinsIncidence of malformations per fetus
MC > BC = single
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• Acardias/Acephalus• Arterial/flow/from/normal/twin
– 1&anastomosis&A3A&+&1&V3V– no&own&placenta
• Incidence:/1%/MZ/twins• 30>50%/death/normal/“pump”/twin
– Cardiac&failure,&hydrops– Severe&polyhydramnios
Twin Reverse Arterial Sequence
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12
14to
28
30+
DIAGNOSIS OF CHORIONICITY Evaluation of risk (Anatomy, NT + DV + AC + folding)
SEVERE COMPLICATIONS (mostly managed by intrauterine therapy)
TTTS - Early sIUGR – Discordant malformationClose follow-up and early diagnosis & management
LATE COMPLICATIONS(mostly managed by elective delivery)
Late TTTS – Late sIUGR - TAPS - Single IUFDClose follow up and elective delivery
Monitoring of monochonionic twin pregnancy3 stages
BIOMETRY + DOPPLER
12
20
28
141618
222426
3230
AC + AF ASSESSMENT
Elective delivery 36-37s
3436
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1. Diagnosis and pregnancy management
2. The main syndromes
3. Differential diagnosis algorithm
4. Main principles for management
Chronic(unbalanced(transfusion•'Twin%twin'transfusion'syndrome'(TTTS)
•'Twin'anemia'polycytemia'syndrome'(TAPS)
COMPLICATIONS OF MONOCHORIONIC TWINS
Discordance(in(placental(territories•'Selec;ve'IUGR'(sIUGR)
Unidirec5onal(acute(transfusion•'Single'fetal'death•"Pressure"loss"in"one"fetus
High'
Risk
High'risk
Discordant(Malforma5on
Chronic unbalanced transfusion • Twin-twin transfusion syndrome (TTTS)• Twin anemia polycytemia syndrome (TAPS)
COMPLICATIONS OF MONOCHORIONIC PREGNANCY
POLIHYDRAMNIOS'+'ENLARGED'BLADDER(>8'cm'<20w'%'>10'cm'<26w)
OLIGOIANHYDRAMNIOS'+'COLLAPSED'BLADDER(<2'cm)
DiagnosDc&criteria&of&TTTS&Eurofoetus,"Curr"Opin"Obstet"Gynecol"1999""8""WAPM."J"Perinat"Med"2011
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A staging system for TTTSQuintero R et al, J Perinatol 2000
I: Bladder donor visible
II: Bladder non-visible
III: Abnormal Doppler! a- recipient DV abnormal! b- donor UA with AREDF
IV: Hydrops
V: Death one fetus
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TTTS:'laser'of'placental'anastomosesWAPM'guidelines,'2011
60:70%
20:25%
5:15(%
2survivors
1
0
At(least(one(≈85:95(%
Severe(sequelae(≈10%
(related"with""prematurity)
TTTS: laser therapy
Chronic unbalanced transfusion • Twin-twin transfusion syndrome (TTTS)• Twin anemia polycytemia syndrome (TAPS)
COMPLICATIONS OF MONOCHORIONIC PREGNANCY
Transfusion BUT very small vessels.• 5% in MC twins • 0.5-6 % post-laser
Hematological not hemodynamic problem
Diagnosis: DISCORDANCE OF• In utero: Vmax-MCA (>1.5 + <1 MoM)•Neonatal: Hb>5g/L + reticulocytes >2%
F1
F2
NORMALLY GOOD PROGNOSIS
COMPLICATIONS OF MONOCHORIONIC PREGNANCY
Discordant placental territories• selective IUGR
MC + sIUGR (EFW<P10)
Poor prognosis: high risk of IUFD and neurological damage for both twinsNormally good prognosis
No change in Doppler pattern from diagnosis (≈20w) to deliveryLee 04, Vanderheyden 05, Gratacós 04, 07
Quintero 03, Gratacós 04, Vanderheyden 05
Gratacós&07
TYPE(II TYPE(IIITYPE(I
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MC + sIUGR (EFW<P10)
Poor outcome: risk IUFD + neurological damage both twinsNormally good prognosis
Discuss therapy options with parents
Quintero 03, Gratacós 04,07,08 Vanderheyden 05, Ishi 09
Gratacós&07
TYPE(II TYPE(IIITYPE(I
Expectant Management
Active Management
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Decision tree for counseling in sIUGR
1: DIAGNOSISsIUGR + no TTTS
2: sIUGR TYPE
I II III
Expectant + Follow-up 1/w
Expectant + Follow-up 1/w
3: SEVERITYGA<24w /Disc >35%
AREDF /DV>p95
NO YES
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1. Diagnosis and pregnancy management
2. The main syndromes
3. Differential diagnosis algorithm
4. Main principles for management
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MC twins: discrepancy in size and/or AFAlgorithm for differential diagnosis
AF: > 8 cm (> 10 cm) / < 2cmClearly discordant bladders
EFW <P10
• discordant for AF• discordant for EFW
TTTS
sIUGR
yes
yes
no
noNothing for the moment
Close surveillance
MCA-PSV >1.5 / < 1 MoM TAPSyes
no
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1. Diagnosis and pregnancy management
2. The main syndromes
3. Differential diagnosis algorithm
4. Main principles for management
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A SIMPLIFIED (BUT USEFUL) APPROACH TO FOLLOW UP AND MANAGEMENT OF MONOCHORIONIC TWINS
1. Early diagnosis. Rule out malformations.2. Follow up every 2 weeks (EFW, AF, MCA)3. If suspicious: weekly follow-up4. If Δ AF=TTTS: Immediate treatment5. If Δ EFW<P10=sIUGR: Doppler UA:
a. Normal: Expectantb. Abnormal: counsel about options
6. If uneventful deliver 36-37 weeks.