emanuel gaziano, md multiple gestation pregnancies monochorionic twins and twin transfusion syndrome...
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Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Monochorionic Twins and Twin Transfusion SyndromeMonochorionic Twins and
Twin Transfusion Syndrome
Emanuel P. Gaziano, M.D.
Minnesotal Perinatal Physicians
Abbott Northwestern Hospital, Minneapolis
Professor, Department of Ob/Gyn
University of Minnesota
Emanuel P. Gaziano, M.D.
Minnesotal Perinatal Physicians
Abbott Northwestern Hospital, Minneapolis
Professor, Department of Ob/Gyn
University of Minnesota
Multiple GestationsMultiple Gestations
• Twins occurrence– 1/90 Natural – 1/45 ART
• Ovulation induction increases: – Twins rate 4X– Triplet or higher 72X
• MZ twins 3.8X
• Twins occurrence– 1/90 Natural – 1/45 ART
• Ovulation induction increases: – Twins rate 4X– Triplet or higher 72X
• MZ twins 3.8XLogerot-Lebrun. Contracept Fertil Sex:1993;21:362Luke B, Martin, JA. Clinical Obstetrics and Gynecology 47:1, 2004
Multiple GestationsMultiple Gestations
• Membranes
• Placental symmetry
• Blood vessels
• Membranes
• Placental symmetry
• Blood vessels
Type of placenta determines frequency and severity of complications
What Type of Twining Event Has Occurred?
Dizygotic or “Fraternal” Twin “arise from two fertilized ova”
Dizygotic or “Fraternal” Twin “arise from two fertilized ova”
• ~ 2/3 of spontaneous twin pregnancies are dizygoticFrequently affected by • Maternal ethnicity
– Blacks highest in Africa > white intermediate in USA & Europe > Asians lowest in Japan & China
– Maternal central gonadotropin levels – high FSH levels• Maternal Age
– > 35 years old• Multi-parity• Maternal genetics
– Previous / family history of dizygotic twins • Ovulation induction therapy
• ~ 2/3 of spontaneous twin pregnancies are dizygoticFrequently affected by • Maternal ethnicity
– Blacks highest in Africa > white intermediate in USA & Europe > Asians lowest in Japan & China
– Maternal central gonadotropin levels – high FSH levels• Maternal Age
– > 35 years old• Multi-parity• Maternal genetics
– Previous / family history of dizygotic twins • Ovulation induction therapy
Dizygotic or “Fraternal” Twin “arise from two fertilized ova”
Dizygotic or “Fraternal” Twin “arise from two fertilized ova”
• Dichorionic (2 placentas) & Diamniotic
• Membrane: 4 layers (2 chorion & 2 amnion)
• Dichorionic (2 placentas) & Diamniotic
• Membrane: 4 layers (2 chorion & 2 amnion)
Monozygotic or “Identical” Twin“arise from one fertilized ovum”
Monozygotic or “Identical” Twin“arise from one fertilized ovum”
• Constant rate across population – 3-5 / 1000
• ~ 1/3 natural conception
• Can occur in ART
• Variable chorionicity
• Variable amnionicity
• Variable risk
• Constant rate across population – 3-5 / 1000
• ~ 1/3 natural conception
• Can occur in ART
• Variable chorionicity
• Variable amnionicity
• Variable risk
Depends on when the zygote (fertilized ovum) divides
Monozygotic or “Identical” Twin“arise from one fertilized ovum”
Monozygotic or “Identical” Twin“arise from one fertilized ovum”
• Monochorionic & Diamniotic
• Dividing membrane: 2 layers of amnion with no interposing chorion
Placentation & Chorionicity
Placentation & Chorionicity Relative Risks
Placentation & Chorionicity Relative Risks
Division of zygote
Frequency Placentation RiskMortality Rate
< 3 daysafter fertilization
25% Di – Di 10%
4 – 8 daysafter fertilization
75% Mono – Di 25%
9 – 13 daysafter fertilization
2% Mono – Mono 50%
> 13 daysafter fertilization
Rare Conjoined 99%
Twin Gestations & Relative Risks
Twin Gestations & Relative Risks
Diamniotic-Dichorionic
• Age risk for aneuploidy higher than singleton rate
• Early loss greater than
singleton
• Greater congenital anomaly
rate compared to singleton
Diamniotic-Dichorionic
• Age risk for aneuploidy higher than singleton rate
• Early loss greater than
singleton
• Greater congenital anomaly
rate compared to singleton
Diamniotic-Monochorionic
• Age risk for aneuploidy same as singleton rate
• Early loss rate greater than
Di-Di twins
• Greater congenital anomaly
rate compared to Di-Di twins
Diamniotic-Monochorionic
• Age risk for aneuploidy same as singleton rate
• Early loss rate greater than
Di-Di twins
• Greater congenital anomaly
rate compared to Di-Di twins
Chorionicity & AmnionicityChorionicity & Amnionicity• DC-DA
– Thick membrane around each sac
• MC-DA– Thick membrane around
periphery, but thin membrane between sacs
• MC-MA– Thick membrane around
periphery and no visible membrane between sacs
• DC-DA– Thick membrane around
each sac
• MC-DA– Thick membrane around
periphery, but thin membrane between sacs
• MC-MA– Thick membrane around
periphery and no visible membrane between sacs
Chorionicity & AmnionicityChorionicity & Amnionicity• DC-DA
– Thick membrane around each sac
• MC-DA– Thick membrane around
periphery, but thin membrane between sacs
• MC-MA– Thick membrane around
periphery and no visible membrane between sacs
• DC-DA– Thick membrane around
each sac
• MC-DA– Thick membrane around
periphery, but thin membrane between sacs
• MC-MA– Thick membrane around
periphery and no visible membrane between sacs
Chorionicity & AmnionicityChorionicity & Amnionicity• DC-DA
– Thick membrane around each sac
• MC-DA– Thick membrane around
periphery, but thin membrane between sacs
• MC-MA– Thick membrane around
periphery and no visible membrane between sacs
• DC-DA– Thick membrane around
each sac
• MC-DA– Thick membrane around
periphery, but thin membrane between sacs
• MC-MA– Thick membrane around
periphery and no visible membrane between sacs
Implications of Early Chorionicity Determination
Implications of Early Chorionicity Determination
• The rate of miscarriage & perinatal death in monochorionic twins > dichorionic twins
• Death of a monochorionic fetus is associated with a high chance of sudden death or severe neurologic impairment in the co-twin
• Genetic disorders & chromosomal abnormalities is dependent on chorionicity
• Management of pregnancy
• The rate of miscarriage & perinatal death in monochorionic twins > dichorionic twins
• Death of a monochorionic fetus is associated with a high chance of sudden death or severe neurologic impairment in the co-twin
• Genetic disorders & chromosomal abnormalities is dependent on chorionicity
• Management of pregnancy
Complications
General Risks of Multiple PregnancyGeneral Risks of Multiple Pregnancy
Fetal Complications
• Preterm births
• Growth restriction
• Early post-maturity
• Fetal anomalies
Maternal Complications
• Preeclampsia
• Placenta abruption
• Placenta previa
• Pre & postpartum hemorrhage
Fetal Complications
• Preterm births
• Growth restriction
• Early post-maturity
• Fetal anomalies
Maternal Complications
• Preeclampsia
• Placenta abruption
• Placenta previa
• Pre & postpartum hemorrhage
• Monozygotic twins anomalies
• Monochorionic twins– TTTS
– Acardiac twin
• Monoamniotic twins– Cord entanglement
– Conjoining
– Death of a twin
• Monozygotic twins anomalies
• Monochorionic twins– TTTS
– Acardiac twin
• Monoamniotic twins– Cord entanglement
– Conjoining
– Death of a twin
Monozygotic TwinsMonozygotic Twins
• Congenital anomalies – structural– Twins - 2x singletons– Monozygotic - 2x dizygotic
• 80 to 90 % of structural malformations are discordant
• Congenital anomalies – structural– Twins - 2x singletons– Monozygotic - 2x dizygotic
• 80 to 90 % of structural malformations are discordant
Monoamniotic TwinsMonoamniotic Twins
• Cord entanglement
• Conjoining
• Death of a twin
• Cord entanglement
• Conjoining
• Death of a twin
Monoamniotic TwinsMonoamniotic Twins
• The umbilical cords usually insert near one another
• The placental vessels typically have large-caliber anastomoses between them– TTS is less common because
imbalance in the two circulations could not be sustained for long period
• The umbilical cords usually insert near one another
• The placental vessels typically have large-caliber anastomoses between them– TTS is less common because
imbalance in the two circulations could not be sustained for long period
Monoamniotic TwinsMonoamniotic Twins
• MC-MA twins have a further increased incidence of entangled cords
• MC-MA twins have a further increased incidence of entangled cords
Conjoined TwinsConjoined Twins
• form when a single fertilized egg fails to divide completely to create two distinct individuals
• 1 in 50,000 to 1 in 200,000
• form when a single fertilized egg fails to divide completely to create two distinct individuals
• 1 in 50,000 to 1 in 200,000
Twin Reversed Arterial Perfusion“Acardiac Twin”
Twin Reversed Arterial Perfusion“Acardiac Twin”
• 1% of MC Pregnancies
• 1 in 35,000 Pregnancies
• Acardiac twin perfused by deoxygenated blood from “pump” twin
• 1% of MC Pregnancies
• 1 in 35,000 Pregnancies
• Acardiac twin perfused by deoxygenated blood from “pump” twin
Flow in umbilical artery of abnormal twin is toward fetus
Flow in umbilical artery of abnormal twin is toward fetus
Twin Reversed Arterial Perfusion“Acardiac Twin”
Twin Reversed Arterial Perfusion“Acardiac Twin”
• Delayed cardiac function of one twin• Delayed cardiac function of one twin
Twin Reversed Arterial Perfusion“Acardiac Twin”
Twin Reversed Arterial Perfusion“Acardiac Twin”
• Commonly edematous, cystic appearing mass (similar to cystic hygroma)
• Absent cranium, cervical spine and upper extremities
• No cardiac structures or activity
• Lower half of body better developed
• Commonly edematous, cystic appearing mass (similar to cystic hygroma)
• Absent cranium, cervical spine and upper extremities
• No cardiac structures or activity
• Lower half of body better developed
Twin Reversed Arterial Perfusion“Acardiac Twin”
Twin Reversed Arterial Perfusion“Acardiac Twin”
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Twin Twin Transfusion Twin Twin Transfusion
• A syndrome occurring in MC pregnancies due to artery to vein anastomoses in which the donor twin partially perfuses the recipient twin.
• Also known as TTTS or TOPS (Twins oligohydramnios, polyhydramnios sequence.)
• A syndrome occurring in MC pregnancies due to artery to vein anastomoses in which the donor twin partially perfuses the recipient twin.
• Also known as TTTS or TOPS (Twins oligohydramnios, polyhydramnios sequence.)
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Twin-twin Transfusion SyndromeTwin-twin Transfusion Syndrome
Outcome:
• Without treatment, mortality is 90-100%
• Neurological morbidity: 37%
• If one fetus dies, there is a 25% risk of severe neurologic impairment probably due to hypotension, hypoxia or thromboembolism
Adegbite AJOBG 190:156, 2004
Outcome:
• Without treatment, mortality is 90-100%
• Neurological morbidity: 37%
• If one fetus dies, there is a 25% risk of severe neurologic impairment probably due to hypotension, hypoxia or thromboembolism
Adegbite AJOBG 190:156, 2004Turrentine et al. Am J Perinatol 13:351,1996
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Outcome Outcome
• Less than 28 weeks survival 21% irrespective of method of management including decompression amniocentesis or tocolytics.
• Gondoulin W, et al. 1990, Obstet Gynecol 75:214.
• Less than 28 weeks survival 21% irrespective of method of management including decompression amniocentesis or tocolytics.
• Gondoulin W, et al. 1990, Obstet Gynecol 75:214.
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
FrequencyFrequency
• About 15% of monochorionic twins will show some evidence of twin to twin transfusion syndrome
• About 15% of monochorionic twins will show some evidence of twin to twin transfusion syndrome
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Frequency TTTSFrequency TTTS
Twin GestationTwin Gestation
Diamniotic DichorionicDiamniotic Dichorionic(70-80%)(70-80%)
TTTS RareTTTS Rare
Diamniotic monochorionicDiamniotic monochorionic(20-30%)(20-30%)
MC-TTSMC-TTS(6-15%)(6-15%)
MC-non TTSMC-non TTS(85-94%)(85-94%)
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
EtiologyEtiology
• MC Twins • Vascular anastomoses• Unequal placental
sharing• Abnormal size of
umbilical cord• Velamentous insertion
of cord
• MC Twins • Vascular anastomoses• Unequal placental
sharing• Abnormal size of
umbilical cord• Velamentous insertion
of cord
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
4 to 7 Days after fertilization
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Vascular arrangementTTTS
Vascular arrangementTTTS
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Surface Vessels on Chorionic PlateSurface Vessels on Chorionic Plate
• Artery to vein anastomoses primary defect
• Actually fewer balanced anastomoses
• Nose to nose A-V connections
• Artery to vein anastomoses primary defect
• Actually fewer balanced anastomoses
• Nose to nose A-V connections
Gaziano E, Harkness, U. Doppler Velocimetry and Multiple Gestation.In Doppler Ultrasound in Obstetrics and Gynecology, D. Maulik, ed. 2005
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Contrast Medium Demonstrating Vascular Anastomoses in MC Twins
Contrast Medium Demonstrating Vascular Anastomoses in MC Twins
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Etiology: Hemoglobin DifferencesEtiology: Hemoglobin Differences
• Mean hemoglobin difference is 4.8 gr/dl.
• In cordocentesis studies any range of hemoglobin differences have been observed even in the presence of hydrops in the recipient.
• Neonatal criteria is more rigid for diagnosis requiring 5.0 gr/dl difference
Gaziano E, Harkness, U. Doppler Velocimetry and Multiple Gestation.In Doppler Ultrasound in Obstetrics and Gynecology, D. Maulik, ed. 2005
• Mean hemoglobin difference is 4.8 gr/dl.
• In cordocentesis studies any range of hemoglobin differences have been observed even in the presence of hydrops in the recipient.
• Neonatal criteria is more rigid for diagnosis requiring 5.0 gr/dl difference
Gaziano E, Harkness, U. Doppler Velocimetry and Multiple Gestation.In Doppler Ultrasound in Obstetrics and Gynecology, D. Maulik, ed. 2005
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Diagnosis: 1st TrimesterDiagnosis: 1st Trimester
• NT in DiMo twins• If NT abnormal measure
DV• Abnormal NT +
Abnormal DV predicts TTTS
Sebire Human Reproduction, Vol.15, No. 9, 2008-2010, September 2000
• NT in DiMo twins• If NT abnormal measure
DV• Abnormal NT +
Abnormal DV predicts TTTS
Sebire Human Reproduction, Vol.15, No. 9, 2008-2010, September 2000
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
20 week scan20 week scan
TWIN A: HC=23 1/7ths Wks TWIN B: HC=20 6/7ths Wks
TWIN A: AC=23 4/7ths Wks TWIN B: HC=19 5/7ths Wks
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
20 week scan 20 week scan
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
20 week scan20 week scan
TWIN B: Cord Insertion TWIN B Umbilical Artery Doppler
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Ultrasound of TTTSUltrasound of TTTS
• Features of MC Features of MC PlacentaPlacenta
• Fused placentaFused placenta• Thin dividing Thin dividing
membranemembrane• Dissimilar AF volumesDissimilar AF volumes
• Features of MC Features of MC PlacentaPlacenta
• Fused placentaFused placenta• Thin dividing Thin dividing
membranemembrane• Dissimilar AF volumesDissimilar AF volumes
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Sonographic Signs TTTSSonographic Signs TTTS
• Oligohydramnios– Donor sac <2 cm
• Hydramnios– Recipient sac >8cm
• Growth discordance• Thin dividing
membrane• Same gender pair
• Oligohydramnios– Donor sac <2 cm
• Hydramnios– Recipient sac >8cm
• Growth discordance• Thin dividing
membrane• Same gender pair
Blickstein I. Obstet Gynecol 1990;76:714-22Blickstein I. Obstet Gynecol 1990;76:714-22
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Ultrasound of TTTSUltrasound of TTTS
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
TTTSTTTS
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Ultrasound TTSUltrasound TTS
• Assess cord insertion site for each twin
• Assess cord insertion site for each twin
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Ultrasound TTTSUltrasound TTTS
• Assess for velamentous insertion
• Assess for velamentous insertion
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Ultrasound TTTSUltrasound TTTS
• Assess Placental Mass• Assess Placental Mass
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Other sonographic signs TTTSOther sonographic signs TTTS
• Echogenic bowel• Cardiac: enlargement,
tricuspid regurgitation,
ROF obstruction• Pulmonary artery
calcification
• Echogenic bowel• Cardiac: enlargement,
tricuspid regurgitation,
ROF obstruction• Pulmonary artery
calcification
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Doppler In TTTSDoppler In TTTS
• Initial studies: CW no difference in Doppler values (Trudinger)
• Abnormal UA Doppler values may be seen in either donor or recipient but more common in Donor.
• Abnormal Doppler values predict adverse outcomes.• Role for Doppler in Staging of TTTS• Abnormal venous values seen in TTTS
• Initial studies: CW no difference in Doppler values (Trudinger)
• Abnormal UA Doppler values may be seen in either donor or recipient but more common in Donor.
• Abnormal Doppler values predict adverse outcomes.• Role for Doppler in Staging of TTTS• Abnormal venous values seen in TTTS
Gaziano E, Harkness, U. Doppler Velocimetry and Multiple Gestation. In Doppler Ultrasound in Obstetrics and Gynecology, D. Maulik, ed. 2005
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Abnormal Doppler also predicts poor outcome in TTTS
Abnormal Doppler also predicts poor outcome in TTTS
• Umbilical artery PI Doppler difference is greater in MC twins who are destined to develop hydrops.
• Poor prognostic factors in TTTS:
zero or REDF in umbilical artery Doppler
Abnormal venous Doppler Absence of artery to artery
anastomosesTaylor et al, 2000 Am J Obstet Gynecol
183:1023
• Umbilical artery PI Doppler difference is greater in MC twins who are destined to develop hydrops.
• Poor prognostic factors in TTTS:
zero or REDF in umbilical artery Doppler
Abnormal venous Doppler Absence of artery to artery
anastomosesTaylor et al, 2000 Am J Obstet Gynecol
183:1023
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Extreme Cases of TTTSExtreme Cases of TTTS
When cord Hb differences are >5 Doppler values in Donor and Recipient
may be similar
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Quintero Staging of twin-twin transfusion syndrome
Quintero Staging of twin-twin transfusion syndrome
• Stage I– Amniotic fluid differences
• Stage II– Absence of bladder
• Stage III– Critically abnormal Dopplers
• Stage IV– Presence of ascites or frank
hydrops
• Stage V– Demise of either fetus.
• Stage I– Amniotic fluid differences
• Stage II– Absence of bladder
• Stage III– Critically abnormal Dopplers
• Stage IV– Presence of ascites or frank
hydrops
• Stage V– Demise of either fetus.
J Perinatol 19:550-555
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Quintero Staging of twin-twin transfusion syndrome
Quintero Staging of twin-twin transfusion syndrome
• Stage II– Diastolic flow in UA and
forward flow in the DV
• Stage III– Zero or AED flow in UA
and reverse flow in DV
• Stage II– Diastolic flow in UA and
forward flow in the DV
• Stage III– Zero or AED flow in UA
and reverse flow in DV
J Perinatol 19:550-555
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Twin-twin Transfusion SyndromeTwin-twin Transfusion Syndrome
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Options for TreatmentOptions for Treatment
• Septostomy
• Amnioreduction
• Laser separation of the circulations
• Feticide
• Septostomy
• Amnioreduction
• Laser separation of the circulations
• Feticide
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Options for TreatmentOptions for Treatment
Septostomy• Separates the dividing
membrane• Equalizes fluid pressure• Usually small holes
punctured in the dividing membrane
• Risk for cord entanglement
Septostomy• Separates the dividing
membrane• Equalizes fluid pressure• Usually small holes
punctured in the dividing membrane
• Risk for cord entanglement
Amnioreduction• Reduce amniotic fluid
volume in the recipient sac.
• Usually for Stage I or II• Decompress when DVP
>11• Decompress to normal
range <DVP of 8• Risk: infection
Amnioreduction• Reduce amniotic fluid
volume in the recipient sac.
• Usually for Stage I or II• Decompress when DVP
>11• Decompress to normal
range <DVP of 8• Risk: infection
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Technique similar to genetic amnio: larger
needle and vacuum bottle.Technique similar to genetic amnio: larger
needle and vacuum bottle.
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Prospective randomized trial comparing amnioreduction to septostomy
Prospective randomized trial comparing amnioreduction to septostomy
• Survival in each group was 65%
• No data on neurologic outcome
Saade GR, Moise K, Dormar KA et al: Randomized trial of septostomy verses amnioreduction in the treatment of twin oligohydramnios polyhydramnios sequence (TOPS). American Journal of Obstetrics
and Gynecology (abstr) 187: 3, 2003.
• Survival in each group was 65%
• No data on neurologic outcome
Saade GR, Moise K, Dormar KA et al: Randomized trial of septostomy verses amnioreduction in the treatment of twin oligohydramnios polyhydramnios sequence (TOPS). American Journal of Obstetrics
and Gynecology (abstr) 187: 3, 2003.
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
DeLia 1995 N=26 Severe TTTS by LaserDeLia 1995 N=26 Severe TTTS by Laser
• Surviving fetuses were delivered for obstetric reasons at a mean of 32.2 weeks (range, 26 to 37 weeks).
• Fifty-three percent (28 of 53) of fetuses survived• 96% (27 of 28) showed normal development at a
mean of 35.8 months of follow-up (range, 1 to 68 months).
• DeLia JE, et al: Fetoscopic laser ablation of placental vessels in severe previable twin-twin transfusion syndrome. American Journal of Obstetrics and Gynecology 172:1202, 1995.
• Surviving fetuses were delivered for obstetric reasons at a mean of 32.2 weeks (range, 26 to 37 weeks).
• Fifty-three percent (28 of 53) of fetuses survived• 96% (27 of 28) showed normal development at a
mean of 35.8 months of follow-up (range, 1 to 68 months).
• DeLia JE, et al: Fetoscopic laser ablation of placental vessels in severe previable twin-twin transfusion syndrome. American Journal of Obstetrics and Gynecology 172:1202, 1995.
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Laser vs AmnioreductionLaser vs Amnioreduction
• N=73 women were treated between 1995 and 1997 in one center by fetoscopic laser photocoagulation
• N=43 patients were treated at another center between 1992 and 1996 by serial amnioreduction.
•
Hecher K, et al: Endoscopic laser surgery versus serial amniocentesis in the treatment of severe twin-twin transfusion syndrome. American Journal of Obstetrics and Gynecology 180:717, 1999.
• N=73 women were treated between 1995 and 1997 in one center by fetoscopic laser photocoagulation
• N=43 patients were treated at another center between 1992 and 1996 by serial amnioreduction.
•
Hecher K, et al: Endoscopic laser surgery versus serial amniocentesis in the treatment of severe twin-twin transfusion syndrome. American Journal of Obstetrics and Gynecology 180:717, 1999.
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Hecher K, et al: Endoscopic laser surgery versus serial amniocentesis in the treatment of severe twin-twin transfusion syndrome. American Journal
of Obstetrics and Gynecology 180:717, 1999
Hecher K, et al: Endoscopic laser surgery versus serial amniocentesis in the treatment of severe twin-twin transfusion syndrome. American Journal
of Obstetrics and Gynecology 180:717, 1999
Laser versus Amnioreduction for Severe TTTS
0
20
40
60
80
100
Survival IUFD Abn HeadUS
GA atBirth
Laser
Amnio
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Long-term neurodevelopmental outcome of children born after laser for severe TTTS
Long-term neurodevelopmental outcome of children born after laser for severe TTTS
N=167 follow up to 3 years and 2months
• 145 (86.8%) showed normal development,
• 12 infants (7.2%) showed minor neurologic abnormalities,
• 10 infants (6.0%) major neurologic abnormalities.
N=167 follow up to 3 years and 2months
• 145 (86.8%) showed normal development,
• 12 infants (7.2%) showed minor neurologic abnormalities,
• 10 infants (6.0%) major neurologic abnormalities.
Graef C. Am J Obstet Gynecol. 2006 Feb;194(2):303-8.
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Long-term neurodevelopmental outcome of children born after Laser for severe TTTS
Long-term neurodevelopmental outcome of children born after Laser for severe TTTS
No difference in outcome for the former donors/recipients (P = .349)
CONCLUSION: intrauterine laser coagulation seems to be the best treatment option for severe twin-twin transfusion syndrome.
No difference in outcome for the former donors/recipients (P = .349)
CONCLUSION: intrauterine laser coagulation seems to be the best treatment option for severe twin-twin transfusion syndrome.
Graef C. Am J Obstet Gynecol. 2006 Feb;194(2):303-8.
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Perinatal death rate higher when laser used for treatment of TTTS in Stage I and II (p=.02)
Perinatal death rate higher when laser used for treatment of TTTS in Stage I and II (p=.02)
Quintero et al, Am J Obstet Gynecol 2003;188:1333
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Perinatal death rate lower when laser used for treatment of TTTS in Stage III and IV (p=.02)Perinatal death rate lower when laser used for treatment of TTTS in Stage III and IV (p=.02)
Quintero et al, Am J Obstet Gynecol 2003;188:1333
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Two prospective randomized clinical trials
Two prospective randomized clinical trials
• The Eurofetus trial in Europe
• The National-Institutes-of-Health-sponsored trial in the United States
• Compare aggressive serial amnioreduction to fetoscopic laser photocoagulation.
• The Eurofetus trial in Europe
• The National-Institutes-of-Health-sponsored trial in the United States
• Compare aggressive serial amnioreduction to fetoscopic laser photocoagulation.
2011 NIH Trial2011 NIH Trial
• The trial had uncovered higher mortality among recipient twins who received laser treatment. But overall, survival of one or both twins of the same pregnancy was no different between the two treatments. In addition, there was no difference between survival rates of donor twins and recipient twins.
• The trial had uncovered higher mortality among recipient twins who received laser treatment. But overall, survival of one or both twins of the same pregnancy was no different between the two treatments. In addition, there was no difference between survival rates of donor twins and recipient twins.
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Cochrane ReviewCochrane Review
• Laser coagulation resulted in less overall death (48% vs. 59%) when compared with amnioreduction.
• The results suggest that endoscopic laser coagulation of anastomotic vessels should be considered in the treatment of all stages of TTTS to improve perinatal and neonatal
outcome
• Laser coagulation resulted in less overall death (48% vs. 59%) when compared with amnioreduction.
• The results suggest that endoscopic laser coagulation of anastomotic vessels should be considered in the treatment of all stages of TTTS to improve perinatal and neonatal
outcome
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Treatment SummaryTreatment Summary
• Most studies show outcomes for laser separation superior to amnioreduction.
• Always exceptions due to the small placental mass and complications due to velamentous insertions in some MC pregnancies.
• Spontaneous improvement occurs in some cases (anastomoses change)
• Most studies show outcomes for laser separation superior to amnioreduction.
• Always exceptions due to the small placental mass and complications due to velamentous insertions in some MC pregnancies.
• Spontaneous improvement occurs in some cases (anastomoses change)
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Discordant Growth (AEDF)Discordant Growth (AEDF)
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Thank you!