Management of

Monozygotic twins

Isaac Blickstein, MD

It’s all about

Territory

http://www.google.co.il/url?sa=i&rct=j&q=fight+on+territory&source=images&cd=&cad=rja&docid=u8NnBRML0IweQM&tbnid=QUx26-uVUwqOOM:&ved=0CAUQjRw&url=http://www.oceanlight.com/log/elephant-seals-fighting.kml&ei=FgmOUZ3QHcmTtAa1joGoDA&psig=AFQjCNEl3qpNmC3OHbYZngzHPzEaoDaCyA&ust=1368349230992052

It’s all about

Territory

Pipelines

http://www.google.co.il/url?sa=i&rct=j&q=centre+pompidou&source=images&cd=&cad=rja&docid=rzUEao0gMRsWZM&tbnid=0ripLe-WouY35M:&ved=0CAUQjRw&url=http://www.fotopedia.com/albums/a0050c06-82e9-467c-b384-4882ebc7c2fc/entries/1195fd8e-5278-4e56-84a2-5873af9b7bfb&ei=kguOUeDpKMiOswbhloC4DA&psig=AFQjCNGWhy9Pxk05X7NrkHwbxawebT_cWg&ust=1368349760273649

L. Lewi, Leuven

Velamentous

insertion

Territoriality

Anastomosis

Anastomosis

Territoriality

Velamentous

insertion

http://www.google.co.il/url?sa=i&rct=j&q=pipes+game&source=images&cd=&cad=rja&docid=94gJKqNbKRJ16M&tbnid=vwWkm77dqSsNaM:&ved=0CAUQjRw&url=http://www.technologytell.com/apple/49863/appletell-reviews-iphone-games-youve-already-played-elsewhere/&ei=Zg-OUfXML8HctAa3s4GgDA&psig=AFQjCNEKDNCTHzMg7yqWjRwNUR5gaqs9Hg&ust=1368350398440353

http://www.google.co.il/url?sa=i&rct=j&q=pipes+connecting&source=images&cd=&cad=rja&docid=NlKvoQoKOveoDM&tbnid=bGkLx3QOgL-SHM:&ved=0CAUQjRw&url=http://www.ehow.com/how_7364576_keep-pipes-water-tank-freezing.html&ei=UxGOUaqfFIWUtAaql4CgDA&psig=AFQjCNGE_G_8Jf6i1JxPppqFksO1ShwQsg&ust=1368351425838812

http://www.google.co.il/url?sa=i&rct=j&q=pipes+connecting+unequal+diameter&source=images&cd=&cad=rja&docid=IKHljTiQTCCwnM&tbnid=CJC48_xxeHQ1ZM:&ved=0CAUQjRw&url=http://en.wikipedia.org/wiki/Piping_and_plumbing_fitting&ei=thKOUYy0BIiItQa464CYDA&psig=AFQjCNG8JktMeCmnV3UwPYefKH2kRspQPg&ust=1368351779369943

http://www.google.co.il/url?sa=i&rct=j&q=AA+anastomosis&source=images&cd=&cad=rja&docid=UnFN3qqQbXTZSM&tbnid=ttXvAfqGtMMWkM:&ved=0CAUQjRw&url=http://neoreviews.aappublications.org/content/9/9/e370/F2.full&ei=xhOOUY74EInQtAb3xIGwDA&psig=AFQjCNEWpxfVHiyZZ0FO5axiFemvGwGNjQ&ust=1368352031961060

http://www.google.co.il/url?sa=i&rct=j&q=ttts+ultrasound&source=images&cd=&cad=rja&docid=RLKvpKwLFRJTDM&tbnid=jrycGnI5XY88EM:&ved=0CAUQjRw&url=http://www.feldmanshepherd.com/5-results-23-Million-Settlement-in-Obstetrics-Radiology-Malpractice-Case.php&ei=sRqOUbHlA8zhtQa40ICgDA&psig=AFQjCNHVtoxuZG6RmWOP2NfCWugna_qXXg&ust=1368353707976680

http://www.google.co.il/url?sa=i&rct=j&q=ttts+ultrasound&source=images&cd=&cad=rja&docid=RLKvpKwLFRJTDM&tbnid=jrycGnI5XY88EM:&ved=0CAUQjRw&url=http://www.feldmanshepherd.com/5-results-23-Million-Settlement-in-Obstetrics-Radiology-Malpractice-Case.php&ei=sRqOUbHlA8zhtQa40ICgDA&psig=AFQjCNHVtoxuZG6RmWOP2NfCWugna_qXXg&ust=1368353707976680

Shunt(s)

Cardiac overload (r)

Polyhydramnios

[Hormonal output (r)]

Oligohydramnios (d)

Twin Oligo Polyhydramnios Sequence = TOPS

Shunt(s)

Cardiac overload (r)

Polyhydramnios

Hormonal output (r)

Oligohydramnios (d)

Twin Oligo Polyhydramnios Sequence = TOPS

Shunt(s)

Cardiac overload (r)

Polyhydramnios

Hormonal output (r)

Oligohydramnios (d)

Twin Poly Oligohydramnios Sequence = TPOS

TOPS

Crombleholme et al, 2009

Crombleholme et al, 2009

So what ?

Territoriality

http://www.google.co.il/url?sa=i&rct=j&q=ttts+ultrasound&source=images&cd=&cad=rja&docid=Pd3tJzoz_JEXWM&tbnid=3VpoEV0ovtdXtM:&ved=0CAUQjRw&url=http://www.sciencedirect.com/science/article/pii/S1744165X07000807&ei=oRuOUe3eGIeqtAay0oGgDA&psig=AFQjCNHVtoxuZG6RmWOP2NfCWugna_qXXg&ust=1368353707976680

IUGR in twins

Relative growth restriction

Absolute growth restriction

sIUGR in twins

Relative growth restriction

+ Absolute growth restriction

http://www.kanpai-japan.com/travel-guide/sumo-wrestling-tournament.html/attachment/sumo-tournament-8

http://www.kanpai-japan.com/travel-guide/sumo-wrestling-tournament.html/attachment/sumo-tournament-8

1540 g 450 g

Growth restricted MC twins

UA Doppler A/R

EDF

Good

I

-

Growth restricted MC twins

UA Doppler A/R

EDF

Good Bad

I II

- +

Growth restricted MC twins

UA Doppler A/R

EDF

Good Bad Intermittent

I II III

- + ±

So what

?

Prognosis for the co-twin following single-twin death in MC twins

Ong et al, BJOG 2006

Dead

12%Alive, Neuro

(+)

18%

Alive, Neuro

(-)

70%

In MC twins

Risk of sIUGR:

sIUFD

ISHII et al

Rescue anastomosis

http://www.google.co.il/url?sa=i&rct=j&q=pipelines&source=images&cd=&cad=rja&docid=wiikeeFod7vxgM&tbnid=-x9-xZZbbCh-qM:&ved=0CAUQjRw&url=http://www.123rf.com/photo_15175878_industrial-zone-steel-pipelines-and-cables-in-blue-tones.html&ei=6dORUejnC8nFtAbV8oGIBw&psig=AFQjCNFqHB6UcrQTPzYM7Wiw1Nn7fV6rFw&ust=1368597845235259

•Spontaneous in 5%

•Following incomplete laser Tx for

TTTS

Twin Anemia Polycythemia

Sequence Large Hb difference without TTTS

http://www.google.co.il/url?sa=i&rct=j&q=pipelines&source=images&cd=&cad=rja&docid=wiikeeFod7vxgM&tbnid=-x9-xZZbbCh-qM:&ved=0CAUQjRw&url=http://www.123rf.com/photo_15175878_industrial-zone-steel-pipelines-and-cables-in-blue-tones.html&ei=6dORUejnC8nFtAbV8oGIBw&psig=AFQjCNFqHB6UcrQTPzYM7Wiw1Nn7fV6rFw&ust=1368597845235259

Prenatal Dx of

TAPS

So what

?

http://www.google.co.il/url?sa=i&rct=j&q=discordant+twins&source=images&cd=&cad=rja&docid=Irkb75IOF9O9iM&tbnid=QUyhza3MzrCC_M:&ved=0CAUQjRw&url=http://en.wikipedia.org/wiki/Twin-to-twin_transfusion_syndrome&ei=eEaPUbuxM8X2sgbuzICoDA&psig=AFQjCNF4keHY3Mecjzxfzm7h7mIMm3XMzA&ust=1368430579832040

Severe anemia

Hyper-viscosity

Brain (other organs)

damage

MZ =

embryonic

accident

Pathogen

Zygotic splitting

Pathogen

Zygotic splitting

Malformations

Classification of malformations among

multiples

Isaac Blickstein,

1999

Category

1. Malformations more common in twins

than in singletons

Classification of malformations among multiples

Category

2. Malformations unique to MZs

Classification of malformations among multiples

Category

4. Deformation owing to intrauterine

crowding

Classification of malformations among multiples

http://www.google.co.il/url?sa=i&rct=j&q=dolichocephalic+dogs&source=images&cd=&cad=rja&docid=9efHMs0n87oNSM&tbnid=raynheTEMW3egM:&ved=0CAUQjRw&url=http://www.caninest.com/dog-head-face-terminology/&ei=XeqRUemFCofXtAbOu4DIBA&psig=AFQjCNE1B3maBmv2QqU4Ayc7QSqJAJyC_Q&ust=1368603603338602

http://www.google.co.il/url?sa=i&rct=j&q=brachycephalic dogs&source=images&cd=&cad=rja&docid=wpGejU_1XD5O1M&tbnid=-O0ybGK8ZKHNnM:&ved=0CAUQjRw&url=http://retrieverman.net/tag/brachycephalic-dogs/&ei=M-qRUYW1NomNtQaYnoDwBw&psig=AFQjCNFV20ndD06Fusz_AKs_s_izfrJ07w&ust=1368603517346000

http://www.google.co.il/url?sa=i&rct=j&q=animal+with+clubfoot&source=images&cd=&cad=rja&docid=R_BmpZGZkvwjMM&tbnid=J_HxiugK8G3PHM:&ved=0CAUQjRw&url=http://en.wikipedia.org/wiki/Club_foot&ei=N-uRUaKhLoOptAbSqYC4BQ&psig=AFQjCNH4-P8T2CpcJo4ywqWc_ueOR8VGrQ&ust=1368603746650039

Category

3. Placental malformations

Classification of malformations among multiples

Size

Discordant

AFI

Dopplers

Size

Hb

sIUGR

TTTS,

TOPS

TTTS,

sIUGR,

TAPS sIUGR

TAPS

Thank you