management of selective iugr in monochorionic...
TRANSCRIPT
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Eduard Gratacos
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MANAGEMENT OF SELECTIVE IUGR IN MONOCHORIONIC TWINS
BCNatal – Barcelona Center of Maternal-Fetal and Neonatal Medicine!Hospital Clinic and Hospital Sant Joan de Déu, University of Barcelona!
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1. Diagnosis and types!!2. Expectant vs active management!
3. Technical aspects!
4. Conclusions
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1. Diagnosis and types!!2. Expectant vs active management!
3. Technical aspects!
4. Conclusions
http://www.fetalmedicinebarcelona.org
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Chronic unbalanced transfusion !• Twin-twin transfusion syndrome (TTTS)• Twin anemia polycytemia syndrome (TAPS)
COMPLICATIONS OF MONOCHORIONIC PREGNANCY
Discordant placental territories!• selective IUGR
Unidirectional acute transfusion!• Single fetal demise• Sustained bradichardia in one fetus
High!risk
High risk
Discordant Malformation
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selective IUGR (sIUGR) • EFW < P10 in one fetus • ≈10 % of MC
Unequal placental sharing+ placental anastomoses
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MC twins: apparent discrepancy in AF and/or fetal size
Algorithm for differential diagnosis
AF: > 8 cm (> 10 cm) / < 2cm!Clearly discordant bladders
EFW 1.5 /
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Latency
Survival IUGR
Hemodynamic accidents
GA@delivery
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Very long Short Very long!but unstable
OR AND AND
Very high Low High
Very low Very low!Only if IUFD High
High (>34) Low (34)
Unequal placental sharing+ placental anastomoses
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MC + sIUGR (EFW
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MC + sIUGR (EFW
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1. Diagnosis and types!!2. Expectant vs active management!
3. Technical aspects!
4. Conclusions
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Expectant!(n=138)
Laser!(n=50)
Cord Occlusion!(n=98)
GA@delivery 29-32 32-35 33-37
Survival! ! AGA! ! IUGR
!70-85 %!40-85 %
!70-90 %!30-40 %
!>90 %!
0 %
Sequelae (*) !! AGA! ! IUGR
!15-35%!25-50%
!
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Severity !Cord Occlusion!
Laser!Expectant!
Severe early discordance!Pronounced REDF
Moderate discordance!Telediastolic AEDF
Parents’ wishes
Technical aspects
sIUGR is not a unique disease as TTTS!FACTORS INFLUENCING MANAGEMENT STRATEGY
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Feasible 90%!More difficult than TTTS!• NO polihydramnios (amnioinfusion/
drainage required)!• equator often in smaller sac!• type and size of anastomoses
LASER THERAPY IN sIUGR
Quintero, Gratacos, Chaloui
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Fetal Diagn Ther 2014www.fetalmedicinebarcelona.org/
Type I!UA N
II!AREDV
III!iAREDV
Subtype a!DV N
b!DV pat
a!AEDV
b!AREDV, Disc>30%,
DVpatol
Follow up 2w 1w 1w 1w 1w
Attitude Expectant Discuss expectantDiscuss therapy
Discuss expectant
Discuss therapy
Consider delivery !
(if not treated)34-35w 32w
30w DV>95!>26w if DV atrial flow neg
33-34w30w DV>95!>26w if DV atrial flow neg
sIUGR in MC pregnancy Tentative management scheme
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Poor prognosis: high risk of IUFD and neurological damage for both twins
Normally good prognosis
TYPE II TYPE IIITYPE I
EXPECTANT CORD OCCLUSION LASER
MODULATORS!• Severity!• Parents’ wishes!• Technical aspects
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1. Clinical forms!!2. Expectant vs active management!
3. Technical aspects!
4. Conclusions
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III: iAREDF
II: AREDF 1. Adequate diagnosis.!
2. UA Doppler.!
3. Abnormal Doppler has poor prognosis.!
4. Active management protects normal fetus but worsens that of IUGR.!
5. Final decision: balance between severity + parents’ wishes (+ rarely technical issues).!
6. A randomized trial in homogeneous groups is difficult due to clinical variability.
Conclusions!Management of sIUGR in MC twins
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