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Hemolytic Disease of the Fetus and Newborn
Published in Vincenzo Berghella, Maternal-Fetal Evidence Based Guidelines, 2022
Pedro Argoti, Ana M. Angarita, Giancarlo Mari
Exchange transfusion rather than the simple or “top off” transfusion is an alternative for intrauterine correction of fetal anemia and experience with this alternative therapeutic modality has been reported [120]. The hypothesized advantages include lower risk of hypervolemia and improvement of the efficacy of the transfusion by removal of incompatible fetal red blood cells. However retrospective studies have failed to support these anticipated benefits and/or increased risks [120]. Combination of IUT and partial exchange transfusion has been reported in the management of twin anemia polycythemia sequence (TAPS) [121].
Multiple gestation
Published in Hung N. Winn, Frank A. Chervenak, Roberto Romero, Clinical Maternal-Fetal Medicine Online, 2021
In the classic definition of TTTS (28), the twins are supposed to be discordant in size (at least 20–25%) and in hemoglobin levels (at least 5 g/dL). This concept changed over time, and at present, neither hemoglobin difference nor size discordance is part of the definition of TTTS. At times, however, a difference in hemoglobin is present—the so-called twin anemia-polycythemia sequence. The anemic twin can manifest all signs of anemia, especially by measuring the MCA-PSV. At birth, the donor is usually pale and anemic, whereas the recipient is polycythemic. The donor twin might be acutely distressed, with severe anemia and hypovolemic shock necessitating transfusion or exchange of blood products, or both. The recipient occasionally requires partial dilution exchange and support for cardiac failure.
Multiple pregnancy
Published in Louise C Kenny, Jenny E Myers, Obstetrics, 2017
One of the commonest and most serious complications of dichorionic diamniotic pregnancies is preterm delivery, either spontaneous or iatrogenic due to the occurrence of other adverse pregnancy complications such as pre-eclampsia or FGR (Figure 7.3). Overall, approximately 60% of twin pregnancies result in spontaneous birth before 37 weeks’ gestation. In a dichorionic pregnancy, the chance of late miscarriage is 2%. In 15% of cases, delivery will be very preterm. For monochorionic twins, the chance of preterm delivery is increased even further, with 12% born before viability and 25% delivering between 24 and 32 weeks. With two or more babies resulting from each delivery, multiple gestations account for 20–25% of Neonatal Intensive Care Unit (NICU) admissions. In addition to the other complications of twin pregnancy described above, monochorionic diamniotic pregnancies are also at risk of twin-to-twin transfusion syndrome (TTTS) and, more rarely, twin anaemia–polycythaemia sequence (TAPS).
Twin-twin transfusion syndrome in the era of fetoscopic laser surgery: antenatal management, neonatal outcome and beyond
Published in Expert Review of Hematology, 2020
Marjolijn S. Spruijt, Enrico Lopriore, Sylke J. Steggerda, Femke Slaghekke, Jeanine M.M. Van Klink
Placental injection studies have played an important role in the discovery of another form of intertwin transfusion in MC pregnancy termed twin anemia-polycythemia sequence (TAPS) [18]. Like TTTS, TAPS results from unbalanced blood flow through placental anastomoses. However, because TAPS is characterized by the presence of only very small anastomoses, transfusion in TAPS is much slower, allowing time for hemodynamic compensatory mechanisms to take effect and thus preventing the development of hypovolemia in the donor and hypervolemia in the recipient. Therefore, the essential difference between TTTS and TAPS is the absence of oligohydramnios/polyhydramnios in TAPS [19,20]. TAPS can be diagnosed antenatally by measurement of the middle cerebral artery peak systolic velocity (MCA-PSV) in both twins. In a recent study, it was shown that the difference in MCA-PSV between the donor and recipient is the most accurate predictor of postnatal TAPS with high sensitivity (83%) and specificity (100%). Based on these findings, a new antenatal classification system was proposed using a delta MCA-PSV of > 0.5 multiples of the median (MoM) as criterion for Stage 1 TAPS. Postnatally, TAPS is present when the intertwin hemoglobin difference is > 8 g/dL, combined with either a reticulocyte count ratio > 1.7 or the presence of only very small (< 1 mm) placental anastomoses [21]. TAPS can occur spontaneously (3-5% of MC pregnancies) or after laser for TTTS [22].
Acute twin-twin transfusion syndrome without labour
Published in Journal of Obstetrics and Gynaecology, 2019
The acute twin-twin transfusion syndrome (TTTS) was diagnosed according to the following criteria: (1) inter-twin haemoglobin difference >8.0 g/dL at birth; (2) normal reticulocyte counts; and (3) no signs of chronic TTTS or spontaneous twin anemia-polycythemia sequence (TAPS) (Lopriore and Oepkes 2008; Lopriore et al. 2014).
Fetal surgery: how recent technological advancements are extending its applications
Published in Expert Review of Medical Devices, 2019
The first example is the use of fetoscopy to map and guide the fulguration of placental anastomoses in twin-to-twin transfusion syndrome (TTTS) [2]. TTTS occurs in 10–20% of monochorionic pregnancies with the natural history showing a mortality rate of near 90%. In TTTS, abnormal vascular communications lead to an unbalanced blood flow from one twin (the donor) to the other twin (the recipient) [2]. This can cause anuria, oligohydramnios and poor fetal growth in the donor twin due to hypovolemia, as well as polyuria, polyhydramnios, heart failure, and hydrops in the recipient twin due to hypervolemia. Fetoscopic selective laser coagulation (FSLC) of the placental anastomoses has become the standard-of-care treatment in severe TTTS [2]. Essentially, a 1-3 mm endoscope is introduced into the polyhydramniotic sac of the recipient twin and a laser fiber is used to cauterize the placental anastomoses. Originally, the photocoagulation of the anastomoses was done in a non-selective laser ablation of placental anastomoses, meaning that all vessels crossing the intertwin membranes were targeted by the laser [3]. However, research indicated that non-selective photocoagulation of placental anastomoses was associated with higher frequency of donor twin demise [3]. Therefore, a selective laser ablation was developed that endoscopically identifies all anastomoses and occludes only such connections avoiding ablating important vessels to the twins that are not causing TTTS. Residual anastomosis leading to twin anemia polycythemia sequence (TAPS) and recurrent TTTS were found to be an issue with this technique in up to 33% of cases. In order to minimize the risk of residual anastomoses that are invisible to the naked eye, the Solomon technique was introduced. After selectively ablating the anastomoses, we ablate the area between the anastomoses making a line on the placental vascular equator, with the objective of occluding small anastomoses that are usually not seen through fetoscope. The Solomon technique is different than the non-selective technique initially described since we follow the placental vascular equator where the anastomoses are really located, preserving important vessels to both twins. Solomonization not only coagulates all identified anastomotic vessels, but it also creates a continuous line of coagulation on the chorionic plate [3]. Recent studies demonstrated that this approach significantly reduces the incidence of TAPS and recurrent TTTS in comparison to the selective laser method and may improve survival and neonatal outcome [3]. Fortunately, because of the technological advancements, outcomes for fetoscopic laser surgery have significantly improved over the past 25 years, with up to 70% overall double survival and >80% single survival rates [1]. Flexible mini-telescopes have recently been applied to allow for better visualization of the vascular equator in anterior placentas, especially in cases where anastomoses are close to the insertion site of the fetoscope [3].