We report a case of a monochorionic diamniotic twin diagnosed with twin-twin transfusion syndrome (TTTS; stage 3) with co-existing severe cerebral damage in the donor twin at 18 + 4 weeks'... Show moreWe report a case of a monochorionic diamniotic twin diagnosed with twin-twin transfusion syndrome (TTTS; stage 3) with co-existing severe cerebral damage in the donor twin at 18 + 4 weeks' gestation. After counselling, the parents opted for selective foeticide of the donor twin. For the procedure, radiofrequency ablation (RFA) was used. Serial ultrasound examinations at 20 + 1 and 21 + 1 weeks' gestation showed good recovery of the ex-recipient, after which the patient was sent back to the referring hospital. At 29 + 5 weeks' gestation, an unexpected foetal death was diagnosed. On macroscopic placental examination, (iatrogenic) monoamnionicity was detected. In addition, the umbilical cord of the recipient was found to be constricted by the macerated umbilical cord of the ex-donor. This case demonstrates that iatrogenic monoamnionicity can be a serious complication of RFA in monochorionic twins complicated by TTTS, with a subsequent risk for cord entanglement leading to a fatal outcome for the remaining co-twin. Although the actual incidence of iatrogenic monoamnionicity after RFA remains unknown, increased attention to the intactness of the inter-twin membrane even weeks after the RFA may be required. Show less
We report a case of a monochorionic diamniotic twin diagnosed with twin-twin transfusion syndrome (TTTS; stage 3) with co-existing severe cerebral damage in the donor twin at 18 + 4 weeks'... Show moreWe report a case of a monochorionic diamniotic twin diagnosed with twin-twin transfusion syndrome (TTTS; stage 3) with co-existing severe cerebral damage in the donor twin at 18 + 4 weeks' gestation. After counselling, the parents opted for selective foeticide of the donor twin. For the procedure, radiofrequency ablation (RFA) was used. Serial ultrasound examinations at 20 + 1 and 21 + 1 weeks' gestation showed good recovery of the ex-recipient, after which the patient was sent back to the referring hospital. At 29 + 5 weeks' gestation, an unexpected foetal death was diagnosed. On macroscopic placental examination, (iatrogenic) monoamnionicity was detected. In addition, the umbilical cord of the recipient was found to be constricted by the macerated umbilical cord of the ex-donor. This case demonstrates that iatrogenic monoamnionicity can be a serious complication of RFA in monochorionic twins complicated by TTTS, with a subsequent risk for cord entanglement leading to a fatal outcome for the remaining co-twin. Although the actual incidence of iatrogenic monoamnionicity after RFA remains unknown, increased attention to the intactness of the inter-twin membrane even weeks after the RFA may be required. Show less
OBJECTIVE:To investigate the predictive value of delta middle cerebral artery - peak systolic velocity (MCA-PSV) > 0.5 multiples of the median (MoM) compared to cut-off MCA-PSV values (>1.5... Show moreOBJECTIVE:To investigate the predictive value of delta middle cerebral artery - peak systolic velocity (MCA-PSV) > 0.5 multiples of the median (MoM) compared to cut-off MCA-PSV values (>1.5 MoM in the donor, < 1.0 MoM in the recipient) for the diagnosis of twin anemia polycythemia sequence (TAPS).METHODS:Retrospective consecutive cohort study comprising consecutive uncomplicated monochorionic twins and twins with postnatal TAPS between 2003 and 2017 in the Dutch national referral center for fetal therapy. We compared the accuracy to predict postnatal TAPS between the current method using the specific MCA-PSV cut-off values (>1.5 MoM in the donor and <1.0 in the recipient) and a new method using a delta MCA-PSV > 0.5 MoM.RESULTS:In total, 45 uncomplicated monochorionic and 35 TAPS twins were analyzed. The sensitivity and specificity of the cut-off MCA-PSV values (>1.5 MoM, <1.0 MoM) to predict postnatal TAPS was 46% (95%CI 30-62%) and 100% (95%CI 92-100%), respectively; positive predictive value was 100% (95%CI 81-100%) and negative predictive value 70% (95%CI 58-80%). Delta MCA-PSV showed a sensitivity of 83% (95%CI 67-92%) and a specificity of 100% (95%CI 92-100%); the positive predictive value and negative predictive value were 100% (95%CI 88-100%) and 88% (95%CI 77-94%), respectively. Out of the 35 cases with postnatal TAPS, 13 twin pairs showed a delta MCA-PSV > 0.5 MoM, but did not reach both the cut-off MCA-PSV levels (>1.5 MoM, <1.0 MoM). Out of these 13 TAPS twins, 9 donors and 4 recipients had normal MCA-PSV values. There was a high correlation between delta MCA-PSV and inter-twin hemoglobin difference (R= 0.725, p < 0.01).CONCLUSION:Delta MCA-PSV > 0.5 MoM has a higher diagnostic accuracy for predicting TAPS compared to the currently used MCA-PSV cut-off values. We therefore propose a new antenatal classification system. In case of a delta MCA-PSV > 0.5 MoM on Doppler ultrasound, but with normal MCA-PSV values in donor or recipient, obstetricians should be aware of the therapeutic implications and neonatal morbidities associated with TAPS. This article is protected by copyright. All rights reserved. Show less
Akkermans, J.; Donk, L. van der; Peeters, S.H.P.; Tuijl, S. van; Middeldorp, J.M.; Lopriore, E.; Oepkes, D. 2017
