With the studies described in this thesis, we were able to investigate cardiovascular compromise in complicated monochorionic twin pregnancy in great detail.All clinicians caring for monochorionic... Show moreWith the studies described in this thesis, we were able to investigate cardiovascular compromise in complicated monochorionic twin pregnancy in great detail.All clinicians caring for monochorionic twins should perform an echocardiogram at mid‑gestation and should carefully examine both neonates at birth. In case of abnormal perioperative fetal Dopplers in twin-twin transfusion syndrome (TTTS), we should be aware of the increased risk of fetal demise or neurodevelopmental impairment. In all surviving TTTS twins, but also in twin pregnancies with selective fetal growth restriction, cardiac abnormalities should be ruled out by follow-up fetal and neonatal echocardiography. Routine long‑term follow-up should be available to all TTTS twins, since TTTS may also have an impact beyond the perinatal phase.Furthermore, both color‑coded Tissue Doppler Imaging (cTDI) and myocardial performance index (MPI) are potentially valuable techniques which can be used in the risk stratification in monochorionic twins. Show less
Monochorionc twin pregnancies carry a high risk for adverse pregnancy outcome. The unique placenta angioarchitecture in monochorionic twin pregnancies might cause specific complications such as... Show moreMonochorionc twin pregnancies carry a high risk for adverse pregnancy outcome. The unique placenta angioarchitecture in monochorionic twin pregnancies might cause specific complications such as twin-to-twin transfusion syndrome (TTTS) and selective intrauterine growth restriction (sIUGR). The hemodynamic challenges in these complications require specific adaptation of the fetal heart. Subsequently, a higher risk for fetal demise and acquired cardiac abnormalities is present in these cases.In part one of this thesis we focused on the risk for fetal demise. We investigated possible predictors for fetal demise after laser therapy for TTTS, and found that abnormal Doppler profiles and the presence and absence of certain anastomoses are associated with this complication. Beside this, we investigated the possible relation between proximate cord insertion and fetal deterioration.In part two we investigated possible predictors for the development of right ventricular outflow tract obstruction (RVOTO), and found that an early gestational age at onset of TTTS and cardiac dysfunction are associated with this complication. We described that postnatal RVOTO is not only found in recipients, but also in donors and sIUGR cases. We described the spectrum of prenatal RVOTO in relation to postnatal RVOTO. Lastly we introduced a new modality to detect fetal cardiac dysfunction. Show less
Introduction:Invasive fetal cardiac intervention (FCI) for pulmonary atresia with intact ventricular septum (PAIVS) and critical pulmonary stenosis (PS) has been performed with small single... Show moreIntroduction:Invasive fetal cardiac intervention (FCI) for pulmonary atresia with intact ventricular septum (PAIVS) and critical pulmonary stenosis (PS) has been performed with small single-institution series reporting technical and physiological success. We present the first multicenter experience.Objectives:Describe fetal and maternal characteristics of those being evaluated for FCI, including pregnancy/neonatal outcome data using the International Fetal Cardiac Intervention Registry (IFCIR).Methods:We queried the IFCIR for PAIVS/PS cases evaluated from January 2001 to April 2018 and reviewed maternal/fetal characteristics, procedural details, pregnancy and neonatal outcomes. Data were analyzed using standard descriptive statistics.Results:Of the 84 maternal/fetal dyads in the registry, 58 underwent pulmonary valvuloplasty at a median gestational age of 26.1 (21.9-31.0) weeks. Characteristics of fetuses undergoing FCI varied in terms of tricuspid valve (TV) size, TV regurgitation, and pulmonary valve patency. There were fetal complications in 55% of cases, including 7 deaths and 2 delayed fetal losses. Among those who underwent successful FCI, the absolute measurement of the TV increased by 0.32 (+/- 0.17) mm/week from intervention to birth. Among 60 liveborn with known outcome, there was a higher percentage having a biventricular circulation following successful FCI (87 vs. 43%).Conclusions:Our data suggest a possible benefit to fetal therapy for PAIVS/PS, though rates of technically unsuccessful procedures and procedure-related complications, including fetal loss were substantial. FCI criteria are extremely variable, making direct comparison to nonintervention patients challenging and potentially biased. More uniform FCI criteria for fetuses with PAIVS/PS are needed to avoid unnecessary procedures, expose only fetuses most likely to sustain a benefit, and to enable comparisons to be made with nonintervention patients. Show less
