Short-term outcomes of fetoscopic laser surgery for severe twin–twin transfusion syndrome from Taiwan single center experience: Demonstration of learning curve effect on the fetal outcomes

AbstractObjectiveTo evaluate the learning curve effect on fetal outcomes while using fetoscopic laser photocoagulation (FLP) for twin–twin transfusion syndrome (TTTS) as managed by a newly established single center in Taiwan.Materials and MethodsBetween October 2005 and October 2010, women diagnosed to have TTTS before 26 weeks of gestation were offered FLP surgery. Cases were divided into first-half and second-half groups to evaluate the learning effect on fetal outcomes including at least one survival rate, two survival rate, and gestational age of delivery.ResultsA total of 44 cases with a median gestational age of 20.1 weeks (range 16–25) at operation were included in the study. Overall, both twins survived in 22 (50.0%) cases, whereas only one twin was born alive in 13 (29.5%), and neither was born alive in the remaining nine cases (20.5%). The total survival rate was 64.8%. When comparing the first-half 22 cases and the second-half 22 cases, there were significant improvements in total survival rate (54.7% vs. 75.0%, p = 0.045), a prolonged interval between operation and delivery (62.1 vs. 89.1 days, p = 0.042), and more advanced gestational age of delivery (28.3 vs. 33.0 weeks, p = 0.008) in the second-half 22 cases.ConclusionsWith increasing experience in using fetoscopic guide laser therapy for TTTS, the fetal survival rate could be improved with advanced gestational age at delivery

Maternal Complications and Perinatal Outcomes Associated with Gestational Hypertension and Severe Preeclampsia in Taiwanese Women

The role of proteinuria in disease severity of preeclampsia and gestational hypertension has not been determined. The objective of this study was to compare the effects of disease severity on maternal complications and pregnancy outcome between women with severe preeclampsia and women with gestational hypertension. Methods: A retrospective case-control study using daily records from the birth registry for the years 1994 to 2003 was conducted. Cases (n = 364) were defined as women with severe preeclampsia. Controls (n = 249) were selected from women with gestational hypertension. The outcome measures were maternal complications and perinatal-related factors. Results: Women with severe preeclampsia had an increased risk of intrauterine growth restriction (adjusted odds ratio [aOR], 2.16; 95% confidence interval [CI], 1.10-4.24; p = 0.026). Risk factors associated with severe preeclampsia patients were lack of prenatal care (aOR, 2.95; 95% CI, 1.45-5.99), systolic blood pressure ≥ 180 mmHg (aOR, 14.3; 95% CI, 1.69-121.0), and diastolic blood pressure ≥ 105 mmHg (aOR, 21.2; 95% CI, 6.99-64.3) compared with women with gestational hypertension in Model I. When we added proteinuria as a variable, two significant risk factors, diastolic blood pressure ≥ 105 mmHg (aOR, 18.2; 95% CI, 4.85-68.3) and significant proteinuria (aOR, 1.01; 95% CI, 1.006-1.014), were associated with severe preeclampsia patients in Model II. A subgroup of women with gestational hypertension and proteinuria had an increased risk of placental abruption (unadjusted OR, 4.36; 95% CI, 1.05-18.1) and disseminated intravascular coagulation (unadjusted OR, 6.46; 95% CI, 1.05-39.8). Finally, maternal complications (aOR, 2.59; 95% CI, 1.34-5.04) became the single significant factor associated with gestational hypertension and proteinuria. Conclusion: Proteinuria may play a role in the progression of gestational hypertension to severe forms of preeclampsia associated with subsequent maternal complications and extremely-low-birth-weight babies

Spontaneous Cessation of Communicating Flow in a Twin Reversed-arterial Perfusion with Large Acardiac Twin

We report a case of twin reversed-arterial perfusion diagnosed at the gestational age of 17 weeks. Though the acardiac/pump twin abdominal circumference ratio was 1.5, there was no critical Doppler finding of reverse A wave of ductus venosus, polyhydramnios or hydrops of the pump twin at the time of diagnosis, so the patient was regularly followed-up at clinic at 1-week intervals. Two weeks after the diagnosis, the patient requested surgical intervention because she was worried about the risk of heart failure in the pump twin. Fetoscopic guide laser coagulation of the communicating vessels was arranged. On the morning of the operation, cessation of the communicating flow was found, so the operation was cancelled. On the afternoon of the same day, amniocentesis was performed and the pump twin was found to have scalp edema. The patient was followed-up at clinic at 2-week intervals. A healthy female baby was born by vaginal delivery at the gestational age of 36 weeks

Predisposing factors and neonatal outcomes for twin-twin transfusion syndrome cases developing transient donor hydrops after fetoscopic laser coagulation: a case control study

Abstract Background Transient donor hydrops (TDH) is defined as donor hydrops developed within days after laser therapy for twin–twin transfusion syndrome (TTTS) followed by resolution later. The purpose of this study was to evaluate the incidence, neonatal outcomes and predisposing factors of post laser therapy TDH in severe TTTS. Methods A total of 142 patients with severe TTTS who received laser therapy were included into this study. The pre-operative characteristics and neonatal outcomes were compared between TTTS with and without post laser therapy TDH. All live neonates received cranial ultrasound examination after delivery, mild cerebral injury was defined as exhibiting at least one of the following: intraventricular hemorrhage (IVH) grade I and II, lenticulostriate vasculopathy and subependymal pseudocysts; severe cerebral injury comprised at least one among the following: IVH grade III or grade IV, cystic periventriculoleukomalacia (PVL) grade II or more, porencephalic cysts, and ventricular dilatation. Fetal survival was defined as living more than 30 days after delivery. Result

Preliminary report of altered insulin secretion pattern in monochorionic twin pregnancies complicated with selective intrauterine growth restriction

Objective: Fetuses with intrauterine growth restriction (IUGR) have adaptive hormonal changes including changes in insulin, which may increase their future risks for developing diabetes mellitus. This study compared cord blood insulin concentrations in IUGR and appropriate for gestational age (AGA) fetuses in a monochorionic (MC) twin model. Materials and methods: Ten pairs were classified as selective IUGR (sIUGR) based on having one twin weight below the 10th percentile and with an intertwin birth weight discordance>20%. Fourteen pairs without IUGR were included as a comparison group. Pregnancies with twin–twin transfusion syndrome, congenital structural malformations, and genetic abnormalities were excluded. Insulin and glucose concentrations were measured in cord venous blood at the time of delivery. Results: Cord blood insulin concentrations of sIUGR fetuses were significantly lower than those of AGA counterpart fetuses in MC twins affected by sIUGR (5.1±4.1 mU/L, range: 0.7–9.9 mU/L for sIUGR fetuses and 12.2±7.6 mU/L, range: 3.5–23.7 mU/L for AGA fetuses, p=0.019). No significant difference in insulin concentrations between larger and smaller fetuses in MC twins without IUGR was observed. Insulin concentration was inversely correlated with gestational age of delivery in all fetuses except in those with sIUGR. We did not find any difference in cord blood glucose concentrations between the two fetuses in both groups. Conclusion: Our data show reduced insulin secretion and loss of the physiological decline in concentration over time as gestational age increases in fetuses with sIUGR compared to AGA counterparts

Long-term outcome of pregnancy complicating with severe aplastic anemia under supportive care

Objectives: Pregnancy associated with aplastic anemia (AA) is a rare and heterogeneous disorder. We aimed to identify and evaluate the maternal and pregnant outcomes of pregnancy-associated severe AA treated with supportive care. Materials and methods: A 25-year retrospective study was conducted at in a single center between 1990 and 2014 with pregnancy associated severe AA. In addition, relevant published cases of antenatally diagnosed pregnancy-associated severe AA after 1990 were identified by PubMed. The main goal was to determine the impact of various risk factors on maternal and fetal outcomes. Results: 15 women with 18 pregnancies were enrolled. With addition of the published reports in literature, a total of 36 cases were included for reference review. Univariate analysis showed that low platelet counts (<2.0 × 109/L), bone marrow hypocellularity (<25%), and late diagnosis during pregnancy were predictors of poor maternal outcomes (P < 0.05). The complication rate of pregnancy outcomes was 53.3%, including preterm delivery, small gestational age (SGA), preterm premature ruptured of membranes (PPROM) and preeclampsia. Conclusions: This study identified the risk factors of mortality and morbidity in pregnant women with severe AA, as well as the obstetrical complications associated with neonatal outcome

Monozygotic twins discordant for trisomy 21: Discussion of etiological events involved

Objective: To elucidate the etiologies of discordant trisomy 21 in monozygotic twin pregnancy. Case report: A monochorionic diamniotic twin pregnancy with hydrops and cleft lip (twin 1) found in one fetus presented at gestational age of 17 weeks. Amniotic fluid karyotyping showed nonmosaic trisomy 21 in twin 1 (47, XY, +21 [20]) and a normal karyotype in twin 2 (46, XY [20]). Short tandem repeat (STR) polymorphism markers revealed that the two fetuses were monozygotic, and the two chromosomes 21 were maternal isodisomy in the trisomy fetus. The chromosomal constitution of placentas in the territory of trisomy 21 cotwin was 47, XY, +21 [20] and was a mosaic 47, XY+21 [12]/46, XY [8] in the normal karyotyped twin. Conclusion: Our case of monozygotic twin with discordant trisomy 21 might start with a prezygotic maternal meiosis II non-disjunction error-caused trisomy 21 zygote, and after twinning, one remained trisomy 21, and the other twin underwent trisomy rescue and became a mosaic trisomy 21 in morula or early blastocyst stage before the formation of pre-embryo, which subsequently resulted in mosaic trisomy 21 of the placental tissue and normal chromosomal constitution of the fetus