Monochorionic Twins: A Delicate Balance.

Monochorionic (MC) twins are identical twins who share one placenta, with vascular anastomoses connecting the circulations of both fetuses [...]

Bloedbroeders

Oratie uitgesproken door Prof.dr. E. Lopriore bij de aanvaarding van het ambt van hoogleraar in de Kindergeneeskunde, in het bijzonder Neonatologie en Foetale Geneeskunde aan de Universiteit Leiden op vrijdag 23 juni 2017Oratie uitgesproken door Prof.dr. E. Lopriore bij de aanvaarding van het ambt van hoogleraar in de Kindergeneeskunde, in het bijzonder Neonatologie en Foetale Geneeskunde aan de Universiteit Leiden op vrijdag 23 juni 2017LUMC / Geneeskunde Repositoriu

Twin-to-twin transfusion syndrome : from placental anastomoses to long term outcome

Twin-to-twin transfusion syndrome (TTTS) is a severe complication of monochorionic twin pregnancies associated with high perinatal mortality and morbidity rates. Placental vascular anastomoses, almost invariably present in monochorionic placentas, are the essential anatomical substrate for the development of TTTS. TTTS is thought to result from unbalanced inter-twin blood flow between the donor twin and the recipient twin through the vascular anastomoses, leading to hypovolemia and oligohydramnios in the donor and hypervolemia and polyhydramnios in the recipient. Despite significant developments in the diagnosis, staging and management of TTTS, the pathogenesis of TTTS is still poorly understood and, most importantly, perinatal mortality and morbidity in TTTS remain strikingly high. In this thesis, several studies on TTTS are presented regarding various aspects of this disease, including studies on monochorionic placentas to investigate the pathogenesis of TTTS, description of a new form of chronic TTTS and the short and long-term outcome in TTTS treated with fetoscopic laser surgery. In Chapter 2, an overview of the literature is presented. This review analyzes the possible pathophysiologic mechanisms involved, discusses the latest findings in diagnosis, therapy and prognosis, and focuses on neonatal and pediatric morbidity associated with TTTS. In Chapter 3 we describe a novel technique to calculate the net feto-fetal blood flow through placental arterio-venous anastomoses in a case of TTTS treated with laser surgery and subsequent intrauterine transfusion. In this study we determined that the net blood flow through the five unidirectional arterio-venous anastomoses was approximately 28 ml/24h, much lower than previously measured with Doppler ultrasound. This finding may also explain the inaccuracy of Doppler flow measurements, as such low flow velocities cannot possibly be detected with current Doppler techniques. Measurements of anastomotic blood flow are of major importance for the validation and development of accurate computer modeling in TTTS. In Chapter 4 we studied the role of velamentous cord insertion and discordant placental sharing in the pathogenesis of TTTS by comparing monochorionic placentas with and without TTTS. Previously, several studies reported an increased incidence of velamentous cord insertions in TTTS placentas and suggested a direct relation between velamentous cord insertion, unequal placental sharing and the development of TTTS. In this study we examined 76 monochorionic placentas with TTTS and 63 monochorionic placentas without TTTS. The incidence of velamentous cord insertion (per fetus) in the TTTS group and the no-TTTS group was 13% and 14% (p = 0.79), respectively. Placental sharing discordance in the TTTS group and the no-TTTS group was 20% in both groups (p = 0.83). In the TTTS group, donor twins had more often a velamentous cord insertion than recipient twins (24% and 3%, respectively, P 5 g/dL) were found in 65% (11/17) of cases with residual anastomoses and 20% (7/35) of cases without residual anastomoses (p LEI Universiteit LeidenKarl Storz BV, Stichting FEMAR, Viasys BV, Nycomed BVFoetale geneeskunde, in het bijzonder reproductieve immunologi

Neonatal outcome in twin-to-twin transfusion syndrome not treated with fetoscopic laser surgery

The aim of this study was to describe the neonatal management and outcome in monochorionic twins with twin-to-twin transfusion syndrome (TTTS) not treated with fetoscopic laser surgery. All consecutive live-born neonates with TTTS managed at our center between 2002 and 2021 were included in this retrospective study. Neonatal outcome was assessed in 44 twin pairs with TTTS not treated with laser (nonlaser group) compared to a control group of 88 twin pairs with TTTS successfully treated with laser (laser group), matched for gestational age at birth. Primary outcome was adverse neonatal outcome, a composite outcome including neonatal mortality or severe neonatal morbidity. The incidence of adverse neonatal outcome in the nonlaser group and laser group was 30% (26/88) and 11% (19/176), respectively (relative risk = 3.46, 95% CI [1.79, 6.71]). In the nonlaser group, 11% had necrotizing enterocolitis (vs. 2% in the laser group) and 24% had hypotension (vs. 10% in the laser group). Recipients in the nonlaser group had, compared to recipients in the laser group, significantly more severe cerebral injury (18% vs. 5%) and more polycythemia at birth (21% vs. 1%). Donors in the nonlaser group had, compared to donors in the laser group, more severe growth restriction (71% vs 42%), renal failure (11% vs 1%), and anemia at birth (25% vs. 7%). Thus, the risk for neonatal mortality and/or severe morbidity is three-fold higher in TTTS not treated with laser than in TTTS treated with laser, which highlights the fact that these neonates with TTTS are very sick at birth, requiring accurate and prompt intensive treatment.Research into fetal development and medicin

Fetal and neonatal alloimmune thrombocytopenia: evidence based antenatal and postnatal management strategies

INTRODUCTION:Fetal and neonatal alloimmune thrombocytopenia (FNAIT) is a relatively rare but potentially lethal disease, leading to severe bleeding complications in 1 in 11.000 newborns. It is the leading cause of thrombocytopenia in healthy term-born neonates. Areas covered: This review summarizes the antenatal as well as postnatal treatment, thus creating a complete overview of all possible management strategies for FNAIT. Expert commentary: The optimal antenatal therapy in order to prevent bleeding complications in pregnancies complicated by FNAIT is non-invasive treatment with weekly intravenous immunoglobulin (IVIG). Based on risk stratification, weekly doses of IVIG of 0.5 or 1.0g/kg should be administered started early in the second in high risk cases or at the end of the second trimester in low risk cases. The optimal postnatal treatment depends on the platelet count and the clinical condition of the newborn. Prompt administration of compatible platelet transfusion is the first treatment of choice in case of severe thrombocytopenia or active bleeding. In case matched platelets are not directly available, random platelets can also be administered initially to gain time until matched platelets are available. In case of persistent thrombocytopenia despite transfusions, IVIG 1.0-2.0g/kg can be administered.Research into fetal development and medicin

Does Parenteral Nutrition Influence Electrolyte and Fluid Balance in Preterm Infants in the First Days after Birth?

New national guidelines recommend more restricted fluid intake and early initiation of total parenteral nutrition (TPN) in very preterm infants. The aim was study the effect of these guidelines on serum sodium and potassium levels and fluid balance in the first three days after birth.Two cohorts of infants <28 weeks gestational age, born at the Leiden University Medical Center in the Netherlands, were compared retrospectively before (2002–2004, late-TPN) and after (2006–2007, early-TPN) introduction of the new Dutch guideline. Outcome measures were serum sodium and potassium levels, diuresis, and changes in body weight in the first three postnatal days.In the first three postnatal days no differences between late-TPN (N = 70) and early-TPN cohort (N = 73) in mean (SD) serum sodium (141.1 (3.8) vs 141.0 (3.7) mmol/l) or potassium (4.3 (0.5) vs 4.3 (0.5) mmol/l) were found, but in the early-TPN cohort diuresis (4.5 (1.6) vs 3.2 (1.4) ml/kg/h) and loss of body weight were decreased (−6.0% (7.7) vs −0.8% (8.0)).Initiation of TPN immediately after birth and restricted fluid intake in very preterm infants do not seem to influence serum sodium and potassium levels in first three postnatal days. Further research is needed to see if a decreased diuresis and loss of body weight in the first days is the result of a delayed postnatal adaptation or better energy balance

Fetal anemia in monochorionic twins: a review on diagnosis, management, and outcome

Introduction: Monochorionic twins may develop fetal anemia when blood is unequally distributed via the placental vascular anastomoses. This review focuses on the causes of fetal anemia in complicated monochorionic twins and highlights the differences in management and outcome. Areas: coveredFetal anemia can occur in the context of twin anemia polycythemia sequence (TAPS), chronic twin-twin transfusion syndrome (TTTS) and acute peripartum TTTS, and in cotwins after single fetal demise. Diagnosis of fetal anemia is based on abnormal Doppler ultrasound measurements. Management options include fetoscopic laser surgery, intrauterine blood transfusion, or expectant management, depending on the type of complication and the severity of the disease. In all complications, fetal anemia may lead to perinatal mortality, neonatal morbidity, severe cerebral injury, and long-term neurodevelopmental impairment. In TAPS specifically, anemic donors may also show bilateral deafness.Expert opinion: Knowledge on the diagnosis and optimal treatment in TTTS is nowadays widespread, but caregivers often fail to distinguish TAPS from acute peripartum TTTS at birth. A full blood count including reticulocyte count is required, and placental dye injection is extremely helpful to reach the correct diagnosis and establish the optimal management.</p

Call to action: long-term neurodevelopment in monochorionic twins.

Developmen

Intrauterine transfusion and non-invasive treatment options for hemolytic disease of the fetus and newborn - review on current management and outcome

Research into fetal development and medicin

Hypothermia during umbilical catheterization in preterm infants

Objective: To describe the effect of umbilical catheterization (UC) on skin temperature and cardiorespiratory status in preterm infants.Materials and methods: In a prospective observational study of infants <32 weeks of gestation, the duration of UC, course of skin temperature, and cardiorespiratory status were registered. Hypothermia was defined as a temperature below 36.5C.Results: UC was performed in 55 infants with a median (range) gestational age of 28 weeks (24-31) and birth weight of 1120g (625-2091). Mean (SD) temperature first decreased 0.6 (0.6)degrees C during UC followed by a rise of 0.4 (0.4)degrees C after reaching the minimal temperature. Hypothermia already existed in 69% (38/55) of the infants before start of UC, which increased to 89% (49/55) during UC (p = .001). Duration of UC was not associated with the development of hypothermia during the procedure (p = .48). Heart rate (mean(SD)) significantly increased (162 (17) versus 152 (15); p <.001) and there was a trend toward an increase in supplemental oxygen (mean(SD)) (0.31 (0.17) versus 0.28 (0.13); p = .78), but both changes were only temporary.Conclusion: Hypothermia was frequent in preterm infants before start of UC and increased during UC. Postponing UC until the infant has a normal temperature should be considered.Developmen