Granja, C

Martins, C

Miranda, M

Santos, AV

BMJ Case Reports

PubMed

Repositório do Hospital Prof. Doutor Fernando Fonseca

Twin reversed arterial perfusion (TRAP) sequence:an acardiac fetusCátia Filipa Martins,1 Ana Vanessa Santos,2 Mariana Miranda,2 Carla Granja11Department of Gynecology-Obstetrics, Centro Hospitalardo Algarve, Portimão, Portugal2Hospital Fernando Fonseca,Amadora, PortugalCorrespondence toDr Cátia Filipa Martins,paixaocatia@gmail.comAccepted 23 October 2014To cite: Martins CF,Santos AV, Miranda M, et al.BMJ Case Rep Publishedonline: [please include DayMonth Year] doi:10.1136/bcr-2014-207688DESCRIPTIONA 32-year-old primigravida referred at 22 weekswith contractions. Ultrasound examination showeda 20 mm cervix and a monochorionic diamnioticpregnancy with one structurally normal fetus withhydramnios and a second twin anencephalic andacardiac (ﬁgure 1 and video 1). The patient wasadmitted with the diagnosis of twin reversed arter-ial perfusion (TRAP) and submitted to amnioreduc-tion. A normal 46 XX cariotype was obtained.Owing to worsening of hydramnios and aftercounselling, the patient was sent to Hospital Clinicin Barcelona where a successful cord occlusion andlaser ablation of the vascular anastomoses was per-formed at 25 weeks. Two weeks later, she wasreadmitted with premature rupture of membranesand delivered by C-section at 28 weeks due tosevere oligohydramnios. A normal live fetus weigh-ing 1005 g (ﬁgure 2) and a 135 g acardiac acepha-lus twin were born (ﬁgure 3). The autopsyconﬁrmed an acardiac twin with no fetal thoracicorgans and absent head, a rudimentary bowel anddeformed lower extremities (ﬁgures 4 and 5). Thesurvival twin remained in the neonatal care unitdue to prematurity-related complications and wasdischarged at 53 days of life.TRAP is a unique complication of monochorio-nic twin pregnancy, in which a twin with an absentheart (‘acardiac twin’) is perfused by its co-twin(‘pump twin’) via placental arterial anastomoses.1Figure 1 Acardiac fetus diagnosed during ultrasoundexamination.Video 1 Acardiac fetus diagnosed during ultrasoundexam.Figure 2 Normal female fetus in intensive care unit.Figure 3 Abnormal fetus—delivered acardiac mass.Martins CF, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2014-207688 1Images in…Prenatal diagnosis is suspected on ﬁrst trimester ultrasound,when one fetus appears anatomically normal and the other lacksapparent cardiac structures. Deﬁnitive diagnosis is made whenpulsatile ﬂow is seen in the umbilical artery going towards theacardius.2 Fetuses with signs of high-output cardiac failure havepoor prognosis and are candidates for intervention such astarget occlusion of the umbilical cord of the acardiac twin,including laser ablation, bipolar cord coagulation or radiofre-quency ablation.3Learning points▸ A twin reversed arterial perfusion (TRAP) sequence is rareand occurs in about 1% of monochorionic twin pregnanciesand 1 in 35 000 deliveries.▸ TRAP should be suspected in monochorionic twinpregnancies when one fetus appears anatomically normaland the other lacks apparent cardiac structures.▸ The pump twin is at risk of heart failure and problemsrelated to preterm birth, with a perinatal mortality rate ofabout 55% without treatment.▸ Surveillance includes weekly ultrasound surveillance to lookfor the development of fetal hydrops. Fetuses between 18and 27 weeks of gestation with signs indicative of a poorprognosis are candidates for intervention.▸ Continuing pregnancies should be delivered at 34–36 weeksof gestation.Competing interests None.Patient consent None.Provenance and peer review Not commissioned; externally peer reviewed.REFERENCES1 Gillim DL, Hendricks CH. Holoacardius; review of the literature and case report.Obstet Gynecol 1953;2:647.2 Bornstein E, Monteagudo A, Dong R, et al. Detection of twin reversed arterialperfusion sequence at the time of ﬁrst-trimester screening: the added value of3-dimensional volume and color Doppler sonography. J Ultrasound Med2008;27:1105.3 Ville Y, Hyett JA, Vandenbussche FP, et al. Endoscopic laser coagulation of umbilicalcord vessels in twin reversed arterial perfusion sequence. Ultrasound Obstet Gynecol1994;4:396.Figure 4 X-ray of acardiac mass.Figure 5 Anatomopathological examination of the acardiac fetus.Copyright 2014 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visithttp://group.bmj.com/group/rights-licensing/permissions.BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission.Become a Fellow of BMJ Case Reports today and you can:▸ Submit as many cases as you like▸ Enjoy fast sympathetic peer review and rapid publication of accepted articles▸ Access all the published articles▸ Re-use any of the published material for personal use and teaching without further permissionFor information on Institutional Fellowships contact consortiasales@bmjgroup.comVisit casereports.bmj.com for more articles like this and to become a Fellow2 Martins CF, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2014-207688Images in…

Twin reversed arterial perfusion (TRAP) sequence: an acardiac fetus.

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Twin reversed arterial perfusion (TRAP) sequence: an acardiac fetus.

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