Frank P.H.A. Vandenbussche

The pregnancy and long-term neurodevelopmental outcome of monochorionic diamniotic twin gestations: a multicenter prospective cohort study from the first trimester onward

OBJECTIVES We sought to document the pregnancy and neurodevelopmental outcome in monochorionic diamniotic twin pregnancies and to identify risk factors for death and impairment. STUDY DESIGN We conducted a prospective cohort study of 136 monochorionic twins followed up from the first trimester until infancy. RESULTS A total of 122 (90%) pregnancies resulted in 2 survivors, 6 (4%) in 1 survivor and 8 (6%) in no survivor. In all, 230 (92%) of 250 surviving infants were assessed at a mean age of 24 months. Neurodevelopmental impairment was present in 22 (10%) infants. Death or impairment of 1 or both infants occurred in 28 (22%) of 126 pregnancies. Twin-to-twin transfusion syndrome and assisted conception increased the risk of both death and impairment, whereas early-onset discordant growth only increased the risk of death. CONCLUSION The mortality in this prospective series was 8% and neurodevelopmental impairment occurred in 10% of infants.

Long-term outcome after fetal transfusion for hydrops associated with parvovirus B19 infection.

OBJECTIVE: To evaluate neurodevelopmental status of children treated with intrauterine red blood cell and platelet transfusion for fetal hydrops caused by parvovirus B19. METHODS: Maternal and neonatal records of all intrauterine transfusions for congenital parvovirus B19 infection in our center between 1997 and 2005 were reviewed. Congenital B19 virus infection was confirmed by the presence of parvovirus B19–specific immunoglobulin M or parvovirus B19 DNA in fetal blood samples. All children underwent a general pediatric and neurological examination. Primary outcome measure was neurodevelopmental status (developmental index by Bayley Scales of Infant Development or Snijders-Oomen test). Secondary outcome measure was general health status of surviving children. RESULTS: A total of 25 intrauterine transfusions were performed in 24 hydropic fetuses. Median fetal hemoglobin concentration, platelet count, and blood pH before intrauterine transfusions were 4.5 g/dL (range 2.4–11.4 g/dL), 79×109/L (range 37–238×109/L) and 7.36 (range 7.31–7.51), respectively. Sixteen survivors aged 6 months to 8 years were included in the follow-up study. Eleven children (68%) were normal, and 5 children (32%) demonstrated a delayed psychomotor development with an suboptimal neurological examination (mild delay n=3, severe delay n=2). Neurodevelopmental status did not correlate with pre-intrauterine transfusion hemoglobin, platelet, or blood pH values. Growth and general health status were normal in all. Two children had minor congenital defects. CONCLUSION: Neurodevelopmental status was abnormal in 5 of 16 survivors and was not related to the severity of fetal anemia and acidemia. We hypothesize that fetal parvovirus B19 infection may induce central nervous system damage. LEVEL OF EVIDENCE: III

Risk Factors for Neurodevelopment Impairment in Twin-Twin Transfusion Syndrome Treated With Fetoscopic Laser Surgery

OBJECTIVE: To estimate the risk factors for adverse long-term neurodevelopment outcome in twin–twin transfusion syndrome treated with laser surgery. METHODS: Twin–twin transfusion syndrome cases treated with laser surgery at three European centers from August 2000 to December 2005 were included in this case-control study. Neurological, mental, and psychomotor development (using the Bayley Scales of Infant Development, 2nd edition) was evaluated at 2 years of age. RESULTS: A total of 212 twin–twin transfusion syndrome pregnancies were treated with laser surgery during the study period. Overall mortality rate was 30% (129 of 424). Seventeen children (6%) were lost to follow-up. Long-term outcome was assessed in 278 infants. The incidence of neurodevelopment impairment was 18% (50 of 278). Four risk factors were found to be significantly associated with increased risk for neurodevelopment impairment: greater gestational age at laser surgery (odds ratio [OR] 1.30, 95% confidence interval [CI] 1.00–1.69; P=.05), higher Quintero stage (OR 3.55 for each increment in stage, 95% CI 1.07–11.82, P=.04), lower gestational age at birth (OR 1.39 for each week, 95% CI 1.06–1.81; P=.01), and lower birth weight (OR 1.18 for each 100-g decrease, 95% CI 1.05–1.32; P<.01). In a multivariable analysis, lower gestational age at birth was the only factor independently associated with neurodevelopmental impairment (OR 1.33 for each week, 95% CI 1.05–1.67, P=.02). CONCLUSION: Neurodevelopment impairment in twin– twin transfusion syndrome survivors treated with laser surgery is associated with advanced gestational age at laser surgery, low gestational age at birth, low birth weight, and high Quintero stage. LEVEL OF EVIDENCE: II

Fetoscopic Laser Surgery in 100 Pregnancies with Severe Twin-to-Twin Transfusion Syndrome in the Netherlands

Objective: In this prospective cohort study, we evaluated the initial results of fetoscopic laser surgery for severe second trimester twin-to-twin transfusion syndrome (TTTS) treated at our centre. Method: A total of 100 consecutive pregnancies with severe second trimester TTTS treated at our centre with selective fetoscopic laser coagulation of vascular anastomoses on the placental surface between August 2000 and November 2004 were included in the study. Perinatal survival was analysed in relation to Quintero stage. Results: Median gestational age was 20 weeks at fetoscopy (range: 16–26) and 33 weeks at delivery (range: 18–40). Perinatal survival rate was 70% (139/200). The treatment resulted in at least one survivor at the age of 4 weeks in 81% of pregnancies. Perinatal survival was significantly higher when treatment was performed in the early Quintero stages (95% in stage 1, 76% in stage 2, 70% in stage 3, 50% in stage 4) (p = 0.02). Conclusion: Results of fetoscopic laser surgery for TTTS in our centre are similar to those in specialised centres in other countries. Diagnosis and treatment in the early Quintero stages resulted in significantly higher perinatal survival.

Residual anastomoses in twin-to-twin transfusion syndrome treated with selective fetoscopic laser surgery: localization, size, and consequences

OBJECTIVE To study the localization and size of residual anastomoses in twin-to-twin transfusion syndrome treated with fetoscopic laser surgery and correlate the findings with outcome. STUDY DESIGN Placental injection in twin-to-twin transfusion syndrome placentas treated with laser was performed by using colored dye. RESULTS A total of 77 twin-to-twin transfusion syndrome placentas were included in the study. Residual anastomoses (n = 48) were found in 32% (25/77) of lasered placentas. Most residual anastomoses were localized near the margin of the placenta. The majority of residual anastomoses (67%; 32/48) were very small (diameter, < 1 mm). Eleven of the 25 cases (44%) in the residual anastomoses group developed twin anemia-polycythemia sequence. CONCLUSION Most residual anastomoses in twin-to-twin transfusion syndrome placentas treated with laser are very small and localized near the placental margin. Almost half of cases with residual anastomoses developed twin anemia-polycythemia sequence after laser surgery.

Follow-up of children born with an umbilical arterial blood pH <7

OBJECTIVE We performed neurodevelopmental assessment in children born with an umbilical artery pH < 7. STUDY DESIGN All infants born with an umbilical artery pH < 7 from a 19-month period were retrieved from the obstetric database. Obstetric, neonatal, and pediatric records were reviewed. At an age of 1 to 3 years, children were visited at home for semi-structured questioning of the mother and a Denver Developmental Screening Test of the child. RESULTS During the study period 1614 umbilical artery pH measurements were entered in the database. Thirty (1.9%) were < 7. From this group 23 infants were admitted to the neonatal intensive care unit, and 8 of them required intubation. Twenty-eight children survived the neonatal period. Three children experienced an episode of mild hypertonia. One child had a mild motor developmental delay. CONCLUSION Babies born with an umbilical artery pH < 7 are at greater risk to experience considerable short-term morbidity. Those who leave the neonatal intensive care unit without major problems have good outcomes, and pessimism in counseling their parents in unwarranted.

Timely diagnosis of twin‐to‐twin transfusion syndrome in monochorionic twin pregnancies by biweekly sonography combined with patient instruction to report onset of symptoms

To assess the value of serial ultrasound examinations together with patient instructions to report the onset of symptoms in achieving timely detection of twin‐to‐twin transfusion syndrome (TTTS) in a cohort of monochorionic diamniotic twin pregnancies, and to evaluate sonographic TTTS predictors.

Ultrasonographic fetal spleen measurements in red blood cell-alloimmunized pregnancies

OBJECTIVES This study was performed to evaluate the possible relationship between fetal spleen size and fetal hemoglobin levels and to assess the predictive value of ultrasonographically measured fetal spleen size as an estimate of the severity of fetal hemolytic anemia. STUDY DESIGN Before 85 consecutive fetal blood samples in 28 red blood cell-alloimmunized pregnancies ultrasonographic fetal spleen measurements were performed. Results were compared with our own longitudinally derived reference ranges and were correlated with fetal hemoglobin deficit. RESULTS A significant positive correlation was found between spleen perimeter and fetal hemoglobin deficit. The ultrasonographic finding of splenomegaly correctly predicted severe fetal anemia (hemoglobin deficit > 5 SD from normal mean) in 44 of 47 cases, a positive predictive value of 94%. At first transfusion all fetuses showing splenomegaly were severely anemic. CONCLUSION Fetal spleen measurements may be a useful adjunct to ultrasonographic evaluation in the management of severe red blood cell-alloimmunized pregnancies.

The use of ultrasonography and Doppler in the prediction of fetal haemolytic anaemia: a multivariate analysis

Objective To assess the value of ultrasonography and Doppler to predict the severity of fetal haemolytic anaemia.

Twin-to-twin transfusion syndrome after 26 weeks of gestation: is there a role for fetoscopic laser surgery?

Objective  To compare fetoscopic laser surgery with amniodrainage in the treatment of twin‐to‐twin transfusion syndrome (TTTS) diagnosed after 26 weeks of gestation.