Masahiro Sumie

Perinatal Outcome of Monochorionic Twins with Selective Intrauterine Growth Restriction and Different Types of Umbilical Artery Doppler under Expectant Management

Objectives: To evaluate the prognosis of monochorionic twins with selective intrauterine growth restriction (sIUGR), classified according to the type of umbilical artery Doppler, under expectant management. Methods: The outcome of 81 cases with isolated sIUGR was evaluated according to a classification based on umbilical artery (UA) Doppler diastolic flow in the IUGR twin (I: present, II: constantly absent/reverse, III: intermittently absent/reverse). Selective feticide was not considered due to legal constraints. Perinatal outcomes included perinatal death and neurological outcome at 6 months of age. Results: From 81 cases with the diagnosis of sIUGR, twin-twin transfusion was diagnosed in 18 cases. This left 63 cases, of which 23 were classified as type I (36.5%), 27 as type II (42.9%) and 13 as type III (20.6%). Intrauterine death occurred in 4.3% (1), 29.6% (8) and 15.4% (2) among IUGR twins, and 4.3% (1), 22.2% (6) and 0.0% (0) among larger twins. Neonatal death occurred in 0.0% (0), 18.5% (5) and 0.0% (0) among IUGR twins, and 0.0% (0), 11.1% (3) and 23.0% (3) among larger twins. Neurological abnormalities at 6 months were found in 4.3% (1), 14.8% (4) and 23.1% (3) in smaller twins and 0.0% (0), 11.1% (3) and 38.5% (5) in larger twins, respectively. Intact survival at 6 months was recorded in 91% (21), 37% (10) and 61% (8) in smaller twins and 95% (22), 55% (15) and 38% (5) in larger twins, respectively. Conclusion: The outcome in monochorionic twins with sIUGR and abnormal umbilical artery Doppler is poor under expectant management. Normal Doppler seems to be associated with a good prognosis.

Ultrasound predictors of mortality in monochorionic twins with selective intrauterine growth restriction

The aim of this study was to evaluate the use of ultrasound assessment to predict risk of mortality in expectantly managed monochorionic twin fetuses with selective intrauterine growth restriction (sIUGR).

The Doppler cerebroplacental ratio predicts non‐reassuring fetal status in intrauterine growth restricted fetuses at term

Aim:  To investigate whether cerebroplacental ratio (CPR) can be a useful marker to predict non‐reassuring fetal status (NRFS) in small for gestational age (SGA) infants at term.

Prenatal sonographic chest and lung measurements for predicting severe pulmonary hypoplasia in left-sided congenital diaphragmatic hernia

To assess the prenatal evaluation of lung hypoplasia in congenital diaphragmatic hernia (CDH), we attempted to measure the right lung area/thorax area ratio (rLT ratio) in normal fetuses and in seven cases of left-sided CDH. In addition, we analyzed early neonatal blood gas data, which were compared with the prenatal evaluation. The rLT ratio was significantly (p<0.05) higher in normal fetuses (0.27+/-0.02) than in CDH (0.14+/-0.18). The values of PaO(2), arterial-alveolar oxygen difference (A-aDO(2)) and oxygenation index (OI) showed no significant relationship with the rLT ratio in CDH at the early neonatal period. Three infants with CDH survived and showed significant higher values of rLT ratio compared with those in nonsurvived infants (p<0.05). All of the rLT ratios in nonsurvived infants were <0.11. PaO(2) at the early neonatal period was significantly (p<0.05) higher, and both A-aDO(2) and OI were significantly (p<0.05) lower in survived infants than in nonsurvived infants. These results indicated that prenatal evaluation of rLT ratio is useful to predict the severity of lung hypoplasia in infants with left-sided CDH, and blood gas analysis at early neonatal period is also useful to predict the neonatal outcome.

Modified sequential laser photocoagulation of placental communicating vessels for twin–twin transfusion syndrome to prevent fetal demise of the donor twin

Aims:  Twin–twin transfusion syndrome (TTTS) complicated with absent or reversed end‐diastolic flow in the umbilical artery (UA‐AREDF) of the donor has a high perinatal mortality rate. To improve the prenatal outcome, we introduced and modified the technique of sequential selective laser photocoagulation of communicating vessels (SQLPCV), and assessed the clinical efficacy.

Resolution of mirror syndrome after successful fetoscopic laser photocoagulation of communicating placental vessels in severe twin–twin transfusion syndrome

Mirror syndrome, also known as Ballantyne syndrome or triple edema, characterizes maternal edema related to severe fetal hydrops and placental edema. In singleton pregnancies, various etiologies associated with this syndrome have been reported: parvovirus B19 infection (Brochot et al., 2006), fetal arrhythmia (Midgley and Harding, 2000), Rh isoimmunization (Kaiser, 1971), sacrococcygeal teratoma (Livingston et al., 2007), and placental chorioangioma (Dorman and Cardwell, 1995). In multiple pregnancies, hydrops related to twin–twin transfusion syndrome (TTTS) (Hayashi et al., 2006; Chang et al., 2007) can cause mirror syndrome; in some cases, however, the etiology is unknown (Heyborne and Chism, 2000). Several reports have shown that mirror syndrome can be cured provided the hydrops is treated by fetal therapy (Heyborne and Chism, 2000; Midgley and Harding, 2000; Livingston et al., 2007). We report the first case of spontaneous resolution of mirror syndrome after successful fetoscopic laser photocoagulation (FLP) of the communicating placental vessels in TTTS complicated with hydrops fetalis of the recipient twin. A 33-year-old gravida 1, para 0 woman was referred to our hospital at 21 weeks and 3 days of gestation for management of TTTS. She conceived and gestated monochorionic twins after in vitro fertilizationembryo transfer. The monochorionic twin pregnancy was diagnosed by ultrasonography in the referral hospital at an earlier gestational age. Initial ultrasound examination demonstrated polyhydramnios in the recipient’s sac (maximum vertical pocket (MVP), 8.4 cm) and oligohydramnios in the donor’s sac (MVP, 0 cm). Moreover, the recipient twin manifested hydrops fetalis with skin edema, ascites, and pleural effusion complicated with hypertrophic cardiomegaly. A Doppler study revealed pulsatile umbilical venous flow and reverse

Fetoscopic laser photocoagulation of placental communicating vessels for twin-reversed arterial perfusion sequence.

Twin‐reversed arterial perfusion (TRAP) sequence is a rare and compromised complication in monochorionic pregnancies. The retrograde blood flow through placental communicating vessels is mainly involved to develop the syndrome. Increased cardiac output in the pump twin can lead to severe clinical manifestations. Various surgical techniques to occlude vascular communications between the pump twin and acardiac twin have been reported. A woman with TRAP sequence, at 22 weeks of gestation, complicated with progressive polyhydramnios underwent fetoscopic laser photocoagualtion of vascular communications on the placental surface. Fetoscopic observation demonstrated one artery‐to‐artery anastomosis and one venous‐to‐venous anastomosis from the pump twin to the acardiac twin, and these communications were successfully photocoagulated. The patient delivered a 2308‐g female infant at 34 weeks and 1 day of gestation, following premature rupture of membrane. The infant is now 1 year old without any neurological problem. Fetoscopic laser photocoagulation of placental communicating vessels can be the procedure of choice for TRAP sequence.

Thoracoamniotic shunting for fetal pleural effusions using a double‐basket shunt

To describe the safety and efficacy of thoracoamniotic shunting for fetal pleural effusion using a double‐basket catheter with a very small diameter (1.47 mm).

A Case of Monochorionic Twin Pregnancy Complicated with Intrauterine Single Fetal Death with Successful Treatment of Intrauterine Blood Transfusion in the Surviving Fetus

We report a case of monochorionic twin pregnancy complicated with single fetal demise that received successful treatment of intrauterine transfusion for severe anemia of the surviving fetus. A single fetal demise occurred at 20 weeks of gestation and middle cerebral artery peak systolic velocity (MCA-PSV), a marker for fetal anemia, showed marked elevation in the surviving fetus. Fetal blood sampling was immediately done and severe fetal anemia (hemoglobin = 5.5 g/dl, hematocrit = 16.8%) was confirmed, and then intrauterine transfusion was performed. After transfusion, MCA-PSV rapidly decreased to the normal value and remained within normal range until delivery. A healthy 2,640 g male infant was delivered at 35 weeks of gestation without anemic status and no neurological problem was found at 1-year old. The present report supports that intrauterine rescue transfusion is a useful treatment to prevent the adverse outcome of surviving fetus in monochorionic twin pregnancy complicated with single fetal demise, and monitoring of MCA-PSV is also useful to assess anemic status of the surviving fetus.

Twin Anemia-Polycythemia Sequence after Laser Surgery for Twin-Twin Transfusion Syndrome and Maternal Morbidity

Twin anemia-polycythemia sequence (TAPS) is characterized by large inter-twin hemoglobin value differences without inter-twin amniotic fluid discordance. The management of post-laser TAPS remains controversial. Hence, more studies on TAPS, together with the associated maternal complications and outcome of the fetuses and infants are needed. Between 2003 and 2012, we performed 287 cases of fetoscopic laser photocoagulation for twin-twin transfusion syndrome. Among the 114 who were placed under our care until delivery, three cases of TAPS occurred. In one case, we conducted intrauterine intravenous transfusion, while in the other two cases, we adopted expectant management. We performed an emergency caesarean section at 27-30 weeks of gestation in all cases due to a severe condition of anemia in the TAPS donor. Two cases with antenatal TAPS stage 4 had severe maternal complications; one had minute pulmonary embolism, while the other had Mirror syndrome. All three pairs of infants survived. One TAPS donor and one TAPS recipient had neurodevelopmental impairment; bilateral deafness at 9.5 years old and spastic paralysis at 2 years old, respectively. In conclusion, post-laser TAPS in a higher stage can cause severe maternal complications. Close observations for both fetuses and mothers are required for such cases.