Russell Miller

Twin–Twin Transfusion Syndrome

Twin-twin transfusion syndrome (TTTS) is a serious condition that affects 10% to 15% of twin pregnancies with monochorionic diamniotic placentation. The pathophysiology of TTTS is not completely understood; however, the presence of unbalanced placental vascular communications within a shared circulation has been implicated in its development. The presentation of TTTS is highly variable, and it does not always progress in a predictable manner. Monochorionic twin gestations should, therefore, be monitored for signs of TTTS with serial sonograms starting in the second trimester. Early TTTS can be managed conservatively. However, without intervention, early-onset advanced TTTS is associated with a high perinatal loss rate and risk of severe neurologic impairment among survivors. Limited studies suggest that fetoscopic laser photocoagulation is the best available treatment for advanced TTTS diagnosed in the second trimester. Even with laser therapy, there remains a significant risk of twin demise and neurologic handicap in survivors.

Fetal omphalocele ratios predict outcomes in prenatally diagnosed omphalocele

OBJECTIVE The objective of the study was to evaluate whether ratios considering omphalocele diameter relative to fetal biometric measurements perform better than giant omphalocele designation at predicting inability to achieve neonatal primary surgical closure. STUDY DESIGN Cases of fetal omphalocele that underwent evaluation between May 2003 and July 2010 were identified. Inclusion was restricted to live births with plan for postnatal repair. Omphalocele diameter upon antenatal ultrasound was compared with abdominal circumference, femur length, and head circumference, yielding the respective omphalocele (O)/abdominal circumference (AC), O/femur length (FL), and O/head circumference (HC) ratios. The absolute measurements were used to classify giant lesions. Omphalocele ratios and giant omphalocele designations were evaluated as predictors of inability to achieve primary repair. RESULTS Among 25 included cases, staged or delayed closure occurred in 52%. With an optimal cutoff of 0.21 or greater, O/HC best predicted the primary outcome (sensitivity, 84.6%; specificity, 58.3%; odds ratio, 7.7). The O/HC of 0.21 or greater outperformed giant designations. CONCLUSION The O/HC of 0.21 or greater best predicted staged or delayed omphalocele closure. Giant omphalocele designation, regardless of definition, poorly predicted outcome.

Sonographic Fetal Asymmetry Predicts Shoulder Dystocia

The purpose of this study was to evaluate the performance of a sonographic measurement of fetal asymmetry, abdominal diameter minus biparietal diameter (AD – BPD), in the prediction of shoulder dystocia (SD) in a patient population that was unselected for diabetes mellitus (DM) status.

Congenital parvovirus B19 infection: persistent viremia and red blood cell aplasia

We describe a case of fetal parvovirus B19 infection resulting in preterm birth and leading to hydrops fetalis requiring multiple in utero transfusions. The infant developed chronic postnatal anemia responsive to intravenous immunoglobulin therapy. Serum viral load decreased after immunoglobulin treatment but remained detectable for over 1 year.

Do Doppler studies enhance surveillance of uncomplicated monochorionic diamniotic twins

To determine whether isolated abnormal Doppler indices before 28 weeks predict adverse pregnancy outcomes in uncomplicated monochorionic diamniotic (MCDA) twins.

P23.06: Monochorionic twins with discordant congenital malformations

Methods: Data on 209 twin pregnancies and 418 neonates who were delivered in the tertiary center between 2003 and 2009 were retrospectively reviewed. Perinatal and neonatal outcomes were compared between twins from monochorionic and dichorionic pregnancies. Results: We were able to establish chorionicity in 148 out of 209 twin pregnancies, and only these have been recruited in this study. Monochorionic pregnancies (n = 56; 38%) in comparison with dichorionic (n = 92; 62%) were related to a higher risk of preterm birth (both between 33–36 hbd and below 33 hbd; P < 0.01), low and very low birth weight (P = 0.012), Apgar scores between 1–4 (P = 0.029). Monochorionic twins were more often admitted to neonatal intensive care unit (58% vs. 41%; P = 0.006) and had a higher incidence of intraventricular hemorrhage (39% vs. 20%; P < 0.001), anemia (31% vs. 14%; P < 0.001), sepsis (10% vs. 2%; P < 0.001) and metabolic complications (14% vs. 7.6%; P < 0.02). Both groups did not differ in the rate of neonatal death (7.1% vs. 4.3%, NS) and neonatal pneumonia (35% vs. 26%, NS). Exclusion of 10 (18%) pairs of twins with TTTS did not affect the results. Conclusions: Monochorionicity is a risk factor in twin pregnancy. It is associated with a higher risk of prematurity, worse neonatal condition at birth and during the first month of life and longer hospitalization but it is not related to a higher neonatal mortality.

Fetal Laceration Injury at Cesarean Delivery: Comparison between Low-Risk and High-Risk Intrapartum Care [17P]

INTRODUCTION:Our objective was to determine the frequency, severity, and documentation of fetal laceration during cesarean delivery (CD) in patients receiving intrapartum low-risk (LRC) vs high-risk (HRC) care.METHODS:This is a retrospective cohort study of patients delivered at a single, academic m

163 – Twin Reversed Arterial Perfusion Sequence

Abstract Twin reversed arterial perfusion (TRAP) sequence is a rare complication specific to monochorionic twin pregnancies in which a dysmorphic acardiac fetus receives circulatory support from a pump twin via aberrant placental arterioarterial anatomoses. The hemodynamic burden of supporting an acardiac mass places the pump twin at risk for polyhydramnios, heart failure, hydrops, and death. A TRAP diagnosis is secured by ultrasound, with necessary findings including a normal-appearing pump fetus and a grossly abnormal acardiac twin in the setting of a monochorionic pregnancy, with color Doppler study demonstrating reversal of arterial flow to the acardiac fetus. Due to an increased rate of aneuploidy, invasive genetic testing is recommended for pregnancies complicated by TRAP sequence. Therapy with invasive cord occlusion to sever the intertwin vascular circuit should be considered with a relatively large acardiac twin or when pump twin compromise is suspected at a previable gestational age, with radiofrequency ablation (RFA) a commonly used contemporary cord occlusion strategy for this presentation.

Risk of cerebral palsy by gestational age among pregnancies at-risk for preterm birth

Abstract Objective: Our objective was to describe cerebral palsy (CP) incidence stratified by gestational age (GA) groups within a group at risk for spontaneous preterm birth (sPTB). Study design: This is a secondary analysis of a large study of magnesium for neuroprotection. Nonanomalous, singleton gestations complicated by preterm premature rupture of membranes (PPROM) or preterm labor (PTL) were included. Infants that developed CP were compared to controls that did not. The incidence of CP was stratified by GA groups. A logistic regression model was fit to adjust for confounders. Results: Of 1747 included pregnancies, 75 (4.3%) were affected by CP. Increasing GA at delivery was associated with lower rates of CP (RR 0.96, 95% CI 0.95–0.97; p<.0001). The most significant risk factor for CP was neonatal sepsis while the most significant protective factors were magnesium and antibiotic exposure. In the adjusted analysis, magnesium exposure (aRR 0.52, 95% CI 0.33–0.84; p = .007) and antibiotic exposure (aRR 0.52, 95% CI 0.28–0.95; p = .034) remained protective. Conclusion: The risk of CP among populations at high risk for sPTB decreases with advancing GA. While the majority of cases of CP occurred in children born <34 weeks, residual risk persisted thereafter. The effect of magnesium exposure is most pronounced before 28 weeks.

Placental hematoma mimicking twin anemia–polycythemia sequence following selective laser photocoagulation for twin–twin transfusion syndrome

A 31-year-old nullipara was transferred for fetal therapy at19weeks’ gestation following diagnosis of twin–twintransfusion syndrome (TTTS). Intake ultrasound evaluationconfirmed monochorionic, diamniotic twins with a posteriorplacenta and Quintero stage III TTTS. Specific findingsincluded donor twin anhydramnios, recipient twinpolyhydramnios (maximal vertical pocket of fluid 10cm), 22%inter-twin growth discordance, Doppler study absent end-diastolic velocity in the donor twin umbilical artery withnormal peak systolic velocity of the middle cerebral artery(MCA). The patient elected to undergo fetoscopic selectivelaser photocoagulation (SLP) of communicating vessels.Selective laser photocoagulation was performed at 19 1/7weeks gestational age under regional anesthesia. Two large-caliber arterio–venous anastomoses (AVA) were identified andphotocoagulated, as well as seven smaller superficial arterio–arterial and veno–venous anastomoses. Time from the first tolast coagulation was 20min. During photocoagulation of alarge AVA, using diode laser set to 40W and approaching theanastomosis perpendicularly, minor vessel bleeding wasencountered that was controlled with circumferentialphotocoagulation around the area of bleeding. The procedureconcluded with an amnioreduction of 1200cm