Yuichi Torii

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.

Incidence of spontaneous twin anemia-polycythemia sequence in monochorionic-diamniotic twin pregnancies: Single-center prospective study.

The purpose of this study was to prospectively estimate the incidence of spontaneous twin anemia–polycythemia sequence (TAPS) in monochorionic–diamniotic twin pregnancies.

Clinical course of disseminated intravascular coagulopathy-type amniotic fluid embolism: A report of three cases.

Amniotic fluid embolism (AFE) is a rare complication of pregnancy and its mortality rate is high. There have been few reports of AFE with presence of severe coagulopathy and incoagulable bleeding, and absence of cardiopulmonary symptoms or limited cardiopulmonary symptoms, followed by massive blood loss during delivery. Such cases have been referred to as disseminated intravascular coagulopathy‐type AFE, and the characteristics of this condition have been presented previously. Here we report three cases that fulfilled the diagnostic characteristics of disseminated intravascular coagulopathy‐type AFE.

Transitory increase in middle cerebral artery peak systolic velocity of recipient twins after fetoscopic laser photocoagulation for twin-twin transfusion syndrome.

Objective: It was the aim of this study to elucidate the clinical features of recipient twins with increased middle cerebral artery peak systolic velocity (MCA-PSV) after fetoscopic laser photocoagulation (FLP) for twin-twin transfusion syndrome. Methods: Serial Doppler velocimetry of the MCA was performed in 30 recipient twins before and after FLP. Clinical data and perinatal outcome were compared between cases with and without increased MCA-PSV. Results: Increased MCA-PSV was observed in 7 recipients (23.3%) within 14 days after FLP. MCA-PSV gradually decreased to <1.5 multiples of median in 6 recipients; however, 1 patient resulted in fetal demise subsequent to the demise of the co-twin. The incidences of fetal and neonatal demise and neurological morbidity were similar. No recipient was diagnosed as anemic at birth. Conclusions: The increase in MCA-PSV in recipients following FLP appeared to be generally transitory; this differs from twin anemia-polycythemia sequence.

Fetoscopic Laser Photocoagulation for the Treatment of Twin-Twin Transfusion Syndrome in Monochorionic Twin Pregnancies

Fetoscopic laser surgery for severe twin-twin transfusion syndrome (TTTS) has become the optimal treatment choice since the release of the Eurofetus randomized clinical trial. These techniques have been adopted throughout the globe, and many institutions have instituted or will soon institute fetoscopic laser surgery procedures; however, laser sur- gery has a steep learning curve because of the following: challenging placental location, complex and unexpected com- municating anastomoses, residual anastomoses after surgery, or discolored amniotic fluid. We have been performing laser surgery since 2002 in Japan; to date, we have compiled a series of 170 cases. Our data indicates a 78% of overall survival with 5% neonatal morbidity, 63% of survival of both twins, and 93% survival of at least one twin. The recurrent TTTS rate was 1% and the residual vessel rate was 3%. To improve the learning curve of laser surgery, the employment of various techniques is recommended to achieve a suc- cessful surgical outcome: (1) Mapping: before laser ablation, a very thorough mapping of vascular anastomoses should be done, and should be repeated after ablation; (2) Sequential order: obliteration of arterio-venous anastomoses from donor to recipient should be done first to avoid donor hypotension and/or anemia; (3) Trocar (cannula) assisted technique: Trocar assisted technique: Using gentle indent the trocar to the placenta by withdrawing the scope shortly, then anastomoses could be ablated easily; (4) Line method: to avoid residual anastomoses, the laser should draw a virtual line at the hemo- dynamic equator; The operator must be careful not to miss small anastomoses. These techniques can help achieve a successful outcome for fetoscopic laser surgery and improve the outcome for cases of severe TTTS.

Sonographic features of congenital infantile fibrosarcoma that appeared as a sacrococcygeal teratoma during pregnancy

We experienced an extremely rare case of congenital infantile fibrosarcoma originating from the fetal sacrococcygeal region in pregnancy. At first, we suspected fetal sacrococcygeal teratoma; however, the following ultrasonography findings of the tumor complicated this diagnosis: (i) laterality; (ii) no cystic component; (iii) hypervascularity, with the feeding vessels not derived from the middle sacral artery; and (iv) a skin covering. The pathological findings indicated that the tumor was an infantile fibrosarcoma, not a teratoma. Thus, we believe that these sonographic features may aid the prenatal diagnosis of congenital infantile fibrosarcoma, which, in turn, may contribute to a better prognosis and may be useful for parental counseling.

The Treatments of Twin-Twin Transfusion Syndrome in MonochorionicTwin Pregnancies by the Fetoscopic Laser Photocoagulation

Aims: Fetoscopic laser surgery has been widely accepted of optimal treatment for Twin-Twin Transfusion Syndrome (TTTS) in monochorionic twin pregnancies. To avoid surgical complication and to improve the outcome, various techniques employed in our institution. The aim of our study is to assess the clinical outcomes of TTTS after laser surgery with combined various techniques. Methods: We performed 171 cases of fetoscopic laser surgery for TTTS from 2002 to 2011 in our institution. Various techniques employed in our studies to improve the learning of laser surgery and to achieve successful outcome were; (1) A very thorough mapping of vascular anastomoses before and after ablation; (2) Obliteration of arterio-venous anastomoses from donor to recipient should be done first, (3) Trocar assisted technique using gentle indent the trocar withdrawing the scope shortly, to ablate anastomoses easily, (4) A virtual line was drawn by laser at the hemodynamic equator to avoid residual anastomoses, and not to miss small anastomoses. Results: Laser photocoagulation was performed since 2002 in our institute, compiling 171 cases. Overall survival was 78% with 5% neonatal morbidity. Both twins survived for 64%, and the survival of one twin was 93%. The recurrent TTTS rate was 1%, and the residual vessel rate was 2%. Conclusion: A successful outcome for fetoscopic laser surgery is achievable and the outcome is improved in severe TTTS cases by these techniques.