E-Mail Alert

Add your e-mail address to receive forthcoming issues of this journal:

Journal Browser

Journal Browser

Special Issue "Diagnosis, Treatment and Outcome in Complicated Monochorionic Twins"

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Obstetrics & Gynecology".

Deadline for manuscript submissions: closed (20 May 2019).

Special Issue Editors

Guest Editor
Prof. Dr. Enrico Lopriore

Professor of Neonatology and Fetal Medicine, Head of Neonatal Intensive Care Unit, Leiden University Medical Center, Leiden, The Netherlands
Website | E-Mail
Interests: monochorionic twins; fetal therapy
Guest Editor
Prof. Dr. Asma Khalil

St George's Medical School, University of London, UK
Website | E-Mail
Interests: hypertensive disease in pregnancy and multiple pregnancy
Guest Editor
Prof. Dr. Liesbeth Lewi

Department of Gynaecology and Obstetrics, University of Leuven, Belgium
Website | E-Mail
Interests: obstetric delivery; obstetrics; fetal medicine; coagulation; maternal health; prenatal care; pregnancy; amniotic fluid; fetoscopy

Special Issue Information

Dear Colleagues,

Twin gestations occur in 2% of all pregnancies. Two-thirds of these twin gestations are dizygotic and one-third are monozygotic, thus leading to identical twins. Dizygotic twin gestations are always dichorionic and have two separate placentas. In contrast, the majority of monozygotic twin gestations are monochorionic in which both twins share their placenta. Monochorionic twin placentas are characterized by the invariable presence of vascular anastomoses connecting the two fetal circulations. Unbalanced blood transfusion through the vascular anastomoses can lead to severe fetal complications such as twin-twin transfusion syndrome (TTS), twin anemia-polycythemia sequence (TAPS) of twin reversed arterial perfusion (TRAP). In case of unequal placental sharing, selective fetal growth restriction (sFGR) can occur. Accurate and timely detection of these potentially devastating complications is of utmost importance, as well as optimal antenatal and postnatal management. Management options include the use of minimally invasive surgical techniques such as fetoscopic laser coagulation of the vascular anastomoses or selective feticide using cord coagulation with bipolar forceps or radiofrequency ablation. Significant technological improvement in the field of fetal therapy has led to an increase in perinatal survival in the past decades. Nevertheless, the management of the various forms of complications in monochorionic twins remains a challenge in perinatal medicine. Surviving twins are at risk of developing severe cerebral injury and long-term neurodevelopment sequelae. Continuing close collaboration between fetal medicine specialists and neonatologists is crucial to improve the care and outcome of complicated monochorionic twins.

Prof. Dr. Enrico Lopriore
Prof. Dr. Asma Khalil
Prof. Dr. Liesbeth Lewi
Guest Editor

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All papers will be peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Journal of Clinical Medicine is an international peer-reviewed open access monthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 1800 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • Monochorionic twins
  • Twin-twin Transfusion Syndrome (TTS)
  • Twin Anemia-Polycythemia Sequence (TAPS)
  • Twin Reversed Arterial Perfusion (TRAP)
  • Selective Fetal Growth Restriction (sFGR)
  • Discordant anomaly
  • Fetal therapy
  • Clinical management
  • Long-term neurodevelopment outcome

Published Papers (8 papers)

View options order results:
result details:
Displaying articles 1-8
Export citation of selected articles as:

Research

Jump to: Review

Open AccessArticle
Long-Term Neurodevelopmental Outcome in Twin-to-Twin Transfusion Syndrome: Is there still Room for Improvement?
J. Clin. Med. 2019, 8(8), 1226; https://doi.org/10.3390/jcm8081226
Received: 11 July 2019 / Revised: 2 August 2019 / Accepted: 12 August 2019 / Published: 15 August 2019
PDF Full-text (433 KB) | HTML Full-text | XML Full-text
Abstract
Despite many developments in its management, twin-to-twin transfusion syndrome (TTTS) remains an important risk factor for long-term neurodevelopmental impairment (NDI). Our objective was to compare the incidence of severe NDI in a recent cohort of TTTS survivors, treated with laser surgery from 2011 [...] Read more.
Despite many developments in its management, twin-to-twin transfusion syndrome (TTTS) remains an important risk factor for long-term neurodevelopmental impairment (NDI). Our objective was to compare the incidence of severe NDI in a recent cohort of TTTS survivors, treated with laser surgery from 2011 to 2014, with a previous cohort treated from 2008 to 2010. Neurological, cognitive, and motor development were assessed at two years of age. We determined risk factors associated with Bayley-III scores. Severe NDI occurred in 7/241 (3%) survivors in the new cohort compared to 10/169 (6%) in the previous cohort (p = 0.189). Disease-free survival (survival without severe impairment) did not significantly differ. Low birth weight and being small for gestational age (SGA) were independently associated with lower cognitive scores (both p < 0.01). Severe cerebral injury was related to decreased motor scores (B = −14.10; 95% CI −3.16, −25.04; p = 0.012). Children with severe NDI were born ≥32 weeks’ gestation in 53% of cases and had no evidence of cerebral injury on cranial ultrasound in 59% of cases. Our results suggest that improvement in outcome of TTTS has reached a plateau. Low birth weight, SGA, and cerebral injury are risk factors for poor neurodevelopmental outcome. Neither gestational age above 32 weeks nor the absence of cerebral injury preclude severe NDI. Full article
(This article belongs to the Special Issue Diagnosis, Treatment and Outcome in Complicated Monochorionic Twins)
Figures

Figure 1

Open AccessArticle
Maternal Satisfaction with Healthcare after Perinatal Loss in Monochorionic Twin Pregnancy
J. Clin. Med. 2019, 8(8), 1213; https://doi.org/10.3390/jcm8081213
Received: 29 June 2019 / Revised: 30 July 2019 / Accepted: 13 August 2019 / Published: 14 August 2019
PDF Full-text (272 KB) | HTML Full-text | XML Full-text | Supplementary Files
Abstract
Introduction: The analysis of patients’ satisfaction with healthcare is recognised as being useful in the evaluation of health outcomes and perceived quality of care. Little is known, however, about how the psychological status of women who experience perinatal complications may affect their perceived [...] Read more.
Introduction: The analysis of patients’ satisfaction with healthcare is recognised as being useful in the evaluation of health outcomes and perceived quality of care. Little is known, however, about how the psychological status of women who experience perinatal complications may affect their perceived satisfaction with care. Methods: We assessed healthcare satisfaction in 52 women who had undergone intrauterine surgery during a complicated monochorionic twin pregnancy and examined the influence that fetal loss and sociodemographic, clinical, and psychological factors had on the degree of satisfaction. Data were gathered in an individual interview and through the administration of the Medical Patient Satisfaction Questionnaire, Beck Depression Inventory, and State–Trait Anxiety Inventory. Relationships between variables were analysed using a chi-square test, Spearman’s rho, Student’s t test, and the Mann–Whitney U test, in accordance with the metric nature of the variables and the assumptions fulfilled. Results: Age and level of education were not associated with the degree of healthcare satisfaction. Negative but non-significant correlations were observed between the level of satisfaction and symptoms of anxiety and depression. Satisfaction with healthcare was high in the sample as a whole, although it was significantly higher among women who had not experienced fetal loss. There were no differences in satisfaction with services involving direct contact with medical staff, whereas satisfaction with indirect services was lower among women who had experienced perinatal loss. Conclusions: Due to the unique characteristics of this population, specialised care teams of both professional healthcare and indirect services are needed. Although administrative aspects of healthcare are regarded as being of secondary importance, this may not be the case with more vulnerable populations. Full article
(This article belongs to the Special Issue Diagnosis, Treatment and Outcome in Complicated Monochorionic Twins)
Open AccessArticle
Twin-Twin Transfusion Syndrome with Anemia-Polycythemia: Prevalence, Characteristics, and Outcome
J. Clin. Med. 2019, 8(8), 1129; https://doi.org/10.3390/jcm8081129
Received: 6 July 2019 / Revised: 17 July 2019 / Accepted: 24 July 2019 / Published: 30 July 2019
PDF Full-text (503 KB) | HTML Full-text | XML Full-text
Abstract
The aim of this study was to estimate the prevalence of co-existing anemia-polycythemia (AP) in twin pregnancies with twin-twin transfusion syndrome (TTTS) prior to laser surgery, and to evaluate the characteristics and outcomes in TTTS twins with and without AP. All TTTS cases [...] Read more.
The aim of this study was to estimate the prevalence of co-existing anemia-polycythemia (AP) in twin pregnancies with twin-twin transfusion syndrome (TTTS) prior to laser surgery, and to evaluate the characteristics and outcomes in TTTS twins with and without AP. All TTTS cases treated with laser between 2001 and 2019 were retrospectively reviewed for the presence of AP before surgery. AP was defined as delta middle cerebral artery–peak systolic velocity > 0.5 multiples of the median. The primary outcome was a composite of perinatal survival and severe neurodevelopmental impairment (NDI). Secondary outcomes included procedure-related characteristics, severe neonatal morbidity, and disease-free survival. In total, 66% (461/696) of TTTS twin pregnancies were eligible for analysis. AP was detected in 15% (70/461) of the TTTS twins prior to laser surgery. Gestational age at laser was higher in the TTTS+AP group compared to the TTTS-only group—21.0 weeks (interquartile rage (IQR): 18.8–24.0) versus 19.3 weeks (IQR: 17.3–21.9), respectively (p < 0.0001). Fewer placental anastomoses were detected in the TTTS+AP group than in the TTTS-only group—five (IQR: 4–6) versus six (IQR: 5–8), respectively (p < 0.0001). Perinatal survival was 77% (599/782) in the TTTS-only group and 83% (118/142) in the TTTS+AP group (p = 0.130). Severe NDI was 8% (28/370) in TTTS-only and 3% (2/74) in TTTS+AP. TTTS-only twins showed more severe neonatal morbidity than twins with TTTS+AP—23% (132/575) versus 11% (13/115), respectively (p = 0.005). Disease-free survival was lower in the TTTS-only group compared to the TTTS+AP group—62% (341/548) versus 73% (72/98), respectively (p = 0.046). Thus, AP complicates 15% of TTTS twins prior to laser. TTTS+AP twins show a different placental angioarchitecture, a later time of onset of the disease, and a more favorable outcome. Full article
(This article belongs to the Special Issue Diagnosis, Treatment and Outcome in Complicated Monochorionic Twins)
Figures

Figure 1

Open AccessArticle
Twin-Twin Transfusion Syndrome with and without Selective Fetal Growth Restriction Prior to Fetoscopic Laser Surgery: Short and Long-Term Outcome
J. Clin. Med. 2019, 8(7), 969; https://doi.org/10.3390/jcm8070969
Received: 13 June 2019 / Revised: 2 July 2019 / Accepted: 2 July 2019 / Published: 3 July 2019
PDF Full-text (1742 KB) | HTML Full-text | XML Full-text | Supplementary Files
Abstract
As twin-twin transfusion syndrome (TTTS) and selective fetal growth restriction (sFGR) are both prevalent complications of monochorionic (MC) twin pregnancies, its coexistence is not uncommon. The aim of this study is to evaluate the short and long-term outcome in TTTS with and without [...] Read more.
As twin-twin transfusion syndrome (TTTS) and selective fetal growth restriction (sFGR) are both prevalent complications of monochorionic (MC) twin pregnancies, its coexistence is not uncommon. The aim of this study is to evaluate the short and long-term outcome in TTTS with and without sFGR prior to fetoscopic laser coagulation. All TTTS cases treated with laser surgery at our center between 2001–2019 were retrospectively reviewed for the presence of sFGR, defined as an estimated fetal weight (EFW) <10th centile. We compared two groups: TTTS-only and TTTS + sFGR. Primary outcomes were perinatal survival and long-term severe neurodevelopmental impairment (NDI). Of the 527 pregnancies eligible for analysis, 40.8% (n = 215) were categorized as TTTS-only and 59.2% (n = 312) as TTTS + sFGR. Quintero stage at presentation was higher in the TTTS + sFGR group compared to the TTTS-only group (57% compared to 44% stage III). Separate analysis of donors showed significantly lower perinatal survival for donors in the TTTS + sFGR group (72% (224/311) compared to 81% (173/215), p = 0.027). Severe NDI at follow-up in long-term survivors in the TTTS-only and TTTS + sFGR group was present in 7% (13/198) and 9% (27/299), respectively (p = 0.385). Both sFGR (OR 1.5;95% CI 1.1–2.0, p = 0.013) and lower gestational age at laser (OR 1.1;95% CI 1.0–1.1, p = 0.001) were independently associated with decreased perinatal survival. Thus, sFGR prior to laser surgery is associated with a more severe initial presentation and decreased donor perinatal survival. The long-term outcome was not affected. Full article
(This article belongs to the Special Issue Diagnosis, Treatment and Outcome in Complicated Monochorionic Twins)
Figures

Figure 1

Open AccessArticle
Maternal Complications and Hemodynamic Changes Following Intrauterine Interventions for Twin-to-Twin Transfusion Syndrome in Monochorionic Diamniotic Twin Pregnancies
J. Clin. Med. 2019, 8(5), 605; https://doi.org/10.3390/jcm8050605
Received: 27 March 2019 / Revised: 16 April 2019 / Accepted: 28 April 2019 / Published: 2 May 2019
PDF Full-text (1150 KB) | HTML Full-text | XML Full-text
Abstract
Twin-to-twin transfusion syndrome (TTTS) is a challenging complication in monochorionic diamniotic (MCDA) twins. Intrauterine interventions, such as fetoscopic laser ablation and cord occlusion followed by amniodrainage, are established treatments. Little is known about maternal complications and hemodynamics following these interventions. We performed a [...] Read more.
Twin-to-twin transfusion syndrome (TTTS) is a challenging complication in monochorionic diamniotic (MCDA) twins. Intrauterine interventions, such as fetoscopic laser ablation and cord occlusion followed by amniodrainage, are established treatments. Little is known about maternal complications and hemodynamics following these interventions. We performed a retrospective analysis of maternal procedure-related complications and the impact of such procedures on maternal hemodynamics and blood characteristics. Within the study period, 100 women with severe TTTS treated by fetoscopic laser ablation (FLA) or cord occlusion (CO) were identified. Clinically relevant maternal complications were reported in four (4%) cases. There was a significant decrease in hemoglobin, hematocrit, and albumin between admission and postoperative measurements (all p < 0.001). Systolic and diastolic blood pressure, as well as maternal heart rate, decreased from time of skin suture to postoperative measurements (all p < 0.001). Within a 24 h interval, there was a positive correlation between hematocrit (Spearman’s rho 0.325; p = 0.003), hemoglobin (Spearman’s rho 0.379; p < 0.001), and albumin (Spearman’s rho 0.360; p = 0.027), and the amount of amniodrainage during the intervention. Maternal procedure-related complications are relatively rare. Significant hemodynamic alterations and maternal hemodilution are common clinical findings following intrauterine interventions. Full article
(This article belongs to the Special Issue Diagnosis, Treatment and Outcome in Complicated Monochorionic Twins)
Figures

Figure 1

Review

Jump to: Research

Open AccessReview
Dispelling Myths about Antenatal TAPS: A Call for Action for Routine MCA-PSV Doppler Screening in the United States
J. Clin. Med. 2019, 8(7), 977; https://doi.org/10.3390/jcm8070977
Received: 20 May 2019 / Revised: 29 June 2019 / Accepted: 1 July 2019 / Published: 4 July 2019
PDF Full-text (485 KB) | HTML Full-text | XML Full-text
Abstract
In the United States, routine middle cerebral artery peak systolic velocity (MCA-PSV) Doppler screening for the detection of antenatal twin anemia-polycythemia sequence (TAPS) is not recommended. The current and only national clinical guideline from the highly-influential Society for Maternal-Fetal Medicine states that, “There [...] Read more.
In the United States, routine middle cerebral artery peak systolic velocity (MCA-PSV) Doppler screening for the detection of antenatal twin anemia-polycythemia sequence (TAPS) is not recommended. The current and only national clinical guideline from the highly-influential Society for Maternal-Fetal Medicine states that, “There is no evidence that monitoring for TAPS with MCA PSV Doppler at any time, including > 26 weeks, improves outcomes, so that this additional screening cannot be recommended at this time.” We argue this recommendation has disproportionate influence on patients and the care they are offered and receive. We use current evidence to highlight and dispel pervasive myths surrounding antenatal TAPS and the value of routine MCA-PSV screening. An ethical framework that illustrates the importance of giving patients the opportunity for routine screening is presented. Findings demonstrate that: (1) both spontaneous and post-laser TAPS is a serious, potentially life-threatening complication, (2) treatment for TAPS is effective and includes expectant management, intrauterine transfusion (IUT), or surgery, (3) and routine MCA-PSV, which has satisfactory diagnostic accuracy, is currently the only way to provide early detection of TAPS. We conclude that routine TAPS screening is a medically proven valuable resource that should be offered to patients in need and to the clinicians who are trying to act toward their benefit. Full article
(This article belongs to the Special Issue Diagnosis, Treatment and Outcome in Complicated Monochorionic Twins)
Figures

Figure 1

Open AccessReview
The Impact of Selective Fetal Growth Restriction or Birth Weight Discordance on Long-Term Neurodevelopment in Monochorionic Twins: A Systematic Literature Review
J. Clin. Med. 2019, 8(7), 944; https://doi.org/10.3390/jcm8070944
Received: 28 May 2019 / Revised: 10 June 2019 / Accepted: 26 June 2019 / Published: 28 June 2019
PDF Full-text (369 KB) | HTML Full-text | XML Full-text
Abstract
The aim of this review was to assess the impact of selective fetal growth restriction (sFGR) and/or birth weight discordance (BWD) on long-term neurodevelopment in monochorionic (MC) twins. Five out of 28 articles assessed for eligibility were included. One article concluded that the [...] Read more.
The aim of this review was to assess the impact of selective fetal growth restriction (sFGR) and/or birth weight discordance (BWD) on long-term neurodevelopment in monochorionic (MC) twins. Five out of 28 articles assessed for eligibility were included. One article concluded that the incidence of long-term neurodevelopmental impairment (NDI) was higher in BWD MC twins (11/26, 42%) than in BWD dichorionic (DC) (5/38, 13%) and concordant MC twins (6/71, 8%). BWD MC twins had a 6-fold higher risk of cerebral palsy compared to DC twins (5/26, 19% vs. 1/40, 3%, p < 0.05). Another article described a linear relationship between birth weight and verbal IQ scores, demonstrating a 13-point difference for a 1000 gram BWD between the twins, with a disadvantage for the smaller twin (p < 0.0001). Three articles analyzing within-pair differences showed that the smaller twin more frequently demonstrated mild NDI (6/80, 8% vs. 1/111, 1%) and lower developmental test scores (up to 5.3 points) as opposed to its larger co-twin. Although these results suggest that MC twins with sFGR/BWD are at increased risk of long-term NDI as compared to BWD DC or concordant MC twins, with a within-pair disadvantage for the smaller twin, the overall level of evidence is of moderate quality. As only five articles with a high degree of heterogeneity were available, our review mainly demonstrates the current lack of knowledge of the long-term outcomes of MC twins with sFGR/BWD. Insight into long-term outcomes will lead to improved prognostics, which are essential in parent counseling and crucial in the process of forming a management protocol specifically for twins with sFGR to optimally monitor and support their development. Full article
(This article belongs to the Special Issue Diagnosis, Treatment and Outcome in Complicated Monochorionic Twins)
Figures

Figure 1

Open AccessReview
Congenital Heart Defects in Monochorionic Twins: A Systematic Review and Meta-Analysis
J. Clin. Med. 2019, 8(6), 902; https://doi.org/10.3390/jcm8060902
Received: 20 May 2019 / Revised: 14 June 2019 / Accepted: 18 June 2019 / Published: 24 June 2019
PDF Full-text (1123 KB) | HTML Full-text | XML Full-text
Abstract
Monochorionic (MC) twins are at an increased risk of developing congenital heart defects (CHDs) compared to singletons and dichorionic twins. The development of acquired CHDs in this specific group of twins is associated with twin–twin transfusion syndrome (TTTS). We performed a systematic review [...] Read more.
Monochorionic (MC) twins are at an increased risk of developing congenital heart defects (CHDs) compared to singletons and dichorionic twins. The development of acquired CHDs in this specific group of twins is associated with twin–twin transfusion syndrome (TTTS). We performed a systematic review and meta-analysis to provide an overview of the reported birth prevalence of CHDs in liveborn MC twins with and without TTTS. Twelve studies were included in this review. Compared to the reference population, MC twins were 6.3 times more likely to be born with a CHD (59.3 per 1000 liveborn twins; relative risk (RR) 6.3; 95% confidence interval (CI): 4.4–9.1), and TTTS twins had a 12-fold increased risk of having a CHD at birth (87.3 per 1000 live births; RR 12.4, 95% CI: 8.6–17.8). The increased incidence of CHDs can mainly be attributed to the risk of right ventricular outflow tract obstruction (35/1000 TTTS twin live births vs. 0.5/1000 singleton live births). We recommend an expert fetal echocardiogram in all MC twins, follow-up scans in the event of TTTS, and a postnatal cardiac evaluation in all TTTS survivors. Full article
(This article belongs to the Special Issue Diagnosis, Treatment and Outcome in Complicated Monochorionic Twins)
Figures

Figure 1

J. Clin. Med. EISSN 2077-0383 Published by MDPI AG, Basel, Switzerland RSS E-Mail Table of Contents Alert
Back to Top