Twin Anemia Polycythemia Sequence: a Single Center Experience And

European Journal of Obstetrics & Gynecology and Reproductive Biology 205 (2016) 158–164

Contents lists available at ScienceDirect

European Journal of Obstetrics & Gynecology and

Reproductive Biology

journal homepage: www.elsevier.com/locate/ejogrb

Review

Twin anemia polycythemia sequence: a single center experience and

literature review

a a,d a a

Amirhossein Moaddab , Ahmed A. Nassr , Jimmy Espinoza , Rodrigo Ruano ,

a a b b

Zhoobin H. Bateni , Amir A. Shamshirsaz , George T. Mandy , Stephen E. Welty ,

a c a a,

Hadi Erfani , Edwina J. Popek , Michael A. Belfort , Alireza A. Shamshirsaz *

Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA

Department of Pediatric Medicine, Neonatology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA

Department of Pathology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA

Department of Obstetrics and Gynecology, Women’s Health Hospital, Faculty of Medicine, Assiut University, Egypt

A R T I C L E I N F O A B S T R A C T

Article history:

ﬁ ﬁ

Received 10 June 2016 Twin anemia polycythemia sequence (TAPS) is de ned by signi cant intertwin hemoglobin discordance

Received in revised form 23 July 2016 without the amniotic ﬂuid discordance that characterizes twin–twin-transfusion syndrome (TTTS) in

Accepted 13 August 2016 monochorionic twin pregnancies. TAPS is an uncommon condition which can either occur spontaneously,

or following fetoscopic laser ablation for TTTS. This complication is thought to result from chronic

Keywords: transfusion through very small placental anastomoses; however, the pathogenesis of TAPS remains

Twin to twin transfusion syndrome

unknown. Consequently, there is no consensus in the management of TAPS. In this article, three cases of

Twin anemia polycythemia sequence

TAPS are described and we review the literature on this uncommon pregnancy complication.

Partial blood exchange

Blood transfusion

Contents

Introduction ...... 158

Methods ...... 159

Case 1 ...... 159

Case 2 ...... 160

Case 3 ...... 161

Review of the literature ...... 161

TAPS in triplet pregnancies ...... 163

Discussion ...... 163

Declaration of interest ...... 164

References ...... 164

Introduction anastomoses for the management of TTTS. TAPS, which was ﬁrst

described by Robyr et al. in 2006 [1], frequently occurs in the late

Twin anemia polycythemia sequence (TAPS) is a form of feto- second or third trimester and is deﬁned by a large intertwin

fetal transfusion that may occur in monochorionic multiples either hemoglobin (Hb) discordance (>8 g/dl postnatally) in the absence

spontaneously or following fetoscopic laser ablation of placental amniotic ﬂuid discordance characteristic for twin to twin

transfusion syndrome (TTTS) [1,2]. TAPS complicates approximate-

ly 6% of monochorionic diamniotic twin pregnancies, but has also

been reported in monoamniotic twins [3,4]. TAPS also may occur in

* Corresponding author at: Baylor College of Medicine and Texas Children's Fetal

Center, F1040-04, 6621 Fannin St., Pavilion for Women, Houston, TX 77030, USA. triplet pregnancy spontaneously or after laser surgery [2,5,6].

Fax: +1 832 825 9351. The antepartum diagnosis of TAPS is made using Doppler

E-mail addresses: [email protected], [email protected]

ultrasound, and depends on the presence of a difference in the

(A.A. Shamshirsaz).

http://dx.doi.org/10.1016/j.ejogrb.2016.08.033

A. Moaddab et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 205 (2016) 158–164 159

peak systolic velocity in the middle cerebral artery (MCA-PSV)

between the donor and recipient twins. Robyr et al. [1] recommend 745 arcles idenﬁed through MEDLINE, PubMed and

Ovid search by 4 relevant terms (twin anemia

using an MCA-PSV of 1.5 multiples of the median (MoM) for the polycythemia sequence, twin anemia polycythemia,

chronic twin to twin transfusion and placental

donor twin and 0.8 MoM in the recipient twin, as the diagnostic anast omoses)

criteria.

Slaghekke et al. [4] have suggested using an MCA-PSV of the

recipient of 1.0 MoM based on their data which suggests that the

recipient’s MCA-PSV does not necessarily always fall under the

586 arcles ineligible based on 159 arcles retrieved for further

0.8 MOMs cut off proposed by Robyr et al. [1]. Slaghekke et al. [4]

study tle or abstract assessme nt via full text

also deﬁned postnatal TAPS as the presence of an intertwin Hb

difference >8.0 g/dl, in addition to at least of one of the following

conditions: reticulocyte count ratio >1.7 and/or a placenta that has

only small (diameter < 1 mm) vascular anastomoses. Recently, a 145 arcles exclude :

study that was conducted to assess the accuracy of MCA-PSV for did not meet inclusion criteria (139

arcles)

prediction of polycythemia in monochorionic twins showed that

full text not in English (3 arcles)

decreased MCA-PSV is not an accurate parameter for detecting study overlapped with another (6 arcles)

polycythemia in suspected TAPS cases. In the study, the authors

proposed that MCA-PSV difference between the twins would be a

more reliable diagnostic parameter for TAPS prenatally than the

absolute MCA-PSV value [7]. 15 arcles included in the

literature review

The etiology of TAPS, the hemodynamic effects in both twins

and the natural history remain unclear. However, there is

accumulating evidence of the association of TAPS with adverse

Fig. 1. Flow diagram of literature review.

pregnancy outcomes. Slaghekke et al. recently reported that TAPS

is associated with signiﬁcant pre and post-natal morbidity and

mortality [8,9]. Therapeutic approaches such as selective feticide the donor and the recipient twins. Fetal echocardiography showed

and elective preterm delivery have been reported, as well as normal cardiac function in both fetuses. Due to frequent uterine

expectant management [4]. The use of fetoscopic laser surgery, contractions and worsening polyhydramnios in the recipient twin,

intrauterine blood transfusion (IUT), and intrauterine exchange and after discussing with the patient all treatment options, the

transfusion had also been reported [8,10]. However, there is no patient chose to proceed with laser treatment. Due to a complete

consensus on the optimal management of TAPS. In the present anterior placenta with no window for direct fetoscopy, a

report, we describe one case of spontaneous TAPS and two cases of laparoscopically-assisted laser ablation was performed at 22

post-laser severe TAPS managed with exchange transfusions. The weeks 4 days gestation. The cord insertions of the two fetuses

literature on TAPS is also reviewed. were noted to be very close to each other with multiple

connections. All visible vascular anastomoses on the placenta

Methods were ablated using Diode laser in a selective fashion. The Solomon

technique was used and the procedure was deemed successful.

A literature review of an eight-year period from 2008 to May On post-operative day 3, ultrasound examination revealed

ﬂ

2106 was performed by two reviewers (AM and AAN) using the normal amniotic uid volume and bladder size in both fetuses and

MEDLINE, PubMed and Ovid databases. The search was restricted the patient was discharged home. Weekly follow up ultrasound

to English-language articles. The following search terms were examinations performed by her local obstetrician were normal

used: twin anemia polycythemia sequence, twin anemia polycy- until two weeks after surgery at which time she was 25-week

themia, chronic twin to twin transfusion and placental anastomo- gestation. Doppler evaluation revealed increased MCA-PSV in the

ses. The related articles were searched to single out all reported ex-donor (2.24 MoM). The ex-recipient had a MCA-PSV of

cases/series of antenatal TAPS with adequate pregnancy history to 0.71 MoM.

allow analysis. In order to avoid double counting of cases, we Fetal echocardiographic evaluation of the ex-recipient revealed

ﬁ

checked all references, demographic and clinical characteristics. normal structural and functional ndings. The ex-donor was noted

ﬁ

Articles that contain the following information were collected and to be hydropic for the rst time (scalp edema, pleural effusion and

tabulated: gestational age (GA) at diagnosis, whether TAPS ascites) and echocardiography showed a constricted ductus

occurred spontaneously or post laser therapy for TTTS, Doppler arteriosus, mild tricuspid regurgitation and mild biventricular

measurements of the middle cerebral artery peak systolic velocity hypertrophy. There was also reversed a wave in the DV and UA

(MCA-PSV) in the donor and recipient twins at diagnosis, GA at the notching. TAPS stage IV was diagnosed. Due to the anterior

ﬂ

time of intervention if an intervention was done, GA at birth, donor placenta and oating amniotic membranes a repeat laser proce-

and recipient hemoglobin (Hb) at birth and early neonatal follow- dure was considered technically challenging. Given the probability

up. The literature review process has been demonstrated in Fig. 1. of imminent fetal death and after a full discussion with the parents

about the risks and beneﬁts of all available interventions including

Case 1 selective reduction of the ex-donor and IUT, the couple chose the

latter option which was performed on the ex-donor at 25 weeks

A 32-year-old gravida 3 para 2 patient was referred to our 1 day gestation. The total volume of blood transfused to the ex-

center at 22 weeks’ gestation with Quintero stage 2 TTTS The donor donor was 40 ml into the umbilical vein and 15 ml into the

had estimated fetal weight less than 10th percentile, oligohy- peritoneal cavity. The intravenous transfusion increased the fetal

dramnios with no visible fetal bladder. The recipient demonstrated hemoglobin (Hb) from 3.7 to 8.9 g/dl. In the 72 h following this

’

growth within the normal range and had polyhydramnios with an transfusion, the ex-donor s hydrops almost completely resolved,

enlarged bladder. The Doppler blood velocity studies in the and MCA-PSV decreased to 1.93 MoM. Fetal echocardiography at 24

ﬁ

umbilical artery (UA), umbilical vein (UV), ductus venosus (DV) and and 48 h after IUT revealed signi cantly improved fetal cardiac

ﬁ

the MCA revealed normal patterns and velocities/ratios for both function in the ex-donor. On the fth day post-IUT, the ex-donor Download English Version: https://daneshyari.com/en/article/3919293

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