[Selective feticide in monochorionic twin pregnancies with discordant fetal anomalies: management and outcome]. / Selektivní fetoredukce u monochoriálních gravidit komplikovaných vrozenou vývojovou vadou jednoho z plodu: management a výsledky péce.

OBJECTIVE: To analyze results and outcome after selective feticide for discordant anomalies in monochorionic twins. DESIGN: Prospective cohort study. SETTING: Fetal medicine center, Institute for the Care of Mother and Child, Praha. METHODS: Analysis of outcome of monochorionic pregnancies after intrauterine surgery for structural abnormalities between January 2013 and June 2016. RESULTS: We performed 13 intrauterine operations in monochorionic twins with structural anomalies during the period. There were 12 monochorionic diamniotic and one monochorionic monoamniotic twins. We encountered four cases of Twin Reversed Arterial Perfusion sequence (TRAP), six central nervous system lesions, two abdominal wall defects and one heterokaryotypic pregnancy with trisomy 13. In seven cases we performed bipolar cord occlusion, in four cases of TRAP sequence we performed radiofrequency ablation (RFA). We also performed laser photocoagulation of placental anastomoses in a case of gastroschisis complicated with twin-to-twin transfusion syndrome. One operation was unsuccessful for technical reasons - failing to perform amnioinfusion in a fetus with eventeration and anhydramnios. All procedures were performed in local anesthesia. Fetuses were born between 26 a 41 weeks of gestation (mean 35 weeks; 77% of fetuses were delivered after 32 weeks). Mean neonatal weight 2260 g. We encountered no intrauterine demise of a healthy fetus. CONCLUSION: Patients with discordant fetal anomalies in monochorionic twins can be offered a selective feticide via bipolar umbilical cord occlusion or radiofrequency ablation that are proven to be safe and effective.

[Retrospective analysis of monochorionic twin pregnancies born in the Institute for the Care of Mother and Child between 2012-2015]. / Analýza prípadu monochoriálních dvojcat porozených v Ústavu pro péci o matku a díte ve ctyrletém období (2012-2015).

OBJECTIVE: The purpose of this study was to describe monochorionic twin pregnancies and their complications, born between 24th and 37th week of gestation in the Institute for the Care of Mother and Child in years 2012-2015. DESIGN: Retrospective cohort. SETTING: The Institute for the Care of Mother and Child, Praha. METHODS: From 2012 to 2015 we observed 177 monochorionic twin pregnancies from which two or one viable fetuses were born, or both fetuses died in utero. RESULTS: From a total of 177 women, 12 (6.8%) gave birth before 26th week of gestation, between 26+0 - 27+6 four women (2.3%) gave birth, 37 women (20.9%) between 28+0 - 31+6, 84 women (47.8%) between 32+0 - 35+6 and after 36th week of gestation 40 women (22.6%) gave birth. Mean week of delivery was 33.8. Indications for termination of pregnancies were premature rupture of membranes (PPROM) in 11.9%, onset of spontaneus uterine contractions in 12.4% and in 53.3% other iatrogenic indication. 23.3% of pregnancies in our cohort were uncomplicated and terminated after 36th week of gestation. We performed caesarean section in 94.3%, in 5.7% patients gave birth vaginally. In vitro fertilization had 19.9% women, 80.1% conceived spontaneously. The age range of pregnant women in our cohort was 20-43, with median 32.3. Mean weight of bigger fetus was 2047.6 g (min. 520 g, max. 3530 g), mean weight of smaller fetus was 1799.5 g (min. 350 g, max. 2790 g). In 30 cases (16. 9%) we performed intrauterine intervetion. In 21/30 cases (11.9%) for TTTS diagnose, in 5/30 cases (2.8%) for congenital abnormalities or TRAP sequence and in 4/30 cases (2.2%) for sIUGR type III. The most frequent complication in our cohort was sIUGR (36 patients - 20.3%), TTTS (21 patients - 11.9%) and on the third place congenital abnormality or TRAP sequence (five patients - 2.8%) Nineteen patients gave birth to one viable fetus, in two cases both fetuses died in utero. In one case, in twin pair, one new-born died shortly after the birth - it had several congenital abnormalities and due to anhydramnion it was impossible to perform amnioinfusion and umbilical cord occlusion. After the birth it was given palliative care. CONCLUSION: The study brought data about specific risks in monochorionic twin pregnancies and suggests careful observation of women in fixed intervals and necessity of immediate referral to perinatal centre in case of any suspicious or pathological finding.

Laboratory options for risk assessment of pregnancy pathologies.

The most effective method of screening for chromosomal abnormalities and evaluating the risk of pregnancy pathologies in the first trimester is combined screening. The algorithm of screening is based on the combination of maternal age, measuring of the nuchal translucency and the fetal heart rate and analysis of the placental products of free ß-hCG and PAPP-A. For the screening of preeclampsia, placental growth factor (PlGF) is added. To distinguish between preeclampsia and other pathologies caused by placental dysfunction it is recommended to also extend the screening with selected immunological markers. We concluded that elevated biochemical and immunological markers can help to predict the threat of preeclampsia in the third trimester. Some markers can probably predict the development of particularly severe pathological conditions.