Severe coronavirus disease pneumonia in a pregnant woman at 25 weeks' gestation: A case report.

There are numerous reports on the effects of the coronavirus disease on mothers and fetuses during pregnancy. It is currently unknown whether pregnancy is associated with a high risk of severe coronavirus disease. We report a pregnant patient with coronavirus disease who underwent a cesarean section. A pregnant 39-year-old Japanese woman was diagnosed with coronavirus disease at 25 weeks of gestation. Her breathing condition worsened daily, and she required oxygen administration. On day 6 of her 26th week of gestation, she developed severe pneumonia and required tracheal intubation and artificial ventilation, and an emergency cesarean section was performed under general anesthesia. It is necessary to investigate the risk of increased coronavirus disease severity during pregnancy, the effects of coronavirus disease on perinatal prognosis, and the management of pregnancy with coronavirus disease.

Influence of preoperative light vaginal bleeding for perinatal adverse outcomes on physical examination-indicated cerclage.

PURPOSE: To clarify the relationship between light vaginal bleeding (LVB) before physical examination-indicated cerclage (PEIC) and perinatal adverse outcomes. METHODS: This was a retrospective cohort study involving 94 singleton pregnancies undergoing PEIC <26 weeks of gestation at a single perinatal medical center between 2008 and 2015. The primary outcome was set as spontaneous preterm birth (sPTB) <34 weeks of gestation. The secondary outcomes were set as the second-trimester loss prior to 22 weeks of gestation, sPTB before 28 weeks of gestation, sPTB before 37 weeks of gestation, and stillbirth or neonatal death. Relationships between LVB and adverse outcomes were evaluated using logistic regression analysis. RESULTS: Preoperative LVB was detected in 16 cases (17.0%). Multivariate logistic regression analyses revealed that preoperative LVB was an independent risk factor for sPTB <34 weeks of gestation (adjusted odds ratio [aOR]: 8.42; 95% confidence interval [CI]: 1.72-41.1; p < .01), sPTB <28 weeks of gestation (aOR: 5.98; 95% CI: 1.67-21.4; p < .01) and perinatal death (aOR: 8.47; 95% CI: 1.11-64.5; p = .04). CONCLUSIONS: Vaginal bleeding prior to PEIC, even nonsignificant or self-limiting, is associated with sPTB before 28 or 34 weeks of gestation and perinatal death.

Prenatal diagnosis of fetal skeletal dysplasia using 3-dimensional computed tomography: a prospective study.

BACKGROUND: Fetal skeletal dysplasia (FSD) comprises a complex group of systemic bone and cartilage disorders. Many FSD phenotypes have indistinct definitions, making definitive prenatal diagnosis difficult. The condition is typically diagnosed using sonography; however, three-dimensional computed tomography (3D-CT) also aids in making a prenatal diagnosis. This study aimed to examine the efficacy of 3D-CT in the prenatal diagnosis of FSD by comparing the diagnostic accuracy of fetal sonography and 3D-CT. METHODS: On suspicion of FSD based on ultrasound examination, we performed 3D-CT prenatally to obtain detailed skeletal information on FSD. To minimize exposure of the fetuses to radiation without compromising image quality, we used predetermined 3D-CT settings for volume acquisition. RESULTS: Nineteen fetuses were suspected of having skeletal dysplasia based on ultrasonography findings. Of these, 17 were diagnosed with FSD using 3D-CT. All 17 fetuses diagnosed with FSD prenatally were confirmed postnatally to have the condition. The postnatal diagnosis (campomelic dysplasia) differed from the prenatal diagnosis (osteogenesis imperfecta) in only one infant. Sixteen cases (94.1%) were diagnosed both prenatally and postnatally with FSD. Five infants had lethal skeletal dysplasia; one died in utero, and four died as neonates. We determined the appropriate delivery method for each infant based on the prenatal diagnosis. CONCLUSIONS: 3D-CT is a valuable tool for augmenting ultrasound examinations in the diagnosis of FSD. While improving the diagnostic tool of sonography is essential in cases of suspected FSD, 3D-CT imaging is indispensable for diagnosis and classification, enabling better planning for resuscitation of the infant after birth. TRIAL REGISTRATION: University Hospital Medical Information Network (UMIN) Center trial registration number is UMIN000034744 . Registered 1 October, 2018 - Retrospectively registered.

Telediagnosis system for congenital heart disease in a Japanese prefecture.

PURPOSE: This study aimed to evaluate the accuracy of prenatal diagnosis using a spatio-temporal image correlation-based telediagnosis system at a tertiary referral unit in a Japanese prefecture over a 9-year period, and to investigate the validity of delivery hospital selection. METHODS: This study retrospectively analyzed telediagnosis cases from 2009 to 2018 in six geographically remote hospitals. We built a telediagnosis system called the Kyoto Fetal Ultrasonographic Telediagnosis System (K-FUTS). Three-dimensional ultrasonographic images from these referral hospitals were forwarded to the Kyoto Prefectural University of Medicine (KPUM) Hospital through an optical fiber network system for analysis. The primary endpoint was accuracy of prenatal diagnosis. Cases with severe congenital heart disease (CHD) that required immediate postnatal treatment were identified using the K-FUTS. These cases were then examined to determine whether they were delivered at appropriate hospitals. RESULTS: During the study period, datasets from 182 cases were transferred to KPUM Hospital. Twenty-one datasets were excluded because of data unavailability or poor image quality. CHD was detected in 14.9% of cases (24/161); the accuracy of prenatal diagnosis was 95.0% (153/161). The K-FUTS identified seven severe cases with CHD requiring immediate postnatal surgical or medical treatment. These cases were delivered at KPUM Hospital with a pediatrician present. The remaining 17 cases considered suitable for delivery at the referral hospitals were delivered there, and they did not require intervention immediately after birth. CONCLUSION: Our telediagnosis system contributed to the prenatal diagnosis of CHD and management of pregnancies in patients who were geographically remote from a tertiary hospital.

Transient amniotic fluid leakage after fetoscopic laser photocoagulation for twin-twin transfusion syndrome.

AIM: Iatrogenic premature rupture of membrane (PROM) is one of the major complications related to fetoscopic laser photocoagulation (FLP) for twin-twin transfusion syndrome (TTTS). However, amniotic fluid leakage (AFL) sometimes spontaneously disappears. This study evaluated the incidence and clinical characteristics of transient AFL after FLP. METHODS: We retrospectively reviewed pregnancies that underwent FLP for TTTS at a single center. Patients with apparent AFL within 2 weeks after FLP were divided into two groups: transient AFL, defined by the disappearance of fluid leakage within a week; and PROM, if AFL persisted continuously for more than a week or premature birth occurred, including miscarriage, within a week of the first symptom of AFL. RESULTS: Among 201 monochorionic twin pregnancies that underwent FLP during the study period, nine patients (4.5%) were diagnosed with AFL within a week after FLP. Four patients (2.0%) were classified as transient AFL and five as PROM. Median gestational age at FLP was not significantly different between the groups; operative time in the PROM group was significantly longer (P = 0.01). The surgery to delivery interval and median gestational age at delivery were greater in the transient AFL group (87.8 vs 17.6 days, P = 0.01; 32.5 vs 23.6 weeks, P = 0.01, respectively). CONCLUSIONS: The incidence of transient AFL after FLP was 2%. Perinatal outcomes of transient AFL might be better than that of PROM.

Prior uterine bleeding is associated with low visibility due to discolored amniotic fluid on fetoscopic laser photocoagulation.

AIM: To investigate the association between uterine bleeding preceding fetoscopic laser photocoagulation (FLP) and the presence of discolored amniotic fluid that impedes FLP. METHODS: A retrospective review of all multiple gestations requiring FLP at the present institution was conducted. The rate of low visibility because of discolored amniotic fluid at the beginning of FLP was compared between patients with and without a history of uterine bleeding, defined as either genital bleeding or ultrasonographically detected subchorionic hematoma. RESULTS: The prevalence of low visibility because of discolored amniotic fluid was 4.5% (seven in 156 patients). Two of the seven cases of low visibility resulted in double fetal death. The incidence of low visibility was significantly higher in the group with uterine bleeding before surgery compared with that without bleeding (28.6% vs 0.74%, P < 0.001). CONCLUSIONS: Patients with a history of uterine bleeding prior to FLP may encounter more technical difficulties owing to discolored amniotic fluid during FLP.

Perinatal outcome of monochorionic diamniotic twin pregnancies complicated with isolated amniotic fluid volume abnormality of one twin less than 26 weeks of gestation.

AIM: To evaluate the incidence of twin-twin transfusion syndrome (TTTS) and the perinatal outcome at 28 days of age in monochorionic diamniotic (MCDA) pregnancies complicated with isolated polyhydramnios (I-Poly) and isolated oligohydramnios (I-Oligo) diagnosed < 26 weeks of gestation. METHODS: This was a retrospective study of women with MCDA pregnancies diagnosed with I-Poly or I-Oligo before 26 weeks of gestation over a period of six years. The incidence of subsequent TTTS and neonatal outcome in terms of intact survival (IS) at 28 days of age were evaluated. Intact survival was defined as being alive without any neurological complications at 28 days of age. RESULTS: There were 30 cases of I-Poly and 53 of I-Oligo that were eligible as per the inclusion criteria. Subsequent TTTS were complicated in six (20.0%) of the I-Poly and 26 (49.0%) of the I-Oligo cases. Among subjects with I-Poly, 17 had spontaneously normalized amniotic fluid volume. Prolonged oligohydramnios until intrauterine death, delivery or the onset of emerging TTTS was noted in 16 cases of I-Oligo. Both the twins exhibited IS in 26 (86.7%) cases of I-Poly and 31 (58.4%) cases of I-Oligo. CONCLUSION: One-fifth of I-Poly and half of I-Oligo MCDA twins at < 26 weeks of gestation potentially develop TTTS. I-Oligo in particular should be regarded as a high-risk condition as neonatal IS is less than 60%.

Risk assessment of hypertensive disorders in pregnancy with maternal characteristics in early gestation: A single-center cohort study.

OBJECTIVE: Hypertensive disorders in pregnancy are major causes of maternal mortality and morbidity. Although the combined risk assessments of maternal history, blood pressure, uterine artery Doppler, and maternal serum marker seem to be highly predictive of the development of hypertensive disorders, this method is a little complicated to be performed on many low-risk pregnant women. The aim of this study is to evaluate the use of maternal characteristics, and physical findings early in the second trimester, as predictive factors of hypertensive disorders. MATERIALS AND METHODS: This is a retrospective cohort study undertaken in a single tertiary care center in Japan. Singleton pregnant women without underlying disease and evaluated before 14 weeks of gestation were included. We conducted multivariate logistic regression analysis and decision tree analysis to elucidate the potential risk factors of hypertensive disorders, including gestational hypertension and preeclampsia. RESULTS: In total, 1986 women were evaluated, of whom 863 were nulliparous and 1123 were multiparous, and 166 (8.3%) were diagnosed with hypertensive disorders. In multivariate analysis, maternal age ≥ 40 years, prepregnancy BMI ≥ 30 kg/m(2), in vitro fertilization and embryo transfer (IVF-ET), family history of hypertension, and blood pressure ≥ 130/85 mmHg at first visit were independent risk factors for the nulliparous women. Maternal age ≥ 40 years, a history of previous hypertensive disorders, and blood pressure ≥ 130/85 mmHg at first visit were independent risk factors for the multiparous women. According to the decision tree analysis, high-risk populations were as follows: women ≥ 40 years old who conceived thorough IVF-ET and women with prepregnancy BMI ≥ 30 kg/m(2) who conceived spontaneously in nulliparous women; women with a history of hypertensive disorders and women with blood pressure ≥ 130/85 mmHg in the absence of the previous history. CONCLUSION: The combination of maternal background and physical findings is useful to identify the population with a high risk of hypertensive disorders.

Significance of high-normal blood pressure during early second trimester for predicting the onset of hypertensive disorders in pregnancy.

OBJECTIVE: The aim of this study was to determine the predictive value of high-normal blood pressure (HNBP) during the early second trimester for hypertensive disorders in pregnancy, including gestational hypertension (GH) and preeclampsia (PE). METHODS: This was a retrospective single-center cohort study of 2143 singleton pregnant women. The association of HNBP, ranging from 130/85 to 139/89 mmHg between 14 and 19 weeks of gestation, with the development of hypertensive disorders was assessed by multivariable logistic regression analyses. RESULTS: In a cohort of 2102 pregnant women, 93 (4.4%) pregnancies had HNBP during early second trimester. Pregnant women with HNBP more frequently developed hypertensive disorders than normotensive women (20.4% vs. 8.2%, p < 0.001). HNBP was significantly associated with the development of GH (adjusted odds ratio (aOR): 1.81; 95% confidence interval (CI): 1.16-3.25, p = 0.015) and PE (aOR: 6.05; 95% CI: 3.46-12.6, p = 0.013) after adjustment for confounders. CONCLUSION: HNBP during the early second trimester is an independent risk factor for both GH and PE.

Clinical features and antenatal risk factors for postpartum-onset hypertensive disorders.

OBJECTIVE: To identify the clinical features and risk factors for diagnosis of a postpartum-onset hypertensive disorder. METHODS: A retrospective cohort study of singleton pregnancies. Clinical features of postpartum-onset hypertensive disorders were evaluated, and prenatal risk factors were also identified with a multivariate logistic regression model. RESULTS: Of 1,964 women, 57 (2.9%) developed hypertensive disorder after delivery. The independent risk factors were assisted reproductive technology, pre-pregnancy body mass index, chronic nephritis, hypothyroidism, high-normal blood pressure before or at delivery, and cesarean section. CONCLUSION: Careful monitoring of blood pressure should be considered for women with the identified risk factors even after delivery.

Perinatal and one-year outcomes of non-immune hydrops fetalis by etiology and age at diagnosis.

AIM: The prognosis for non-immune hydrops fetalis (NIHF) is still poor despite progress in perinatal care. We have examined perinatal and 1-year outcomes for NIHF in relation to gestational age at diagnosis and underlying etiology in order to identify predictors of mortality. METHODS: A retrospective review was conducted of 92 pregnancies with NIHF managed in hospital between 2000 and 2012. The gestational age at diagnosis, etiology, perinatal outcome, and 1-year outcome were recorded, and their associations assessed. RESULTS: A total of 41 of 92 cases (45%) resulted in fetal death, 33 patients (36%) survived to 1 year, but only 15 of the 33 survivors were developmentally intact. Aneuploidy was the most common cause of NIHF (27%; 25/92). Of the 34 patients who were diagnosed before 22 weeks, 29 fetuses (85%) died, and four (12%) survived to 1 year without developmental delay. Meanwhile, of the 26 patients diagnosed after 30 weeks, 18 (69%) survived to 1 year. Of those 18, seven (27%) were developmentally intact. Approximately half of the pregnancies with cardiac anomalies (8/13) resulted in intrauterine fetal death (IUFD) or early neonatal death. Aneuploidy was associated with a high frequency of IUFD, and of the remaining five surviving newborns, three had developmental delay. CONCLUSION: The prognosis for NIHF differs according to underlying etiology and gestational age at diagnosis. NIHF diagnosed early in gestation is associated with poor outcome. Knowledge of the primary etiology is important for counseling and therapy.

Significance of Velamentous Cord Insertion for Twin-Twin Transfusion Syndrome.

INTRODUCTION: The objective of this study was to evaluate the actual association between velamentous cord insertion (VCI) and twin-twin transfusion syndrome (TTTS) in the native cohort concerning the natural history of monochorionic twin pregnancies. MATERIAL AND METHODS: All monochorionic diamniotic twin pregnancies who received prenatal care from <16 weeks of gestation until delivery at our center between 2004 and 2013 were included in this retrospective cohort study. Macroscopically defined cord insertion site was recorded as velamentous, marginal, or central. The effects of VCI on TTTS and a composite of adverse outcomes, including abortion, death, and neurological morbidities ≤28 days of age, were evaluated with a multiple logistic regression model. RESULTS: A total of 357 monochorionic diamniotic twin pregnancies were analyzed. VCI in both twins was noted in 2.5% of cases and VCI in at least one twin was noted in 22.1% of cases. The incidence of TTTS was 8.4%; the incidence of a composite of adverse outcomes in at least one twin was 9.8%. There was no correlation between VCI and TTTS as well as a composite of adverse outcomes. DISCUSSION: VCI in monochorionic twin pregnancies was not a risk factor for TTTS and severe perinatal morbidities.

Significance of chorionicity on long-term outcome of low birthweight infants of <1500g in twin pregnancies.

AIM: The aim of this study was to evaluate the long-term outcomes of very low birthweight twins by chorionicity and to identify the perinatal predictors for outcomes in the era of laser surgery for twin-twin transfusion syndrome. MATERIAL AND METHODS: This was a retrospective single-center cohort study of twin pregnancy infants <1500 g from 2003 through 2010. During the study period, laser surgery was performed on cases of twin-twin transfusion syndrome. The composite of adverse outcomes at 3 years of age was defined, including death, cerebral palsy, and developmental delay. The association between perinatal factors and adverse outcomes was evaluated by multiple logistic regression analysis. RESULTS: A total of 162 infants (79 dichorionic diamniotic twins [DCDA] and 83 monochorionic diamniotic twins [MCDA]) were included in this study. Laser surgery was performed on 11 cases. The rate of adverse outcomes was 13.9% for DCDA and 26.5% for MCDA. The incidence of each outcome for DCDA and MCDA was: cerebral palsy, 1.3% and 4.8%; developmental delay, 8.9% and 9.6%; and death, 3.8% and 14.5%. Gestational age at birth (adjusted odds ratio: 0.69; 95% confidence interval, 0.57-0.84); and anemia at birth (adjusted odds ratio, 10.64; 95% confidence interval, 1.69-66.9) were independent risk factors, whereas chorionicity did not have significance for outcomes. CONCLUSION: The long-term outcome of very low birthweight MCDA was almost identical to that of DCDA. Gestational age and anemia at birth were independent risk factors for adverse outcomes.

Prenatally diagnosed monochorionic diamniotic triplet pregnancy.

We present an extremely rare case of monochorionic diamniotic (MD) triplet pregnancy diagnosed via ultrasonography at the end of the first trimester that resulted in delivery of three healthy newborns. Ultrasonography for a 34-year-old woman at 12 weeks of gestation showed three fetuses and one placenta with a T-sign at the initial segment of the dividing membrane. Color Doppler examination revealed umbilical cord entanglement between two fetuses in one sac in addition to another sac containing one fetus. Therefore, this was diagnosed as MD triplet pregnancy. The triplets were delivered by cesarean section at 35 weeks of gestation and were healthy without neurological morbidities at the age of 28 days. Histopathological examination also revealed an MD triplet placenta. The possibility of MD triplet pregnancy should be recognized, although it is rare.

Associated anomalies in congenital diaphragmatic hernia: perinatal characteristics and impact on postnatal survival.

OBJECTIVE: We aimed to investigate the clinical characteristics and postnatal outcomes of fetuses with congenital diaphragmatic hernia (CDH) and additional anomalies. MATERIALS AND METHODS: We reviewed the charts of fetuses with CDH managed between 2005 and 2013. Patients were divided into complex and isolated groups based on the presence of additional anomalies. We analyzed the respective polyhydramnios, liver herniation, stomach position, lung to thorax transverse area ratio (LTR), and prognoses of the two groups. The survival rates of both groups were assessed based on the LTR as well as on stomach and liver positions. RESULTS: CDH was diagnosed in 65 fetuses, and additional anomalies were found in 23. The incidences of liver herniation, polyhydramnios, and death were significantly higher, and LTR was significantly lower, in the complex group. The mortality rate of fetuses with a LTR <0.08 was lower than that of fetuses with a LTR of ≥0.08 in the complex group. Further, the survival rate of fetuses with intrathoracic liver was lower than those without liver herniation. CONCLUSIONS: The prognosis of complex CDH is poor. This may result from both the associated anomalies and the severity of CDH itself. Even in complex CDHs, intrathoracic liver and LTR values are useful in estimating postnatal outcome.

Clinical features and prenatal risk factors for hypertensive disorders in twin pregnancies.

AIM: The aim of this study was to identify the incidence, clinical features, and prenatal risk factors for hypertensive disorders, including gestational hypertension (GH) and pre-eclampsia (PE), in twin pregnancies. MATERIAL AND METHODS: We carried out a retrospective cohort study of twin pregnancies managed from the first trimester onward at a single center from 2002 through 2011. We retrospectively evaluated the incidence, severity, time-point onset of GH or PE, as well as maternal and neonatal outcomes. Prenatal risk factors for disease were also analyzed with a multivariable logistic regression model. RESULTS: Of 742 twin pregnancies, 165 (22%) were diagnosed with GH or PE. Five women developed GH or PE at <32 weeks' gestation (early onset), and the remaining 160 developed them at ≥ 32 weeks (late onset). Of all 165 cases, 110 women (66.7%) developed their disease during the intrapartum or postpartum period. The significant risk factors associated with developing a hypertensive disorder in a twin pregnancy were primiparity (adjusted odds ratio [aOR]: 1.77; 95% confidence interval [CI]: 1.21-2.61), pregestational high body mass index (aOR 1.35, 95%CI: 1.08-1.70), family history of hypertension (aOR: 1.50; 95%CI: 1.02-2.17) and previous history of GH or PE (aOR 8.85; 95%CI: 2.70-29.0). CONCLUSIONS: One-fifth of the twin pregnancies developed GH or PE. Furthermore, more than half of the patients were diagnosed with the disease during the intrapartum or postpartum period. Significant risk factors for GH or PE in twin pregnancies were primiparity, pregestational body mass index, family history of hypertension, and history of a hypertensive disorder during a previous pregnancy. The significance of monitoring blood pressure after delivery for a twin pregnancy is stressed.

Adverse perinatal outcomes related to the delivery mode in women with monochorionic diamniotic twin pregnancies.

AIMS: The association between the planned delivery mode and adverse perinatal outcomes of monochorionic diamniotic (MCDA) twin pregnancies at ≥36 weeks' gestation was evaluated. METHODS: This retrospective cohort study included uncomplicated MCDA twin pregnancies delivered after 36 weeks' gestation during a 10-year period. Cases were classified into the trial of labor (TOL) or cesarean section (CS) group according to the planned delivery mode. The primary outcome was a composite of adverse outcomes for at least one twin, including intrauterine fetal death (IUFD) after 36 weeks, neonatal death, umbilical artery pH<7.1, 5-min Apgar scores<7, hypoxic ischemic encephalopathy (HIE), meconium aspiration syndrome (MAS), respiratory distress syndrome (RDS), or acute feto-fetal hemorrhage (AFFH). The relationship between outcomes and the planned delivery mode was evaluated using a multiple logistic regression analysis. RESULTS: We included the 310 pregnancies delivered after 36 weeks' gestation. After excluding 15 patients, the final analysis included 295 MCDA pregnancies: 63% had delivered through TOL and 37% through CS. The incidences of composite adverse outcomes in the TOL and CS groups were 4.3% and 1.9%, respectively. No IUFD, neonatal death, MAS, RDS, or AFFH was observed; two infants in each group developed HIE. Adverse outcomes were not significantly associated with any risk factor, including delivery through TOL. CONCLUSION: TOL may not influence the perinatal outcomes of MCDA twin pregnancies delivered at ≥36 weeks' gestation.

Therapy by laser equatorial placental dichorionization for early-onset spontaneous twin anemia-polycythemia sequence.

We report a case of twin anemia-polycythemia sequence (TAPS) treated by fetoscopic laser equatorial placental dichorionization, also known as the 'Solomon technique', at 24 weeks of gestation. TAPS was present despite the absence of fetoscopically visualized chorionic anastomoses from the donor to the recipient twin. The goal of this procedure was to prevent post-laser TAPS in cases of twin-twin transfusion syndrome. The surgery and subsequent intrauterine blood transfusion to the donor twin could result in the survival of both twins without hematologic or neurological complications. Following the surgery, a placental injection test revealed no residual anastomoses. At present, laser therapy is not always feasible for TAPS, primarily because of its difficulty. However, laser therapy using the Solomon technique could be a viable approach for early-onset TAPS, especially in difficult situations in which undetectable vascular anastomoses related to TAPS are present.

The prevalence and clinical features of twin-twin transfusion syndrome with onset during the third trimester.

OBJECTIVE: To describe the incidence and clinical features of twin-twin transfusion syndrome (TTTS) with third trimester onset. METHODS: We performed a retrospective chart review of monochorionic diamniotic (MD) twin pregnancies delivered during a recent 4-year period. The inclusion criterion was women who received prenatal care at our center from the first trimester onward. Serial ultrasound examinations were performed at least every 2 weeks until delivery to evaluate fetal growth as well as to estimate amniotic fluid volume. The prevalence of TTTS onset after 28 weeks of gestation and clinical features, including neonatal outcomes and placental findings, were elucidated. RESULTS: Meeting our inclusion criterion were 143 MD twin pregnancies, including 15 TTTS cases (10%). Five cases (4%) developed TTTS during the third trimester and underwent a cesarean section immediately after the diagnosis. All of these women exhibited either abdominal distension or uterine contractions. Recipient twins tended to require more intensive cardiopulmonary treatment than donors, however, neither a recipient nor a donor twin suffered neonatal death or neurological impairment. Placental arterio-arterial anastomoses were detected in three out of five cases. Arteriovenous anastomoses were present in all cases, however, venovenous anastomoses were not found in any case. CONCLUSIONS: TTTS is a relatively rare complication during the third trimester. It is imperative to be observant for the development of TTTS in MD twin pregnancies with any abdominal symptoms, even if they appear insignificant.