The assessment of placental sharing using X-ray angiogram versus digital photograph: A prospective study.

INTRODUCTION: We aim to compare two different methods for the assessment of placental sharing in monochorionic diamniotic twins: X-ray-angiogram and digital photograph of the placenta. METHOD: We included the placentas of a prospective series of twins that were followed from the first trimester onward and resulted in a double live birth or double stillbirth between April 2016 and February 2019. Injection was performed after delivery and an X-ray angiogram was made, as well as a digital photograph. On both of these, the territory of each twin was measured two investigators (IC and LL). Placental sharing discordance was determined using the following formula: (larger territory - smaller territory)/larger territory. We calculated the intra-class correlation coefficients for intra-observer and inter-observer reliability and used Bland-Altman analysis to compare both methods. RESULTS: 77 placentas were included in the analysis. For both methods, there was an excellent intra- and inter-observer reliability. The mean difference in sharing (bias) on the X-ray and digital photograph using Bland-Altman analysis was 3,7% (95% CI 1,1% - 6,3%), where the digital photograph tends to overestimate the discordance. Limits of agreement were between -19% and 26%. CONCLUSION: Delineation of the placental sharing on a digital photograph slightly overestimates the discordance. Since the venous territory on X-ray angiogram physically determines where each twin gets its oxygenated blood, X-ray angiogram may be a better method to determine placental sharing, although the digital photograph constitutes a valid alternative.

Psychosocial aspects of invasive fetal therapy as compared to prenatal diagnosis and risk assessment.

OBJECTIVE: To explore the psychosocial impact of invasive fetal therapy (FT). METHODS: We studied 100 consecutive patients scheduled for invasive FT. Contemporary controls were women undergoing (1) invasive prenatal diagnosis (AC/CVS) and (2) first trimester risk assessment of aneuploidy (NT), and (3) women who declined the latter (CTR). Prior to the procedure, participants completed the Beck Depression Inventory II, the State-Trait Anxiety Inventory, the Dyadic Adjustment Scale and a questionnaire specifically designed to evaluate the process preceding the intervention. RESULTS: Thirty-five percent of women in the FT group had mild to severe depressive symptoms, and 30% showed high levels of state anxiety. Mean state anxiety was significantly higher in women facing invasive as compared to non-invasive procedures. Trait anxiety levels and relationship scores were comparable across all groups. FT patients were more satisfied with the information and support given, whereas women in the NT group felt a greater degree of self-determination and contentedness with the choices they made. CONCLUSION: Pregnant women awaiting invasive prenatal diagnosis and FT face higher levels of state anxiety than women undergoing non-invasive procedures. Traits of depression and high state anxiety are found in at least one third of women undergoing FT.

Prenatal assessment and management of sacrococcygeal teratoma.

Sacrococcygeal teratoma (SCT) is one of the most common tumors in newborns with a birth prevalence of up to 1 in 21,700 births. Routine fetal anomaly screening programs allow for prenatal diagnosis in many cases. Fetal ultrasound with Doppler evaluation and more recently magnetic resonance imaging may be used to document the extent of the tumor as well as identifying the population at risk for serious fetal complications. Rapidly growing SCT and highly vascularized tumors are more likely to have hemodynamic repercussions. Fetal hydrops is usually considered as a poor prognostic marker and a potential indicator for fetal intervention. Newborns with SCT require stabilization prior to early surgical resection. In case of malignancy additional chemotherapy may be required. SCT may result in significant morbidity, either directly or as a consequence of surgical therapy. Careful postnatal follow-up is required for timely identification and treatment of complications as well as recurrence. This paper aims to review the perinatal management of this condition.

Assessment of fetal cardiac function before and after therapy for twin-to-twin transfusion syndrome.

OBJECTIVE: We sought to assess fetal cardiac function in monochorionic twins before and after therapy for twin-to-twin transfusion syndrome (TTTS) and compare it with control subjects. STUDY DESIGN: We conducted prospective longitudinal assessment of fetal cardiac function in cases undergoing curative fetal therapy for TTTS (n = 39) until 4 weeks postoperatively and in uncomplicated monochorionic twins (n = 23). Fetal cardiac function was assessed by the left and right ventricular myocardial performance index, atrioventricular valve flow pattern, ductus venosus a-wave, and umbilical vein pulsations. RESULTS: Nomograms for the myocardial performance index were constructed. Fetal cardiac function was grossly abnormal in recipient twins of TTTS when compared with control subjects (P < .001 for all indices) but normalized by 4 weeks postoperatively. The donor developed abnormal ductus venosus flow and tricuspid regurgitation postoperatively that regressed within 4 weeks. CONCLUSION: The cardiac dysfunction in the recipient twin of TTTS normalizes within 1 month after laser. The donor develops a transient impairment of cardiac function postoperatively.

Prevalence and management of late fetal complications following successful selective laser coagulation of chorionic plate anastomoses in twin-to-twin transfusion syndrome.

OBJECTIVE: This study was undertaken to report on the prevalence and management of late complications in twin-to-twin transfusion syndrome (TTTS) treated by laser therapy when both twins are alive 1 week after surgery. STUDY DESIGN: A total of 151 consecutive TTTS cases were treated by selective fetoscopic laser therapy. Cases in which both twins were alive 1 week after surgery were followed up with ultrasound and Doppler examination, including middle-cerebral artery peak systolic velocity measurement (MCA-PSV). RESULTS: In the 151 cases treated with laser, both twins were still alive 7 days after the procedure in 101 cases. Intrauterine death of 1 and both twins occurred in 7 and 1 cases, respectively. Recurrence of TTTS with the polyhydramnios-oligohydramnios sequence occurred in 14 (14%) cases. In another 13 (13%) cases, amniotic fluid remained normal in both sacs, but MCA-PSV increased above 1.5 MoM in 1 twin and decreased concomitantly below 0.8 MoM in the co-twin. This was related to anemia and polycythemia, respectively, and resulted from unidirectional feto-fetal blood transfusion, mainly from former recipients into former donors. Late complications were managed accordingly by repeat laser, amnioreduction, cord coagulation, intrauterine blood transfusion, or elective delivery. CONCLUSION: MCA-PSV Doppler measurements are useful in the follow-up of double survivors to detect and manage late complications after selective laser therapy.