Roles of venovenous anastomosis and umbilical cord insertion abnormalities in birthweight discordance in monochorionic-diamniotic twin pregnancies without twin-twin transfusion syndrome.

AIM: We evaluated risk factors for birthweight discordance in monochorionic diamniotic (MCDA) twin pregnancies without twin-twin transfusion syndrome (TTTS). METHODS: We investigated all MCDA twin placentas injected with colored dye at our institution between 2007 and 2015. We excluded pairs of twins with TTTS, fetal demise, or severe fetal malformation. All pairs of twins were assigned to the discordant group (birthweight discordance ≥ 25%) or the concordant group (birthweight discordance < 25%). In each pair of twins, we described vascular anastomoses as either arterioarterial, venovenous (VV), or arterial-venous, and abnormal umbilical cord insertion as either marginal or velamentous. We also recorded placental sharing discordance. RESULTS: A total of 150 placentas were analyzed. The incidence of VV anastomosis in the discordant group (40%) was significantly higher than that in the concordant group (12%, P = 0.005). Unilateral abnormal umbilical cord insertion was significantly more common in the discordant group (85%) than in the concordant group (38%, P < 0.001). Placental sharing discordance was seen more frequently in the discordant group than in the concordant group. Multiple logistic analysis revealed that VV anastomosis (odds ratio: 4.7; 95% confidence interval: 1.2-18.6, P < 0.01) and unilateral abnormal umbilical cord insertion of the smaller twin (odds ratio: 5.7; 95% confidence interval: 1.4-22.9, P < 0.01) were independent risk factors for birthweight discordance. CONCLUSION: VV anastomoses and unilateral abnormal umbilical cord insertion of the smaller twin are independent risk factors for birthweight discordance in MCDA twin pregnancies without TTTS.

Valosin-containing protein-interacting membrane protein (VIMP) links the endoplasmic reticulum with microtubules in concert with cytoskeleton-linking membrane protein (CLIMP)-63.

The distribution and morphology of the endoplasmic reticulum (ER) in mammalian cells depend on both dynamic and static interactions of ER membrane proteins with microtubules (MTs). Cytoskeleton-linking membrane protein (CLIMP)-63 is exclusively localized in sheet-like ER membranes, typical structures of the rough ER, and plays a pivotal role in the static interaction with MTs. Our previous study showed that the 42-kDa ER-residing form of syntaxin 5 (Syn5L) regulates ER structure through the interactions with both CLIMP-63 and MTs. Here, we extend our previous study and show that the valosin-containing protein/p97-interacting membrane protein (VIMP)/SelS is also a member of the family of proteins that shape the ER by interacting with MTs. Depletion of VIMP causes the spreading of the ER to the cell periphery and affects an MT-dependent process on the ER. Although VIMP can interact with CLIMP-63 and Syn5L, it does not interact with MT-binding ER proteins (such as Reep1) that shape the tubular smooth ER, suggesting that different sets of MT-binding ER proteins are used to organize different ER subdomains.

Incidence of spontaneous twin anemia-polycythemia sequence in monochorionic-diamniotic twin pregnancies: Single-center prospective study.

AIM: The purpose of this study was to prospectively estimate the incidence of spontaneous twin anemia-polycythemia sequence (TAPS) in monochorionic-diamniotic twin pregnancies. METHODS: We prospectively examined umbilical cord hemoglobin (Hb) and reticulocyte count of consecutive monochorionic-diamniotic twin pregnancies delivered at Seirei Hamamatsu General Hospital from December 2006 to September 2013. We excluded cases of twin-twin transfusion syndrome, intrauterine fetal demise, and missing data (Hb and reticulocyte count missing from the medical record). TAPS was diagnosed using the postnatal criteria of intertwin Hb difference >8.0 g/dL and reticulocyte count ratio >1.7. Acute feto-fetal hemorrhage was defined as Hb difference >7 g/dL and reticulocyte count ratio <1.7. RESULTS: A total of 185 monochorionic-diamniotic twin pregnancies were included in this study. Three fulfilled the diagnostic criteria for postnatal TAPS, and one fulfilled the diagnostic criteria for acute feto-fetal hemorrhage. CONCLUSION: The incidence of spontaneous TAPS in monochorionic-diamniotic twin pregnancies was 1.6% (3/185) at Seirei Hamamatsu General Hospital.

The use of amniotic fluid discordance in the early second trimester to predict severe twin-twin transfusion syndrome.

INTRODUCTION: The appropriate effectiveness of inter-twin amniotic fluid discordance (AFD) in the early second trimester for the prediction of severe twin-twin transfusion syndrome (TTTS) was evaluated. MATERIALS AND METHODS: The largest AFD between 16 and 18 weeks' gestation was analyzed in correlation with TTTS development defined by polyhydramnios with a maximum vertical pocket (MVP) ≥8 cm combined with oligohydramnios with a MVP ≤2 cm using the receiver operating characteristics curve. All pregnancies were stratified according to an AFD cutoff, and perinatal outcomes were compared between two groups. RESULTS: A total of 223 twin monochorionic pregnancies met the inclusion criteria and 20 patients (8.9%) developed TTTS. An AFD ≥4 cm was calculated to be the optimal point of demarcation to predict subsequent TTTS. The sensitivity and specificity of this AFD cutoff for the development of TTTS were 70 and 97%, respectively. An AFD ≥4 cm was associated with a significantly increased risk of the development of TTTS (70 vs. 2.9%; p < 0.01). Those pregnancies with AFD tended to deliver at an earlier gestational age and were also significantly associated with intrauterine fetal deaths. DISCUSSION: The AFD between monochorionic diamniotic twins in the early second trimester may be useful for the prediction of severe TTTS development.

Perinatal outcome of monochorionic twins with selective intrauterine growth restriction and different types of umbilical artery Doppler under expectant management.

OBJECTIVES: To evaluate the prognosis of monochorionic twins with selective intrauterine growth restriction (sIUGR), classified according to the type of umbilical artery Doppler, under expectant management. METHODS: The outcome of 81 cases with isolated sIUGR was evaluated according to a classification based on umbilical artery (UA) Doppler diastolic flow in the IUGR twin (I: present, II: constantly absent/reverse, III: intermittently absent/reverse). Selective feticide was not considered due to legal constraints. Perinatal outcomes included perinatal death and neurological outcome at 6 months of age. RESULTS: From 81 cases with the diagnosis of sIUGR, twin-twin transfusion was diagnosed in 18 cases. This left 63 cases, of which 23 were classified as type I (36.5%), 27 as type II (42.9%) and 13 as type III (20.6%). Intrauterine death occurred in 4.3% (1), 29.6% (8) and 15.4% (2) among IUGR twins, and 4.3% (1), 22.2% (6) and 0.0% (0) among larger twins. Neonatal death occurred in 0.0% (0), 18.5% (5) and 0.0% (0) among IUGR twins, and 0.0% (0), 11.1% (3) and 23.0% (3) among larger twins. Neurological abnormalities at 6 months were found in 4.3% (1), 14.8% (4) and 23.1% (3) in smaller twins and 0.0% (0), 11.1% (3) and 38.5% (5) in larger twins, respectively. Intact survival at 6 months was recorded in 91% (21), 37% (10) and 61% (8) in smaller twins and 95% (22), 55% (15) and 38% (5) in larger twins, respectively. CONCLUSION: The outcome in monochorionic twins with sIUGR and abnormal umbilical artery Doppler is poor under expectant management. Normal Doppler seems to be associated with a good prognosis.

The roles of superficial anastomoses in twin-twin transfusion syndrome.

OBJECTIVE: We aimed to evaluate whether types of vascular anastomoses affect fetal demise (FD) in twin-twin transfusion syndrome (TTTS) after fetoscopic laser photocoagulation (FLP). METHODS: All TTTS patients who underwent FLP in our institution from 2005 to 2017 were included. We described vascular anastomoses during FLP as either arterio-arterial (AA), veno-venous (VV), or arterial-venous (AV), and abnormal fetal Doppler waveforms before FLP. We also analyzed risk factors for FD following FLP. RESULTS: In total, 184 TTTS placentas following FLP were analyzed (36 cases of donor-only FD, 12 cases of recipient-only FD, 3 cases of double FD, and 133 cases of both alive). AA anastomoses prevalence, absent or reverse end-diastolic velocity of umbilical artery (UAAREDV) of donor before FLP, gestational age at the time of FLP and operation time of FLP were independent risk factors for donor FD. VV anastomoses prevalence and UAAREDV of recipient before FLP were independent risk factors for recipient FD. VV anastomoses prevalence was higher in double FD cases than in FD of one twin or both alive (p = 0.002). AV anastomoses number and number of cases with more AV anastomoses from donor to recipient were not significantly different between FD and non-FD cases. DISCUSSION: AA anastomoses are associated FD of the donor following FLP and may protect the donor from hypovolemia before FLP. VV anastomoses are detected more frequently in FD of the recipient and double FD placentas following FLP and may rescue hypervolemia of the recipient or circulations of both fetuses before FLP.

Embryo transfer is a risk factor for severe postpartum hemorrhage and blood transfusion requirement.

PURPOSE: This study aimed to investigate the risk factors for severe postpartum hemorrhage (PPH) and blood transfusion requirement that are recognizable during any period of pregnancy. MATERIALS AND METHODS: We retrospectively reviewed the medical data of 4829 pregnant women who received care and delivered at our institution between July 2010 and March 2015. The cohort was divided into patients with and without severe PPH. Multivariate logistic regression analysis was performed to assess risk factors associated with severe PPH. The same analysis was repeated for blood transfusion requirement. RESULTS: A total of 127 (2.7%) patients had severe PPH and 43 (0.87%) required blood transfusion. The multivariate logistic regression analysis demonstrated that embryo transfer (odds ratio [OR] 2.6; p < .001), uterine myoma (OR 2.0; p < .01), prior uterine surgery (OR 1.9; p = .03), prior cesarean section (OR 1.8; p = .01), and maternal age (OR 1.5; p = .03) were independent risk factors for severe PPH. Embryo transfer was an independent risk factor for blood transfusion requirement (OR 3.1, p < .001). CONCLUSIONS: Embryo transfer is a risk factor for both severe postpartum hemorrhage and blood transfusion requirement.

Repeat epidural blood patch at the level of unintentional dural puncture and its neurologic complications: a case report.

BACKGROUND: Autologous epidural blood patch (AEBP) is effective for post-dural-puncture headache (PDPH). In some cases, repeat procedures are required for complete cure. In rare instances, severe adverse effects can occur. We present a case of neurologically complicated AEBPs, one of which was performed at the interspace of unintentional dural puncture (UDP). CASE PRESENTATION: A 40-year-old primigravida sustained UDP at the L2-3 interspace during combined spinal-epidural anesthesia for a scheduled cesarean section. She developed PDPH and underwent a single AEBP at L3-4. The PDPH recurred and she required another AEBP at L2-3, after which she reported radicular pains. A diagnosis of subdural hematoma and adhesive arachnoiditis was made. Her symptoms partially resolved in the following months. CONCLUSION: It may be prudent to reconsider the use of repeated AEBP and to avoid the interspace of UDP. A thorough evaluation is warranted to exclude treatable lesions when adverse effects occur.

Transitory increase in middle cerebral artery peak systolic velocity of recipient twins after fetoscopic laser photocoagulation for twin-twin transfusion syndrome.

OBJECTIVE: It was the aim of this study to elucidate the clinical features of recipient twins with increased middle cerebral artery peak systolic velocity (MCA-PSV) after fetoscopic laser photocoagulation (FLP) for twin-twin transfusion syndrome. METHODS: Serial Doppler velocimetry of the MCA was performed in 30 recipient twins before and after FLP. Clinical data and perinatal outcome were compared between cases with and without increased MCA-PSV. RESULTS: Increased MCA-PSV was observed in 7 recipients (23.3%) within 14 days after FLP. MCA-PSV gradually decreased to <1.5 multiples of median in 6 recipients; however, 1 patient resulted in fetal demise subsequent to the demise of the co-twin. The incidences of fetal and neonatal demise and neurological morbidity were similar. No recipient was diagnosed as anemic at birth. CONCLUSIONS: The increase in MCA-PSV in recipients following FLP appeared to be generally transitory; this differs from twin anemia-polycythemia sequence.

Osteogenesis imperfecta IIC caused by a novel heterozygous mutation in the C-propeptide region of COL1A1.

Osteogenesis imperfecta IIC (OI IIC), which is a rare variant of lethal OI that has been considered to be an autosomal recessive trait, is characterized by twisted, slender long bones with dense metaphyseal margins. Here, we report a typical case of OI IIC caused by a novel heterozygous mutation in the C-propeptide region of COL1A1. OI IIC seems to be caused by a dominant mutation of COL1A1.

Perinatal magnetic resonance fetal lung volumetry and fetal lung-to-liver signal intensity ratio for predicting short outcome in isolated congenital diaphragmatic hernia and cystic adenomatoid malformation of the lung.

AIM: To evaluate the usefulness of magnetic resonance imaging (MRI) in predicting the risk of lethal pulmonary hypoplasia in fetuses. METHODS: The subjects consisted of 15 fetuses (29-40 weeks' gestation), including fetuses with major malformation diagnosed on prenatal ultrasonography. MRI using a 1.5 T magnet and half-Fourier acquisition single-shot fast spin-echo sequences were applied to all fetuses at 29-36 weeks. Fetal lung-to-liver signal intensity ratio (LLSIR) was calculated by medians of region-of-interest analysis; estimated fetal bodyweight (FBW), by ultrasonography; and estimated fetal lung volume (FLV), by planimetric measurement of total lung volume. FLV/FBW was also calculated. The presence of the pulmonary hypoplasia in neonates was identified based on clinical and anatomico-pathological findings. Differences in LLSIR and FLV/FBW were analyzed for surviving and non-surviving neonates. RESULTS: Ten surviving neonates had a median LLSIR of 3.00, range: 1.60-4.40, while that in seven non-surviving neonates was 2.21, range: 0.70-3.72; no significant difference was found between the groups. Surviving neonates had a median FLV/FBW of 11.4, range: 7.1-15.7, while that in non-surviving neonates was 4.4, range: 3.1-5.7. FLV/FBW in non-surviving neonates was significantly lower than that of the FLV/FBW for surviving fetuses (P<0.05). CONCLUSIONS: Low FLV/FBW may be useful in prenatally predicting mortality in fetuses with pulmonary hypoplasia.

Stage Ia1 cervical squamous cell carcinoma: conservative management after laser conization with positive margins.

OBJECTIVE: Cone margin status has been reported to be the most important predictor of recurrent disease in patients with cervical intraepithelial neoplasia (CIN) undergoing cervical conization. Our purpose was to evaluate the conservative management of selected patients with microinvasive (FIGO stage Ia1) squamous cell carcinoma who have been treated by cervical conization with positive margins. METHODS: Twenty-seven patients underwent KTP laser conization and vaporization for stage Ia1 squamous cell carcinoma followed by careful observation. Involved margins were diagnosed if CIN III or more was present at the ectocervical or endocervical margin and 7 patients formed the basis of the present study. Follow-up consisted of cytology, histology, and pelvic examination. Disease recurrence was defined as a histology diagnosis of CIN III or more on colposcopically directed biopsy or endocervical curettage. RESULTS: The endocervical margins were involved by carcinoma in situ in seven (26%) patients. No ectocervical margin involvement was detected. No lymph-vascular space involvement (LVSI) and confluent invasion were seen. All seven patients were free of recurrent disease during median follow-up of 4.0 (range 2.3-7.6) years. CONCLUSION: These results suggest that laser conization and vaporization may be a reasonable treatment option in patients with microinvasive (FIGO Stage Ia1) squamous cell carcinoma despite positive cone margins without invasive disease when LVSI is not demonstrated.