Twin reversed arterial perfusion sequence-a rare and dangerous complication form of monochorionic twins: A case report.

BACKGROUND: Twin reversed arterial perfusion (TRAP) sequence is an extremely rare congenital anomaly in monochorionic (MC) twins. The condition is characterized by a malformed fetus (acardiac twin) without cardiac activities being perfused by a structurally normal one (pump twin) via an artery-to-artery anastomosis in a reverse direction. CASE SUMMARY: We described the first case of TRAP to receive laser surgery in Vietnam. The 26-wk pregnancy was originally misdiagnosed in another hospital as MC twins with single intrauterine fetal death. Following admission to our center, the diagnosis was amended to a 26-wk TRAP sequence stage IIb. The acardiac twin was 7.5 cm at the longest length, the ratio of the weight of the acardiac twin to the weight of the pump twin was more than 90%, the pump twin showed fetal distress with absent diastolic flow in umbilical artery of pump twin, and the peak systolic velocity in the middle cerebral artery = 1.6 MoM. We performed emergency laser photocoagulation of the acardiac twin's umbilical cord. After surgery, we successfully maintained the pregnancy for 8 wk and ended it electively by cesarean section at 34 wk of gestation due to rupture of membranes. CONCLUSION: TRAP should be appropriately diagnosed and treated early to avoid complications of the pump twin. Fetoscopic laser photocoagulation is a new and effective treatment for this condition.

Fetoscopic Laser Ablation for the Selective Fetal Reduction in Twin-Twin Transfusion Syndrome Stage II-IV: The Experience of a New Fetal Medicine Center.

Objective: To evaluate the surgery outcomes of fetoscopic laser ablation (FLA) for selective umbilical cord in treating twin-twin transfusion syndrome (TTTS) with special conditions and neonatal outcomes post-operation. Methods: A prospective study, 21 monochorionic diamniotic (MCDA) twins diagnosed with TTTS stage II-IV according to Quintero classification from 16 to 26 weeks of gestation, among that, 12 cases of TTTS stage II with selective intrauterine growth restriction (sIUGR), 6 cases of TTTS stage II with proximate cord insertions, 3 cases of TTTS stage IV underwent fetoscopic laser ablation for the selective fetal reduction at Hanoi Obstetrics and Gynecology Hospital from September 2019 to July 2021. Complications and surgical outcomes were noted. Prenatal care was carried out every 2 weeks post operation until birth. Newborn neurologic complications were assessed at birth, three months, and six months after birth using Denver II test and magnetic resonance imaging (MRI). Results: The mean gestational age at operation was 20.30 weeks. The average operation duration was 39.52 minutes. No complications of operation, such as bleeding or infection, were recorded. The mean gestational age at birth was 34.70 ± 4.33 weeks, with a mean duration of 12.97 ± 6.87 weeks between intervention and delivery. The survival rate of newborns after the operation was 90.48%. There were two stillbirths (9.52%) within seven days after the operation. No short-term neurological complications have been reported with follow-up of the newborn to 6 months after birth. Conclusion: Our study showed that fetoscopic laser ablation of selected fetal reduction surgery for treatment of special conditions of TTTS had no complications of operation, high neonatal survival result (90.48%), no short-term neurological complications. This should be considered for TTTS in cases of indication.

Maternal vascular endothelial growth factor receptor and interleukin levels in pregnant women with twin-twin transfusion syndrome.

Twin-twin transfusion syndrome (TTTS) is an unusual and serious condition that occurs in twin pregnancies when identical twins share a placenta but develop discordant amniotic fluid volumes. TTTS is associated with an increased risk of fetal death and birth defects if untreated. This study investigated the soluble levels of biomarkers including growth factors and interleukins in pregnant women with and without TTTS during pregnancy. We quantified plasma levels of VEGF-R1, VEGF-R2, IL-1ß, IL-6 and IL-8 in twin pregnant women with (n=53) and without TTTS (n=72) and in women with single pregnancy (n=30) by ELISA and analyzed the association of maternal circulating biomarker levels with TTTS. Our results showed that maternal VEGF-R1 levels were significantly higher in twins compared to single pregnancy (P<0.05) and were decreased in the second trimester compared to the first trimester (P = 0.065, 0.019 and 0.072 for twins with and without TTTS and single pregnancy, respectively). VEGF-R2 levels had a trend to be lower in twins compared to single pregnancy. In addition, soluble VEGF-R1 and VEGF-R2 levels were significantly decreased while IL-6 levels were increased after surgical treatment with laser in twin pregnant women with TTTS (P = 0.016, 0.041 and 0.04, respectively). These results suggest that IL-6, VEGF-R1 and VEGF-R2 are involved in vascular regulation and stabilization in twin pregnancies and may contribute to the pathogenesis of TTTS and thus play a prognostic role in the surgical treatment of TTTS.