Cases reported "Fetofetal Transfusion"

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1/13. Cord ultrasonic transection procedure for selective termination of a monochorionic twin.

    Placental vascular communications can present a life-threatening problem in monochorionic twins when one fetus has a lethal anomaly. Although selective feticide is the best option for salvaging the normal twin, techniques normally employed (i.e. intracardiac potassium, air embolism) are not prudent given the common circulatory system. Furthermore, in monoamniotic, monochorionic twin gestations it is important to transect the umbilical cord completely to prevent entanglement of the dead fetus around the cord of the normal twin. We present two cases of monochorionic twins in which the cords were transected with a harmonic scalpel under ultrasonic guidance via one trocar. The harmonic scalpel is an instrument which can simultaneously coagulate and cut blood vessels or tissues. The cord ultrasonic transection procedure is a novel, minimally invasive technique which offers several advantages over the methods currently used for selective feticide in discordant monochorionic twin gestations.
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2/13. Endoscopic documentation of unintentional perforation of the dividing membrane during amnioreduction for twin-twin transfusion syndrome.

    OBJECTIVE: The purpose of this report is to document endoscopically the occurrence of unintentional piercing of the dividing membrane in a monochorionic twin pregnancy with twin-twin transfusion syndrome (TTTS). MATERIALS AND methods: The dividing membrane was visualized endoscopically during laser therapy in a patient with TTTS who had previously undergone therapeutic amniocentesis. The donor twin had no visible bladder, but the amniotic fluid volume had normalized after amniocentesis. RESULTS: The suspected membrane perforation was identified endoscopically during laser surgery. Five areas of vascular communications were identified and photocoagulated. CONCLUSIONS: Sonographic evidence of normalization of the amniotic fluid volumes after therapeutic amniocentesis with persistent nonvisualization of the bladder of the donor twin should not be interpreted as a sign of improvement of TTTS, but rather as indirect evidence of unintentional perforation of the dividing membrane. This complication can be confirmed endoscopically.
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3/13. Operative fetoscopy via telesurgery.

    We describe a case in which telesurgical consultation from Tampa, florida, USA was used to accomplish operative fetoscopy in Santiago, chile for the treatment of a twin pregnancy involving an acardiac twin. The procedure was successful and a healthy infant was delivered at 37.5 weeks. Operative fetoscopy, a surgical approach to correct birth defects in utero via combined ultrasound and endoscopy, is only available in a handful of centers worldwide. Telesurgery makes use of telecommunication to allow a surgeon at a primary operating site to consult with another experienced surgeon for complex surgical cases. This case illustrates the potential for ultrasound and telesurgery to expand the horizons of operative fetoscopy.
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4/13. Spontaneous cessation of umbilical blood flow in the acardiac fetus of a twin pregnancy.

    The acardiac fetus is a rare entity found only in monozygotic multiple pregnancy. Although the acardiac fetus is non-viable, the perinatal mortality rate for the normal fetus may be as high as 50 per cent, and is usually associated with fetal heart failure and hydrops fetalis, or as the result of prematurity. In this communication, we describe a case of spontaneous cessation of blood flow to an acardiac fetus and discuss the management of this condition with special reference to optimizing the outcome for the normal fetus.
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5/13. Monopolar thermocoagulation in the management of acardiac twins.

    OBJECTIVE: To demonstrate the equipment setup and the application of monopolar thermocoagulation in the management of acardiac twins. methods: We described 2 cases of acardiac acephalus twins who developed congestive heart failure and polyhydramnios at 20 weeks of gestation. A monopolar wire electrode was inserted through a 14-gauge trocar under ultrasound guidance. The inter-twin circulation was interrupted and confirmed by color Doppler flow examination. RESULTS: Case 1 was detected at 20 weeks of gestation with progression to early signs of fetal congestive heart failure at 22 weeks. This case had smooth operative procedure and delivered a healthy infant at 32 weeks. Case 2 was referred at 24 weeks of gestation with marked fetal congestive heart failure. Although thermocoagulation cessed the inter-twin perfusion, the fetus died in utero 12 h later with persistent irreversible circulatory compensation. CONCLUSION: Monopolar thermocoagulation was an effective and generally available alternative technique to fetal endoscopic surgery for the interruption of vascular communication between acardiac twins.
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6/13. Comparison of pregnancy course and outcome with color and radiographic angiography of the placenta in a monochorionic triplet pregnancy.

    A patient with spontaneous monochorionic (MC) triamniotic triplet pregnancy developed symptoms of feto-fetal-transfusion-syndrome (FFTS) at 18 weeks of gestation with one donor (oligohydramnios) and one receptor (polyhydramnios) triplet. The patient "received" a diet enriched with proteins. Amniotic-fluid volume returned to normal after 24 weeks. At 32 weeks, a cesarean section was performed due to intra-uterine growth restriction of the donor triplet. Post partum color injection and computer angiograms showed arterio-arterial (AA) anastomoses between all triplets. Deep arterio-venous (AV) anastomoses between the two triplets who had demonstrated with oligo- and polyhydramnios between 18 and 26 weeks were revealed by computer angiography that were not seen by placental color angiogram. Detailed analysis of placental vascular communications by use of color injection angiogram of the chorionic plate and computer angiogram demonstrating deep anastomoses beneath the chorionic plate helps to understand the individual pathophysiology and clinical course in patients with FFTS, which is even more complex in MC triplet compared to MC twin pregnancies.
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7/13. Intravascular pancuronium bromide infusion for prenatal diagnosis of twin-twin transfusion syndrome.

    The diagnosis of twin-twin transfusion syndrome remains a problem. Intravascular infusion of pancuronium bromide, a nondepolarizing neuromuscular blocking agent, for the smaller of a set of twins demonstrated paralysis of both twins in one case. However, in a second case, paralysis was shown only in the smaller twin who demonstrated no transplacental vascular communications postnatally. We suggest that infusion of pancuronium bromide, 'pancuronium test', is a simple and safe method for confirming transplacental communications and aids in the diagnosis of twin-twin transfusion syndrome.
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8/13. A study on prognosis of surviving cotwin.

    It has been suggested that the surviving cotwin and the mother are seriously affected when intrautrine fetal death of one monozygotic twin occurs. Several authors have reported brain damage in the surviving twin coexisting in utero with dead monozygotic cotwin. Most of such instances are monochorionic and show vascular communication between paired twins in the placenta. In a total of 133 pairs of monochorionic twins, death of one twin during pregnancy occurred in 33 cases (24.8%). Of 33 surviving twins, 8 babies suffered from porencephaly, cerebral palsy and other abnormalities. More unfavorable prognosis was recognized when a cotwin died in the latter half of pregnancy, while when a monozygotic cotwin died in the early stage of pregnancy, the surviving twin uneventfully grew to term in most cases.
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9/13. Fetoscopic neodymium:YAG laser occlusion of placental vessels in severe twin-twin transfusion syndrome.

    Most pregnancies with severe twin-twin transfusion syndrome before 27 weeks' gestation result in perinatal death. Previous attempts at therapy have been generally unsatisfactory and rarely successful. We have developed a technique for intrauterine ablation of the vascular communications between the fetoplacental circulations with a fetoscopically directed neodymium:YAG laser. The operation was performed on three women at risk for pregnancy loss from acute hydramnios at 18.5, 22, and 22.5 weeks' gestation. The first two procedures were uneventful, but the third was complicated by a placental vessel perforation. The first two patients delivered at 27 and 34 weeks after premature rupture of membranes and spontaneous labor, whereas the third woman developed severe preeclampsia at 29 weeks which necessitated delivery. Four of the six infants survived. Clinical and ultrasonographic evidence, as well as pathologic examination of the placentas, suggested that stabilization or resolution of the syndrome was due to photocoagulation of the vascular communications. This initial experience suggests that fetoscopic laser occlusion of placental vessels is feasible and superior to previous therapies because it treats the underlying pathophysiology directly.
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10/13. Clinical pathology conference: acute twin-to-twin in utero transfusion.

    This clinical pathology conference discusses a case of monochoriontic twins with chronic twin-to-twin transfusion based on unequal venous return and a large arterial communication. polyhydramnios resulted in preterm labor, fetal distress, and a reversed acute twin-to-twin transfusion through the arterial shunt.
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