Recurrence of twin-to-twin transfusion syndrome (TTTS) after fetoscopic laser coagulation (FLC) of placental anastomoses is unfavorable complication. Multiparous woman 34 years old in TTTS stage 2 was performed FLC of 8 arteriovenous anastomoses of the placenta followed by amnioreduction of 1000 ml on the gestational age of 22 weeks and 2 days. At gestational age of 24 weeks 6 days was revealed a recurrence of the TTTS, with considerable polyhydramnion of recipient and anhydramnion of the donor, a repeated FLC of 5 residual placental anastomoses was performed and amnioreduction of 2000 ml at 25 weeks 1 day of gestation. On the fifth day was normalized the amount of amniotic fluid of both fetuses. At 32 weeks of gestation spontaneously was began the birth, the weights of newborns were 1560 and 1600 g, both had Apgar score 8/9. Respiratory therapy continued for 7 hours at the second newborn and for 13 hours at the first newborn girl after transferring to the ICU. The signs of the respiratory failure were not observed. There were no differences between complete blood counts. This clinical case confirms the possibility of effective correction of recurrence TTTS with the help of repeated FLC of placental anastomoses.
Congenital diaphragmatic hernia is a condition characterized by a defect in the diaphragm that leads to protrusion of abdominal contents into the thoracic cavity interfering with normal development of the fetal lungs. The defect may range from a small aperture in the posterior muscle rim to complete absence of the diaphragm. The pathophysiology of congenital diaphragmatic hernia is a combination of lung hypoplasia and immature birth associated with persistent pulmonary hypertension of the newborn and cardiac dysfunction. Prenatal assessment of the lung-to-head ratio and the position of the liver (presence or absence of a liver lobe in the chest) by ultrasound are used to diagnose and predict outcomes. Delivery of infants with congenital diaphragmatic hernia is recommended close to term gestation. Immediate management at birth includes bowel decompression, avoidance of mask ventilation and endotracheal tube placement if required. The primary focus of management includes gentle ventilation of the lungs, hemodynamic monitoring and treatment of pulmonary hypertension, followed by preparation for surgery only after stabilization of the newborns condition. Although the US Food and Drug Administration do not approve inhaled nitric oxide, it is commonly used to treat persistent pulmonary hypertension of the newborn induced by congenital diaphragmatic hernia. Extracorporeal membrane oxygenation is usually considered after failure of standard resuscitative interventions in neonates with congenital diaphragmatic hernia born at 34 weeks of gestational age or with body weight 2 kg and no associated gross fetal anomalies. Multiple factors such as premature birth, congenital anomalies, severity of pulmonary hypertension, type of postpartum recovery, and the need for extracorporeal membrane oxygenation affect the overall survival of infants with congenital diaphragmatic hernia. Thanks to advances in the management of patients with congenital diaphragmatic hernia, overall survival has increased, reaching 7090 %, and with the use of extracorporeal membrane oxygenation up to 50 %.
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