Dispelling Myths about Antenatal TAPS: A Call for Action for Routine MCA-PSV Doppler Screening in the United States

Abstract

In the United States, routine middle cerebral artery peak systolic velocity (MCA-PSV) Doppler screening for the detection of antenatal twin anemia-polycythemia sequence (TAPS) is not recommended. The current and only national clinical guideline from the highly-influential Society for Maternal-Fetal Medicine states that, “There is no evidence that monitoring for TAPS with MCA PSV Doppler at any time, including > 26 weeks, improves outcomes, so that this additional screening cannot be recommended at this time.” We argue this recommendation has disproportionate influence on patients and the care they are offered and receive. We use current evidence to highlight and dispel pervasive myths surrounding antenatal TAPS and the value of routine MCA-PSV screening. An ethical framework that illustrates the importance of giving patients the opportunity for routine screening is presented. Findings demonstrate that: (1) both spontaneous and post-laser TAPS is a serious, potentially life-threatening complication, (2) treatment for TAPS is effective and includes expectant management, intrauterine transfusion (IUT), or surgery, (3) and routine MCA-PSV, which has satisfactory diagnostic accuracy, is currently the only way to provide early detection of TAPS. We conclude that routine TAPS screening is a medically proven valuable resource that should be offered to patients in need and to the clinicians who are trying to act toward their benefit.

Middle Cerebral Artery Doppler Velocimetry for the Diagnosis of Twin Anemia Polycythemia Sequence: A Systematic Review

“…The primary search of the Pubmed, Embase, and SCOPUS databases produced 432 publications. Based on abstract review, 54 of these publications were selected to be reviewed in their entirety [1,2,4,5,7,[9][10][11][12]16,19,. The secondary search of bibliographies produced three additional publications which were also reviewed in their entirety for a total 57 publications [6,66,67].…”

“…The primary search of the Pubmed, Embase, and SCOPUS databases produced 432 publications. Based on abstract review, 54 of these publications were selected to be reviewed in their entirety [ 1 , 2 , 4 , 5 , 7 , 9 , 10 , 11 , 12 , 16 , 19 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 ]. The secondary search of bibliographies produced three additional publications which were also reviewed in their entirety for a total 57 publications [ 6 , 66 , 67 ].…”

“…Since 2013, TAPS has received considerable attention in the literature and the first randomized clinical trial for treatment of TAPS is currently underway [15]. Following these developments, there has been increased enthusiasm for screening protocols utilizing serial MCA Doppler velocimetry [16].…”

Consensus diagnostic criteria and monitoring of twin anemia–polycythemia sequence: Delphi procedure

“…However, robust evidence of improved perinatal outcome when TAPS is diagnosed antenatally does not yet exist. Nevertheless, this dearth of evidence should not translate into a recommendation by national guidelines not to monitor twin pregnancies for the development of TAPS, particularly in monochorionic twin pregnancies complicated by TTTS and treated by fetoscopic laser, for which the development of TAPS and its associated adverse outcomes is well described 19 .…”

Monochorionic Twins: A Delicate Balance

“…In the United States, routine Doppler screening for the detection of TAPS is not recommended. Nicholas et al argue that routine TAPS screening is a medically proven valuable resource that should be offered to all patients with MC twin pregnancies [12]. Although the optimal antenatal screening strategy remains to be established, an increasing body of work clearly shows that TAPS is associated with a high risk of perinatal mortality and morbidity and long-term sequelae, warranting increased scrutiny in the antenatal period as well as postnatally [13].…”