Fetofetal transfusion syndrome: do the neonatal criteria apply in utero?

Abstract

Thirteen fetuses (five twin, one triplet) were compromised by fetofetal transfusion syndrome in six pregnancies, five in the mid trimester, and one in the third trimester. This diagnosis, which was suspected because of ultrasound findings of discordant growth, discordant amniotic fluid volumes, concordant external genitalia, and monochorial placentation, was confirmed postnatally in each. Nine fetuses underwent blood sampling to aid diagnosis and assessment of fetal welibeing. In contrast to fetofetal transfusion syndrome investigated postnatalHy, a difference in haemoglobin concentration of 50 g/l or more in utero was found in only one pregnancy, which was near term, although ali had fetal erythroblastaemia and a difference in weight of 20% or more. In vivo confirmation of shared circulation was achieved in two pregnancies by transfusing adult Rh negative red celis into the smaller fetus and then detecting them by Kleihauer testing in blood aspirated from the larger. Invasive procedures also yielded information on fetal blood gas measurements (acidaemia in four and hypoxaemia in six) and amniotic pressure (raised in two). We suggest that comparison of haemoglobin concentrations is inaccurate in fetofetal transfusion syndrome in utero, the diagnosis of which may necessitate detection of a shared circulation using a marker such as adult red celHs.

Paradoxic Activation of the Renin-Angiotensin System in Twin-Twin Transfusion Syndrome: An Explanation for Cardiovascular Disturbances in the Recipient

“…Amnioreduction, by reducing intra-amniotic pressure (33), improves uteroplacental perfusion (32) and thus presumably also perfusion in the umbilical vein and eventually the renal arteries of the donor, inducing a resumption of urine output (34). Because of the frequency of velamentous insertion (22), the donor's umbilical cord is likely to be particularly susceptible to changes in pressure.…”

Twin-to-twin transfusion syndrome: a case report. Antepartum prediction of underlying placental vascular pattern in monochorionic twin pregnancies may be possible

“…1,2 A l though the syndrome has recei ved much attenti on si nce Schatz's publ i cati ons 3 more than a century ago, i ts underl yi ng pathophysi ol ogy i s poorl y understood and di agnosti c cri teri a are not unequi vocal l y agreed. 4 Neonatal cri teri a as formul ated by Bl i ckstei n 5 may not appl y in utero. A s a consequence, antenatal treatment i s surrounded by controversy.…”

Maternal metabolic abnormalities in twin–to–twin transfusion syndrome at mid–pregnancy

“…1 The pathophysi ol ogy i s l i nked to pl acental vascul ar anastomoses betw een monochori oni c (M C) monozygous tw i ns. 2 How ever, TTTS i s consi dered by some to be poorl y understood 3 or eni gmati c 4 due to the l ack of cl assi c fi ndi ngs (hematocri t and w ei ght di fferences) i n the twins, 5 the inability to document transfusion of bl ood in vivo betw een the tw i ns i n each case, 3,6,7 the w i de and unpredi ctabl e cl i ni cal fl uctuati ons, 8 and the di ffi cul ty rel ati ng cl i ni cal outcome di rectl y to pl acental fi ndi ngs. 9 Despi te these concerns, the syndrome conti nues to affect approxi matel y 15% of previ abl e M C tw i ns w here hi gh morbi di ty and mortal i ty rates are seen both w i th and w i thout therapeuti c i nterventi ons.…”