Perinatal Outcome of Conservative Management versus Fetal Intervention for Twin Reversed Arterial Perfusion Sequence with a Small Acardiac Twin

Abstract

Objective: To examine the outcomes of patients with twin reversed arterial perfusion (TRAP) sequence in which the acardiac twin was ≤50% the weight of the pump twin. Methods: This was a retrospective study conducted with institutional review board approval. The records of all patients referred to UCSF for suspected diagnosis of TRAP between 1994 and 2009 were reviewed (n = 76). Patients with pregnancies complicated by TRAP with an acardiac twin ≤50% the weight of the pump twin were included (21 patients). Exclusion criteria were loss to follow-up (1 patient) and syndromic abnormalities in the pump twin (2 patients). Results: Of the 18 patients with viable pregnancies that met the criteria for analysis, 7 (39%) underwent radiofrequency ablation (RFA) of the acardiac twin and 11 (61%) underwent conservative management. None of the pump twins in either group had hydrops fetalis. Three of the 11 acardiac twins in the conservative management group did not undergo RFA because they did not have blood flow at presentation to UCSF. Survival to delivery was 100% (7/7) in the RFA group and 91% (10/11) in the conservative management group. When we eliminated from our analysis the 3 pregnancies in the conservative management group without blood flow to the acardiac twin, survival to delivery was 88% (7/8). The single death occurred in 1 of the 3 monochorionic-monoamniotic pregnancies in the conservative management group, all of whom had blood flow to the acardiac twin. There were no statistically significant differences in gestational age at delivery, birth weight or survival between the RFA and conservative management groups, even after stratification by blood flow. Conclusions: Conservative management with close monitoring appears to be a safe option for TRAP pregnancies in which the acardiac twin is ≤50% the weight of the pump twin.

Perinatal outcome of twin reversed arterial perfusion sequence: A single center's experience

“…Our study shows that 8 of the 11 pump twins who were treated with RFA (73%) survived without complications. Although this survival rate is lower in comparison with other studies, which are 92%, 86%, 94%, 100%, respectively [7,[9][10][11], our results are worthwhile as the first and largest series performed in Korea. There are only 2 other case reports in Korea on the successful use of in utero intervention to manage the TRAP sequence.…”

“…The second series by Livingston et al [10] demonstrated that using a 19-gauge needle resulted in only 1 of 13 cases (8%) that were treated with RFA to be delivered in less than 32 weeks due to PPROM. Although no details regarding preterm delivery were noted in the latest series, the authors reported a 100% survival rate for their 7 RFA cases [11]. Along with the development of these instruments, RFA has become known as a safe and effective treatment modality.…”

“…Although from this result, Tan and Sepulveda [8] suggested the possibility that membrane ruptures and preterm delivery are associated with the use of the larger devices than other modalities (e.g., alcohol ablation, monopolar diathermy, and interstitial laser), the morbidity related to RFA was not accepted as the only series reported at that time. Since then, 3 more series have been published on the efficacy of RFA [7,10,11]. Lee et al [7] reported an update to their initial experiences.…”

A case report of twin reversed arterial perfusion sequence with expectant management

“…2 The conservative approach can be considered if the acardiac fetus is small, its growth is rather slower and the pump fetus has no complications. 8,9 Yet expectant management can yield to perinatal mortality due to the development of heart failure or preterm delivery as shown in a case series of Pagani et al 10 It's controversial whether conservative management or therapeutic treatment is better in TRAP-sequence. It seems appropriate to choose an interventional approach in the cases of hydrops, polyhidroamnios and abnormal vascular anastomosis.…”

Conservative management in a case of uncomplicated trap sequence: a case report and brief literature review

“…These techniques partly target the umbilical cord vessels using coil occlusion ligation, laser coagulation or bipolar coagulation. Other methods are aimed at the intrafetal umbilical vessels using alcohol injection, thermocoagulation, laser coagulation, radiofrequency or, very recently, high-intensity focused ultrasound (22). Laser coagulation of the vascular anastomoses on the placental surface has been proven as an effective and safe measure in many studies and case reports (23).…”