Twin reversed arterial perfusion sequence in twin‐to‐twin transfusion syndrome after the death of the donor co‐twin in the second trimester

Abstract

A twin-to-twin transfusion syndrome was diagnosed in a monochorionic-diamniotic pregnancy at 18 weeks' gestation without any malformation, especially heart defect. In spite of the aggressive treatment (serial amnioreduction, digoxin treatment) the donor twin died at 25 weeks and twin reversed arterial perfusion (TRAP) sequence developed and was documented by Doppler ultrasound. In the TRAP-twin, the route of the reversed blood flow from the umbilical arteries was as follows: descending aorta, aortic arch, ascending aorta, aortic valve, left ventricle, mitral valve, left atrium, foramen ovale, right atrium, inferior vena cava, ductus venosus; and back to the placenta through the umbilical vein. After a 12-h observation period the twin reversed arterial perfusion sequence disappeared. During this period ultrasound and fetal blood sampling revealed no sign of fetal anemia or disseminated intravascular coagulation in the surviving twin. Based on our observations, we propose, that the death of one of the twins in monochorionic pregnancy can result in twin reversed arterial perfusion sequence, which is an ultimately rare phenomenon in the second trimester. To our knowledge, this is the first reported case of twin reversed arterial perfusion sequence subsequent to the intrauterine demise of one twin in twin-to-twin transfusion syndrome in which the TRAP-twin had no cardiac malformation.

Successful Intrauterine Management of Severe Feto-Fetal Transfusion in a Monochorionic Triplet Pregnancy Using Bipolar Umbilical Cord Coagulation

“…Demise of the 1st triplet presumably resulted in intrauterine injury of the smaller surviving triplet who may have been the recipient at this time. Ventriculomegaly can be considered a marker of neurologic injury sustained during a period of hypotension due to reversed arterial perfusion following this demise [10]. After the 1st triplet died in utero, ongoing vascular disequilibrium established the surviving smaller triplet as the donor and the larger triplet as the recipient of this transfusion syndrome.…”

Perimortem Demonstration and Treatment of Recipient-to-Donor Transfusion in Monochorionic-Diamniotic Twin Gestation

“…Cordocentesis in the surviving recipient twin at 1 and 2 h confirmed a nonacidotic fetus with normal hemoglobin suggesting a net balance in the types of placental anastomoses. Delivery subsequently occurred at 30 weeks after premature rupture of membranes [2] .…”

First Trimester Twin-to-Twin Transfusion Syndrome in a Trichorionic Quadruplet Pregnancy – A Diagnostic Challenge

“…However, selective fetocide was favored in our case in view of the morbidity and mortality of high-grade multiple pregnancies in addition to the poor outcome of severe TTS. Excellent outcomes of quadruplets and triplets reduced to twins have recently been published, proposing similar pregnancy results for reduced versus non-reduced twins [12], We chose expectant management after a single intracardiac injection of the donor, as the recipient most probably also dies due to the transfer of potassium chloride through placental vascular anastomoses, or in some cases due to acute transfusion of the survivor into the demised twin, resulting in a 50% mortality [13]. In most of these cases a second injection increasing the risk of premature rupture of membranes can therefore be avoided.…”