Premium
Fetoscopic cord transection for treatment of monoamniotic twin reversed arterial perfusion sequence
Author(s) -
Prefumo F.,
Fichera A.,
Zanardini C.,
Frusca T.
Publication year - 2014
Publication title -
ultrasound in obstetrics and gynecology
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 3.202
H-Index - 141
eISSN - 1469-0705
pISSN - 0960-7692
DOI - 10.1002/uog.13229
Subject(s) - medicine , umbilical cord , cord , monochorionic twins , surgery , obstetrics , anesthesia , pregnancy , fetus , anatomy , genetics , biology
We read with interest two articles discussing the role and timing of intrafetal procedures, particularly interstitial laser therapy, for the treatment of twin reversed arterial perfusion (TRAP) sequence1,2. In both case series and in the systematic review by Pagani et al.1, no case appeared to involve a monoamniotic twin pregnancy. However, approximately 3−4% of cases of TRAP sequence are monoamniotic3. Since the umbilical cord of the parasitic twin is often very short, this does not usually affect treatment modality. However, when the cord is long enough to allow cord entanglement with the pump twin, this can pose a major challenge. Although cord entanglement per se is not associated with increased risk of complications in monoamniotic pregnancies4, occlusion of blood flow to the abnormal twin may be associated with increased risk of intrauterine death of the surviving twin and has been described as a cause of intrauterine demise in TRAP sequence5. It is possible that the unperfused cord undergoing involution may easily act as a band constricting the cotwin’s cord more than a normally perfused cord with an adequate amount of Wharton’s jelly. To avoid such risks, it is feasible to transect the umbilical cord with laser after its occlusion, thus allowing release of the entanglement; this has been reported in only one case of TRAP sequence5. We describe here two further cases of TRAP sequence in monoamniotic twin pregnancies with cord entanglement (Figures 1 and 2), treated by fetoscopic laser cord coagulation and transection. Procedures were performed between March 2012 and March 2013, both with a single-entry technique using a 2-mm fetoscope inserted under ultrasound guidance in the amniotic cavity through a sheath with an outer diameter of 3 mm (Karl Storz, Tuttlingen, Germany). The umbilical cord of the parasitic Figure 1 Ultrasound image of Case 1 at 23 + 2 weeks, showing entanglement of the two cords (long arrow) and a very short length of free parasitic twin umbilical cord at abdominal insertion (short arrow). Asterisk indicates the parasitic twin.