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Monochorionic diamniotic twin pregnancy with selective fetal growth restriction Type II: sonographic and fetoscopic findings of poor prognosis
Author(s) -
Gil Guevara E.,
Bower S.,
Nicolaides K. H.
Publication year - 2017
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.17369
Subject(s) - ductus venosus , medicine , monochorionic twins , obstetrics , fetus , twin pregnancy , twin to twin transfusion syndrome , intrauterine growth restriction , fetal circulation , pregnancy , anastomosis , gestational age , gestation , fetoscopy , prenatal diagnosis , placenta , surgery , genetics , biology
Monochorionic diamniotic (MCDA) twin pregnancies pose a challenge for the fetal medicine specialist in terms of diagnosis and management, largely attributable to complications arising from a shared placental circulation. About 95% of MC twins have vascular anastomoses on the placental surface that connect the two circulations. The almost continuous blood exchange between these twins accounts for unique complications, including twin-to-twin transfusion syndrome, twin anemia–polycythemia sequence and twin reversed-arterial perfusion sequence1. This should be borne in mind when considering options for management in cases complicated by selective fetal growth restriction (sFGR). We describe here the sonographic and fetoscopic findings in a MCDA twin pregnancy with sFGR. A 23-year-old primigravida with spontaneous MCDA twin pregnancy was referred to our unit at 16 weeks of gestation due to a marked discrepancy in growth between the fetuses. In the first trimester, the discrepancy in nuchal translucency was not marked (1.7 mm vs 1.9 mm) but the intertwin difference in crown–rump length was 22% (63.4 mm vs 80.4 mm). At 17 weeks, the discrepancy between fetuses in estimated fetal weight (EFW) was 45%. Doppler assessment showed abnormal flow in both umbilical arteries, reversed a-wave in the ductus venosus of the smaller twin (Figure 1) but normal findings in the cotwin, prompting a diagnosis of sFGR Type II. In view of the rapid deterioration of the smaller twin and the high chance of intrauterine demise, laser separation of the placental circulations was recommended in order to avoid exsanguination of the healthy twin through the placental anastomoses. Fetoscopic surgery was performed uneventfully under local anesthesia.