Selective intrauterine growthSelective intrauterine growthrestriction in MC twinsrestriction in MC twins

Eduard&GratacósDepartment&and&Research&Centre&of&Maternal8Fetal&Medicine

Hospital&Clínic8IDIBAPS,&University&of&Barcelona,&Spain

1. Clinical forms and diagnosis

2. Expectant vs. active management

3. Technical issues

4. Conclusions

1. Clinical forms and diagnosis

2. Expectant vs. active management

3. Technical issues

4. Conclusions

Chronic unbalancedChronic unbalancedtransfusion transfusion

Twin-twin transfusion syndrome (TTTS)Twin anemia polycytemia syndrome (TAPS)

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COMPLICATIONS OF MONOCHORIONICCOMPLICATIONS OF MONOCHORIONICPREGNANCYPREGNANCY

Discordant placentalDiscordant placentalterritoriesterritories

selective IUGR•

Unidirectional acuteUnidirectional acutetransfusiontransfusion

Single fetal demise Sustained bradichardia in one fetus

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Highrisk

High risk

DiscordantDiscordantMalformationMalformation

selective IUGR (sIUGR) EFW < P10 in one fetus

≈10 % of MC•

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Unequal placentalsharing+ placental anastomoses (=INTERFERENCE INNATURAL HISTORY)

www.medicinafetalbarcelona.org/

MC twins with subjective discrepancy in size or AFAlgorithm for differential diagnosis

EFW<p10 (± D-EFW>25%)

AF discordanceEFW discordanceCloser follow-up

TFF

sIUGR

yes

yes

no

no

Vmax-MCA >1.5 / <0.8 MoM TAPSyes

no

AF: > 8 cm (>10 cm) / <2cmVery discordant bladders

Latency

Survival IUGR

Hemodynamicaccidents

GA@delivery

Very long Short Very longbut unstable

OR AND AND

Very high Low High

Very low Very lowOnly if IUFD High

High (>34) Low (<32) High (>34)

Unequal placentalsharing+ placental anastomoses (=INTERFERENCE INNATURAL HISTORY)

MC + sIUGR (EFW<PMC + sIUGR (EFW<P1010))

Poor prognosis: high risk of IUFD and neurologicalPoor prognosis: high risk of IUFD and neurologicaldamage for damage for bothboth twins twins

Normally good prognosisNormally good prognosis

No change in Doppler pattern from diagnosis (≈20w) to deliveryLee 04, Vanderheyden 05, Gratacós 04, 07

Quintero 03, Gratacós 04, Vanderheyden 05

Gratacós(07

TYPE%II TYPE%IIITYPE%I

MC + sIUGR (EFW<P10)

Poor prognosis: high risk of IUFD and neurologicalPoor prognosis: high risk of IUFD and neurologicaldamage for damage for bothboth twins twins

Normally goodNormally goodprognosisprognosis

Latency Dx-Del ivery 11 w (3w singletons)Latency Dx-Del ivery 11 w (3w singletons)

Deterioration IUGR<32wDeterioration IUGR<32w

≈90%≈90% ≈15%≈15%

Later GA@deliveryLater GA@delivery(32w)(32w)

10-15% 10-15% IUFD of IUGRIUFD of IUGR(unpredictable)(unpredictable)

10-20% Brain injury10-20% Brain injurylargerlarger

Earl ier GA@deliveryEarl ier GA@delivery(29w)(29w)

High risk IUFD of lUGRHigh risk IUFD of lUGR(predictable)(predictable)

Quintero 03, Gratacós 04,

Vanderheyden 05, lshii 09

1. Pathohysiology and clinical forms

2. Expectant vs. active management

3. Technical issues

4. Conclusions

Poor prognosis: high risk of IUFD andPoor prognosis: high risk of IUFD andneurological damage for neurological damage for bothboth twins twins

Normally goodNormally goodprognosisprognosis

TYPE IITYPE II TYPE IIITYPE IIITYPE ITYPE I

EXPECTANTEXPECTANT CORD OCCLUSIONCORD OCCLUSION LASERLASER

MODULATORSMODULATORSSeveritySeverityParents’Parents’wisheswishesTechnicalTechnicalissuesissues

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•

SeveritySeverity

Cord OcclusionLaser

Expectant

Severe ea r lySevere ea r lydiscordancediscordance

Pronounced REDFPronounced REDF

Modera te discordanceModera te discordanceTe lediastolic AEDFTelediastolic AEDF

Parents’Parents’wisheswishes

Technical issuesTechnical issues

sIUGR is not a unique disease as TTTSFACTORS INFLUENCING MANAGEMENT STRATEGYFACTORS INFLUENCING MANAGEMENT STRATEGY

1. Pathohysiology and clinical forms

2. Expectant vs. active management

3. Technical issues

4. Conclusions

Technically feasible >90%But more difficult than TTTS

absence of polihydramnios(amnioinfusion/drainage required)

equator often in smaller sactype and size of anastomoses

•

••

LASER THERAPY IN sIUGRLASER THERAPY IN sIUGR

Quintero, Gratacos, Chaloui

1. Pathohysiology and clinical forms

2. Expectant vs. active management

3. Technical issues

4. Conclusions

ExpectantExpectant LaserLaser Cord OcclusionCord Occlusion

GA@delivery 29-32 33-35 32-34

Survival AGA IUGR

70-85 %50-85 %

70-90 %30 %

>90 %0 %

Sequelae(*)

AGA IUGR

10-30%25-50%

<5%15%

<5%-

Quintero 03, Gratacós 04-10, Vanderheyden 05, lshii 09, Chaloui 12

sIUGR in MC twinsexpected outcomes with different management schemes

(*limited info - smallseries)

III: iAREDF

II: AREDF Proper diagnosis.Doppler UA.Abnormal Doppler has a poor prognosisActive management improves outcome

of larger twin but worsens that of smaller.Decision is a balance between severity,

parents’ wishes and technical issues.RCT is very unlikely to change current

clinical scenario

1.2.3.4.

5.

6.

CONCLUSIONSCONCLUSIONSManagement of sIUGR