Selective intrauterine growth restriction in MC twins · Selective intrauterine growth restriction...
Transcript of Selective intrauterine growth restriction in MC twins · Selective intrauterine growth restriction...
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
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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