management of selective iugr in monochorionic twins · mc twins: apparent discrepancy in af and/or...
TRANSCRIPT
Eduard Gratacos
www.fetalmedicinebarcelona.org/
MANAGEMENT OF SELECTIVE IUGR IN MONOCHORIONIC TWINS
BCNatal – Barcelona Center of Maternal-Fetal and Neonatal Medicine!Hospital Clinic and Hospital Sant Joan de Déu, University of Barcelona!
www.fetalmedicinebarcelona.org
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1. Diagnosis and types!!2. Expectant vs active management!
3. Technical aspects!
4. Conclusions
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1. Diagnosis and types!!2. Expectant vs active management!
3. Technical aspects!
4. Conclusions
Chronic unbalanced transfusion !• Twin-twin transfusion syndrome (TTTS) • Twin anemia polycytemia syndrome (TAPS)
COMPLICATIONS OF MONOCHORIONIC PREGNANCY
Discordant placental territories!• selective IUGR
Unidirectional acute transfusion!• Single fetal demise • Sustained bradichardia in one fetus
High!risk
High risk
Discordant Malformation
selective IUGR (sIUGR) • EFW < P10 in one fetus • ≈10 % of MC
Unequal placental sharing+ placental anastomoses (=INTERFERENCE IN NATURAL HISTORY)
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MC twins: apparent discrepancy in AF and/or fetal size
Algorithm for differential diagnosis
AF: > 8 cm (> 10 cm) / < 2cm!Clearly discordant bladders
EFW <P10 (+/- disc 25%)
• discordant for AF!• discordant for EFW
TTTS
sIUGR
yes
yes
no
noNothing for the moment!Close surveillance
Gratacos et al. Fetal Diagn Ther 2012
MCA Doppler >1.5 / <0.8 MoMs TAPSyes
no
Latency
Survival IUGR
Hemodynamic accidents
GA@delivery
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Very long Short Very long!but unstable
OR AND AND
Very high Low High
Very low Very low!Only if IUFD High
High (>34) Low (<32) High (>34)
Unequal placental sharing+ placental anastomoses (=INTERFERENCE IN NATURAL HISTORY)
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MC + sIUGR (EFW<P10)
Poor prognosis: high risk of IUFD and neurological damage for both twins
Normally good prognosis
No change in Doppler pattern from diagnosis (≈20w) to delivery!Lee 04, Vanderheyden 05, Gratacós 04, 07
Quintero 03, Gratacós 04, Vanderheyden 05
Gratacós 07
TYPE II TYPE IIITYPE I
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MC + sIUGR (EFW<P10)
Poor prognosis: high risk of IUFD and neurological damage for both twins
Normally good prognosis
Latency Dx-Delivery 11 w (3w singletons)
Deterioration IUGR<32w
≈90% ≈15%
Later GA@delivery (32w)!10-15% IUFD of IUGR
(unpredictable)!10-20% Brain injury larger
Earlier GA@delivery (29w)!
High risk IUFD of lUGR (predictable)
Quintero 03, Gratacós 04,
Vanderheyden 05, lshii 09
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1. Diagnosis and types!!2. Expectant vs active management!
3. Technical aspects!
4. Conclusions
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Expectant!(n=138)
Laser!(n=50)
Cord Occlusion!(n=98)
GA@delivery 29-32 32-35 33-37
Survival! ! AGA! ! IUGR
!70-85 %!40-85 %
!70-90 %!30-40 %
!>90 %!
0 %
Sequelae (*) !! AGA! ! IUGR
!15-35%!25-50%
!<5%!15%
!<5%!
-
Quintero 03, Gratacós 04-10, Vanderheyden 05, lshii 09, Chaloui 12, Parra 14 (*), Nicolaides 14(*)
(* unpublished data)
sIUGR in MC twins with abnormal Doppler (II and III)!pooled published data with different management schemes
(*limited info - small series)
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Severity !Cord Occlusion!
Laser!Expectant!
Severe early discordance!Pronounced REDF
Moderate discordance!Telediastolic AEDF
Parents’ wishes
Technical aspects
sIUGR is not a unique disease as TTTS!FACTORS INFLUENCING MANAGEMENT STRATEGY
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Feasible 90%!More difficult than TTTS!• NO polihydramnios (amnioinfusion/
drainage required)!• equator often in smaller sac!• type and size of anastomoses
LASER THERAPY IN sIUGR
Quintero, Gratacos, Chaloui
Fetal Diagn Ther 2014www.fetalmedicinebarcelona.org/
Type I!UA N
II!AREDV
III!iAREDV
Subtype a!DV N
b!DV pat
a!AEDV
b!AREDV, Disc>30%,
DVpatol
Follow up 2w 1w 1w 1w 1w
Attitude Expectant Discuss expectant
Discuss therapy
Discuss expectant
Discuss therapy
Consider delivery !
(if not treated)34-35w 32w
30w DV>95!>26w if DV atrial flow neg
33-34w30w DV>95!>26w if DV atrial flow neg
sIUGR in MC pregnancy Tentative management scheme
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Poor prognosis: high risk of IUFD and neurological damage for both twins
Normally good prognosis
TYPE II TYPE IIITYPE I
EXPECTANT CORD OCCLUSION LASER
MODULATORS!• Severity!• Parents’ wishes!• Technical aspects
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1. Clinical forms!!2. Expectant vs active management!
3. Technical aspects!
4. Conclusions
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III: iAREDF
II: AREDF 1. Adequate diagnosis.!
2. UA Doppler.!
3. Abnormal Doppler has poor prognosis.!
4. Active management protects normal fetus but worsens that of IUGR.!
5. Final decision: balance between severity + parents’ wishes (+ rarely technical issues).!
6. A randomized trial in homogeneous groups is difficult due to clinical variability.
Conclusions!Management of sIUGR in MC twins
