A rare case report of twin reversed arterial perfusion sequence in monochorionic diamniotic twin and outcome of Dr. Pump and Mr. Acardiac acephalus in a tertiary care centre

Kalaivani Thirupathi; Jayalakshmi M. Meganathan

doi:10.18203/2320-1770.ijrcog20251609

Authors

Kalaivani Thirupathi Department of Obstetrics and Gynaecology, Government Villupuram Medical College and Hospital, Tamil Nadu, India
Jayalakshmi M. Meganathan Department of Obstetrics and Gynaecology, Government Thiruvarur Medical College and Hospital, Tamil Nadu, India https://orcid.org/0000-0002-1179-6193

DOI:

https://doi.org/10.18203/2320-1770.ijrcog20251609

Keywords:

Monochorionic twin gestation, TRAP sequence, Acardiac acephalus twin, Pump twin

Abstract

Twin reversed arterial perfusion (TRAP) sequence or Acardiac twinning is a rare complication seen in monozygotic gestation. The reported incidence of Acardiac twin is 1 in 35000 births and 1 in 100 monozygotic twin gestation. In monochorionic twin pregnancies, a twin with poorly developed heart and upper torso (the “Acardiac”) is perfused by its co-twin (the “pump”) via superficial arterio-arterial or veno-venous anastomoses located on the placental surface, through which blood pumped backwards. Due to poor prognosis of TRAP sequence in monochorionic pregnancies, 100% mortality was reported in Acardiac twin due to its severe malformations and also due to heart failure and prematurity in pump twin 50-55% mortality was reported. We hereby report a case of 22-year-old primigravida, monochorionic diamniotic (MCDA) twins presented with abruption at 24 weeks of gestation, resulted fetal demise of pump twin. Our study also reviewed necessity of thorough sonological evaluation and therapeutic opportunities in monochorionic multifetal pregnancies.

Metrics

Metrics Loading ...

References

Beck MM, Rathore S, Benjamin SJ. Acardiac Twin: A Report of Two Cases. J Fetal Med. 2023;4:3.

Miller R. Twin reversed arterial perfusion (TRAP) sequence. UpToDate. Available at: https://www.upto date.com/contents/diagnosis-and-management-of-twin-reversed-arterial-perfusion-trap-sequence. Accessed on 12 March 2025.

Thapa B. Acardiac twin-Case report. J Kathmandu Med Coll. 2014;3(1):7. DOI: https://doi.org/10.3126/jkmc.v3i1.10922

Quaas P, Markfeld-Erol F. TRAP-ped with an Acardius: case series of twin reversed arterial perfusion (TRAP) sequence and review of literature. J Fetal Med. 2021;8:27-33. DOI: https://doi.org/10.1007/s40556-020-00286-z

Simonds JP, Gowen GA. Fetus amorphous: report of a case. Surg Gynecol Obstet. 1925;41:171.

Barth RA, Crow HC. Ultrasound evaluation of multifetal gestations. In: Callen PW, editor. Callen ultrasonography in obstetrics and gynaecology. 4th ed. Pennsylvania: W B Saunders. 2000;196-8.

Chandramouly M, Namitha. Case series: TRAP sequence. Indian J Radiol Imaging. 2009;19(1):81-3. DOI: https://doi.org/10.4103/0971-3026.45352

Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse DJ, Spong CY. Williams Obstetrics 23rd Edition. McGraw Hill, New York. 2010;872.

Shwarzler P, Ville Y, Moscosco G, Tennstedt, C, Bollmann R, Chaoui R. Diagnosis of twin reversed arterial perfusion sequence in the first trimester by transvaginal color Doppler ultrasound. Ultrasound Obstet Gynecol. 1999;13:143-6. DOI: https://doi.org/10.1046/j.1469-0705.1999.13020143.x

Steffensen TS, GilbertBarness E, Spellacy W, Quintero RA. Placental pathology in trap sequence: Clinical and pathogenetic implications. Fetal Pediatr Pathol. 2008;27:13-29. DOI: https://doi.org/10.1080/15513810801893389

Benirschke K. The monozygotic twinning process, the twin-twin transfusion syndrome and Acardiac twins. Placenta. 2009;30(11):923-8. DOI: https://doi.org/10.1016/j.placenta.2009.08.009

van Gemert MJC, van Den Wijngaard JPHM, Paarlberg KM, Gardiner HM, Nikkels PGJ. Acardiac twin pregnancies part IV: Acardiac onset from unequal embryonic splitting simulated by a fetoplacental resistance model. Birth Defects Res. 2017;109(3):211-23. DOI: https://doi.org/10.1002/bdra.23581

Lehr C, DiRe J. Rare occurrence of a Holoacardius acephalic monster: sonographic and pathologic findings. J Clin Ultra-sound. 1978;6:259-61. DOI: https://doi.org/10.1002/jcu.1870060414

Yapicioglu-Yildizdas H, Ece U, Sucu M, Yurdakul G, Simsek H, Ozlu F. Twin reversed arterial perfusion syndrome in a monochorionic monoamniotic twin pregnancy. Turk J Pediatr. 2017;59:724-9. DOI: https://doi.org/10.24953/turkjped.2017.06.020

Smith AM, McHugo JM, Pilling DW. Abnormalities of twin pregnancies. In: Twining P, McHugo JM, Pilling DW, editors. Textbook of fetal abnormalities. London: Churchill Living-Stone. 2000;404-5.

Bonilla-Musoles F, Machado LE, Raga F, Osborne NG. Fetus acardius: Two- and three-dimensional ultrasonographic diagnoses. J Ultrasound Med. 2001;20:1117-27. DOI: https://doi.org/10.7863/jum.2001.20.10.1117

Guimaraes CV, Kline-Fath BM, Linam LE, Garcia MA, Rubio EI, Lim FY. MRI findings in multifetal pregnancies complicated by twin reversed arterial perfusion sequence (TRAP). Pediatr Radiol. 2011;41:694-701. DOI: https://doi.org/10.1007/s00247-010-1921-2

Ishimatsu J, Nakanami H, Hamada T, Yakushiji M. Color and pulsed Doppler ultrasonography of reversed umbilical blood flow in an acardiac twin. Asia-Oceania J Obstet Gynaecol. 1993;19:271-5. DOI: https://doi.org/10.1111/j.1447-0756.1993.tb00385.x

Sebire NJ, Sepulveda W, Jeanty P, Nyberg DA, Nicolaides KH. Multiple gestations. In: Nyberg DA, McGahan JP, Pretorius DH, editors. Diagnostic imaging of fetal anomalies. Philadelphia: Lippincott Williams & Wilkins. 2003;777-81.

Smith AM, McHugo JM, Pilling DW. Abnormalities of twin pregnancies. In: Twining P, McHugo JM, Pilling DW, editors. Textbook of fetal abnormalities. London: Churchill Living-stone. 2000;404-5.

Pinet C, Colau JC, Delezoide AL, Menez F. Acardiac twins. J Gynecol Obstet Biol Reprod. 1994;23:85-92.

Lewi L, Valencia C, Gonzalez E, Deprest J, Nicolaides KH. The outcome of twin reversed arterial perfusion sequence diagnosed in the first trimester. Am J Obstet Gynecol. 2010;203:e1-4. DOI: https://doi.org/10.1016/j.ajog.2010.04.018

Sullivan AE, Varner MW, Ball RH, Jackson M, Silver RM. The management of acardiac twins: A conservative approach. Am J Obstet Gynecol. 2003;189:1310-3. DOI: https://doi.org/10.1067/S0002-9378(03)00597-0

Stamatian F, Muresan D, Caracostea G, Kovacs T. Advances in Ultrasonic Assessment of Acardiac Twin. Donald School J Ultrasound Obstet Gynaecol. 2011;5(3):213-8. DOI: https://doi.org/10.5005/jp-journals-10009-1198

Jelin E, Hirose S, Rand L, Curran P, Feldstein V, Guevara-Gallardo S, et al. Perinatal outcome of conservative management versus fetal intervention for twin reversed arterial perfusion sequence with a small acardiac twin. Fetal Diagn Ther. 2010;27:138-41. DOI: https://doi.org/10.1159/000295176

Mann S, Johnson MP, Rosner M, Wilson RD, Bebbington M. 503: Prognostic indicators in twin reversed arterial perfusion sequence: Does size matter. Am J Obstet Gynecol. 2007;197:S147. DOI: https://doi.org/10.1016/j.ajog.2007.10.505

Platt LD, DeVore GR, Bieniarz A, Benner P, Rao R. Antenatal diagnosis of acephalus acardia: a proposed management scheme. Am J Obstet Gynecol. 1983;146(7):857-9. DOI: https://doi.org/10.1016/0002-9378(83)91090-6

Sepulveda W, Sebire NJ. Acardiac twin: too many invasive treatment options—the problem and not the solution. Ultrasound Obstet Gynecol. 2004;24(4):387-9. DOI: https://doi.org/10.1002/uog.1724

Lee H, Wagner AJ, Sy E, Ball R, Feldstein VA, Goldstein RB, et al. Efficacy of radiofrequency ablation for twin-reversed arterial perfusion sequence. Am J Obstet Gynecol. 2007;196(5):459.e1-4. DOI: https://doi.org/10.1016/j.ajog.2006.11.039

Tan TY, Sepulveda W. Acardiac twin: A systematic review of minimally invasive treatment modalities. Ultrasound Obstet Gynecol. 2003;22(4):409-19. DOI: https://doi.org/10.1002/uog.224

Cabassa P, Fichera A, Prefumo F. The use of radiofrequency in the treatment of twin reversed arterial perfusion sequence: a case series and review of the literature. Eur J Obstet Gynecol Reprod Biol. 2013;166(2):127-32. DOI: https://doi.org/10.1016/j.ejogrb.2012.10.009

Chaveeva P, Poon LC, Sotiriadis A, Kosinski P, Nicolaides KH. Optimal method and timing of intrauterine intervention in twin reversed arterial perfusion sequence: case study and meta-analysis. Fetal Diagn Ther. 2014;35(4):267-79. DOI: https://doi.org/10.1159/000358593

Wong AE, Sepulveda W. Acardiac anomaly: current issues in pre-natal assessment and treatment. Prenat Diagn. 2005;25(9):796-806. DOI: https://doi.org/10.1002/pd.1269

Pagani G, D’Antonio F, Khalil A, Papageorghiou A, Bhide A, Thilaganathan B. Intrafetal laser treatment for twin reversed arterial perfusion sequence: Cohort study and meta-analysis. Ultrasound Obstet Gynecol. 2013;42:6-14. DOI: https://doi.org/10.1002/uog.12495

Roethlisberger M, Strizek B, Gottschalk I, Mallmann MR, Geipel A, Gembruch U, et al. First-trimester intervention in twin reversed arterial perfusion sequence: does size matter. Ultrasound Obstet Gynecol. 2017;50(1):40-4. DOI: https://doi.org/10.1002/uog.16013

Moore TR, Gale S, Benirschke K. Perinatal outcome of forty-nine pregnancies complicated by acardiac twinning. Am J Obstet Gynecol. 1990;163:907-12. DOI: https://doi.org/10.1016/0002-9378(90)91094-S

Tang Y, Zeng Y, Yang T, Yang P, Bao S, He M, et al. Ultrasound assessment of twin reversed arterial perfusion sequence for the prediction of adverse pregnancy outcomes in the first trimester. J Evid-Based Med. 2022;15:230-5. DOI: https://doi.org/10.1111/jebm.12488