Twin reversed arterial perfusion sequence: the heartless twin
DOI:
https://doi.org/10.18203/2320-1770.ijrcog20201837Keywords:
Acardiac twin, Complication of twins, Laser photocoagulation, Monochorionic monoamniotic twin, Perfused twin, Radiofrequency ablation, Twin to twin transfusion, Twin reversed arterial perfusion sequenceAbstract
To report a case of twin reversal arterial perfusion sequence and its management by means of laser coagulation of the vascular malformation in the placenta. Twin reversed arterial perfusion sequence is a rare form of twin to twin transfusion syndrome occurring primarily in Monochorionic monoamniotic twins. The prevalence is about 1 in 35,000 pregnancies. The significance of this condition is that there is a normal foetus and an acardiac foetus. The blood is shunted from the normal twin to the acardiac twin through vascular malformations in the placenta. The normal twin faces a high risk of both morbidity and mortality due to cardiac failure. A case of twin reversal arterial perfusion sequence diagnosed at 22 weeks following a target scan underwent laser photocoagulation and gave birth vaginally at 30 weeks without any complications. Early detection of this condition can lead to timely intervention and thereby improve the outcome. In Twin reversal arterial perfusion sequence, the normal or the pump twin has a high chance of mortality due to cardiac failure. As the size of the acardiac twin increases, there is a higher chance of mortality of the pump twin. There is a need for regular follow up with ultrasonography and foetal echocardiography along with early therapeutic interventions to ensure the survival of the normal twin. In our case, despite the large size of the acardiac twin, we had a successful pregnancy outcome for the normal twin due to timely intervention.
References
Barth RA, Crow HC. Ultrasound evaluation of multifetal gestations. In: Callen PW, editor. Callen ultrasonography in obstetrics and gynaecology. 4th ed. Pennsylvania: WB Saunders; 2000:196-198.
Weber MA, Sebire NJ. Genetics and developmental pathology of twinning. Semin Fetal Neonatal Med. 2010;15(6):313-8.
Shashidhar B, Kumar BN, Sheela R, Kalyani R, Anithae N, Reddy PS. Twin reversed arterial perfusion (TRAP) sequence: (Acardius Amorphous) a case report and review of literature. Int J Biol Med Res. 2012;3:1453-5.
Levi CS, Lyons EA, Martel MJ. Sonography of multifetal pregnancy. In: Carol M, Rumack, editors. Diagnostic ultrasound. 3rd ed. Vol. 2. Missouri: Elsivier Mosby; 2005:1207-1209.
Dashe JS, Fernandez CO, Twickler DM. Utility of Doppler velocimetry in predicting outcome in twin reversed-arterial perfusion sequence. Am J Obstet Gynecol. 2001;185(1):135-9.
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(3):138-41.
Egan JF, Borgida AF. Ultrasound evaluation of multiple pregnancies. In: Callen PW, editor. Ultrasonography in obstetrics and gynecology. 5th ed. Pennsylvania: WB Saunders; 2008:286-288.
Schwärzler P, Ville Y, Moscosco G, Tennstedt C, Bollmann R, Chaoui R. Diagnosis of twin reversed arterial perfusion sequence in the first trimester by transvaginalcolor Doppler ultrasound. Ultrasound Obstet Gynecol. 1999;13(2):143-6.
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 Off J IntSoc Ultrasound Obstet Gynecol. 2013;42(1):6-14.
Morel O, Malartic C, Barranger E. Radiofrequency ablation for twin-reversed arterial perfusion sequence: the unknown cord occlusion delay calls for long term neonatal follow-up of the surviving twins. Am J Obstet Gynecol. 2007;197(5):557-8.
Okai T, Ichizuka K, Hasegawa J, Matsuoka R, Nakamura M, Shimodaira K, et al. First successful case of non-invasive in-utero treatment of twin reversed arterial perfusion sequence by high-intensity focused ultrasound. Ultrasound Obstet Gynecol Off J Int Soc Ultrasound Obstet Gynecol. 2013;42(1):112-4.
Ichizuka K, Hasegawa J, Nakamura M, Matsuoka R, Sekizawa A, Okai T, et al. High-intensity focused ultrasound treatment for twin reversed arterial perfusion sequence. Ultrasound Obstet Gynecol. 2012;40(4):476-8.
Moore TR, Gale S, Benirschke K. Perinatal outcome of forty-nine pregnancies complicated by acardiac twinning. Am J Obstet Gynecol. 1990;163(3):907-12.
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.
