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Consensus definition and essential reporting parameters of selective fetal growth restriction in twin pregnancy: a Delphi procedure
Khalil, A.; Beune, I.; Hecher, K. ...
Ultrasound in obstetrics & gynecology,
January 2019, 2019-Jan, 2019-01-00, 20190101, Letnik:
53, Številka:
1
Journal Article
Recenzirano
Odprti dostop
ABSTRACT
Objectives
Twin pregnancy complicated by selective fetal growth restriction (sFGR) is associated with increased perinatal mortality and morbidity. Inconsistencies in the diagnostic criteria ...
for sFGR employed in existing studies hinder the ability to compare or combine their findings. It is therefore challenging to establish robust evidence‐based management or monitoring pathways for these pregnancies. The main aim of this study was to determine, by expert consensus using a Delphi procedure, the key diagnostic features of and the essential reporting parameters in sFGR.
Methods
A Delphi process was conducted among an international panel of experts in sFGR in twin pregnancy. Panel members were provided with a list of literature‐based parameters for diagnosing sFGR and were asked to rate their importance on a five‐point Likert scale. Parameters were described as solitary (sufficient to diagnose sFGR, even if all other parameters are normal) or contributory (those that require other abnormal parameter(s) to be present for the diagnosis of sFGR). Consensus was sought to determine the cut‐off values for accepted parameters, as well as parameters used in the monitoring, management and assessment of outcome of twin pregnancy complicated by sFGR. The questions were presented in two separate categories according to chorionicity.
Results
A total of 72 experts were approached, of whom 60 agreed to participate and entered the first round; 48 (80%) completed all four rounds. For the definition of sFGR irrespective of chorionicity, one solitary parameter (estimated fetal weight (EFW) of one twin < 3rd centile) was agreed. For monochorionic twin pregnancy, at least two out of four contributory parameters (EFW of one twin < 10th centile, abdominal circumference of one twin < 10th centile, EFW discordance of ≥ 25%, and umbilical artery pulsatility index of the smaller twin > 95th centile) were agreed. For sFGR in dichorionic twin pregnancy, at least two out of three contributory parameters (EFW of one twin < 10th centile, EFW discordance of ≥ 25%, and umbilical artery pulsatility index of the smaller twin > 95th centile) were agreed.
Conclusions
Consensus‐based diagnostic features of sFGR in both monochorionic and dichorionic twin pregnancies, as well as cut‐off values for the parameters involved, were agreed upon by a panel of experts. Future studies are needed to validate these diagnostic features before they can be used in clinical trials of interventions. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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First‐trimester intervention in twin reversed arterial perfusion sequence
Tavares de Sousa, M.; Glosemeyer, P.; Diemert, A. ...
Ultrasound in obstetrics & gynecology,
January 2020, Letnik:
55, Številka:
1
Journal Article
Recenzirano
Odprti dostop
ABSTRACT
Objective
To report the outcome of monochorionic twins with twin reversed arterial perfusion (TRAP) sequence following interstitial laser therapy in the first trimester.
Methods
This was a ...
retrospective cohort study of all consecutive cases of TRAP that underwent interstitial laser therapy at ≤ 14 + 3 weeks' gestation between January 2014 and April 2016. Interstitial laser treatment was performed under ultrasound guidance using a 400‐nm Nd:YAG laser fiber. Hospital records were reviewed to ascertain perinatal survival and morbidity.
Results
Twelve monochorionic twin pregnancies underwent interstitial laser treatment of the umbilical artery of the acardiac fetus, at a median gestational age of 13 + 5 (interquartile range (IQR), 13 + 4 to 14 + 0) weeks. In all cases, one treatment was sufficient to achieve complete interruption of the perfusion of the acardiac twin. There were no procedure‐related complications during or within 48 h after the procedure. In one (8.3%) case, intrauterine death of the pump twin occurred 2 weeks after the intervention. All other cases (91.7%) resulted in a live birth at a median gestational age of 39 + 6 (IQR, 37 + 1 to 41 + 2) weeks and with a median birth weight of 3370 (IQR, 2980–3480) g. No neonatal mortality or serious morbidity occurred.
Conclusions
Our results support the use of interstitial laser therapy in the first trimester of pregnancy complicated by TRAP sequence, showing a live birth rate of 92%. The results of a randomized controlled trial, evaluating early vs late intervention in pregnancy with TRAP sequence, are awaited. © 2019 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.
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Perinatal morbidity and mortality in early‐onset fetal growth restriction: cohort outcomes of the trial of randomized umbilical and fetal flow in Europe (TRUFFLE)
Lees, C.; Marlow, N.; Arabin, B. ...
Ultrasound in obstetrics & gynecology,
October 2013, Letnik:
42, Številka:
4
Journal Article
Recenzirano
Odprti dostop
ABSTRACT
Objectives
Few data exist for counseling and perinatal management of women after an antenatal diagnosis of early‐onset fetal growth restriction. Yet, the consequences of preterm delivery and ...
its attendant morbidity for both mother and baby are far reaching. The objective of this study was to describe perinatal morbidity and mortality following early‐onset fetal growth restriction based on time of antenatal diagnosis and delivery.
Methods
We report cohort outcomes for a prospective multicenter randomized management study of fetal growth restriction (Trial of Randomized Umbilical and Fetal Flow in Europe (TRUFFLE)) performed in 20 European perinatal centers between 2005 and 2010. Women with a singleton fetus at 26–32 weeks of gestation, with abdominal circumference < 10th percentile and umbilical artery Doppler pulsatility index > 95th percentile, were recruited. The main outcome measure was a composite of fetal or neonatal death or severe morbidity: survival to discharge with severe brain injury, bronchopulmonary dysplasia, proven neonatal sepsis or necrotizing enterocolitis.
Results
Five‐hundred and three of 542 eligible women formed the study group. Mean ± SD gestational age at diagnosis was 29 ± 1.6 weeks and mean ± SD estimated fetal weight was 881 ± 217 g; 12 (2.4%) babies died in utero. Gestational age at delivery was 30.7 ± 2.3 weeks, and birth weight was 1013 ± 321 g. Overall, 81% of deliveries were indicated by fetal condition and 97% were by Cesarean section. Of 491 liveborn babies, outcomes were available for 490 amongst whom there were 27 (5.5%) deaths and 118 (24%) babies suffered severe morbidity. These babies were smaller at birth (867 ± 251 g) and born earlier (29.6 ± 2.0 weeks). Death and severe morbidity were significantly related to gestational age, both at study entry and delivery and also with the presence of maternal hypertensive morbidity. The median time to delivery was 13 days for women without hypertension, 8 days for those with gestational hypertension, 4 days for pre‐eclampsia and 3 days for HELLP syndrome.
Conclusions
Fetal outcome in this study was better than expected from contemporary reports: perinatal death was uncommon (8%) and 70% survived without severe neonatal morbidity. The intervals to delivery, death and severe morbidity were related to the presence and severity of maternal hypertensive conditions. Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.
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Fetoscopic laser coagulation in 1020 pregnancies with twin–twin transfusion syndrome demonstrates improvement in double‐twin survival rate
Diehl, W.; Diemert, A.; Grasso, D. ...
Ultrasound in obstetrics & gynecology,
December 2017, 2017-Dec, 2017-12-00, 20171201, Letnik:
50, Številka:
6
Journal Article
Recenzirano
Odprti dostop
ABSTRACT
Objective
To investigate the growing experience and learning curve of fetoscopic laser coagulation of the placental vascular anastomoses in severe mid‐trimester twin–twin transfusion ...
syndrome (TTTS) and its influence on perinatal outcome in a single‐center setting.
Methods
Between January 1995 and March 2013 we performed laser therapy in 1020 consecutive pregnancies with TTTS between 15.1 and 27.4 weeks' gestation. We compared perinatal outcome in blocks of five sequential groups of 200 cases, taking into account several covariates in order to adjust for case mix and to demonstrate learning curves and success rates.
Results
The percentage of pregnancies with survival of both fetuses increased from 50.0% (n = 100) in the first 200 cases to 69.5% (n = 153) in the last 220 cases (P = 0.018 for trend) and the overall survival rate for both fetuses in the complete series of 1019 cases with known outcome was 63.3% (n = 645). The survival rate of at least one fetus increased from 80.5% (161/200) in the first group to 91.8% (202/220) in the last group (P = 0.072 for trend) and the overall survival rate of at least one fetus in the complete series was 86.7% (883/1019). In the total population, the mean gestational age at delivery of pregnancies with at least one liveborn neonate was 33.7 ± 3.2 weeks, with a mean interval of 12.9 ± 4.0 weeks between intervention and delivery. Among the first two groups, 124 pregnancies had anterior placentae and were treated with a 0° fetoscope. These cases had the poorest overall outcome, with a double‐twin survival rate of 44.4% (55/124), which increased to 65.1% (207/318; P = 0.001) after the introduction of a 30° fetoscope for cases with anterior placenta. The success rate for double‐twin survival reached a plateau of 69% at 600 procedures, a rate equalled by a new operator who was trained hands‐on and performed 174 of the last 400 procedures.
Conclusions
We report the largest single‐center experience of laser coagulation in TTTS. We observed a continuous increase in double‐twin survival rate owing to the growing experience based on the learning curve and refinements in fetoscopic instruments and techniques. These data provide strong arguments for the centralization of minimally invasive intrauterine surgery in specialized high‐volume centers. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
Resumen
La coagulación fetoscópica láser en 1020 embarazos con síndrome de transfusión feto fetal demuestra una mejoría en la tasa de supervivencia de gemelos
Objetivo
Investigar la experiencia creciente y la curva de aprendizaje de la coagulación fetoscópica láser de anastomosis vasculares placentarias en el síndrome de transfusión feto fetal (TTTS, por sus siglas en inglés) de carácter severo a mitad de trimestre y su influencia en el resultado perinatal en el contexto de un solo centro.
Métodos
Entre enero de 1995 y marzo de 2013 se realizó terapia con láser en 1020 embarazos consecutivos con TTTS entre las semanas de gestación 15.1 y 27.4. Se comparó el resultado perinatal en bloques de cinco grupos secuenciales de 200 casos, teniendo en cuenta varias covariables con el fin de hacer ajustes según la mezcla de casos, y para demostrar las curvas de aprendizaje y las tasas de éxito.
Resultados
El porcentaje de embarazos con supervivencia de ambos fetos aumentó del 50,0% (n=100) en los primeros 200 casos al 69,5% (n=153) en los últimos 220 casos (P=0,018 para la tendencia) y la tasa de supervivencia general para ambos fetos en la serie completa de 1019 casos con resultado conocido fue del 63,3% (n=645). La tasa de supervivencia de al menos un feto aumentó del 80,5% (161/200) en el primer grupo al 91,8% (202/220) en el último grupo (P=0,072 para la tendencia) y la tasa de supervivencia general de al menos un feto en la serie completa fue del 86,7% (883/1019). En la población total, la edad de gestación media al momento del parto con al menos un neonato vivo fue de 33,7 ± 3,2 semanas, con un intervalo promedio de 12,9 ± 4,0 semanas entre la intervención y el parto. Entre los primeros dos grupos, 124 embarazos tenían placenta anterior y fueron tratados con un fetoscopio de 0°. Estos casos tuvieron el peor resultado en general, con una tasa de supervivencia de gemelos del 44,4% (55/124), que aumentó al 65,1% (207/318; P=0,001) después de la introducción de un fetoscopio de 30° para casos con placenta anterior. La tasa de éxito para la supervivencia de gemelos alcanzó un nivel estable del 69% al alcanzar los 600 procedimientos, siendo ésta tasa igualada por una nueva persona que recibió capacitación práctica y realizó 174 de los últimos 400 procedimientos.
Conclusiones
Se reporta la mayor experiencia hasta la fecha en un solo centro en cuanto a coagulación con láser en TTTS. Se observó un aumento continuo en la tasa de supervivencia de gemelos debido a la experiencia cada vez mayor en función de la curva de aprendizaje y los avances en los instrumentos y técnicas fetoscópicas. Estos datos proporcionan argumentos sólidos para la centralización de la cirugía intrauterina mínimamente invasiva en centros especializados de alto volumen.
摘要
采用胎儿镜下激光凝固治疗1020例双胎输血综合征妊娠能够提高双胎存活率
目的
单中心研究采用胎儿镜下激光凝固胎盘吻合血管术治疗重度孕中期双胎输血综合征(twin–twin transfusion syndrome,TTTS)的成长经验和学习曲线以及其对围产结局的影响。
方法
1995年1月至2013年3月间,我们采用激光手术治疗1020例孕15.1~27.4周的连续TTTS孕妇。比较5个序贯组(每组200例)的围产结局,考虑几个协变量,以校正病例混合,来证实学习曲线和成功率。
结果
双胎存活的妊娠比例从前200例的50.0%(n=100)升高至最后220例的69.5%(n=153)(趋势P值=0.018),已知结局的全部1019例中双胎总存活率为63.3%(n=645)。至少一胎存活率从第一组的80.5%(161/200)升高至最后一组的91.8%(202/220)(趋势P值=0.072),全部病例中至少一胎存活率为86.7%(883/1019)。总人群中,至少一胎活产的孕妇平均分娩孕周为33.7 ± 3.2周,治疗与分娩平均间隔2.9 ± 4.0周。前两组中,124例妊娠为前置胎盘,接受0°胎儿镜治疗。这些病例的总体结局最差,双胎存活率为44.4%(55/124),采用30°胎儿镜治疗前置胎盘病例后,双胎存活率升高至65.1%(207/318;P=0.001)。治疗600例后双胎存活治疗成功率达到平稳,为69%,与接受实践培训的新操作者对后400例中174例进行治疗取得的成功率相似。
结论
我们报道了采用激活凝固治疗TTTS的最大单中心经验。我们发现,根据学习曲线取得越来越多的经验以及胎儿镜仪器和技术的成熟,双胎存活率持续升高。这些结果为在专科、患者量大的医疗中心集中进行微创宫内手术提供了有力证据。
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