Cord occlusion followed by laser cord transection in monochorionic monoamniotic discordant twins

Abstract

Objective To compare the outcomes of a consecutive case series of monochorionic (MC) PPROM (35.3% vs. 20.8%, P = 0.22), PTD (41.2% vs. 28.2%, P = 0.29), IUFD (0% vs. 2.8%, P = 1.0) and neonatal survival (76.5% vs. 80.6%, P = 1.0). Gestational age at delivery (median 35.0 (24.5-39.0) vs. 37.1 (26.2-41.0) weeks, P = 0.21) and fetal birth weight (2215 (800-3200) g vs. 2605 (588-3830)

A Systematic Approach to the Differential Diagnosis and Management of the Complications of Monochorionic Twin Pregnancies

“…While many cases may progress well until the third trimester, pregnancy loss may be as high as 50% due to cord entanglement, cardiac failure of the normal twin, also called ‘pump twin’, and complications related with polyhydramnios [83]. The survival rates with cord occlusion – and section in monoamniotic pregnancies – range from 80 to 90% [84]. …”

Fetoscopic cord transection for treatment of monoamniotic twin reversed arterial perfusion sequence

“…However, when the cord is long enough to allow cord entanglement with the pump twin, this can pose a major challenge. Although cord entanglement per se is not associated with increased risk of complications in monoamniotic pregnancies 4 , occlusion of blood flow to the abnormal twin may be associated with increased risk of intrauterine death of the surviving twin and has been described as a cause of intrauterine demise in TRAP sequence 5 . It is possible that the unperfused cord undergoing involution may easily act as a band constricting the cotwin's cord more than a normally perfused cord with an adequate amount of Wharton's jelly.…”

“…It is possible that the unperfused cord undergoing involution may easily act as a band constricting the cotwin's cord more than a normally perfused cord with an adequate amount of Wharton's jelly. To avoid such risks, it is feasible to transect the umbilical cord with laser after its occlusion, thus allowing release of the entanglement; this has been reported in only one case of TRAP sequence 5 . We describe here two further cases of TRAP sequence in monoamniotic twin pregnancies with cord entanglement (Figures 1 and 2), treated by fetoscopic laser cord coagulation and transection.…”

Twin reversed arterial perfusion (TRAP) sequence – does monoamniocity preclude early intervention?

“…Furthermore, it seems reasonable that a string-like umbilical cord of a dead twin is more likely to cause complications. These considerations have resulted in the recommendation of performing cord occlusion and cord transection in selective reduction or TRAP sequence in monoamniotic twins 5,6 . Clearly, with the instruments available today, these measures cannot be performed in the first trimester.…”