Indomethacin for Treatment of Fetofetal Transfusion Syndrome

Abstract

AM Al-Takroni, KBL Mendis, I Reddy, S Agrawal, Indomethacin for Treatment of Fetofetal Transfusion Syndrome. 1995; 15(3): 284-285 Acute severe fetofetal transfusion syndrome, with presentation in the midtrimester, complicates 1% of monochorionic twin pregnancies and until recently was associated with near 100% mortality.1 Aggressive therapeutic amniocentesis changed this grim situation and improved survival rates to between 69% and 79% 2 but only when begun before the onset of uterine activity.1 However, the midtrimester fetofetal transfusion syndrome presenting with uterine activity remains a therapeutic dilemma. We present a case of severe twin transfusion syndrome admitted in midtrimester with uterine activity in which the indomethacin therapy led to a successful outcome. We are not aware of any previous report of successful use of indomethacin in acute severe fetofetal transfusion syndrome. Case ReportA 28-year-old gravida 5, para 4 Saudi, known to be carrying twins and with a normal past obstetric history, was admitted with mild to moderate uterine activity and shortness of breath at 24 weeks' gestation. Her cardiovascular and respiratory systems were normal. The abdomen was grossly distended and tense. The symphysis-fundal height was 43 cm. The cervix was effaced and the cervical os was dilated to 2 cm.The laboratory investigations were within normal limits; ultrasonography performed with ALOKA SSD 630 real time scanner demonstrated two structurally normal male fetuses and a single placental mass located in the fundus of the uterus. Twin A was occupying the dependent portion of the uterus and moved freely, whereas twin B was lying longitudinally in the left superior part of the uterus with its head very close to the placenta. Though it showed good gross activity, it remained fixed in relation to the uterine wall, even when the maternal position was changed. The biometric assessment revealed discordance of growth between the fetuses, which corresponded to a difference of three weeks in favor of twin A.Very careful ultrasonographic examination failed to reveal a separating membrane between the twins. However, the "stuck" appearance of twin B pointed to the presence of a membrane which was invisible, probably because of its thinness and close apposition to the body parts of twin B. Therefore, we inferred that twin A was residing in a polyhydramniotic sac and that twin B was in a sac with reduced liquor. The estimation of the amniotic fluid volume in each sac was made by measuring the depth of the maximal pool. On admission, the depth of the maximal pool in sac A was 15 cm. and that in sac B was 3 cm. All the ultrasonic examinations were carried out by one investigator (S.A.). On the above findings, a diagnosis of twin pregnancy complicated by acute severe fetofetal transfusion syndrome, where twin A was the recipient and twin B the donor, was made.Treatment with indomethacin 50 mg q. 8 h. was started on the day of admission. Within 24 hours, uterine activity ceased. However, we planned to continue indomet...

Multiple Pregnancies

“…Parenthetically, it is worth mentioning that these authors estimated that 2,200 fetuses succumb annually in the Unites States from this syndrome alone. Moise ( 1991 ) and Jones et al ( 1993 ) failed to arrest the syndrome in three pregnancies by administering indomethacin, while Al-Takroni et al ( 1995 ) seem to have more success in their case. Another means of therapy is to divide the intervening amnionic membranes.…”