Late Onset of Discordant Growth in a Monochorionic Twin Pregnancy: Vascular Anastomoses Determine Fetal Growth Pattern and Not Placental Sharing

Nikkels, Peter G. J.; Gemert, Martin J. C. van; Briët, J. W.

doi:10.1159/000053875

Cited by 17 publications

(9 citation statements)

References 6 publications

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“…Steadystate discordant growth may develop if AV anastomotic transfusion is compensated by oppositely directed transfusion, either from other deep oppositely directed AV or superficial arterioarterial (AA) or, less frequently, venovenous (VV) anastomoses. Although the fetal growth predictions of this model are highly consistent with clinical observations (23,35,37,39), the model did not include an assessment of amniotic fluid dynamics.…”

mentioning

confidence: 79%

Amniotic fluid and hemodynamic model in monochorionic twin pregnancies and twin-twin transfusion syndrome

Umur

Gemert

Ross

2001

American Journal of Physiology-Regulatory, Integrative and Comp

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We developed a mathematical model of monochorionic twin pregnancies and twin-twin transfusion syndrome (TTTS), combining both fetal fluid dynamics and fetoplacental growth and circulation alterations and assuming that transplacental fluid flow from mother to fetus accounts for normal fetal and amniotic fluid volumes. Ten coupled differential equations, describing fetal total body and amniotic fluid volumes, their osmolalities, and fetal blood colloid osmotic pressure, for both donor and recipient twins, were solved numerically. Amniotic flows are controlled by fetal plasma osmolality and hydrostatic and colloid osmotic pressures. We included varying placental anastomoses and placental sharing of the circulations. Consistent with clinical experience, model predictions are: fetofetal transfusion from unidirectional arteriovenous anastomoses cause oligo-polyhydramnios, a normal size recipient but hypovolemic donor; compensating oppositely directed deep and superficial anastomoses moderate discordant development; and anhydramnios results from mild and severe TTTS, where milder forms may even present earlier in gestation than severe TTTS. Unequal placental circulatory sharing may exacerbate discordant development. In conclusion, our model simulates a wide variety of realistic manifestations of amniotic fluid volume and fetal growth in TTTS related to placental angioarchitecture. The model may allow an assessment of the efficacy of current therapeutic interventions for TTTS.

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mentioning

confidence: 79%

Amniotic fluid and hemodynamic model in monochorionic twin pregnancies and twin-twin transfusion syndrome

Umur

Gemert

Ross

2001

American Journal of Physiology-Regulatory, Integrative and Comp

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“…Three cases (9,15,19) were from the literature [15][16][17]. Cases 2 [18], 16 [19] and 18 [11] were analyzed in detail elsewhere. In 4 cases (13, 14, 21, 22) fetoscopic laser therapy plus amnioreduction was performed (Dr. K. Hecher, Hamburg).…”

Section: Resultsmentioning

confidence: 99%

“…For TTTS, the net feto-fetal transfusion controls development of the circulatory imbalance, although an unequally shared placenta can somewhat increase the severity of symptoms, or accelerate TTTS onset, if the donor twin occupies the smaller placental part. The opposite occurs if the donor occupies the larger part [11]. In non-TTTS monochorionic twins, unequal placental sharing was predicted to cause a constant imbalance, hence, a constant DAR [2].…”

Section: Introductionmentioning

confidence: 99%

Discordant Fetal Growth Patterns in Monochorionic Twin Pregnancies Described by Simple Algebraic Relations

Umur

Gemert²,

Schaap³

et al. 2003

Fetal Diagn Ther

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Objective: To test whether twin-twin transfusion syndrome (TTTS) and non-TTTS cases that were suspect but not confirmatory for developing the syndrome (non-TTTS-with-symptoms) have discordant fetal growth patterns that correlate with our previously derived algebraic relations. Methods: In 25 monochorionic twin pregnancies, fetal growth was determined by standard ultrasonography. The difference between estimated fetal weights (dEFW) as well as the difference divided by the average of the two weights, the difference average ratio (DAR), were fitted to the predicted trends of discordant fetal growth for TTTS and non-TTTS pregnancies. The best fits were compared with the clinical data. Results: Out of 13 TTTS cases, dEFW analysis correctly correlated with 8 (62%) and DAR analysis correctly with 10 (77%). Out of 12 non-TTTS-with-symptoms cases, dEFW analysis correctly correlated with 7 (58%) and DAR analysis correctly with 9 (75%). If TTTS correlated best, dEFW analysis was correct in 8/12 (67%), and DAR analysis in 10/11 (91%) cases. If non-TTTS correlated best, dEFW analysis was correct in 7/9 (78%), and DAR analysis in 9/12 (75%). The likelihood ratios of TTTS and non-TTTS were 1.9 and 0.26, respectively, with dEFW analysis, and 9.2 and 0.31 with DAR analysis. Conclusion: The simple algebraic relations derived to identify trends of fetal discordant growth show evidence that clinical TTTS and non-TTTS manifestations are quantifiable. The relations may contribute to future risk stratification in monochorionic twin pregnancies, e.g., by prospectively distinguishing between cases that will develop TTTS and those that will not, despite presenting with symptoms.

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“…12, B and D). A large donor placental part delays onset of TTTS (40) and hydrops compared with equal sharing and the opposite effect for a small donor part. Figure 13 shows the interstitial fluid volume using the single AV anastomosis of Fig.…”

Section: Varying Placental Sharingmentioning

confidence: 89%

Modeling a hydropic recipient twin in twin-twin transfusion syndrome

Wijngaard

Umur²,

Krediet³

et al. 2005

American Journal of Physiology-Regulatory, Integrative and Comp

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We developed a mathematical model of twin-twin transfusion syndrome (TTTS) that includes a hydropic recipient twin, adding interstitial and intracellular fluid compartments, fetal congestive cardiac failure, and the dynamics of renin-angiotensin system (RAS) mediators to our previous TTTS model. Ten differential equations for each twin, coupled by the net fetofetal transfusion of blood and blood components, i.e., colloids, osmoles, and RAS mediators, describe the development of fetal arterial and venous blood volumes, blood osmolality and colloid osmotic pressure (COP), interstitial fluid volume and COP, intracellular fluid volume, amniotic fluid volume and osmolality, and RAS mediator concentration. We included varying placental anastomoses, placental sharing, and amnionicity. The 20 differential equations were solved numerically from 0 to 40 wk with a 0.6-s time step. Consistent with clinical experience, model predictions are as follows. Unidirectional arteriovenous anastomoses and arteriovenous anastomoses inadequately compensated by oppositely directed anastomoses cause severe TTTS that includes a hydropic recipient. Adequately compensated arteriovenous anastomoses simulated TTTS without hydrops. The probability that oppositely directed anastomoses prevent onset of a hydropic recipient after TTTS onset, i.e., the largest interval between onset of TTTS and onset of hydrops in the recipient, was best for a venovenous anastomosis, closely followed by an arterioarterial and finally an oppositely directed arteriovenous anastomosis. Hydropic recipients have decreased amniotic fluid volume. Unequal placental sharing and amnionicity modify hydrops onset. In conclusion, our model simulates a sequence of events that results in a hydropic recipient twin in severe TTTS. The model may allow an assessment of the efficacy of current therapeutic interventions for TTTS cases that include a hydropic recipient twin.

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Late Onset of Discordant Growth in a Monochorionic Twin Pregnancy: Vascular Anastomoses Determine Fetal Growth Pattern and Not Placental Sharing

Cited by 17 publications

References 6 publications

Amniotic fluid and hemodynamic model in monochorionic twin pregnancies and twin-twin transfusion syndrome

Amniotic fluid and hemodynamic model in monochorionic twin pregnancies and twin-twin transfusion syndrome

Discordant Fetal Growth Patterns in Monochorionic Twin Pregnancies Described by Simple Algebraic Relations

Modeling a hydropic recipient twin in twin-twin transfusion syndrome

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