Right Ventricular Outflow Tract Obstruction in Monochorionic Twins with Selective Intrauterine Growth Restriction

Haseth, S. B. de; Haak, Monique C.; Roest, Arno A.W.; Rijlaarsdam, María; Oepkes, Dick; Lopriore, Enrico

doi:10.1155/2012/426825

Cited by 7 publications

(12 citation statements)

References 9 publications

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“…The association of RVOTO with an early gestational age at TTTS diagnosis was suggested previously in a case report and is confirmed in this regional cohort of consecutive cases. The cascade of cardiac adaptations in TTTS, in which volume loading and ventricular hypertrophy with tricuspid regurgitation occur in the recipient, is well known.…”

Section: Discussionsupporting

confidence: 87%

“…Pericardial effusion was seen from 17 weeks onwards in the larger twin, which developed severe pulmonary stenosis. This case has been reported previously by our group.…”

Section: Resultssupporting

confidence: 80%

“…These parameters confirm the presence of altered hemodynamics, as in the above‐described cascade of events. Laser therapy often improves cardiac function through restoration of the hemodynamic imbalance, and the majority of fetuses will recover without developing RVOTO. If hydrops is present, up to one third of fetuses develop cardiac abnormalities such as RVOTO.…”

Section: Discussionmentioning

confidence: 99%

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Right ventricular outflow tract obstruction in complicated monochorionic twin pregnancy

Eschbach

Boons

Zwet

et al. 2017

Ultrasound in Obstet & Gyne

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Objectives Severe right ventricular outflow tract obstruction (RVOTO) is a potential complication in recipient twins of twin-to-twin transfusion syndrome (TTTS) that requires postnatal follow-up or treatment. We aimed to evaluate pregnancy characteristics of neonates with RVOTO from complicated monochorionic twin pregnancies, determine the incidence of RVOTO in TTTS cases and construct a prediction model for its development.Methods This was an observational cohort study of all complicated monochorionic twin pregnancies with a postnatal diagnosis of RVOTO examined at our center. Cases were referred for evaluation of the need for fetal therapy or intervention because of TTTS, selective intrauterine growth restriction (sIUGR) or multiple congenital malformations in one of the twins. Ultrasound data were retrieved from our monochorionic twin database. Among liveborn TTTS recipients treated prenatally with laser therapy, those with RVOTO were compared with those without RVOTO (controls). We describe four additional cases with RVOTO that were not TTTS recipients.Results A total of 485 twin pregnancies received laser therapy for TTTS during the study period. RVOTO was diagnosed in 3% (11/368) of liveborn TTTS recipients, of whom two showed mild Ebstein's anomaly. Before laser therapy, pericardial effusion was seen in 45% (5/11) of RVOTO cases (P < 0.01) and abnormal A-wave in the ductus venosus (DV) in 73% (8/11) (P = 0.03), significantly higher proportions than in controls. Mean gestational age at laser therapy was (P = 0.03). A prediction model for RVOTO was constructed incorporating these three significant variables. One TTTS donor had RVOTO after the development of transient hydrops following laser therapy. Three larger twins in pregnancies complicated by sIUGR developed RVOTO, the onset of which was detectable early in the second trimester. Conclusions RVOTO occurs in TTTS recipient twins but can also develop in TTTS donors and larger twins of pregnancies complicated by sIUGR. Abnormal flow in the DV, pericardial effusion and early gestational age at onset of TTTS are predictors of RVOTO in TTTS recipients, which suggests increased vulnerability to hemodynamic imbalances in the fetal heart in early pregnancy. These findings could guide diagnostic follow-up protocols after TTTS treatment.

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Section: Discussionsupporting

confidence: 87%

“…Pericardial effusion was seen from 17 weeks onwards in the larger twin, which developed severe pulmonary stenosis. This case has been reported previously by our group.…”

Section: Resultssupporting

confidence: 80%

Section: Discussionmentioning

confidence: 99%

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Right ventricular outflow tract obstruction in complicated monochorionic twin pregnancy

Eschbach

Boons

Zwet

et al. 2017

Ultrasound in Obstet & Gyne

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“…[1][2][3] Recently, postnatal cardiac complications have been suggested as a cause of such adverse outcomes in monochorionic twin pregnancies with sIUGR. [4][5][6] Brain natriuretic peptide (BNP), or its precursor N-terminal probrain natriuretic peptide (NT-proBNP), is a convenient and objective diagnostic marker of cardiac dysfunction in neonates, as well as in adults and children. 7,8 Although NT-proBNP is theoretically small enough to pass from mother to child, it is derived from the fetus itself and does not reflect transplacental exchange of maternal NT-proBNP.…”

Section: Introductionmentioning

confidence: 99%

N-terminal pro-brain natriuretic peptide levels in monochorionic diamniotic twins with selective intrauterine growth restriction

et al. 2013

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“…The incidence of sIUGR is approximately 11-14% in all monochorionic twin pregnancies, and this is associated with a poor pregnancy outcome, including perinatal death or neurological morbidity for both twins [26,33,34]. We and others have proposed that postnatal cardiac complications are a cause of such adverse outcomes in monochorionic twin pregnancies with sIUGR [6,27,44,45]. For the purpose of clarifying postnatal cardiovascular adaptations of sIUGR, we carried out an observational study of NT-proBNP levels at birth, comparing MD twins with sIUGR and those without.…”

Section: Neonatal Nt-probnp Levels In MD Twins With Siugrmentioning

confidence: 99%

N-Terminal Pro-brain Natriuretic Peptide and Cardiovascular Adaptations in Monochorionic Diamniotic Twins

Fujioka¹

2014

J Neonatal Biol

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Monochorionic diamniotic pregnancies are associated with adverse perinatal outcomes, including neonatal death and handicaps. Additionally, postnatal circulatory collapse has been suggested to be associated with a poor perinatal outcome, but this has not been fully investigated. We have assessed postnatal cardiac adaptations of monochorionic diamniotic twins by measuring N-terminal pro-brain natriuretic peptide, a precursor of brain natriuretic peptide. We observed the following findings. First, monochorionic diamniotic twins with twin-to-twin transfusion syndrome show an increased cardiac load at birth, and they require complete intensive care for both twins for postnatal circulatory collapse, which is alleviated by fetoscopic laser photocoagulation. Second, monochorionic diamniotic twins with selective intrauterine growth restriction show mildly increased cardiac load at birth compared with twin-to-twin transfusion syndrome, and most require intensive care for both twins because of poor cardiovascular adaptations. Third, the reason for the increased cardiac load in these monochorionic diamniotic twins is unbalanced blood transfusion via intertwin vascular anastomoses, as shown by a comparative study between monochorionic diamniotic and dichorionic diamniotic twins with selective intrauterine growth restriction. Further study is necessary to determine other high risk monochorionic diamniotic twin groups. Additionally, a novel therapeutic strategy, including fetal therapy, is mandatory to prevent postnatal cardiovascular collapse in monochorionic diamniotic twins.

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Right Ventricular Outflow Tract Obstruction in Monochorionic Twins with Selective Intrauterine Growth Restriction

Cited by 7 publications

References 9 publications

Right ventricular outflow tract obstruction in complicated monochorionic twin pregnancy

Right ventricular outflow tract obstruction in complicated monochorionic twin pregnancy

N-terminal pro-brain natriuretic peptide levels in monochorionic diamniotic twins with selective intrauterine growth restriction

N-Terminal Pro-brain Natriuretic Peptide and Cardiovascular Adaptations in Monochorionic Diamniotic Twins

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