Eduard Gratacos

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MANAGEMENT OF SELECTIVE IUGR IN MONOCHORIONIC TWINS

BCNatal – Barcelona Center of Maternal-Fetal and Neonatal Medicine!Hospital Clinic and Hospital Sant Joan de Déu, University of Barcelona!

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1. Diagnosis and types!!2. Expectant vs active management!

3. Technical aspects!

4. Conclusions

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1. Diagnosis and types!!2. Expectant vs active management!

3. Technical aspects!

4. Conclusions

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Chronic unbalanced transfusion !• Twin-twin transfusion syndrome (TTTS)• Twin anemia polycytemia syndrome (TAPS)

COMPLICATIONS OF MONOCHORIONIC PREGNANCY

Discordant placental territories!• selective IUGR

Unidirectional acute transfusion!• Single fetal demise• Sustained bradichardia in one fetus

High!risk

High risk

Discordant Malformation

selective IUGR (sIUGR) • EFW < P10 in one fetus • ≈10 % of MC

Unequal placental sharing+ placental anastomoses

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MC twins: apparent discrepancy in AF and/or fetal size

Algorithm for differential diagnosis

AF: > 8 cm (> 10 cm) / < 2cm!Clearly discordant bladders

EFW 1.5 /

Latency

Survival IUGR

Hemodynamic accidents

GA@delivery

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Very long Short Very long!but unstable

OR AND AND

Very high Low High

Very low Very low!Only if IUFD High

High (>34) Low (34)

Unequal placental sharing+ placental anastomoses

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MC + sIUGR (EFW

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MC + sIUGR (EFW

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1. Diagnosis and types!!2. Expectant vs active management!

3. Technical aspects!

4. Conclusions

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Expectant!(n=138)

Laser!(n=50)

Cord Occlusion!(n=98)

GA@delivery 29-32 32-35 33-37

Survival! ! AGA! ! IUGR

!70-85 %!40-85 %

!70-90 %!30-40 %

!>90 %!

0 %

Sequelae (*) !! AGA! ! IUGR

!15-35%!25-50%

!

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Severity !Cord Occlusion!

Laser!Expectant!

Severe early discordance!Pronounced REDF

Moderate discordance!Telediastolic AEDF

Parents’ wishes

Technical aspects

sIUGR is not a unique disease as TTTS!FACTORS INFLUENCING MANAGEMENT STRATEGY

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Feasible 90%!More difficult than TTTS!• NO polihydramnios (amnioinfusion/

drainage required)!• equator often in smaller sac!• type and size of anastomoses

LASER THERAPY IN sIUGR

Quintero, Gratacos, Chaloui

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Fetal Diagn Ther 2014www.fetalmedicinebarcelona.org/

Type I!UA N

II!AREDV

III!iAREDV

Subtype a!DV N

b!DV pat

a!AEDV

b!AREDV, Disc>30%,

DVpatol

Follow up 2w 1w 1w 1w 1w

Attitude Expectant Discuss expectantDiscuss therapy

Discuss expectant

Discuss therapy

Consider delivery !

(if not treated)34-35w 32w

30w DV>95!>26w if DV atrial flow neg

33-34w30w DV>95!>26w if DV atrial flow neg

sIUGR in MC pregnancy Tentative management scheme

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Poor prognosis: high risk of IUFD and neurological damage for both twins

Normally good prognosis

TYPE II TYPE IIITYPE I

EXPECTANT CORD OCCLUSION LASER

MODULATORS!• Severity!• Parents’ wishes!• Technical aspects

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1. Clinical forms!!2. Expectant vs active management!

3. Technical aspects!

4. Conclusions

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III: iAREDF

II: AREDF 1. Adequate diagnosis.!

2. UA Doppler.!

3. Abnormal Doppler has poor prognosis.!

4. Active management protects normal fetus but worsens that of IUGR.!

5. Final decision: balance between severity + parents’ wishes (+ rarely technical issues).!

6. A randomized trial in homogeneous groups is difficult due to clinical variability.

Conclusions!Management of sIUGR in MC twins

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