title: Tailored management of twin reversed arterial perfusion (TRAP) sequence.
abstract: OBJECTIVE
  To describe our management of pregnancies complicated by twin reversed arterial perfusion (TRAP) sequence.
  
  
  METHODS
  This was a retrospective study involving all cases of TRAP sequence referred to our fetal medicine unit in a 3-year period (2000-2002). Patients were routinely managed by repeat sonographic surveillance with sonographic anatomical evaluation and detailed echocardiography. Cases with signs of impending cardiac failure were treated by in-utero YAG-laser coagulation of the umbilical vessels of the acardiac twin.
  
  
  RESULTS
  Six cases were studied. Three patients in whom there were no signs of deterioration in the status of the pump twin, and in whom the acardiac twin was smaller than the pump twin, were managed conservatively. However, one of these with monoamniotic twins ended in intrauterine fetal death of the pump twin. The other two cases presented with spontaneous cessation of blood flow in the umbilical artery of the acardiac twin. Both delivered at term normal neonates whose follow-up revealed no signs of neurological sequelae. One case of quadruplet pregnancy (with TRAP sequence and two dichorionic twins) was treated by selective termination of the monochorionic twins. Two cases with signs of impending cardiac failure were treated by in-utero YAG-laser occlusion of the vessels in the acardiac mass. Both interventions had a favorable outcome.
  
  
  CONCLUSIONS
  Conservative treatment is suitable for milder cases of TRAP sequence in which the pump twin is the larger one. Cases in which the acardiac twin is larger have a poorer prognosis and should be treated by invasive intervention and cord occlusion.
authors.affiliation: Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel-Hashomer, affiliated to the Sackler School of Medicine, Tel Aviv University, Israel. boazmd@inter.net.il
authors.forename: B
authors.initials: B
authors.lastname: Weisz
authors.forename: R
authors.initials: R
authors.lastname: Peltz
authors.forename: B
authors.initials: B
authors.lastname: Chayen
authors.forename: M
authors.initials: M
authors.lastname: Oren
authors.forename: Y
authors.initials: Y
authors.lastname: Zalel
authors.forename: R
authors.initials: R
authors.lastname: Achiron
authors.forename: S
authors.initials: S
authors.lastname: Lipitz
mesh_terms: D000328:Adult; D004452:Echocardiography; D005260:Female; D005313:Fetal Death; D005318:Fetal Heart / Q000002:abnormalities; D005330:Fetofetal Transfusion / Q000000981:diagnostic imaging / Q000601:surgery / Q000628:therapy*; D006801:Humans; D053685:Laser Therapy; D011247:Pregnancy; D011256:Pregnancy Outcome; D018607:Pregnancy Reduction, Multifetal / Q000379:methods*; D012189:Retrospective Studies; D014427:Twins; D018615:Ultrasonography, Doppler, Color; D016216:Ultrasonography, Prenatal