Search for hemodynamic compromise at 11-14 weeks in monochorionic twin pregnancy: is abnormal flow in the ductus venosus predictive of twin-twin transfusion syndrome?
OBJECTIVE
Twin-twin transfusion syndrome is a devastating complication of monochorionic twin pregnancies. The presence of increased nuchal translucency thickness (NT) in one of the monochorionic twins has been associated with an increased risk of developing this syndrome. One of the most plausible mechanisms for increased nuchal translucency is heart failure, indirectly manifested by abnormal blood flow in the ductus venosus. We aimed to clarify the pathophysiology of increased NT found more frequently in monochorionic twins prone to develop twin-twin transfusion syndrome.


METHODS
We present 50 cases of monochorionic twin pregnancies in which nuchal translucency thickness was measured and ductus venosus blood flow evaluation was performed at 11-14 weeks of gestation.


RESULTS
Whenever the fetuses of a twin pregnancy were found to have discrepant nuchal translucency thickness measurements and abnormal flow in the ductus venosus was found in the fetus with increased nuchal translucency thickness, twin-twin transfusion syndrome eventually developed. Progression to twin-to-twin transfusion syndrome was not observed in the twins displaying no intertwin difference in nuchal translucency thickness measurements and it was not observed in those with discrepant nuchal translucency thickness but normal flow in the ductus venosus of both fetuses. In the two cases which developed twin-to-twin transfusion syndrome, fetoscopic laser coagulation of the vascular anastomoses was successfully carried out at 18 weeks and normalization of the venous return was recorded.


CONCLUSIONS
Both increased nuchal translucency and abnormal flow in the ductus venosus in monochorionic twins may be early manifestations of haemodynamic imbalance between donor and recipient. The combined evaluation of both parameters in monochorionic twin pregnancies may constitute an effective method for identifying those at risk of developing twin-to-twin transfusion syndrome.
Matias
Alexandra
A
Department of Obstetrics and Gynecology, Faculty of Medicine, Porto, Hospital of S. João, Porto, Portugal. almatias@mail.telepac.pt
Ramalho
Carla
C
Montenegro
Nuno
N
D000293:Adolescent; D000328:Adult; D001783:Blood Flow Velocity; D005260:Female; D005330:Fetofetal Transfusion / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000503:physiopathology*; D005333:Fetus / Q000098:blood supply*; D006330:Heart Defects, Congenital / Q000175:diagnosis / Q000000981:diagnostic imaging / Q000503:physiopathology; D006439:Hemodynamics; D006801:Humans; D017078:Laser-Doppler Flowmetry; D009333:Neck / Q000000981:diagnostic imaging* / Q000196:embryology; D011237:Predictive Value of Tests; D011247:Pregnancy; D011262:Pregnancy Trimester, Second; D011673:Pulsatile Flow; D012680:Sensitivity and Specificity; D014427:Twins; D016216:Ultrasonography, Prenatal; D014682:Vena Cava, Inferior / Q000502:physiology*