Die monochoriale Zwillingsgravidität und ihre Problematik

Zusammenfassung

Monochoriale Zwingsschwangerschaften weisen ein erhöhtes Risiko für intrauterine und postnatale Komplikationen infolge von plazentaren Gefäßanastomosen auf. Die Hauptprobleme sind die Entwicklung eines fetofetalen Transfusionssyndroms, einer selektiven intrauterinen Wachstumsrestriktion, von monoamnialen Zwillingen und eines intrauterinen Fruchttodes eines Zwillings. Des Weiteren sind monochoriale Zwillinge durch kongenitale Anomalien wie die TRAP-Sequenz und siamesische Zwillinge kompliziert. Die fetoskopische Lasertherapie mit selektiver Koagulation von plazentaren Gefäßanastomosen stellt derzeit die Therapie der Wahl in der Behandlung des fetofetalen Transfusionssyndroms dar. Bei monochorialen Zwillingsschwangerschaften besteht ein erhöhtes Risiko für eine Frühgeburt, für zerebrale Schädigungen sowie neuromotorischen Entwicklungsstörungen in der Langzeitzeitbeobachtung.

Abstract

Monochorionic twin pregnancies have an increased risk of intrauterine and postnatal complications because of the present placental vascular anastomoses. The main problems are the development of twin-to-twin transfusion syndrome, selective intrauterine growth restriction, monoamniotic twins and single intrauterine death on the one hand and congenital abnormalities like twin reversed-arterial perfusion and conjoined twins on the other hand. Fetoscopic laser therapy with selective coagulation of placental intertwin anastomoses is the best option in the treatment of twin-to-twin transfusion syndrome. The risk of preterm delivery, cerebral injury and abnormalities of long-term neurodevelopmental outcome are increased. Perinatal management of monochorionic twin pregnancies should be performed in specialized tertiar centers.

Schlüsselwörter

monochoriale Zwillingsschwangerschaft - fetofetales Transfusionssyndrom - TRAP-Sequenz - Morbidität

Key words

monochorionic twin pregnancy - twin-twin transfusion syndrome - TRAP-Sequence - morbidity

Literatur

• 1 Adegbite AL, Castille S, Ward S. et al . Neuromorbidity in preterm twins in relation to chorionicity and discordant birth weight.  Am J Obstet Gynecol. 2004;  190 156-163
• 2 Allen V, Windrim R, Barrett J. et al . Management of monoamniotic twin pregnancies: A case series and systematic review of the literature.  Br J Obstet Gynaecol. 2001;  108 931-936
• 3 Ananth CV, Vintzileos AM, Shen-Schwarz S. et al . Standards of birth weight in twin gestations stratified by placental chorionicity.  Obstet Gynecol. 1998;  91 917-924
• 4 Bahlmann F. Farbkodierte Darstellung des Dopplerfrequenzspektrum des Ductus venosus im Rahmen der physiologischen und pathophysiologischen Fetalentwicklung.  Kapitel 5.4: Fetofetales Transfusionssyndrom. Habilitationsschrift 2003 Mainz
• 5 Bahlmann F. Fetofetales Transfusionssyndrom. Überwachung und Therapie.  Gynäkologe. 2004;  37 725-736
• 6 Bajora R, Wigglesworth J, Fisk NM. Angioarchitecture of monochorionic placentas in relation to the twin-twin transfusion syndrome.  Am J Obstet Gynecol. 1995;  172 856-863
• 7 Bajora R, Ward S, Sooranna SR. Atrial natriuretic peptide mediated polyuria: Pathogenesis of polyhydramnios in the recipient twin of twin-twin transfusion syndrome.  Placenta. 1997;  22 716-724
• 8 Banek CS, Hecher K, Hackeloer BJ. et al . Long-term neurodevelopment outcome after intrauterine laser treatment for severe twin-twin transfusion syndrome.  Am J Obstet Gynecol. 2003;  188 876-880
• 9 Beasley E, Megerian G, Gerson A. et al . Monoamniotic twins: case series and proposal for antenatal management.  Obstet Gynecol. 1999;  93 130-134
• 10 Bejar R, Vigliocco G, Gramajo H. et al . Antenatal origin of neurologic damage in newborn infants. II. Multiple gestations.  Am J Obstet Gynecol. 1990;  162 1230-1236
• 11 Benirschke K, Kaufmann P. Multiple pregnancy.  Pathology of the human placenta, 3rd edn. Springer-Verlag: New-York 1995
• 12 Blickstein I. The twin-to-twin transfusion syndrome.  Obstet Gynecol. 1990;  76 714-721
• 13 Cavicchioni O, Yamamoto M, Robyr R. et al . Prognosis of the surviving co-twin after intrauterine fetal demise in TTTS treated by laser.  Am J Obstet Gynecol. 2004;  191 43
• 14 Caroll SGM, Soothill PW, Abdel-Fattah SA. et al . Prediction of chorionicity in twin pregnancies at 10–14 weeks of gestation.  Br J Obstet Gynaecol. 2002;  109 182-186
• 15 Dashe JS, Fernandez CO, Twickler DM. Utility of Doppler velocimetry in predicting outcome in twin reversed-arterial perfusion sequence.  Am J Obstet Gynecol. 2001;  185 135-139
• 16 De Lia JE, Cruikshank D, Keye W. Fetoscopic neodymium: Yag laser occlusion of placental vessels in severe twin-twin transfusion syndrome.  Obstet Gynecol. 1990;  75 1046-1053
• 17 De Lia JE, Kuhlmann RS, Harstad TW. et al . Fetoscopic laser ablation of placental vessels in severe previable twin-twin transfusion syndrome.  Am J Obstet Gynecol. 1995;  172 1202-1211
• 18 De Lia JE, Kuhlmann RS, Lopez KP. Treating previable twin-twin transfusion syndrome with fetoscopic laser surgery: outcomes following the learning curves.  J Perinat Med. 1999;  27 61-67
• 19 Denbow ML, Cox P, Taylor M. et al . Placental angioarchitecture in monochorionic twin pregnancies: relationship to fetal growth, fetofetal transfusion syndrome, and pregnancy outcome.  Am J Obstet Gynecol. 2000;  182 417-426
• 20 Denbow ML, Battin MR, Cowan F. et al . Neonatal cranial ultrasonographic findings in preterm twins complicated by severe fetofetal transfusion syndrome.  Am J Obstet Gynecol. 1989;  178 479-483
• 21 Dickinson JE, Evans SFE. Obstetric and perinatal outcome from the Australian and New Zealand twin-twin transfusion syndrome registry.  Am J Obstet Gynecol. 1999;  182 706-712
• 22 Diehl W, Hecher K. Selective cord coagulation in acardiac twins.  Sem Fet Neo Med. 2007;  12 458-463
• 23 Dubecq F, Dufour P, Vinatier D. et al . Monoamniotic twin pregnancies Review of the literature, and a case report with vaginal delivery.  Eur J Obstet Gynecol. 1996;  66 183-186
• 24 Duncombe GJ, Dickinson JE, Evans SF. Perinatal characteristics and outcomes of pregnancies complicated by twin-twin transfusion syndrome.  Obstet Gynecol. 2003;  101 1190-1196
• 25 Duncan KR. Twin to twin transfusion: update on management options and outcomes.  Curr Opin Obstet Gynecol. 2005;  17 618-622
• 26 Farmer DL, Hirose S. Fetal intervention for complications of monochorionic twinning.  World J Surg. 2003;  27 103-107
• 27 Fox C, Kilby MD, Khan K. Contemporary treatments for twin-twin transfusion syndrome.  Obstet Gynecol. 2005;  105 1469-1477
• 28 Fox C, Cox P, Kilby MD. Peripheral skin necrosis in the recipient of monochorionic twins complicated by twin-twin transfusion syndrome.  Ultrasound Obstet Gynecol. 2006;  28 717-719
• 29 Fries MH, Goldstein RB, Kilpatrick SJ. et al . The role of velamentous cord insertion in the etiology of twin-twin transfusion syndrome.  Obstet Gynecol. 1993;  81 569-574
• 30 Galea P, Jain V, Fisk NM. Insights into the pathophysiology of twin-twin transfusion syndrome.  Prenat Diagn. 2005;  25 777-785
• 31 Graef C, Ellenrieder B, Hecker K. et al . Long-term neurodevelopmental outcome of 167 children after intrauterine laser treatment for severe twin-twin transfusion syndrome.  Am J Obstet Gynecol. 2006;  194 303-308
• 32 Gratacos E, Lewi L, Carreras E. et al . Inzidence and characteristics of umbilical artery intermittent absent and/or reversed end-diastolic flow in complicated and uncomplicated monochorionic twin pregnancies.  Ultrasound Obstet Gynecol. 2004;  23 456-460
• 33 Gratacos E, Carreras E, Becker J. et al . Prevalence of neurological damage in monochorionic twins with selective intrauterine growth restriction and intermittent absent or reversed end-diastolic umbilical artery flow.  Ultrasound Obstet Gynecol. 2004;  24 159-163
• 34 Gratacos E, Lewi L, Munoz R. et al . A classification system for selective intrauterine growth restriction in monochorionic pregnancies according to umbilical artery Doppler flow in the smaller twin.  Ultrasound Obstet Gynecol. 2007;  30 28-34
• 35 Gratacos E, Antolin E, Lewi L. et al . Monochorionic twins with selective intrauterine growth restriction and intermittent absent or reversed end-diastolic flow (Typ III): feasibility and perinatal outcome of fetoscopic placental laser coagulation.  Ultrasound Obstet Gynecol. 2008;  31 669-675
• 36 Gray PH, Cincotta R, Chan FY. et al . Perinatal outcomes with laser surgery for twin-twin transfusion syndrome.  Twin Res Hum Genet. 2006;  9 438-443
• 37 Haverkamp F, Lex C, Hanisch C. et al . Neurodevelopmental risks in twin-to-twin transfusion syndrome: preliminary findings.  Eur J Pediatr Neurol. 2001;  5 21-27
• 38 Hecher K, Ville Y, Snijders R. et al . Doppler studies of the fetal circulation in twin-twin transfusion syndrome.  Ultrasound Obstet Gynecol. 1995;  5 318-324
• 39 Hecher K, Ville Y, Nicolaides KH. Fetal arterial Doppler studies in twin-twin transfusion syndrome.  J Ultrasound Med. 1995;  14 101-108
• 40 Hecher K, Plath H, Bregenzer T. et al . Endoscopic laser surgery versus serial amniocenteses in the treatment of severe twin-to-twin transfusion syndrome.  Am J Obstet Gynecol. 1999;  180 717-724
• 41 Hecher K, Diehl W, Zikulnig L. et al . Endoscopic laser coagulation of placental anastomoses in 200 pregnancies with severe mid-trimester twin-to-twin transfusion syndrome.  Eur J Obstet Gynecol Reprod Biol. 2000;  92 135-139
• 42 Hecher K, Lewi L, Gratacos E. et al . Twin reversed arterial perfusion: fetoscopic laser coagulation of placental anastomoses or the umbilical cord.  Ultrasound Obstet Gynecol. 2006;  28 688-691
• 43 Heyborne K, Porreco R, Garite T. et al . Improved perinatal survival monoamniotic twins with intensive inpatient monitoring.  Am J Obstet Gynecol. 2005;  192 96-101
• 44 Jauniaux E, Holmes A, Hyett J. et al . Rapid and radical amniodrainage in the treatment of severe twin-twin transfusion syndrome.  Prenat Diagn. 2001;  21 471-476
• 45 Kagan KO, Gazzoni A, Sepulveda-Gonzalez G. et al . Discordance in nuchal translucency thickness in the prediction of severe twin-to-twin transfusion syndrome.  Ultrasound Obstet Gynecol. 2007;  29 527-532
• 46 Kilby MD, Howe DT, McHugo JM. et al . Bladder visualisation as a prognostic sign in oligohydramnios-polyhydramnios sequence in twin pregnancies treated using therapeutic amniocentesis.  Br J Obstet Gyneacol. 1997;  104 939-942
• 47 Kontopoulos E, Quintero R. Assessment of the peak systolic velocity of the middle cerebral artery in twin-twin transfusion syndrome. Part I: preoperative assessment.  Am J Obstet Gynecol. 2009;  200 61.e1-61.e5
• 48 Lee H, Wagner AJ, Sy E. et al . Efficacy of radiofrequency ablation for twin-reversed arterial perfusion sequence.  Am J Obstet Gynecol. 2007;  196 459.e1-459.e4
• 49 Lenclen R, Paupe A, Ciarlo G. et al . Neonatal outcome in preterm monochorionic twins with twin-to-twin transfusion syndrome after intrauterine treatment with amnioreduction or fetoscopic laser surgery: comparison with dichorionic twins.  Am J Obstet Gynecol. 2007;  196 450:1-450:7
• 50 Lewi L, van Schoubroeck D, Gratacos E. et al . Monochorionic diamniotic twins: complications and management options.  Curr Opin Obstet Gynecol. 2003;  15 177-194
• 51 Lewi L, Lewi P, Diemert A. et al . The role of ultrasound examination in the first trimester and at 16 weeks gestation to predict fetal complications in monochorionic diamniotic twin pregnancies.  Am J Obstet Gynecol. 2008;  199 493.e1-493.e7
• 52 Lopriore E, Vanderbussche F, Tiersma E. et al . Twin-to-twin transfusion syndrome: New perspectives.  J Pediatrics.. 1995;  127 675-680
• 53 Lopriore E, Nagel HT, Vanderbussche FP. et al . Long-term neurodevelopmental outcome in twin to twin transfusion syndrome.  Am J Obstet Gynecol. 2003;  189 1313-1318
• 54 Lopriore E, Middeldorp JM, Sueters M. et al . Twin-to-twin transfusion syndrome: from placental anastomoses to long-term neurodevelopmental outcome.  Curr Pediatr Rev. 2005;  1 191-203
• 55 Lopriore E, Sueters M, Middeldorp JM. et al . Neonatal outcome in twin to twin transfusion syndrome treated with fetoscopic laser occlusion of vascular anastomoses.  J Pediatr. 2005;  147 597-602
• 56 Lopriore E, van Wezel-Meijler G, Middeldorp JM. et al . Incidence, origin, and character of cerebral injury in twin to twin tranfusion syndrome treated with fetoscopic laser surgery.  Am J Obstet Gynecol. 2006;  194 1215-1220
• 57 Lopriore E, Lewi L, Oepkes D. et al . In utero acquired limb ischemia in monochorionic twins with and without twin-to-twin transfusion syndrome.  Prenat Diagn. 2008;  28 800-804
• 58 Machin G, Still K, Lalani T. Correlations of placental vascular anatomy and clinical outcomes in 69 monochorionic twin pregnancies.  Am J Med Genet. 1996;  61 229-236
• 59 Malone F. Monochorionic pregnancy – where have we been? Where are we going?.  Am J Obstet Gynecol. 2003;  188 1308-1309
• 60 Mari G, Detti L, Oz U. et al . Long-term outcome in twin-twin transfusion syndrome treated with serial aggressive amnioreduction.  Am J Obstet Gynecol. 2000;  183 211-217
• 61 Mari G, Roberts A, Detti L. et al . Perinatal morbidity and mortality rates in severe twin-twin transfusion syndrome: Results of the international amnioreduction registry.  Am J Obstet Gynecol. 2001;  185 708-715
• 62 Martinez JM, Bermudez C, Becerra C. et al . The role of Doppler studies in predicting individual intrauterine fetal demise after laser therapy for twin-twin transfusion syndrome.  Ultrasound Obstet Gynecol. 2003;  22 246-251
• 63 Matias A, Ramalho C, Montenegro N. 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?.  J Matern Fetal Neonatal Med. 2005;  18 79-86
• 64 Michelfelder E, Gottliebson W, Border W. et al . Early manifestations and spectrum of recipient twin cardiomyopathy in twin-twin transfusion syndrome: relation to Quintero stage.  Ultrasound Obstet Gynecol. 2007;  30 965-971
• 65 Moore TR, Gale S, Bernischke K. Perinatal outcome of fortynine pregnancies complicated by acardiac twinning.  Am J Obstet Gynecol. 1990;  163 907-912
• 66 Overton T, DenbowM, Duncan K. et al . First trimester cord entanglement in monoamniotic twins.  Ultrasound Obstet Gynecol. 1999;  13 140-142
• 67 Pharoah P, Adi Y. Consequences of in-utero death in a twin pregnancy.  Lancet. 2000;  355 1597-1602
• 68 Plath H, Hansmann M. Diagnostik und Therapie zwillingsspezifischer Anomalien.  Gynäkologe. 1998;  31 229-244
• 69 Quintero R, Morales WJ, Allen MH. et al . Staging of twin-twin transfusion syndrome.  J Perinat. 1999;  19 550-555
• 70 Quintero RA, Comas C, Bornick PW. et al . Selective versus non-selective laser photocoagulation of placental vessels in twin to twin transfusion syndrome.  Ultrasound Obstet Gynecol. 2000;  16 230-236
• 71 Robyr R, Quarello E, Ville Y. Management of fetofetal transfusion syndrome.  Review. Prenat Diagn. 2005;  25 786-795
• 72 Rodis J, McIlveen P, Egan J. et al . Monoamniotic twins: improved perinatal survival with accurate prenatal diagnosis and antenatal fetal surveillance.  Am J Obstet Gynecol. 1997;  177 1046-1049
• 73 Rossi AC, D’Addario V. Laser therapy and serial amnioreduction as treatment for twin-twin transfusion syndrome: a metaanalysis and review of literature.  Am J Obstet Gynecol. 2008;  198 147-152
• 74 Russell Z, Quintero RA, Kontopoulos EV. Intrauterine growth restriction in monochorionic twins.  Sem Fet Neonat Med. 2007;  12 439-449
• 75 Saunders NJ, Snijders RJM, Nicolaides KH. Therapeutic amniocentesis in twin-twin transfusion syndrome appearing in the second trimester of pregnancy.  Am J Obstet Gynecol. 1992;  166 820-824
• 76 Schatz F. Eine besondere Art von einseitiger Polyhydramnie mit anderseitiger Oligohydramnie bei eineiigen Zwillingen.  Arch Gynaekol. 1882;  19 329-369
• 77 Sebire NJ, Snijders RJM, Hughes K. et al . The hidden mortality of monochorionic twin pregnancies.  Br J Obstet Gynaecol. 1997;  104 1203-1207
• 78 Sebire NJ, Souka A, Skentou H. et al . Early prediction of severe twin-to-twin transfusion syndrome.  Human Reproduction. 2000;  15 2008-2010
• 79 Senat MV, Loizeau S, Couderc S. et al . The value of middle cerebral artery peak systolic velocity in the diagnosis of fetal anemia after intrauterine death of one monochorionic twin.  Am J Obstet Gynecol. 2003;  189 1320-1324
• 80 Senat MV, Deprest J, Boulvain M. et al . Endoscopic laser surgery versus serial amnioreduction for severe twin to twin transfusion syndrome.  N Engl J Med. 2004;  351 136-144
• 81 Sepulveda W, Sebire NJ. Acardiac twin: too many invasive treatment options – the problem and not the solution.  Ultrasound Obstet Gynecol. 2004;  24 387-389
• 82 Sergi C, Grischke E, Schnabel P. et al . Akardius oder twin-reversed-arterial-perfusion-Sequenz.  Pathologe. 2000;  21 308-314
• 83 Shetty A, Smith A. The sonographic diagnosis of chorionicity.  Review Prenat Diagn. 2005;  25 735-739
• 84 Spitz L. Conjoined twins.  Prenat Diagn. 2005;  25 814-819
• 85 Stenhouse E, Hardwick C, Maharaj S. et al . Chorionicity determination in twin pregnancies: how accurate are we?.  Ultrasound Obstet Gynecol. 2002;  19 350-352
• 86 Su L. Monoamniotic twins: diagnosis and management.  Acta Obstet Gynecol Scand. 2002;  81 995-1000
• 87 Sullivan AE, Varner MW, Ball RH. et al . The management of acardiac twins: a conservative approach.  Am J Obstet Gynecol. 2003;  189 1310-1313
• 88 Tan TYT, Sepulveda W. Acardiac twin: a systematic review of minimally invasive treatment modalities.  Ultrasound Obstet Gynecol. 2003;  22 409-419
• 89 Taylor MJO, Denbow ML, Duncan KR. et al . Antenatal factors at diagnosis that predict outcome in twin-twin transfusion syndrome.  Am J Obstet Gynecol. 2000;  183 1023-1028
• 90 Umur A, van Germert M, Nikkels P. Monoamniotic-versus diamniotic-monochorionic twin placentas: Anastomoses and twin-twin transfusion syndrome.  Am J Obstet Gynecol. 2003;  189 1325-1329
• 91 Van Germert MJC, Major AL, Scherjon SA. Placental anatomy, fetal demise and therapeutic intervention in monochorionic twins and the transfusion syndrome: new hypothesis.  Eur J Obstet Gynecol Reprod Biol. 1998;  78 53-62
• 92 Van Mieghem T, Klaritsch P, Done E. et al . Assessment of fetal cardiac function before and after therapy for twin-to-twin transfusion syndrome.  Am J Obstet Gynecol. 2009;  200 400.e1-400.e7
• 93 Ville Y, Hyett J, Hecher K. et al . Preliminary experience with endoscopic laser surgery for severe twin-twin transfusion syndrome.  N Engl J Med. 1995;  332 224-227
• 94 Weiner CP, Ludomirski A. Diagnosis, pathophysiology, and treatment of chronic twin-to-twin transfusion syndrome.  Fetal Diag Ther. 1994;  9 283-290
• 95 Wieacker P, Wilhelm C, Prömpeler H. et al . Pathophysiology of polyhydramnios in twin transfusion syndrome.  Fetal Diag Ther. 1992;  7 87-92
• 96 Wong AE, Sepulveda W. Acardiac anomaly: current issues in prenatal assessment and treatment.  Prenat Diagn. 2005;  25 796-806
• 97 Yokoyama Y, Shimizu T, Hayakawa K. Prevalence of cerebral palsy in twins, triplets und quadruplets.  Int J Epidemiol. 1995;  24 943-948
• 98 Yamamoto M, Ville Y. Twin to twin transfusion syndrome. Management options and outcomes.  Clin Obstet Gynecol. 2005;  48 973-980
• 99 Zikulnig L, Hecher K, Bregenzer T. et al . Prognostic factors in severe twin-twin transfusion syndrome treated by endoscopic laser surgery.  Ultrasound Obstet. 1999;  14 380-387

Korrespondenzadresse