A Cohort Analysis of Patients with Stage I Twin-to-Twin Transfusion Syndrome from a Major Referral Hospital in Northern China

Objective:To describe the outcomes of StageⅠtwin-to-twin transfusion syndrome among patients treated with expectant management(EM),amnioreduction(AR),or fetoscopic laser occlusion of chorioangiopagous vessels(FLOC).Methods:A cohort of 89 cases was studied.Based on the initial management strategy,patients were classified into three groups:the EM,AR,and FLOC.We assessed perinatal survival to 28 days of age and categorized pregnancy outcomes as good(twin live birth at≥30.0 weeks),mixed(single fetal demise or delivery between 26.0 and 29.9 weeks),or poor(double fetal demise or delivery at<26.0 weeks).Results:26(29.2%)patients underwent EM,35(39.3%)underwent AR,and 28(31.5%)underwent FLOC therapy.Of those managed expectantly,19.2%experienced spontaneous abortion,50%progressed in stage,and 30.8%remained stable or regressed.After adjusting for potential confounders including maternal age,'null'iparity,placenta location,and recipient maximum vertical pocket,and so on,FLOC therapy and AR were associated with significantly[odds ratio(OR)=0.09]and borderline significantly(OR=0.20)reduced risks of poor pregnancy outcomes and of no survivors to 28 days of age after birth(OR=0.04 and OR=0.20,respectively)compared with EM.Conclusion:About 70%of those treated with EM progressed in stage or experienced fetal loss.Compared to EM,intervention may decrease the risk of poor pregnancy outcomes and improve the perinatal survival rate.

Real-time computerized video enhancement for minimally invasive fetoscopic surgery

Background:The only definitive treatment for twin-to-twin transfusion syndrome is minimally invasive fetoscopic surgery for the selective coagulation of placental blood vessels.Fetoscopic surgery is a technically challenging operation,mainly due to the poor visibility conditions in the uterine environment.We present the design of an algorithm for the computerized enhancement of fetoscopic video and show that the enhanced video increases the ability of human users to identify blood vessels within fetoscopic video rapidly and accurately.Methods:A computer algorithm for the enhancement of fetoscopic video frames was created.First,optical fiber artifacts were removed via a modification of unsharp masking.Second,image contrast was increased via Contrast Limited Adaptive Histogram Equalization(CLAHE).Third,the effect of contrast enhancements on stationary features was removed by normalizing to a windowed mean of the video frames.Fourth,color information was reincorporated by combining the mean-normalized result with the unnormalized contrast enhanced image using the soft light blending algorithm.Medical trainees(n?16)were recruited into a study to validate the algorithm.Subjects were shown enhanced or unenhanced fetoscopic video frames on a screen and were asked to identify whether a randomly placed marker fell on a blood vessel or on background.The accuracy of their responses was recorded.Results:On the subset of images where subjects had the lowest mean accuracy in identifying the placement of the marker,subjects performed better when viewing video frames enhanced by the computer(accuracy 74.27%;SE 0.97)than when viewing unenhanced video frames(accuracy 63.78%;SE 2.79).This result was statistically significant(p<0.01).Conclusion:Real-time computerized enhancement of fetoscopic video has the potential to ease the readability of video in poor lighting conditions,thus providing a benefit to the surgeon intraoperatively.

Fetoscopy Role in Fetal Surgery and Fetal Medicine

Aim: We attempted to illustrate our experience of fetoscopic therapy in a tertial institute, whereby to highlight the present Egyptian situation regarding this issue. We described fetoscopic therapy undergone at Al-Hussein Hospital, Al-Azhar University, Cairo, Egypt, from Dec-2012 to Sep-2019. Presentation of cases: Sixteen women with 17 fetuses were included in the analysis of this study with a mean age of 25.31 ± 6.15 years;four with positive marriage to a near relevant, and eight were primigravida. The fetus of twelve women had lower urinary tract obstruction (LUTO), two fetal anemia, one hydrothorax, and one twin-to-twin transfusion syndrome (TTTS). The mean time for fetoscopy was gestational week 24.13 ± 3.77. We did therapeutic drainage to amniotic fluid in hydrothorax and LUTO, therapeutic septostomy to the TTTS case, and blood transfusion in cases of fetal anemia. During the operation, the procedure succeeded in 14 out of 16 women. Overall, nine of the 16 women experienced some complications;five with rupture of membranes, four with preterm labor, and three with intrauterine fetal death (IUFD). Conclusion: Fetoscopy can manage LUTO and well-selected cases of TTTS, hydrothorax, and fetal anemia. The procedure is promising. Fetoscopic therapy has just begun in Egypt, and this report may contribute to the future advance of fetoscopic therapy in Egypt.

Evaluation of Fetoscopy Role in Fetal Surgery and Fetal Medicine

Introduction: This study aimed to evaluate, discuss and illustrate the role of fetoscopy diagnostically and therapeutically. Material and Methods: This study was conducted in private center in under the supervision of the professors of Azhar University, Egypt from Dec-2012 to Mar-2017. Women with confirmed fetal congenital malformations, and willing to do fetoscopy were recruited. Fetoscopy was attempted in all cases to treat the underlying fetal conditions. Follow up was made until delivery. Results: Twenty patients with 22 fetuses were included in this study with different congenital anomalies. Therapeutic drainage or coagulation was made in all cases. In cases of lower urinary tract obstruction, fetoscopy confirmed pre-suspected urethral atresia and changed the diagnosis from complete PUV to urethral atresia in some cases. The procedure succeeded in all cases. However, the on-going success rate was 17 (77.3%) of fetuses. The overall number of live birth was 11 fetuses (50%). Overall, 15 (75%) of the 20 patients experienced some complication withpreterm labor the most prevalent 15 (75%). Conclusion: Fetoscopy can diagnose and differentiate between posterior urethral valve (PUV) and atresia, and manage well-selected cases of twin to twin transfusion syndrome (TTTS), and have a reasonable survival rate in lower urinary tract obstruction (LUTO).

Application of fetoscopy in the management of monochorionic multiple pregnancies

The complications of monochorionic （MC） multiple pregnancies include twin-reversed arterial perfusion（TRAP） and twin-to-twin transfusion syndrome （TTTS）. Currently, the most effective treatment for stages Ⅱ,Ⅲ, and Ⅳ TTTS is generally considered to be fetoscopic laser occlusion of chorioangiopagous vessels （FLOC）.3 MC twins who are severely discordant for growth or demonstrate anomalies may undergo selective reduction by means of a variety of different techniques.4 Radiofrequency ablation （RFA） of an acardiac twin has also proved to be an effective method of improving survival of the pump twin in the TRAP. Therefore, care for these complex pregnancies is ideally a coordinated multidisciplinary effort between perinatology, pediatric/fetal surgery, pediatric neurology, radiology/ ultrasound, genetics, social services, neonatology, and labor and delivery.

The Controversies and Challenges in the Management of Twin Pregnancy: From the Perspective of International Federation of Gynecology and Obstetrics Guidelines

The rate of multiple pregnancy is increasing, mainly because of the widespread use of assisted reproduction techniques and families’ desire for twins. Twin pregnancy accounts for a higher risk of chromosomal abnormalities, structural malformations, and neonatal adverse events than singleton pregnancy. The presence of artery-vein anastomoses, unbalanced placenta sharing, and abnormal cord insertion in monochorionic twins is associated with twin complications such as twin-to-twin transfusion syndrome, selective intrauterine growth restriction, and twin anemia polycythemia sequence. Although many guidelines and studies have established and improved the processes about the antenatal surveillance and management of twin pregnancy, they also raise more controversies and challenges. This review aims to highlight the international consensus on the antenatal care of twin pregnancies and analyze the controversies and predicaments based on the published International Federation of Gynecology and Obstetrics guidelines and research.