Twin reversed arterial perfusion sequence-a rare and dangerous complication form of monochorionic twins:A case report

BACKGROUND Twin reversed arterial perfusion(TRAP) sequence is an extremely rare congenital anomaly in monochorionic(MC) twins.The condition is characterized by a malformed fetus(acardiac twin) without cardiac activities being perfused by a structurally normal one(pump twin) via an artery-to-artery anastomosis in a reverse direction.CASE SUMMARY We described the first case of TRAP to receive laser surgery in Vietnam.The 26-wk pregnancy was originally misdiagnosed in another hospital as MC twins with single intrauterine fetal death.Following admission to our center,the diagnosis was amended to a 26-wk TRAP sequence stage IIb.The acardiac twin was 7.5 cm at the longest length,the ratio of the weight of the acardiac twin to the weight of the pump twin was more than 90%,the pump twin showed fetal distress with absent diastolic flow in umbilical artery of pump twin,and the peak systolic velocity in the middle cerebral artery = 1.6 Mo M.We performed emergency laser photocoagulation of the acardiac twin’s umbilical cord.After surgery,we successfully maintained the pregnancy for 8 wk and ended it electively by cesarean section at 34 wk of gestation due to rupture of membranes.CONCLUSION TRAP should be appropriately diagnosed and treated early to avoid complications of the pump twin.Fetoscopic laser photocoagulation is a new and effective treatment for this condition.

Fetal reduction by bipolar cord coagulation in managing complicated monochorionic multiple pregnancies： preliminary experience in China

背景 Monochorionic 多重怀孕(MMP ) 与 interfetal 引起的 perinatal 病态和死亡的更高的率被联系脉管在 monochorionic 胎盘吻合，它能导致胎儿的健康相互作用。在一些情形，影响胎儿的选择杀胎是必要的节省健康合作双胞胎。我们为复杂 MMP 的管理用双极的绳索凝结评估了我们的起始的经验的效果和安全。用指导超声的双极的绳索凝结的方法，我们在 14 复杂 MMP 上执行了选择杀胎(5 与成双双胞胎的输送症候群， 4 与 acardia， 3 与不和的结构的异例，并且 2 与严重选择子宫内的生长限制) 。有 monochorionic 三位字节的一个病人收到了过程两次为不同指示终止 2 个影响胎儿。关于操作，复杂并发症和新生的结果的数据被分析。结果绳索吸藏成功地在 13/14 (93%) 被执行盒子。失败在一个 acardiac 胎儿发生了，怀孕被正式就职终止。与 perinatal 幸存在 35.4 个星期的吝啬的 gestational 年龄交付的包括的盒子 11/13 (85%) 评价。三操作相关的复杂并发症发生了(21%) 包括终止的囊(1 个盒子) 的膜破裂，在 28 星期怀孕期(1 个盒子) 的 preterm 劳动，和 chorioamniotic 膜分离(1 个盒子) 。Amnioinfusion 在 11 过程被显示为进入套管针并且获得足够的工作空间扩展目标囊。在 acardia 的所有 4 个盒子中，然而， acardiac 囊显示出极端 oligohydramnios 并且不能被注入很好扩展；因此，套管针不得不从保存合作双胞胎的囊被插入。在复杂 MMP 的双极的绳索凝结的申请是保险箱并且改进预后的结论。Amnioinfusion 在当工作空间是有限的时，帮助扩展目标囊是有用的。

Selective Fetal Growth Restriction in Monochorionic Diamniotic Twins: Diagnosis and Management

Selective fetal growth restriction (sFGR) is a severe condition that complicates 10% to 15% of all monochorionic diamniotic (MCDA) twin pregnancies. Pregnancies complicated with sFGR are at high risk of intrauterine demise or adverse perinatal outcome for the twins. Three clinical types have been described according to the umbilical artery (UA) Doppler pattern observed in the smaller twin: type I, when the UA Doppler is normal;type II, when there is persistent absent or reversed end-diastolic blood flow in the UA Doppler;and type III, when there is intermittent absent and/or reversed end-diastolic blood flow in the UA Doppler. Clinical evolution and management options mainly depend on the type of sFGR. Type I is usually associated with a good prognosis and is managed conservatively. There is no consensus on the management of types II and III, but in earlier and more severe presentations, fetal interventions such as selective laser photocoagulation of placental anastomoses or selective fetal cord occlusion of the smaller twin may be considered. This review aims to provide updated information about the diagnosis, evaluation, follow-up, and management of sFGR in MCDA twin pregnancies.

Insulin-like growth factor binding protein 1 and human embryonic development during 6-10 gestational weeks

Background Insulin-like growth factor binding protein-1 (IGFBP-1), which is a carrier of Insulin-like growth factors (IGFs) regulates the fetal development by working as an active factor controlling the combination of IGFs with their receptors. This study was designed to investigate the relationship between IGFBP-1 and human embryonic development during weeks 6-10 of gestation. Methods A total of 44 pregnant women with singleton pregnancy were divided into two groups: one with abnormal embryo development (n=32) and the other with normal embryo development (n=12). Enzyme-linked immunosorbent assay (ELISA) was employed to detect IGFBP-1 levels in maternal serum and decidual tissue. The expression of IGFBP-1 mRNA in deciduas was examined by reverse transcription polymerase chain reaction (RT-PCR) technique. Results The level of IGFBP-1 protein in maternal serum was significantly higher in the abnormal group [(125.36±47.93) μg/ml] than in the normal group [(70.72±21.21) μg/ml]. Both of IGFBP-1 and IGFBP-1 mRNA in deciduas were higher in abnormal group [(1.60±1.39) μg/ml and 1.66±1.64, respectively] than in the normal group [(0.35±0.23) μg/ml and 0.40±0.20, respectively]. The level of IGFBP-1 in maternal serum was positively correlated with IGFBP-1 mRNA (r=0.90, P<0.05) and IGFBP-1 protein (r=0.92, P<0.05) in decidual tissue. Conclusions During weeks 6-10 of gestation, abnormal embryonic development is correlated with elevated IGFBP-1. The level of IGFBP-1 in maternal serum is related to the concentrations of IGFBP-1 mRNA and IGFBP-1 in decidual tissue. The IGFBP-1 level in maternal serum may be used as a predictive marker to evaluate embryonic development.

Intrauterine Intervention of Pulmonary Atresia at 26^th Gestational Week

To the Editor:Congenital heart diseases (CHDs)are the most common congenital structural anomalies in China.Most of them are curable after birth.However,some defects progress during fetal period,thus resulting in high neonatal mortality and morbidity. Pulmonary atresia with intact ventricular septum (PA/IVS)during fetal period is partly associated with right ventricle (RV)hypoplasia and its consequent hemodynamic deterioration,which limits the possibility of biventricular (BV)repair after birth.The 1-year survival of PA/IVS live births is around 70%,but the rate of BV outcome is around 30%.[1]

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.

Up-regulation of miR-1245 by c-myc targets BRCA2 and impairs DNA repair

BRCA2,a clinical prognostic factor,is significantly up-regulated in mRNA level,while its protein expression is often decreased in sporadic breast cancer.However,how BRCA2 protein expressions are suppressed in these tumors remains unknown.In this study,we demonstrated that miR-1245 directly suppressed BRCA23′-UTR and translation,impaired homologous recombination(HR)-mediated repair,reduced DNA damage-induced Rad51 nuclear foci,and rendered cells hypersensitive to g-irradiation(IR),ul-timately inducing high chromosomal abnormalities in normal breast cells and breast cancer cells.Conversely,inhibiting miR-1245 in breast cancer cells enhanced BRCA2 levels and induced resistance to IR.Furthermore,we demonstrated that c-myc up-regulated miR-1245 expression via direct binding to the miR-1245 promoter,which led to down-regulation of BRCA2 and reduction in HR efficiency.Significantly,miR-1245 levels in primary breast tumors correlated with c-myc overexpression and BRCA2 suppression.These findings uncover a BRCA2 regulatory and signaling pathway in sporadic breast cancer and support a functionally and clinically relevant epigenetic mechanism in cancer pathogenesis.

Fetoscopic Laser Photocoagulation for Twin-Twin Transfusion Syndrome in a Dizygotic Monochorionic Twins

To editor:Monochorionicity was traditionally considered indicative of monozygosity.However,recent years have witnessed the emergence of several noteworthy instances of monochorionic dizygotic(MCDZ)twins in clinical practice.In 2000,Viëtor et al.1 documented the initial established case of MCDZ twins.Subsequent studies have further documented this unconventional twinning phenomenon.2,3 The recognized complications associated with monochorionic monozygotic pregnancies,including twin-twin transfusion syndrome(TTTS),twin anemia–polycythemia sequence(TAPS),selective intrauterine growth restriction(sIUGR),congenital malformations,and intrauterine fetal death,could also manifest in MCDZ pregnancies.4,5 In this correspondence,we presented an extremely rare case of TTTS in a dizygotic monochorionic diamniotic twin gestation successfully treated with fetoscopic laser photocoagulation.The patients’permission to publish was obtained.