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− hydrops)
V o l u m e 176, N u m b e r 1, Part 2 A m J O b s t e t Gynecol
273
AGGRESSIVE THERAPEUTIC AMNIOCENTESIS IN THE MANAGEMENT OF TWIN TWIN TRANSFUSION SYNDROME. D Challis ~, K
SPO Abstracts
275
CLASS 4 HYDROPS: RESTORATION O F BIOPHYSICAL ACTIVITIES W I T H IVT. C Harman, x F Manning, S Menticoglou, x U of Manitoba, Winnipeg, Canada. OBJECTIVES: Review changes in fetal behaviours as treatment progresses with intravascular transfnsion (IVT) in Class 4 alloinmmne hydrops (moribund, gross hydrops, biophysical profile score (BPS) -<4/10), based on the premises that a) restoring fetal hemoglobin levels restores normal acti~ily and b) failure to respond predicts poor resuhs of therapy. STUDY DESIGN: Comparative stud),'. Prospective data: BPS, umb. vein pH, blood gases, hemoglobin, fetal movement counts (FMC), letal ultrasound appearance, collected pre- and pos~-transfnsion. RESULTS: Three fetuses had BPS - 0, two fetuses had BPS = 4, with occasional flaccid fetal movement, while the remainder had BPS = 2 (hydramnios, no fetal activity). In Group 1, BPS improved during (n = 4) or within 30 minutes (n = 7) of the first transfusion. Pre-IVF: Mean Hb 22.7 g/l, mean pH 7.29 -+ .08, mean pO2 27.8 ram. Group 2 BPS did not ilnprove until the 2nd or 3rd IVT (pre-IVT: Hb 15.0 g/i, pH 7.22 -+ .06, pO2 28.5). Group 3 had no BPS improvement at any point (pre-lVF: Hb 19.2 g/l, pH 7.08 ~ .18, pO2 42.8* all mothers on 55% FiO2). Survival was related m BPS response: Group 1 9 / 1 l , Group 2 3 / 3 (2 with CNS injury), Group 3 0/5. Grot~p 1 all had I" pO2 (+ 14.3 ram) and ~' pH (+.06) by the next 1VT. Group 2 delayed 1"BPS reflected eventual improvement. Group 3 showed falling p O 2 / p H during first and subsequent IVI'. Pre-IVl' values were not diifi~rent between Grooups, while responses of Group 3 were significantly worse post-M', hnproved FMC followed '~ BPS in all cases, but with a broad range of delay (Sm-72h), usually due to hydramnios plus placental edema muffling FMC. CONCLUSIONS: Restoring fetal Hb level does not guarantee resmnption of normal behaviot~r. BPS response indicates successfld resuscitation, correlates well with I"pO2 and "~pH, and predicts good response to nansfusion therapy. If BPS does not improve at first IVI', a prompt repeat IVT is needed.
276
FETAL URINE PRODUCTION IN THE TWIN-TWIN TRANSFUSION SYNDROME. ]-Barrett ~, IL Pittinix, D. Challiy~, G. Seaward, S. GT~sarux, and G. Ryan. Univ. of Toronto, Perinatal Cmnplex, 76 Grenville St., Toronto, Ont. OBJECTIVE: To investigate whether the observed poiyhydramnios in cases of twin-twin transfusion syndrome (TTTS) was associated with an increased fetal urine output of the recipient twin and whether following amniocentesis there would be a return to normal urine production rates. STUDY DESIGN: Fetal bladder volumes were measured in three planes by real time USS, every 2 to 5 min. for one hour, in order to calculate the Hourly Fetal Urine Production Rate (HUFPR). The HFUPR was measured in flae recipient fetus of 12 sets of twins immediately prior to and within 24 hours of amniocentesis, at which at least 1.5 I of fluid was removed. RESULTS: The HFUPR was greater than the 95th centile for gesadonal age in 7 of the 12 fetusues. Five of the 12 fetuses were less than 26 weeks and the normal range for this gestation is not known. There was no change in HFUPR pre and post amniocentesis. (p - 0.2; paired t test)
DockrilF, J Barrett, G Ryan, K O'Brienx, G Seaward, JL Bigras*, D Farine. University of Toronto Perinatal Complex and Fetal Diagnosis & Treamaent Centre, Toronto, Ontario, CANADA. OBJECTIVE: We report our experience with serial aggressive therapeutic amniocentesis (anmioreduction) for monochorionic twin pregnancies presenting with polyhydranmios/olgohydramnios (poly/oli) sequence. STUDY DESIGN: Between Jan. 1993 and June 1996, 1 triplet & 24 twin pregnancies were treated with serial therapeutic amniocentesis. Obstetrical and neonatal charts were reviewed. RESULTS: 37 procedures were performed on 25 patients (range 1 to 4). The mean fluid volume removed per procedure was 2.1 L, (range 0.5 to 6). The mean total volume removed per patient was 3.7 L (range 0.5 to 14). The mean intelval between procedures was 14 days (range 4 to 50). Mean gestation at first procedure was 22.1 weeks (range 19.3 to 30.1). At delivery, mean gestation was 30.1 weeks (range 22.1 to 38.2) with a mean interval from first procedure to delivery of 6.8 weeks (range 0.5 to 16.8). 31 of 51 fetuses survived with 14 stillbirths and 6 neonatal deaths. All 3 neonatal deaths over 26 weeks were in the recipient (poly) twin and all exhibited severe cardiac dysfunction on prenatal echocardiography. Mean birthweight for the larger twin was 1358 g and for the smaller twin 957 g. Mean length of stay for the larger twin in the level 3 nursery was 12 days and tbr the smaller twin was 19 days. Three twin pairs were lost due to procedure related complications (one PROM, one major abruption and an unexplained demise of both twins within 1 hr of amnioreduction). CONCLUSIONS: A policy of serial aggressive amniocentesis in severe poly/oli sequence secondary to TFTS resulted in a su~,ival rate of 61%. Although this represents a significant improvement in prognosis compared to non intervention, this condition still carries a high morbidity and mortality.
274
PLEURAL DRAINAGE IN THE MANAGEMENT OF PRIMARY FETAL HYDROTHORAX ( + / - HYDROPS). S G~isaru~, G Ryan, PG Seaward, RJ M~rrow, AL Jefferies~, E Kelly~, J M Johnson, D Farine. University of Toronto PerinataI Complex, Toronto, Ontario, CANADA OBJECTIVE: Fetal pleural effusions may cause mediastinal and lung compression leading to hydrops, hydramnios, premature labour and pulmonary hypoplasia. We report the impact of antenatal thoracocentesis a n d / o r thoracoamniotic shunting on perinatal outcome. STUDY DESIGN: A retrospective review of 18 fetuses with primary hydrothorax who had antenatal pleural drainage. • analysis was used and results expressed as odds ratio (OR) • 95% confidence intervals (CI). RESULTS: 18 fetuses with pleural effusion (s) were referred at a mean GA of 24.4 wks (range 16-35). Comprehensive workup was negative apart fi-om 3 who were aneuploid (45,X; Trisomy 21 x2). 14 fetuses (77%) had bilateral effusions, 11 (61%) were hydropic and 8 (44%) had hydramnios. 13 fetuses were shun ted and 5 had thoracocentesis only. Indications for shunting were hydrops (11) or persistence of large effusions despite drainage (2). Shunt replacement was necessary in 5/13 (38%) cases. Mean GA at delivel7 was 34.2 wks (3 delivered <28 wks) with a mean birth weight of 2666 gm (1450-4120). Interval from the first drainage procedure to deliver), was 7.5 wks (0-21). Hydrops resolved in 36% cases, and hydramnios in 38%. There was 1 stillbirth (profound hydrops, unshunted), 1 termination (45,X) and 6 neonatal deaths [puhnonary hypoplasia (:3), Trisomy 21 (2), lymphangiectasia (1)]. The caesarean section rate was 42.% (67% for fetal distress). The mean n m n b e r of days on ventilation was 6.2 (0-33), and on O 2 was 11.3 (0-49). 5 neonates needed neither chest robes nor ventilation. All smMvors (10) are alive and well. CONCLUSION: Selected cases of fi~tal hydrothorax can benefit fi-om thoracoamniotic shunting. This may enable resolution of hydrops and hydrmnnios, with good neonatal outcome. The majority of perinatal losses are due to aneuploidy or pulmonm 7 hypoplasia, and the latter is more likely if ettusions are of very early onset and intervention is delayed.
S85
The Change in the HFUPR following Amniocentesis (n=12)
50
40 30 n," a. 20 -r
10
CONCLUSION: The HFUPR is increased in the recipient twin in cases of T I T S . Following aggressive anmiocentesis the HFUPR does not return to normal levels. This suggests that the underlying pathophysiology is unaffected by the procedure and any improved outcome as a result of amniocentesis is likely due to alleviation of polyhydramnios and not due to a resolution ot the underlying process.
273
AGGRESSIVE THERAPEUTIC AMNIOCENTESIS IN THE MANAGEMENT OF TWIN TWIN TRANSFUSION SYNDROME. D Challis ~, K
SPO Abstracts
275
CLASS 4 HYDROPS: RESTORATION O F BIOPHYSICAL ACTIVITIES W I T H IVT. C Harman, x F Manning, S Menticoglou, x U of Manitoba, Winnipeg, Canada. OBJECTIVES: Review changes in fetal behaviours as treatment progresses with intravascular transfnsion (IVT) in Class 4 alloinmmne hydrops (moribund, gross hydrops, biophysical profile score (BPS) -<4/10), based on the premises that a) restoring fetal hemoglobin levels restores normal acti~ily and b) failure to respond predicts poor resuhs of therapy. STUDY DESIGN: Comparative stud),'. Prospective data: BPS, umb. vein pH, blood gases, hemoglobin, fetal movement counts (FMC), letal ultrasound appearance, collected pre- and pos~-transfnsion. RESULTS: Three fetuses had BPS - 0, two fetuses had BPS = 4, with occasional flaccid fetal movement, while the remainder had BPS = 2 (hydramnios, no fetal activity). In Group 1, BPS improved during (n = 4) or within 30 minutes (n = 7) of the first transfusion. Pre-IVF: Mean Hb 22.7 g/l, mean pH 7.29 -+ .08, mean pO2 27.8 ram. Group 2 BPS did not ilnprove until the 2nd or 3rd IVT (pre-IVT: Hb 15.0 g/i, pH 7.22 -+ .06, pO2 28.5). Group 3 had no BPS improvement at any point (pre-lVF: Hb 19.2 g/l, pH 7.08 ~ .18, pO2 42.8* all mothers on 55% FiO2). Survival was related m BPS response: Group 1 9 / 1 l , Group 2 3 / 3 (2 with CNS injury), Group 3 0/5. Grot~p 1 all had I" pO2 (+ 14.3 ram) and ~' pH (+.06) by the next 1VT. Group 2 delayed 1"BPS reflected eventual improvement. Group 3 showed falling p O 2 / p H during first and subsequent IVI'. Pre-IVl' values were not diifi~rent between Grooups, while responses of Group 3 were significantly worse post-M', hnproved FMC followed '~ BPS in all cases, but with a broad range of delay (Sm-72h), usually due to hydramnios plus placental edema muffling FMC. CONCLUSIONS: Restoring fetal Hb level does not guarantee resmnption of normal behaviot~r. BPS response indicates successfld resuscitation, correlates well with I"pO2 and "~pH, and predicts good response to nansfusion therapy. If BPS does not improve at first IVI', a prompt repeat IVT is needed.
276
FETAL URINE PRODUCTION IN THE TWIN-TWIN TRANSFUSION SYNDROME. ]-Barrett ~, IL Pittinix, D. Challiy~, G. Seaward, S. GT~sarux, and G. Ryan. Univ. of Toronto, Perinatal Cmnplex, 76 Grenville St., Toronto, Ont. OBJECTIVE: To investigate whether the observed poiyhydramnios in cases of twin-twin transfusion syndrome (TTTS) was associated with an increased fetal urine output of the recipient twin and whether following amniocentesis there would be a return to normal urine production rates. STUDY DESIGN: Fetal bladder volumes were measured in three planes by real time USS, every 2 to 5 min. for one hour, in order to calculate the Hourly Fetal Urine Production Rate (HUFPR). The HFUPR was measured in flae recipient fetus of 12 sets of twins immediately prior to and within 24 hours of amniocentesis, at which at least 1.5 I of fluid was removed. RESULTS: The HFUPR was greater than the 95th centile for gesadonal age in 7 of the 12 fetusues. Five of the 12 fetuses were less than 26 weeks and the normal range for this gestation is not known. There was no change in HFUPR pre and post amniocentesis. (p - 0.2; paired t test)
DockrilF, J Barrett, G Ryan, K O'Brienx, G Seaward, JL Bigras*, D Farine. University of Toronto Perinatal Complex and Fetal Diagnosis & Treamaent Centre, Toronto, Ontario, CANADA. OBJECTIVE: We report our experience with serial aggressive therapeutic amniocentesis (anmioreduction) for monochorionic twin pregnancies presenting with polyhydranmios/olgohydramnios (poly/oli) sequence. STUDY DESIGN: Between Jan. 1993 and June 1996, 1 triplet & 24 twin pregnancies were treated with serial therapeutic amniocentesis. Obstetrical and neonatal charts were reviewed. RESULTS: 37 procedures were performed on 25 patients (range 1 to 4). The mean fluid volume removed per procedure was 2.1 L, (range 0.5 to 6). The mean total volume removed per patient was 3.7 L (range 0.5 to 14). The mean intelval between procedures was 14 days (range 4 to 50). Mean gestation at first procedure was 22.1 weeks (range 19.3 to 30.1). At delivery, mean gestation was 30.1 weeks (range 22.1 to 38.2) with a mean interval from first procedure to delivery of 6.8 weeks (range 0.5 to 16.8). 31 of 51 fetuses survived with 14 stillbirths and 6 neonatal deaths. All 3 neonatal deaths over 26 weeks were in the recipient (poly) twin and all exhibited severe cardiac dysfunction on prenatal echocardiography. Mean birthweight for the larger twin was 1358 g and for the smaller twin 957 g. Mean length of stay for the larger twin in the level 3 nursery was 12 days and tbr the smaller twin was 19 days. Three twin pairs were lost due to procedure related complications (one PROM, one major abruption and an unexplained demise of both twins within 1 hr of amnioreduction). CONCLUSIONS: A policy of serial aggressive amniocentesis in severe poly/oli sequence secondary to TFTS resulted in a su~,ival rate of 61%. Although this represents a significant improvement in prognosis compared to non intervention, this condition still carries a high morbidity and mortality.
274
PLEURAL DRAINAGE IN THE MANAGEMENT OF PRIMARY FETAL HYDROTHORAX ( + / - HYDROPS). S G~isaru~, G Ryan, PG Seaward, RJ M~rrow, AL Jefferies~, E Kelly~, J M Johnson, D Farine. University of Toronto PerinataI Complex, Toronto, Ontario, CANADA OBJECTIVE: Fetal pleural effusions may cause mediastinal and lung compression leading to hydrops, hydramnios, premature labour and pulmonary hypoplasia. We report the impact of antenatal thoracocentesis a n d / o r thoracoamniotic shunting on perinatal outcome. STUDY DESIGN: A retrospective review of 18 fetuses with primary hydrothorax who had antenatal pleural drainage. • analysis was used and results expressed as odds ratio (OR) • 95% confidence intervals (CI). RESULTS: 18 fetuses with pleural effusion (s) were referred at a mean GA of 24.4 wks (range 16-35). Comprehensive workup was negative apart fi-om 3 who were aneuploid (45,X; Trisomy 21 x2). 14 fetuses (77%) had bilateral effusions, 11 (61%) were hydropic and 8 (44%) had hydramnios. 13 fetuses were shun ted and 5 had thoracocentesis only. Indications for shunting were hydrops (11) or persistence of large effusions despite drainage (2). Shunt replacement was necessary in 5/13 (38%) cases. Mean GA at delivel7 was 34.2 wks (3 delivered <28 wks) with a mean birth weight of 2666 gm (1450-4120). Interval from the first drainage procedure to deliver), was 7.5 wks (0-21). Hydrops resolved in 36% cases, and hydramnios in 38%. There was 1 stillbirth (profound hydrops, unshunted), 1 termination (45,X) and 6 neonatal deaths [puhnonary hypoplasia (:3), Trisomy 21 (2), lymphangiectasia (1)]. The caesarean section rate was 42.% (67% for fetal distress). The mean n m n b e r of days on ventilation was 6.2 (0-33), and on O 2 was 11.3 (0-49). 5 neonates needed neither chest robes nor ventilation. All smMvors (10) are alive and well. CONCLUSION: Selected cases of fi~tal hydrothorax can benefit fi-om thoracoamniotic shunting. This may enable resolution of hydrops and hydrmnnios, with good neonatal outcome. The majority of perinatal losses are due to aneuploidy or pulmonm 7 hypoplasia, and the latter is more likely if ettusions are of very early onset and intervention is delayed.
S85
The Change in the HFUPR following Amniocentesis (n=12)
50
40 30 n," a. 20 -r
10
CONCLUSION: The HFUPR is increased in the recipient twin in cases of T I T S . Following aggressive anmiocentesis the HFUPR does not return to normal levels. This suggests that the underlying pathophysiology is unaffected by the procedure and any improved outcome as a result of amniocentesis is likely due to alleviation of polyhydramnios and not due to a resolution ot the underlying process.