Twin reversed arterial perfusion (TRAP) sequence with fetal intervention: Report of two cases

  • Sowjanya S V N S Department of Neonatology, Mehta multispecialty hospitals Ind Pvt Ltd, Chennai, India
  • Karthik Thiagarajan Department of Neonatology, Mehta multispecialty hospitals Ind Pvt Ltd, Chennai, India
  • Shanmugasundaram R Department of Neonatology, Mehta multispecialty hospitals Ind Pvt Ltd, Chennai, India
Keywords: Acardiac twin, assisted reproductive technique, in vitro fertilization, laser coagulation, pump twin, monochorionic pregnancy and TRAP sequence, twin pregnancy

Abstract

We report 2 cases of TRAP sequence diagnosed antenatally using three‐dimensional color Doppler ultrasound. Case 1 was a 44 year old G3A2 mother with monochorionic diamniotic (MCDA) twin pregnancy conceived after in vitro fertilization. Ultrasound imaging showed TRAP sequence at 18 weeks 6 days gestation with early onset intrauterine growth restriction of first twin and second twin being acardiac with flow reversal in umbilical artery and vein. Interstitial laser cord occlusion was performed at 20 weeks 6 days gestation. Serial ultrasound monitoring of growth of first twin done. The first delivered at 36 weeks 2 days gestation by cesarean section in view of poor growth. Baby weighed 1.55 kg at birth and had an uneventful neonatal period. Case 2 was 37 yr old primigravida with monochorionic diamniotic twin pregnancy conceived after in vitro fertilization. TRAP sequence diagnosed at 21 weeks 3 days gestation. Interstitial laser cord occlusion was performed at 25 weeks 5 days gestation and baby was delivered by cesarean section at 35 weeks 4 days gestation weighing 2.1 kg at birth. We conclude that early and accurate antenatal diagnosis is essential to improve outcomes in TRAP sequence. Minimally invasive intervention in the form of laser or radiofrequency coagulation of cord is safe and significantly improves the survival and long term neurodevelopmental outcome of pump twin.DOI: 10.21276/AWCH.1862

Author Biography

Sowjanya S V N S, Department of Neonatology, Mehta multispecialty hospitals Ind Pvt Ltd, Chennai, India
DNB Neonatology trainee, Department of Neonatology

References

1. Reynolds MA, Schieve LA, Martin JA, Jeng G, Macaluso M. Trends in multiple births conceived using assisted reproductive technology, United States, 1997-2000. Pediatrics. 2003; 111:1159–62.

2. Mascarenhas MN, Flaxman SR, Boerma T, Vanderpoel S & Stevens G. Trends in primary and secondary infertility prevalence since 1990: a systematic analysis of demographic and reproductive health surveys. Lancet 2013.

3. Call for Action: Expanding IVF treatment in India 2015.

4. Sunderam S, Kissin DM, Crawford S, Anderson JE, Folger SG, Jamieson DJ et al. Assisted reproductive technology surveillance – United States, 2010. MMWR Surveill Summ. 2013; 62:1–24.

5. Wenstrom KD, Syrop CH, Hammitt DG, Van Voorhis BJ. Increased risk of monochorionic twinning associated with assisted reproduction. Fertil Steril 1993; 60:510e4.

6. Sebire NJ, Snijders RJ, Hughes K, Sepulveda W, Nicolaides KH. The hidden mortality of monochorionic twin pregnancies. Br J Obstet Gynaecol 1997; 104: 1203e7.

7. Van Gemert MJ, Van den Wijngaard JP, Vandenbussche FP. Twin reversed arterial perfusion sequence is more common than generally accepted. Birth Defects Res A Clin Mol Teratol 2015; 103:641.

8. Healey MG. Acardia: predictive risk factors for the co-twin's survival. Teratology 1994; 50:205.

9. Aggarwal N, Suri V, Saxena S. Acardiac acephalus twins: a case report and review of literature. Acta Obstet Gynecol Scand 2002; 81:983.

10. Moore TR, Gale S, Benirschke K. Perinatal outcome of forty-nine pregnancies complicated by acardiac twinning. Am J Obstet Gynecol 1990; 163:907.

11. Pagani G, D'Antonio F, Khalil A. Intrafetal laser treatment for twin reversed arterial perfusion sequence: cohort study and meta-analysis. Ultrasound Obstet Gynecol 2013; 42:6.

12. Babu CR, Kanchana MP. “Twin reversed arterial perfusion sequence (Acardiac Twin): A rare case report.” Journal of Evolution of Medical and Dental Sciences 2015(4):103:16907-16908.

13. S. Saritha, Sumedha S. Anjankar. Twin Reversed Arterial Perfusion Sequence (TRAP Sequence).The Acardiac /Acephalic Twin-A Case Report. Int J Anat Res 2013, 03:140-44.

14. Seema A, Supreeti K, Kirti G, Bhupendra C and Vikas Y. Indian Journal of Basic and Applied Medical Research; September 2015 (4):4:403-407.

15. Iqbal S, Kariappa M and Robert AP. Twin reversed arterial perfusion sequence: acardiac-acephalic twin- a case report Eur. J. Anat. 2014 (4): 345-352.

16. Khanduri S, Chhabra S, Raja A, Bhagat S. Twin Reversed Arterial Perfusion Sequence: A Rare Entity. J Clin Imaging Sci 2015; 5:9.

17. Prameela RC, Priya R, Niveda S, Pooja GY and Prajwal S. A Rare Case of Acardiac Twin: A Case Report. International Journal of Scientific Study 2014 (2); 8.

18. Shashidhar B, Kishore kumar BN, Sheela R, Kalyani R, Anitha N and Prem Sai Reddy. Int J Biol Med Res. 2012; 3(1):1453-1455.

19. Pushpalatha P, Sindhulakshmi D, Mahendra G, Vijayalakshmi S and Smitha S. A Rare Case Report on Twin Reversal Arterial Perfusion. Journal of Dental and Medical Sciences 2015 (14); 2 :13-15.
Published
2018-02-06
Issue
Vol 4 No 1 (2018)
Section
Case Reports

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