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1 selective IUGR II (and III) Expectant management and Cord Occlusion Eduard Gratacos BCNatal Barcelona Center of Maternal-Fetal and Neonatal Medicine Hospital Clinic and Hospital Sant Joan de Déu, University of Barcelona
2 1. Diagnosis and types 2. Expectant vs active management 3. Results with Cord Occlusion 4. Conclusions
3 1. Diagnosis and types 2. Expectant vs active management 3. Results with Cord Occlusion 4. Conclusions
4 MC twins: apparent discrepancy in AF and/or fetal size Algorithm for differential diagnosis AF: > 8 cm (> 1 cm) / < 2cm Clearly discordant bladders yes TTTS no EFW <P1 (+/- disc 25%) yes siugr no discordant for AF discordant for EFW Nothing for the moment Close surveillance Gratacos et al. Fetal Diagn Ther 212
5 MC-sIUGR and UA Doppler in the IUGR fetus TYPE I TYPE II TYPE III No change in Doppler pattern from diagnosis ( 2w) to delivery Lee 4, Vanderheyden 5, Gratacós 4, 7 Normally good prognosis delivery weeks Survival 5-65% Neurological damage 1-3% Quintero 3, Gratacós 4, Vanderheyden 5, Huber 6, Ishii 9
6 1. Diagnosis and types 2. Expectant vs active management 3. Results with Cord Occlusion 4. Conclusions
7 siugr is not a unique disease as TTTS DETERMINANTS OF MANAGEMENT GA / Severity Discordance / REDF / DV- Technical issues Expectant Cord Occlusion Laser Parents wishes
8 1: DIAGNOSIS siugr + no TTTS Decision tree for counseling in siugr 2: siugr TYPE I II III Expectant + Follow-up 1/w 3: SEVERITY GA<24w /Disc >35% AREDF /DV>p95 Expectant + Follow-up 1/w NO YES Active Management
9 1. Diagnosis and types 2. Expectant vs active management 3. Results with Cord Occlusion 4. Conclusions
10 n=9 (26-213) CORD OCCLUSION IN siugr <p1 + >25% discordance 38 type II / 52 type III 1% on severity criteria (GA<22w or Disc >35% or AREDF or DV>p95) Entry in SGA sac (+/- amnioinfusion) OR septostomy + cord section Median (range) GA at surgery (w) 2.7 (15-25) Median (Range) duration (min) 23.5 (9-53) Only-Mainly Bipolar / Laser (%) 94 % / 6 % Entry in SGA sac 94%
11 CORD OCCLUSION IN siugr Pregnancy Outcomes Miscarriage <24w 5.5 % (5/9) Delivery < 32 w 12.2 % (11/9) (w) 36.3 (15-25) Survival AGA 93.3 % (84/9) Overall 47 % (84/18) Birthweight (g) 2586 ± Overall Type II Type III 1 36,3 36,1 36,7 93,3 93,7 93, Periventr. Leukomalacia 1.1 % (1/9) delivery (w) Survival AGA (%)
12 CORD OCCLUSION IN siugr Parra (n=9) Chalouhi (n=24) Bebbington (n=22) Pregnancy Outcomes Miscarriage <24w 5.5 % (5/9) Delivery < 32 w 12.2 % (11/9) ,3 31,5 34, , 88, 93,1 (w) 36.3 (15-25) 24 6 Survival AGA 93.3 % (84/9) 16 4 Overall 47 % (84/18) 8 2 Birthweight (g) 2586 ± delivery* (w) Survival AGA (%) *Bebbington et al: Estimate.
13 CO (n=136 - Parra, Chalouhi, Bebbington) Laser (n=47 - Quintero, Chalohuhi) Overall Survival 46% vs 54% 4 35,5 33, Survivors per 1 fetuses delivery (w) 2 Survival AGA (%) 2 Survival SGA (%) 2 46 CO 35 Laser AGA SGA NS
14 1. Clinical forms 2. Expectant vs active management 3. Results with Cord Occlusion 4. Conclusions
15 Conclusions Management of siugr II and III in MC twins II: AREDF 1. Expectant management is associated with poor survival and neurological outcome 2. Active management in siugr protects normal fetus but worsens that of IUGR. III: iaredf 3. Final decision: balance between severity + parents wishes (+ rarely technical issues). 4. Cord occlusion: more radical but >9% survival, reduces instances preterm birth and severe IUGR
16 CO (n=136 - Parra, Chalouhi, Bebbington) Laser (n=169 - Peeva, Quintero, Chalohuhi) Overall Survival 46% vs 54% 4 35,5 33, Survivors per 1 fetuses delivery (w) 2 Survival AGA (%) 2 Survival SGA (%) 2 46 CO 35 Laser AGA SGA NS
17 TYPE I TYPE II TYPE III Normally good prognosis Poor prognosis: high risk of IUFD and neurological damage for both twins MODULATORS Severity Parents wishes Technical aspects EXPECTANT CORD OCCLUSION LASER
18 Feasible 9% More difficult than TTTS LASER THERAPY IN siugr NO polihydramnios (amnioinfusion/ drainage required) equator often in smaller sac type and size of anastomoses Quintero, Gratacos, Chaloui
19 siugr in MC twins with abnormal Doppler (II and III) pooled published data with different management schemes Expectant (n=138) Laser (n=5) Cord Occlusion (n=98) Survival AGA IUGR 7-85 % 4-85 % 7-9 % 3-4 % >9 % % Sequelae (*) AGA IUGR 15-35% 25-5% <5% 15% <5% - (*limited info - small series) Quintero 3, Gratacós 4-1, Vanderheyden 5, lshii 9, Chaloui 12, Parra 14 (*), Nicolaides 14(*) (* unpublished data)
20 siugr in MC pregnancy Tentative management scheme Type I UA N II AREDV III iaredv Subtype a b AREDV / Disc>35%, DVpatol a b AREDV / Disc>35%, DVpatol Follow up 2w 1w 1w 1w 1w Attitude Expectant Discuss expectant Discuss therapy Discuss expectant Discuss therapy Consider delivery (if not treated) 34-35w 32w 3w DV>95 >26w if DV atrial flow neg 33-34w 3w DV>95 >26w if DV atrial flow neg Fetal Diagn Ther 214
21 CO (n=9 - Bcn) Laser type III (n=32 - Bcn) Laser type II (n= FMF) Laser II/III (n=23 - Paris) Overall Survival 46% vs 54% ,3 33, Survivors per 1 fetuses delivery (w) Survival AGA (%) Survival SGA (%) 2 46 CO 35 Laser AGA SGA NS
22 CO (n=136 - Parra, Chalouhi, Bebbington) Laser (n=169 - Peeva, Quintero, Chalohuhi) Overall Survival 46% vs 54% 4 35,5 33, Survivors per 1 fetuses delivery (w) Survival AGA (%) Survival SGA (%) 2 46 CO 35 Laser AGA SGA NS
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