Accurate and Simple Evaluation of Vascular Anastomoses in Monochorionic Placenta using Colored Dye
Summary
Twin-to-twin transfusion syndrome and twin anemia polycythemia sequence are two potentially devastating problems in perinatal medicine. Both disorders occur only in monochorionic twins and result from unbalanced blood flow through placental vascular anastomoses. We provide a simple protocol to accurately evaluate the presence of vascular anastomoses using colored dye injection of placental vessels after birth.
Abstract
The presence of placental vascular anastomoses is a conditio sine qua non for the development of twin-to-twin transfusion syndrome (TTTS) and twin anemia polycythemia sequence (TAPS)1,2. Injection studies of twin placentas have shown that such anastomoses are almost invariably present in monochorionic twins and extremely rare in dichorionic twins1. Three types of anastomoses have been documented: from artery to artery, from vein to vein and from artery to vein. Arterio-venous (AV) anastomoses are unidirectional and are referred to as “deep” anastomoses since they proceed through a shared placental cotyledon, whereas arterio-arterial (AA) and veno-venous (VV) anastomoses are bi-directional and are referred to as “superficial” since they lie on the chorionic plate. Both TTTS and TAPS are caused by net imbalance of blood flow between the twins due to AV anastomoses. Blood from one twin (the donor) is pumped through an artery into the shared placental cotyledon and then drained through a vein into the circulation of the other twin (the recipient). Unless blood is pumped back from the recipient to the donor through oppositely directed deep AV anastomoses or through superficial anastomoses, an imbalance of blood volumes occurs, gradually leading to the development of TTTS or TAPS. The presence of an AA anastomosis has been shown to protect against the development of TTTS and TAPS by compensating for the circulatory imbalance caused by the uni-directional AV anastomoses1,2. Injection of monochorionic placentas soon after birth is a useful mean to understand the etiology of various (hematological) complications in monochorionic twins and is a required test to reach the diagnosis of TAPS2. In addition, injection of TTTS placentas treated with fetoscopic laser surgery allows identification of possible residual anastomoses3-5. This additional information is of paramount importance for all perinatologists involved in the management and care of monochorionic twins with TTTS or TAPS. Several placental injection techniques are currently being used. We provide a simple protocol to accurately evaluate the presence of (residual) vascular anastomoses using colored dye injection.
Protocol
Discussion
TTTS and TAPS are two severe disorders that can occur in monochorionic twins. Both disorders are due to AV anastomoses causing imbalanced intertwin blood flow. In the last 2 decades, fetoscopic laser surgery became available and was shown to be the best method for treatment of TTTS10. The aim of fetoscopic laser treatment is to interrupt the inter-twin circulation through coagulation of the vascular anastomoses on the placental surface. However, the laser treatment for TTTS is far from perfect. Treatment with …
Disclosures
The authors have nothing to disclose.
Acknowledgements
No funding sources.
Materials
| Name of reagent | Company | Catalogue number | Comments |
|---|---|---|---|
| Umbilical catheters (various dimensions, Length 40 cm) | Vygon | 1270.08 (8 F) 1270.08 (5 F) 1270.04 (4 F) 1270.03 (3.5 F) 1270.02 (2.5 F) | Any type of catheter can be used |
| 20 ml syringes | BD Plastipak | 300613 | |
| Color dye (different colors) | Royal Talens Schoolverf | 36716010 (blue)36715010 (green) 36712350 (yellow) 36713570 (pink) | Any viscous color dye can be used |
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