RESUMO
We report two cases of conjoined twins complicating a triplet pregnancy diagnosed by two-dimensional ultrasound in the first trimester and evaluated further by three-dimensional ultrasound. A review of the literature over the last 30 years revealed 11 other cases diagnosed prenatally by ultrasound. Overall, three (23%) of these 13 pregnancies were achieved by assisted reproductive techniques and 10 (77%) were diagnosed before 18 weeks. Four women opted for termination of the whole pregnancy and three were managed expectantly, with two delivering before 32 weeks. Two monochorionic pregnancies underwent selective feticide with intrauterine demise of the non-conjoined fetus in both cases. All four dichorionic pregnancies undergoing selective termination or spontaneous embryo reduction to singleton in the first trimester resulted in term delivery of the non-conjoined fetus. The rare condition of conjoined twins in a triplet pregnancy poses a significant obstetric challenge from both diagnostic and management points of view. Accurate determination of chorionicity in these cases plays a critical role in determining management and outcome.
Assuntos
Trigêmeos , Gêmeos Unidos/embriologia , Ultrassonografia Pré-Natal/métodos , Adulto , Feminino , Humanos , Imageamento Tridimensional/métodos , Gravidez , Resultado da GravidezRESUMO
OBJECTIVE: Velamentous insertion of the umbilical cord, with a reported incidence of 1% in singleton pregnancies, has been associated with several obstetric complications including fetal growth restriction, prematurity, congenital anomalies, low Apgar scores, fetal bleeding and retained placenta. The aim of this study was to determine the feasibility of identifying velamentous insertion of the umbilical cord during routine obstetric ultrasound. DESIGN: This was a prospective, cross-sectional ultrasound study in 832 unselected second- and third-trimester singleton pregnancies. Color Doppler ultrasound was routinely performed to identify the placental cord insertion site. The role of three-dimensional (3D) ultrasound in evaluating the placental cord insertion site was also studied in a subset of 50 pregnancies from this population. RESULTS: The placental cord insertion site was identified in 825/832 (99%) cases. Visualization was not achieved in seven third-trimester pregnancies with a posterior placenta. A velamentous insertion was suspected prenatally in eight cases, seven of which were confirmed after delivery as velamentous and one as markedly eccentric (battledore placenta). 3D ultrasound performed poorly at evaluating placental cord insertion site, being less efficient due to poor-quality resolution and far more time-consuming than the combined use of gray-scale and color Doppler ultrasound. CONCLUSIONS: Velamentous insertion of the umbilical cord can reliably be detected prenatally by gray-scale and color Doppler ultrasound. 3D imaging had limited value in the evaluation of the placental cord insertion site in our subset of patients. Systematic assessment of the placental cord insertion site at routine obstetric ultrasound has the potential of identifying pregnancies with velamentous insertion and, therefore, those at risk for obstetric complications including vasa previa.
Assuntos
Artérias Umbilicais/diagnóstico por imagem , Cordão Umbilical/anormalidades , Adulto , Estudos Transversais , Feminino , Idade Gestacional , Humanos , Idade Materna , Placenta/anormalidades , Placenta/diagnóstico por imagem , Gravidez , Estudos Prospectivos , Ultrassonografia Doppler em Cores , Ultrassonografia Pré-Natal , Artérias Umbilicais/fisiopatologia , Cordão Umbilical/diagnóstico por imagemRESUMO
Ultrasonically guided access to the fetal umbilical circulation offers an alternative to the standard management of the severe isoimmunized pregnancy. This technique allows fetal blood sampling, direct hematocrit analysis and intravascular transfusion. A severely Rh isoimmunized pregnancy is described in which five intrauterine transfusions of blood were given directly into the umbilical vein under ultrasound visualization. Technical aspects of the procedure and complications are discussed.