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Monochorionic diamniotic twin pregnancy with selective IUGR type 2: A woman with a monochorionic diamniotic twin pregnancy was referred to our Centre due to a discrepancy in size between the foetuses.

During the fetoscopy, we identified an arterio-venous anastomosis with bidirectional flow, which is atypical in this type of anastomoses unidirectionals and could represent a sign of ominous prognosis for the restricted twin.

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Monochorionic pregnancies pose a great challenge for the fetal medicine specialist in terms of prevention, diagnosis and management due to the shared placental circulation by both twins. Among these complications we have the twinto-twin transfusion syndrome, the selective fetal growth restriction, the twin anaemia polycythemia sequence, the twin reversed arterial perfusion sequence and the monoamniotic pregnancy 1.

One important point to consider is that since both babies are connected to each other through the placental anastomoses, the wellbeing of one of them critically depends on the wellbeing of the other.

It is of paramount importance to consider the latter in one of the complications that arise from the monochorionicity: We report the case of a MCDA twin pregnancy complicated with selective IUGR, managed with fetoscopic surgery, in which we describe ultrasound criteria of severity and a fetoscopic sign of bad prognosis for dr small twin: A 23 year-old primigravida with a spontaneous monochorionic diamniotic twin pregnancy was referred to our Unit at 16 weeks of gestation.

The reason was a marked discrepancy in the growth of both twins Figure 1 and abnormal Dopplers in the small twin. The patient had a first trimester combined screening test with low risk for chromosomal abnormalities. The discrepancy in the nuchal translucencies was not marked 1. Classificacion anatomy of both twins was normal; the deepest pool of amniotic fluid in the small baby was in the normal inferior limit and in the big baby was normal.

Dopplers in the big baby were normal. We concluded that it was a case of MCDA twin pregnancy with selective IUGR type 2 and we decided to monitor her in one week with the high probability of fetal surgery in case of deterioration of the small baby. The small baby, whose AC was still under the 5th centile, presented now oligohydramnios with a deepest vertical pool of 1 cm Figure 2. The big baby remained oliohidramnios normal Dopplers.

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The cervix was long and closed, no funnelling, and measured 30 mm Figure 5. Clasifixacion diagnosis was consistent: Considering the deterioration of the small twin amniotic fluid and Dopplers and its high chance of intrauterine demise, we decided to perform the fetal surgery mainly to protect the wellbeing of the healthy baby thus avoiding the consequent exsanguination of this twin through the placen-tal anastomoses.

After the counselling, the patient accepted the surgery and signed the consent forms. The fetoscopic surgery was performed uneventfully, with local anaesthesia and without any maternal complication.

Síndrome de transfusión fetofetal

A sample of amniotic fluid was obtained for karyotype that turned out to be normal. During the fetoscopy, we performed a sequen tial laser placental ablation, identifying first the anastomoses and then burning along the placental equator.

Among the identified anastomoses, we clearly found one arterio-venous anastomosis from the restricted fetus towards the normal one that showed a fluctuant colour between red and purple which is unusual in this type of anastomoses unidirectionals. We considered this finding a consequence of the low central vascular pressure in the sick foetus and its placental umbilical arterial branches, not able to overcome the pressure of the umbilical venous branches of the normal foetus at the level of the placental anastomoses.

Therefore we proceeded to burn it in order to avoid any possible blood loss from the normal twin into the small one. The patient was discharged the same day of the surgery after checking the cardiac activity in both babies.

One week later, she had rupture of membranes and four weeks after the surgery, at 21 weeks of gestation, the restricted fetus died. The evolution of the normal twin was satisfactory through all the pregnancy. It was born at 34 weeks and 4 days by elective caesarean section due to prolonged premature rupture of membranes, oligohydramnios and breech presentation, weighting 2 grams and without any complication.

Her neurological development has been adequate 6 months of age. As we mentioned before, the shared placental circulation between both babies produce complications inherent to this type of twinning. Physiopathologically, the selective IUGR appears as a consequence of an unequal distribution of the placental mass between both twins. Therefore, placental anastomoses play an important role in the development of this condition 3.

The sIUGR can be diagnosed since the very first trimester by identifying in the ultrasound a marked discrepancy between the CRLs like in our case. Once the diagnosis is done, it is important to classify the sIUGR in three different types according to the Doppler in the umbilical artery UA of the small baby.

Each of these types has different placental characteristics, management and prognosis 1.

The management is generally surgical since the prognosis without doing anything is poor: The ultrasound findings that worsen the prognosis of a pregnancy complicated with sIUGR are the discrepancy in the EFW between the twins, Doppler of the umbilical artery and ductus venosus of the restricted foetus along with oligohydramnios, gestational age at the moment of the surgery and cervical length 7. We consider important to communicate this case because, in addition to the ultrasound findings of ominous prognosis, we found also a fetoscopic sign that worsens the prognosis for the restricted foetus reflecting its critical ill condition: The explanation to this finding starts in the bad general condition of the small baby whose low central blood pressure, due to lack of oxygenation, produces a low vascular pressure in the placental branches of its umbilical arteries that is not high enough to overcome the pressure of the umbilical vein branches of the big baby at the level of the A-V anastomosis.

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This originates a fluctuant change of colour observed during the fetoscopy between purple and red in the arterial part of the A-V anastomosis that belongs to the small baby.

This loss of blood into the small baby through the A-V anastomosis causes a reduced oxygenated blood flow to the healthy baby.

Therefore, we considered necessary to burn this anastomo sis in order to protect the blood flow into the big baby and avoid any risk of mental handicap. First, a thorough week scan that allow us to clasifkcacion clearly the chorionicity and amnionicity of the pregnancy, as well as satisfactory CRL and NT measurements.

And second, an effective ultrasound-fetoscopic correlation that let us assess the progression of the disease and decide the most appropriate moment to intervene considering the oligphidramnios and feto scopic findings already described and yet to be studied.

Los Dopplers en el gemelo grande eran normales. El gemelo sano presentaba Dopplers normales. The vascular anastomoses in monochorionic twin pregnancies and their clinical consequences. Am J Obstet Gynecol. Endoscopic placental laser coagulation in monochorionic diamniotic twins with type II selective fetal growth restriction. Placental clasificqcion in monochorionic twin pregnancies: Selective intrauterine growth restriction in monochorionic diamniotic twin pregnancies.

Selective intrauterine growth restriction in monochorionic twins: Semin Fetal Neonatal Med. Placental sharing, birthweight discordance, and vascular anastomoses in monochorionic diamniotic twin placentas.

Ultrasound predictors of mortality in monochorionic twins with selective intrauterine growth restriction. Fetal Medicine Foundation Conflict of interest: Received for publication 22 June and accepted for publication on 10 July Case A 23 year-old primigravida with a clasifficacion monochorionic diamniotic twin pregnancy was referred to our Unit at 16 weeks of gestation.

None Received for publication 22 June and accepted for publication on 10 July Enrique Gil Guevara gil doctors.