nach oben

Erschienen in:

2018 | OriginalPaper | Buchkapitel

21. Mehrlingsschwangerschaft

verfasst von : W. Diehl, Prof. Dr. med. K. Hecher

Erschienen in: Ultraschalldiagnostik in Geburtshilfe und Gynäkologie

Verlag: Springer Berlin Heidelberg

Einloggen, um Zugang zu erhalten

Zusammenfassung

Durch die plazentaren Gefäßanastomosen hängt das Schicksal monochorialer Gemini voneinander ab. Daher hat die Feststellung der Chorion- und Amnionverhältnisse bei der Diagnose einer jeden Mehrlingsgravidität eine fundamentale Bedeutung und sollte bereits in der Frühgravidität, aber spätestens zum Zeitpunkt des Ersttrimesterscreenings erfolgen. Liegt eine monochoriale Plazenta vor, so ist eine engmaschige sonographische Überwachung der Schwangerschaft indiziert. Die monochorialen Zwillinge und ihre spezifischen Komplikationen (schweres Zwillingstransfusionssyndrom [FFTS], selektive Wachstumsrestriktion [sIUGR], Anämie-Polyzythämie-Sequenz [TAPS] im III. Trimester) sowie deren Therapie werden ausführlich dargestellt. Monoamniale Zwillinge sollten ab der 26.–28. SSW engmaschig sonographisch kontrolliert und aufgrund des erhöhten Risikos für einen intrauterinen Tod nach Lungenreifeinduktion ab der 33. SSW per elektiver Sektio entbunden werden. Eine Reduktion von höhergradigen Mehrlingen oder von Drillingen zu Zwillingen ist in Anbetracht der hohen Risiken einer extremen Prämaturität bei abwartendem Verhalten vertretbar und erfolgt bei dichorialen Verhältnissen durch eine intrakardiale Gabe von Kaliumchlorid. Bei monochorialen Verhältnissen kommt nur eine Nabelschnurkoagulation infrage. Eine Reduktion sollte in der 14. SSW erfolgen, und eine adäquate psychologische Evaluation und Betreuung sollte sichergestellt werden.

Vorheriges Kapitel Geburtshilfliche Zervixsonographie und Diagnostik der drohenden Frühgeburt

Nächstes Kapitel Fetale Wachstumsrestriktion

Akkermans J, Peeters SHP, Klumper FJ, Lopriore E, Middeldorp JM, Oepkes D (2015) Twenty-five years of fetoscopic laser coagulation in twin-twin transfusion syndrome: a systemativ review. Fetal Diagn Ther 38: 241–253

Allen VM, Windrim R, Barrett J, Ohlsson A (2001) Management of monoamniotic twin pregnancies: a case series and systemic review of the literature. Br J Obstet Gynaecol 108: 931–936

Arias F, Sunderji S, Gimpelson R, Colton E (1998) Treatment of acardiac twinning. Obstet Gynecol 91: 818–821

Bamberg C, Diemert A, Glosemeyer P, Hecher K (2017) Quantified discordant placental echogenicity in twin anemia-polycythemia sequence (TAPS) and middle cerebral artery peak systolic velocities. Ultrasound Obstet Gynecol doi: 10.1002/uog.17535

Baschat A, Gungor S, Glosemeyer P, Huber A, Hecher K (2010) Changes in umbilical venous volume flow after fetoscopic laser occlusion of placental vascular anastomoses in twin-to-twin transfusion syndrome. Am J Obstet Gynecol 203: 479.e1–6

Baxi LV, Walsh CA (2009) Monoamniotic twins in contemporary practice: a single-center study of perinatal outcomes. J Matern Fetal Neonatal Med 27: 1–5

Benirschke K, Kim CK (1973) Multiple pregnancy. N Eng J Med 288: 1276e84

Black M, Bhattacharya S (2010) Of multiple pregnancy and the effect of assisted conception. Seminars in Fetal & Neonatal Medicine. Epidemiology 15: 306–312

Bora SA, Papageorghiou AT, Bottomley C, Kirk E, Bourne T (2008) Reliability of transvaginal ultrasonography at 7–9 weeks gestation in the determination of chorionicity and amnionicity in twin pregnancies. Ultrasound Obstet Gynecol 32: 618–621

Brambati B, Tului L (1995) First trimester fetal reduction: its role in the management of twin and higher order multiple pregnancies. Hum Reprod Update 1(397): 397–408

Cabero L, Deprest J (2004) Prevalence of neurological damage in monochorionic twins with selective intrauterine growth restriction and intermittent absent or reversed end-diastolic umbilical artery flow. Ultrasound Obstet Gynecol 24: 159–163

Carroll SG, Soothill PW, Abdel-Fattah SA, Porter H, Montague I, Kyle PM (2002) Prediction of chorionicity in twin pregnancies at 10–14 weeks of gestation. Br J Obstet Gynaecol 109: 182–186

Chaveeva P, Poon LC, Sotiriadis A, Kosinski P, Nicolaides KH (2014) Optimal method and timing of intrauterine intervention in twin reversed arterial perfusion sequence: case study and meta-analysis. Fetal Diagn Ther 35: 267–279

Coulam CB, Wright G (2000) First trimester diagnosis of acardiac twins. Early Pregnancy 4: 261–270

Devine PC, Malone FD, Athanassiou A, Harvey-Wilkes K, D’Alton ME (2001) Maternal and neonatal outcome of 100 consecutive triplet pregnancies. Am J Perinatol 18: 225e35

Dhillon RK, Hillman SC, Pounds R, Morris RK, Kilby MD (2015) Comparison of Solomon technique with selective laser ablation for twin-twin transfusion syndrome: a systematic review. Ultrasound Obstet Gynecol 46: 526–533

Diehl W, Glosemeyer P, Tavares de Sousa M, Hollwitz B, Ortmeyer G, Hecher K (2013) Twin anemia-polycythemia sequence in a case of monoamniotic twins. Ultrasound Obstet Gynecol 42: 108–111

Diehl, W, Diemert A, Grasso D, Sehner S, Wegscheider K, Hecher K (2017) Fetoscopic laser coagulation in 1020 pregnancies with twin-to-twin transfusion syndrome demonstrates improvement of double survival rates. Ultrasound Obstet Gynecol doi: 10.1002/uog.17520

Diemert A, Diehl W, Huber A, Glosemeyer P, Hecher K (2010) Laser therapy of twin-to-twin transfusion syndrome in triplet pregnancies. Ultrasound Obstet Gynecol 35: 71–74

Evans MI, Berkowitz RL, Wapner RJ, Carpenter RJ, Goldberg JD, Ayoub MA, Horenstein J, Dommergues M, Brambati B, Nicolaides KH, Holzgreve W, Timor-Tritsch IE (2001) Improvement in outcomes of multifetal pregnancy reduction with increased experience. Am J Obstet Gynecol 184: 97–103

Fusi L, McParland P, Fisk N, Nicolini U, Wigglesworth J (1991) Acute twin-twin transfusion: a possible mechanism for brain-damaged survivors after intrauterine death of a monochorionic twin. Obstet Gynecol 78: 517–520

Graef C, Ellenrieder B, Hecher K, Hackelöer BJ, Huber A, Bartmann P (2006) Long-term neurodevelopmental outcome of 167 children after intrauterine laser treatment for severe twin-twin transfusion syndrome. Am J Obstet Gynecol 194: 303–308

Gratacos E, Carreras E, Becker J, Lewi L, Enríquez G, Perapoch J, Higueras T, Cabero L, Deprest J (2004) Prevalence of neurological damage in monochorionic twins with selective intrauterine growth restriction and intermittent absent or reversed end-diastolic umbilical artery flow. Ultrasound Obstet Gynecol 24 (2): 159–163

Gratacos E, Lewi L, Munoz B, Acosta-Rojas R, Hernandez-Andrade E, Martinez JM, Carreras E, Deprest J (2007) A classification system for selective intrauterine growth restriction in monochorionic pregnancies according to umbilical artery Doppler flow in the smaller twin. Ultrasound Obstet Gynecol 30: 28–34

Gratacos E, Antolin E, Lewi L, Martinez JM, Hernandez-Andrade E, Acosta-Rojas R, Enriquez G, Cabero L, Deprest J (2008) Monochorionic twins with selective intrauterine growth restriction and intermittent absent or reversed end-diastolic flow (Type III): feasibility and perinatal outcome of fetoscopic placental laser coagulation. Ultrasound Obstet Gynecol 31: 669–675

Gucciardo L, Lewi L, Vaast P, Debska M, De Catte L, Van Mieghem T, Done E, Devlieger R, Deprest J (2010) Twin anemia polycythemia sequence from a prenatal perspective. Prenat Diagn 30: 438–442

Hack KE, Derks JB, Schaap AH, Lopriore E, Elias SG, Arabin B, Eggink AJ, Sollie KM, Mol BWJ, Duvekot HJ, Willekes C, Go AT, Koopman-Esseboom C, Vandenbussche FP, Visser GH (2009) Perinatal outcome of monoamniotic twin pregnancies. Obstet Gynecol 113: 353–360

Hecher K, Plath H, Bregenzer T, Hansmann M, Hackelöer BJ (1999) Endoscopic laser surgery versus serial amniocenteses in the treatment of severe twin-twin transfusion syndrome. Am J Obstet Gynecol 180: 717–724

Hecher K, Lewi L, Gratacos E, Huber A, Ville Y, Deprest J (2006) Twin reversed arterial perfusion: fetoscopic coagulation of placental anastomoses or the umbilical cord. Ultrasound Obstet Gynecol 28: 688–691

Heybourne KD, Porreco RP, Garite TJ, Phair K, Abril D (2005) Improved perinatal survival of monoamniotic twins with intensive inpatient monitoring. Am J Obstet Gynecol 192: 96–101

Hillmann SC, Morris RK, Kilby MD (2011) Co-twin prognosis after single fetal death. Obstet Gynecol 118: 928–940

Huber A, Hecher K (2004) How can we diagnose and manage twin-twin transfusion syndrome? Best Pract Res Clin Obstet Gynaecol 18: 543–556

Huber A, Diehl W, Bregenzer T, Hackelöer BJ, Hecher K (2006a) Stage-related outcome in twin-twin transfusion syndrome treated by fetoscopic laser coagulation. Obstet Gynecol 108: 333–337

Huber A, Diehl W, Zikulnig L, Bregenzer T, Hackelöer BJ, Hecher K (2006b) Perinatal outcome in monochorionic twin pregnancies complicated by amniotic fluid discordance without severe twin-twin transfusion syndrome. Ultrasound Obstet Gynecol 27: 48–52

Huber A, Baschat AA, Bregenzer T, Diemert A, Tchirikov M, Hackelöer BJ, Hecher K (2008) Laser coagulation of placental anastomoses with a 30° fetoscope in severe mid-trimester twin-twin transfusion syndrome with anterior placenta. Ultrasound Obstet Gynecol 31: 412–416

James WH (1977) A note on the epidemiology of acardiac monsters. Teratology 16: 211e6

Kagan KO, Gazzoni A, Sepulveda-Gonzalez G, Sotiriadis A, Nicolaides KH (2007) Discordance in nuchal translucency thickness in the prediction of sebere twin-to-twin transfusion syndrome. Ultrasound Obstet Gynecol 29: 527–532

Khalil A, Rodgers M, Baschat A, Bhide A, Gratacos E, Hecher K, Kilby MD, Lewi L, Nicolaides KH, Oepkes D, Raine-Fenning N, Reed K, Salomon LJ, Sotiriadis A, Thilaganathan B, Ville Y (2016) ISUOG Practice Guidelines: role of ultrasound in twin pregnancy. Ultrasound Obstet Gynecol 47: 247–263

Lee H, Wagner AJ, Sy E, Ball R, Feldstein VA, Goldstein RB, Farmer DL (2007) Efficacy of radiofrequency ablation for twin-reversed arterial perfusion sequence. Am J Obstet Gynecol 196: 459.e1–4

Lee H, Bebbington M, Crombleholme TM for the North American Fetal Therapy Network (NAFTNet) (2013) The North American Fetal Therapy Network Registry Data on outcomes of radiofrequency ablation for twin-reversed arterial perfusion sequence. Fetal Diagn Ther 33: 224–229

Lenclen R, Paupe A, Ciarlo G, Couderc S, Castela F, Örtqvist L, Ville Y (2007) Neonatal outcome in preterm monochorionic twins with twin-to-twin transfusion syndrome after intrauterine treatment with amnioreduction or fetoscopic laser surgery: comparison with dichorionic twins. Am J Obstet Gynecol 196: 450.e1–7

Lewi L, Gratacos E, Ortibus E, Van Schoubroeck D, Carreras E, Higueras T, Perapoch J, Deprest J (2006) Pregnancy and infant outcome of 80 consecutive cord coagulations in complicated monocorionic multiple pregnancies. Am J Obstet Gynecol 194: 782–789

Lewi L, Cannie M, Blickstein I, Jani J, Huber A, Hecher K, Dymarkowski S, Gratacos E, Lewi P, Deprest J (2007) Placental sharing, birthweight discordance, and placental vascular anastomoses in monochorionic diamniotic twin placentas. Am J Obstet Gynecol 197: 587.e1–e8

Lewi L, Gucciardo L, Huber A, Jani J, Van Mieghem T, Done E, Cannie M, Gratacos E, Diemert A, Hecher K, Lewi P, Deprest J (2008a) Clinical outcome and placental characteristics of monochorionic diamniotic twin pairs with arlyand late-onset discordant growth. Am J Obstet Gynecol 199: 511.e1–7

Lewi L, Jani J, Blickstein I, Huber A, Gucciardo L, Van Mieghem T, Done E, Boes AS, Hecher K, Gratacos E, Lewi P, Deprest J (2008b) The outcome of monochorionic diamniotic twin gestations in the era of invasive fetal therapy: a prospective cohort study. Am J Obstet Gynecol 199: 514.e1–8

Lewi L, Lewi P, Diemert A, Jani J, Gucciardo L, Van Mieghem T, Done E, Gratacos E, Huber A, Hecher K, Deprest J (2008c) The role of ultrasound examination in the first trimester and at 16 weeks’ gestation to predict fetal complications in monochorionic diamniotic twin pregnancies. Am J Obstet Gynecol 199: 493.e1–493.e7

Lewi L, Valencia C, Gonzales E, Deprest J, Nicolaides K (2010) The outcome of twin reversed arteial perfusion sequence diagnosed in the first trimester. Am J Obstet Gynecol 203: 213.e1–4

Lewi L, Deprest J, Hecher K (2013) The vascular anastomoses in monochorionic twin pregnancies and their clinical consequences. Am J Obstet Gynecol 208: 19–30

Lopriore A, Middeldorp JM, Sueters M, Oepkes D, Vandenbussche FPHA, Walther FJ (2007) Long-term neurodevelopmental outcome in twin-to-twin transfusion syndrome treated with fetoscopic laser surgery. Am J Obstet Gynecol 196: 231.e1–4

Lust A, De Catte L, Lewi L, Deprest J, Loquet P, Devlieger R (2008) Monochorionic and dichorionic twin pregnancies discordant for fetal anencephaly: a systematic review of prenatal management options. Prenat Diagnosis 28: 275–279

Mackenzie TC, Crombleholme TM, Johnson MP, Schnaufer L, Flake AW, Hedrick HL, Howell LJ, Adzick NS (2002) The natural history of prenatally diagnosed conjoined twins. J Pediatr Surg 37: 303–309

Matias A, Montenegro N, Loureiro T, Cunha M, Duarte S, Freitas D, Severo M (2010) Screening for twin-twin transfusion syndrome at 11–14 weeks of pregnancy: the key role of ductus venosus blood flow assessment. Ultrasound Obstet Gynecol 35: 142–148

Middeldorp JM, Klumper FJ, Oepkes D, Lopriore E, Kanhai HH, Vandenbussche FP (2008) Selective feticide in monoamniotic twin pregnancies by umbilical cord occlusion and transection. Fetal Diagn Ther 23: 121–125

Moore TR, Gale S, Benirschke K (1990) Perinatal outcome of fortynine pregnancies complicated by acardiac twinning. Am J Obstet Gynecol 163: 907–912

Napolitani FD, Schreiber I (1960) The acardiac monster: a review of the world literature and presentation of 2 cases. Am J Obstet Gynecol 80: 582e9

Ombelet W, De Sutter P, Van der Elst J, Martens G (2005) Multiple gestation and infertility treatment: registration, reflection and reaction – the Belgian project. Hum Reprod Update 11: 3–14

Ong SSC, Zamora J, Khan KS, Kilby MD (2006) Prognosis for the co-twin following single-twin death: a systematic review. BJOG 113: 992–998

Pagani G, D’Antonio F, Khalil A, Papageorghiou A, Bhide A, Thilaganathan B (2013) Intrafetal laser treatment for twin reversed arterial perfusion sequence: cohort study and meta-analysis. Ultrasound Obstet Gynecol 42: 6–14

Papageorghiou AT, Avgidou K, Bakoulas V, Sebire NJ, Nicolaides KH (2006) Risks of miscarriage and early preterm birth in trichorionic triplet pregnancies with embryo reduction versus expectant management: new data and systematic review. Hum Reprod 21: 1912–1917

Petterson B, Nelson KB, Watson L, Stanley F (1993) Twins, triplets, and cerebral palsy in births in Western Australia in the 1980 s. BMJ 307: 1239–1243

Quintero R, Morales W, Allen MH, Bornick PW, Johnson PK, Kruger M (1999) Staging of twin-twin transfusion syndrome. J Perinat 19: 550–555

Roberts D, Gates S, Kilby M, Neilson JP (2008) Interventions for twin-twin transfusion syndrome: a Cochrane review. Ultrasound Obstet Gynecol 31: 701–711

Robyr R, Lewi L, Salomon LJ, Yamamoto M, Bernard JP, Deprest J, Ville Y (2006) Prevalence and management of late fetal complications following successful selective laser coagulation of chorionic plate anastomoses in twin-to-twin transfusion syndrome. Am J Obstet Gynecol 194: 796–803

Roethlisberger M, Strizek B, Gottschalk I, Mallmann MR, Geipel A, Gembruch U, Berg C (2017) First-trimester intervention in twin reversed arterial perfusion sequence: does size matter? Ultrasound Obstet Gynecol 50: 40–44

Rossi AC, D’Addario V (2008) Laser therapy and serial amnioreduction as treatment for twin-twin transfusion syndrome: a metaanalysis and review of literature. Am J Obstet Gynecol 198: 147–152

Savvidou MD, Karanastasi E, Skentou C, Geerts L, Nicolaides KH (2001) Twin chorionicity and pre-eclampsia. Ultrasound Obstet Gynecol 18: 228–231

Sebire NJ, Snijders RJ, Hughes K, Sepulveda W, Nicolaides KH (1997) The hidden mortality of monochorionic twin pregnancies. Br J Obstet Gynaecol 104: 1203–1207

Sebire NJ, Souka A, Skentou H, Geerts L, Nicolaides KH (2000) First trimester diagnosis of monoamniotic twin pregnancies. Ultrasound Obstet Gynecol 16: 223–225

Senat M-V, Deprest J, Boulvain M, Paupe A, Winer N, Ville Y (2004) Endoscopic laser surgery versus serial amnioreduction for severe twin-to-twin transfusion syndrome. N Engl J Med 351: 136–144

Sepulveda W, Sebire NJ, Hughes K, Kalogeropoulos A, Nicolaides KH (1997) Evolution of the lambda or twin-chorionic peak sign in dichorionic twin pregnancies. Obstet Gynecol 89: 439–441

Simoes T, Amaral N, Lerman R, Ribeiro F, Dias E, Blickstein I (2006) Prospective risk of intrauterine death of monochorionic-diamniotic twins. Am J Obstet Gynecol 195: 134–139

Slaghekke F, Kist WJ, Oepkes D, Middeldorp JM, Klumper FJ, Vandenbussche FPHA, Lopriore E (2009) TAPS and TOPS: two distinct forms of feto-fetal transfusion in monochorionic twins. Z Geburtshilfe Neonatol 213 (6): 248–254

Slaghekke F, Lopriore E, Lewi L, Middeldorp JM, van Zwet EW, Weingertner A-S, Klumper FJ, DeKoninck P, Devlieger R, Kilby MD, Rustico MA, Deprest J, Favre R, Oepkes D (2014) Fetoscopic laser coagulation of the vascular equator versus selective coagulation for twin-to-twin transfusion syndrome: an open-label randomised controlled trial. Lancet 383: 2144–51

Slaghekke F, Pasmann S, Veujoz M, Middeldorp JM, Lewi L, Devlieger R, Favre R, Lopriore E, Oepkes D (2015) Middle cerebral artery peak systolic velocity to predict fetal hemoglobin levels in twin anemia-polycythemia sequence. Ultrasound Obstet Gynecol 46: 432–436

Sperling L, Kiil C, Larsen LU, Brocks V, Wojdemann KR, Qvist I, Schwartz M, Jørgensen C, Espersen G, Skajaa K, Bang J, Tabor A (2007) Detection of chromosomal abnormalities, congenital abnormalities and transfusion syndrome in twins. Ultrasound Obstet Gynecol 29: 517–526

Spitz L (2005) Conjoined twins. Prenat Diagn 25: 814–819

Stenhouse E, Hardwick C, Maharaj S, Webb J, Kelly T (2002) Chorionicity determination in twin pregnancies: how accurate are we? Ultrasound Obstet Gynecol 19: 350–352

Stone J, Ferrara L, Kamrath J, Getrajdman J, Berkowitz R, Moshier E, Eddleman K (2008) Contemporary outcomes with the latest 1000 cases of multifetal pregnancy reduction (MPR). Am J Obstet Gynecol 199: 406.e1–4

Tollenaar LS, Slaghekke F, Middeldorp JM, Klumper FJ, Haak MC, Oepkes D, Lopriore E (2016) Twin anemia polycythemia sequence: current views on pathogenesis, diagnostic criteria, perinatal management, and outcome. Twin Res Hum Genet 19: 222–233

Tul N, Bricelj K, Ravnik D, Diehl W, Hecher K (2015) Successful laser treatment in monochorionic quadruplets affected by fetofetal transfusion syndrome. Ultrasound Obstet Gynecol 46: 749–750

Umur A, van Gemert MJ, Nikkels PG (2003) Monoamniotic versus diamniotic monochorionic twin placentas: anastomoses and twin-twin transfusion syndrome. Am J Obstet Gynecol 189: 1325–1329

Van Mieghem T, de Heus R, Lewi L, Klaritsch P, Kollmann M, Baud D, Vial Y, Shah PS, Ranzini AC, Mason L, Raio L, Lachat R, Barrett R, Khorsand V, Windrim R, Ryan G (2014) Prenatal management of monoamniotic twin pregnancies. Obstet Gynecol 124: 498–506

Verstraelen H, Goetgeluk S, Derom C, Vansteelandt S, Derom R, Goetghebeur E, Temmerman M (2005) Preterm birth in twins after subfertility treatment: population based cohort study. BMJ 331: 1173

Ville Y, Hyett J, Hecher K, Nicolaides K (1995) Preliminary experience with endoscopic laser surgery for severe twin-twin transfusion syndrome. N Engl J Med 332: 224–227

Wimalasundera RC (2010) Selective reduction and termination of multiple pregancies. Semin Fetal Neonatal Med 15: 327–335

Zikulnig L, Hecher K, Bregenzer T, Bäz E, Hackelöer BJ (1999) Prognostic factors in severe twin–twin transfusion syndrome treated by endoscopic laser surgery. Ultrasound Obstet Gynecol 14: 380–387

Titel: Mehrlingsschwangerschaft
verfasst von: W. Diehl
Prof. Dr. med. K. Hecher
Verlag: Springer Berlin Heidelberg
Buch: Ultraschalldiagnostik in Geburtshilfe und Gynäkologie
Print ISBN: 978-3-662-53661-2

Electronic ISBN: 978-3-662-53662-9

Copyright-Jahr: 2018
DOI: https://doi.org/10.1007/978-3-662-53662-9_21

Springerpflege

Zusammenfassung

Bitte loggen Sie sich ein, um Zugang zu diesem Inhalt zu erhalten