Insights into the pathophysiology of twin–twin transfusion syndrome

Twin–twin transfusion syndrome (TTTS) is attributed to trans-anastomotic transfusion between twins. Anastomoses are ubiquitous in monochorionic (MC) placentae, yet TTTS develops in only 15%. Although ex vivo and in vivo studies fail to identify a unique anastomotic signature, TTTS placentae are typically associated with an imbalance in unidirectional arteriovenous anastomoses with absent bidirectional anastomoses. Doppler detection of an artery-artery anastomosis reduces the chance of TTTS, whereas, in those that develop the disease, it improves stage-independent survival. Selective laser is often curative, but an increasingly recognized risk of persistent or reverse TTTS may be attributable to atypical arteriovenous anastomoses not identifiable from the chorionic plate. Simple dysvolaemia fails to explain several phenotypic features, including haematological concordancy, recipient hypertension, and reversibly absent end diastolic flow in the donor. The renin-angiotensin system is upregulated in the donor and downregulated in the recipient's kidneys, while paradoxically raised renin levels in the recipient may contribute to raised afterload along with endothelin. Although research is limited in humans by therapy and the lack of a suitable experimental model, further studies of placental and vascular pathophysiology may not only refine current treatment modalities but may also, in addition, suggest further avenues for downstream management such as genetic predisposition testing or pharmacological intervention. Copyright © 2005 John Wiley & Sons, Ltd.     

近距双线盾构隧道开挖诱发地层变形演变规律及数值模拟

双线平行隧道盾构施工相互扰动作用对其诱发的地层变形分布特征和演变规律影响显著。以某地铁双线盾构隧道工程为例,考虑双线平行隧道间距与盾构施工相互作用影响,采用数值模拟和现场实测相结合的方法对双线平行隧道盾构施工引起的地层变形演变规律进行了对比分析,并提出了考虑近远距状态的双线平行隧道盾构施工地层变形预测模型。研究结果表明,双线盾构隧道施工地层竖向变形曲线由“V”形发展为非对称“W”形分布,沉降槽宽度由6D扩大为10D,地层深度越深非对称“双峰”特征越明显;地层水平变形曲线以两隧道中线为轴线呈反对称分布,两隧道间区域土体变形受施工扰动影响显著;地表沉降曲线分布随双线隧道近远距变化由深“V”形—浅“V”形—“U”形—浅“W”形—深“W”形—两独立“V”形演变,采用L cr=2CKH可作为双线平行盾构隧道近远距状态临界判据,本文提出的预测模型能较好地反映近远距状态及施工相互扰动对双线平行隧道盾构施工地层变形的影响规律。研究成果可为类似地铁隧道盾构施工变形预测与精细化控制提供科学参考。     

Perinatal hepatic infarction in twin–twin transfusion

We report a case of a twin pregnancy which was complicated by a twin–twin transfusion in which the recipient twin was noted to have an intra-abdominal echogenic mass. This twin died at two days of age of hepatic infarction. The donor twin was healthy at birth, at thirty weeks' gestation, and did not have any subsequent problems. Fetal intra-abdominal echogenicity may be a marker of hepatic infarction. Copyright © 2002 John Wiley & Sons, Ltd.     

Successful early in utero management of fetal hydrothorax in a twin pregnancy

We present a case of dichorionic diamniotic twin pregnancy in which one of the fetuses was found to have a major pleural effusion at 15 weeks of gestation. A single-needle pleural fluid aspiration was performed at 15 and 16 weeks, but the fluid reaccumulated quickly after each procedure and at 16 weeks, the fetus was found to become progressively hydropic. A shunt was then successfully inserted at 17 weeks, which is the earliest gestation reported so far in the literature for such a procedure to treat isolated hydrothorax. Because we felt that the fetus would be too small for a classical double-pigtail pleuroamniotic shunt, we used a multilength double-pigtail bladder stent (Harrison drain; Cook; Spencer; Indiana; USA) via a 13-gauge echo tip trocar. This shunt could be used for both singleton and twin pregnancies presenting with fetal pleural effusion from as early as 16 to 17 weeks to prevent the development of fetal hydrops and polyhydramnios and subsequent premature delivery. Treatment at this stage of gestation would also minimize the risk of lung hypoplasia, which is the main clinical issue when shunts are inserted after 24 weeks. Copyright © 2003 John Wiley & Sons, Ltd.     

Prenatal screening for Down syndrome and neural tube defects in twin pregnancies

Prenatal screening and diagnosis in a twin pregnancy is not straightforward. Once a twin pregnancy has been identified, women and their partners need time to consider the implications and decide whether they wish the pregnancy to be screened for Down syndrome or neural tube defects. We discuss here how multiple marker screening for Down syndrome and alpha-fetoprotein screening for neural tube defects can be carried out, given that this is the parents' chosen option and that the health professionals involved are capable of performing a diagnosis and selective feticide, should this arise. Copyright © 2005 John Wiley & Sons, Ltd.