Skip to main content Accessibility help
×
Home
  • Access
  • Print publication year: 2012
  • Online publication date: February 2013

Chapter 12.1 - Twin reversed arterial perfusion (TRAP) sequence

from Section 2 - Fetal disease
    • Send chapter to Kindle

      To send this chapter to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle.

      Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Available formats
      ×

      Send chapter to Dropbox

      To send content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about sending content to Dropbox.

      Available formats
      ×

      Send chapter to Google Drive

      To send content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about sending content to Google Drive.

      Available formats
      ×

Summary

This chapter discusses the pathophysiological basis and pathology of twin reversed arterial perfusion (TRAP) sequence, briefly discussing prenatal diagnosis and treatment in relation to our understanding of the pathophysiology of the condition and largely focusing on the treatment options. Numerous pregnancy complications may develop, either due to consequences of the abnormal development of the acardiac fetus, or due to secondary effects on the pump twin. The abnormalities present in the affected acardiac twin represent a wide spectrum, ranging from the fetus comprising an amorphous mass of tissue through to a relatively well-formed fetus with trunk, arms, and legs. TRAP sequence is essentially a defect of monozygotic duplication requiring the presence of interfetal placental vascular anastomoses; it is therefore a complication affecting monochorionic multiple pregnancies. Since "pump" twin mortality and morbidity is well reported, several strategies have been described for antenatal intervention in TRAP sequence to improve the outcome.
References
Weber, MA, Sebire, NJ. Genetics and developmental pathology of twinning. Semin Fetal Neonatal Med 2010;15:313–18.
Chanoufi, MB, Ben Temime, R, Masmoudi, A, et al. Clinical and anatomic features of acardiac twins. Med Princ Pract 2004;13:375–9.
Obladen, M. From monster to twin reversed arterial perfusion: a history of acardiac twins. J Perinat Med 2010;38:247–53.
Dahiya, P, Agarwal, U, Sangwan, K, Sen, J. Antenatal diagnosis of twin-reversed arterial perfusion sequence (acardiac amorphous) in a triplet pregnancy: case report. Arch Gynecol Obstet 2004;269:147–8.
Weisz, B, Peltz, R, Chayen, B, et al. Tailored management of twin reversed arterial perfusion (TRAP) sequence. Ultrasound Obstet Gynecol 2004;23:451–5.
Sogaard, K, Skibsted, L, Brocks, V. Acardiac twins: pathophysiology, diagnosis, outcome and treatment. Fetal Diagn Ther 1999;14:53–59.
Sato, T, Kaneko, K, Konuma, S, Sato, I, Tamada, T. Acardiac anomalies: review of 88 cases in Japan. Asia Oceania J Obstet Gynaecol 1984;10:45–52.
Severn, CB, Holyoke, EA. Human acardiac anomalies. Am J Obstet Gynecol 1973;116:358–65.
Baldwin, VJ. Anomalies of monozygotic duplication. In: Pathology of Multiple Pregnancy. New York, Springer-Verlag. 1994; 277–349.
Shih, JC, Shyu, MK, Hunag, SF, et al. Doppler waveform analysis of the intertwin blood flow in acardiac pregnancy: implications for pathogenesis. Ultrasound Obstet Gynecol 1999;14:375–9.
Moore, TR, Gale, S, Benirschke, K. Perinatal outcome of forty nine pregnancies complicated by acardiac twinning. Am J Obstet Gynecol 1990;163:907–12.
Healey, MG. Acardia: predictive risk factors for the co-twin’s survival. Teratology 1994;50:205–13.
Buntinx, IM, Bourgeois, N, Buytaert, PM, Dumon, JE. Acardiac amorphous twin with prune belly sequence in the co-twin. Am J Med Genet 1991;39:453–7.
Genest, DR, Lage, JM. Absence of normal-appearing proximal tubules in the fetal and neonatal kidney: prevalence and significance. Hum Pathol 1991;22:147–53.
Habbal, OA, Kenue, RK, Venugopalan, P. Acardia syndrome coexisting with gastroschisis in the co-twin. Clin Dysmorphol 2005;14:45–7.
Popek, EJ, Strain, JD, Neumann, A, Wilson, H. In utero development of pulmonary artery calcification in monochorionic twins: a report of three cases and discussion of the possible etiology. Pediatr Pathol 1993;13:597–611.
Kosno-Kruszewska, E, Deregowski, K, Schmidt-Sidor, B, et al. Neuropathological and anatomopathological analyses of acardiac and “normal” siblings in an acardiac-twin pregnancy. Folia Neuropathol 2003;41:103–9.
Benirschke, K, Kaufmann, P. Pathology of the Human Placenta. 2nd edn. New York, Springer. 1995; 702–10.
French, CA, Bieber, FR, Bing, DH, Genest, DR. Twins, placentas, and genetics: acardiac twinning in a dichorionic, diamniotic, monozygotic twin gestation. Hum Pathol 1998;29:1028–31.
Masuzaki, H, Miura, K, Yoshimura, S, Yoshiura, K, Ishimaru, T. A monozygotic twin pregnancy discordant for acardia and X-inactivation pattern. Eur J Obstet Gynecol Reprod Biol 2004;117:102–4.
Steffensen, TS, Gilbert-Barness, E, Spellacy, W, Quintero, RA. Placental pathology in Trap sequence: clinical and pathogenetic implications. Fetal Pediatr Pathol 2008; 27:13–29.
Chen, CP, Shih, SL, Liu, FF, et al. Skeletal deformities of acardius anceps: the gross and imaging features. Pediatr Radiol 1997;27:221–5.
Chi, JG. Acardiac twins – an analysis of 10 cases. J Korean Med Sci 1989;4:203–16.
Gimenez-Scherer, JA, Davies, BR. Malformations in acardiac twins are consistent with reversed blood flow: liver as a clue to their pathogenesis. Pediatr Dev Pathol 2003;6:520–30.
Park, HW, Kapur, RP, Shepard, TH. Reversed circulation in acardiac fetuses is associated with anatomic inversions in the aortic wall. Teratology 1994;49:267–72.
Laure-Kamionowska, M, Maslinska, D, Deregowski, K, Piekarski, P, Raczkowska, B. Effects of ischaemia and hypoxia on the development of the nervous system in acardiac foetus. Folia Neuropathol 2004;42:227–33.
Morizane, M, Ohara, N, Mori, T, Murao, S. Neuropathological features of the brain in acardius acormus. J Perinat Med 2002;30:269–72.
Sergi, C, Schmitt, HP. Central nervous system in twin reversed arterial perfusion sequence with special reference to examination of the brain in acardius anceps. Teratology 2000;61:284–90.
Petersen, BL, Broholm, H, Skibsted, L, Graem, N. Acardiac twin with preserved brain. Fetal Diagn Ther 2001;16:231–3.
Wong, AE, Sepulveda, W. Acardiac anomaly: current issues in prenatal assessment and treatment. Prenat Diagn 2005;25:796–806.
Moore, CA, Buehler, BA, McManus, BM, et al. Acephalus- acardia in twins with aneuploidy. Am J Med Genet Suppl 1987;3:139–43.
Blaicher, W, Repa, C, Schaller, A. Acardiac twin pregnancy: associated with trisomy 2: case report. Hum Reprod 2000;15:474–5.
Borrell, A, Pesarrodona, A, Puerto, B, et al. Ultrasound diagnostic features of twin reversed arterial perfusion sequence. Prenat Diagn 1990;10:443–8.
Langlotz, H, Sauerbrei, E, Murray, S. Transvaginal Doppler sonographic diagnosis of an acardiac twin at 12 weeks gestation. J Ultrasound Med 1991;10:175–9.
Stiller, RJ, Romero, R, Pace, S, Hobbins, JC. Prenatal identification of twin reversed arterial perfusion syndrome in the first trimester. Am J Obstet Gynecol 1989;160:1194–6.
Pretorius, DH, Leopold, GR, Moore, TR, Benirschke, K, Sivo, JJ. Acardiac twin. Report of Doppler sonography. J Ultrasound Med 1988;7:413–16.
Benson, CB, Bieber, FR, Genest, DR, Doubilet, PM. Doppler demonstration of reversed umbilical blood flow in an acardiac twin. J Clin Ultrasound 1989;17:291–5.
Coulam, CB, Wright, G. First trimester diagnosis of acardiac twins. Early Pregnancy 2000;4:261–70.
Gembruch, U, Viski, S, Bagamery, K, Berg, C, Germer, U. Twin reversed arterial perfusion sequence in twin-to-twin transfusion syndrome after the death of the donor co-twin in the second trimester. Ultrasound Obstet Gynecol 2001;17:153–6.
Kamitomo, M, Kouno, S, Ibuka, K, et al. First-trimester findings associated with twin reversed arterial perfusion sequence. Fetal Diagn Ther 2004;19:187–90.
Cox, M, Murphy, K, Ryan, G, et al. Spontaneous cessation of umbilical blood flow in the acardiac fetus of a twin pregnancy. Prenat Diagn 1992;12:689–93.
Tan, TYT, Sepulveda, W. Acardiac twin: a systematic review of minimally invasive treatment modalities. Ultrasound Obstet Gynecol 2003;22:409–19.
Goh, A, Loke, HL, Tan, KW. The ‘TRAP’ sequence – life threatening consequences to the pump twin. Singapore Med J 1994;35:329–31.
Sullivan, AE, Varner, MW, Ball, RH, Jackson, M, Silver, RM. The management of acardiac twins: a conservative approach. Am J Obstet Gynecol 2003;189:1310–13.
Dashe, JS, Fernandez, CO, Twickler, DM. Utility of Doppler velocimetry in predicting outcome in twin reversed-arterial perfusion sequence. Am J Obstet Gynecol 2001;185:135–9.
Brassard, M, Fouron, JC, Leduc, L, Grignon, A, Proulx, F. Prognostic markers in twin pregnancies with an acardiac fetus. Obstet Gynecol 1999;94:409–14.
Sepulveda, W, Sebire, NJ. Acardiac twin: too many invasive treatment options – the problem and not the solution. Ultrasound Obstet Gynecol 2004;24:387–9.