Paper fetus

Introduction A paper-like fetus refers to a fetus with twin-fetal or multiple-pregnancy, which is caused by fetal growth restriction and early death is sliced by other fetuses. This kind of paper-like fetus occurs mostly in twin-child transfusion syndrome. Therefore, prenatal monitoring of early system is a necessary condition for the diagnosis of twin-child transfusion syndrome. Correct diagnosis and reasonable intervention can reduce fetal perinatal mortality. Mainly due to twin-transfusion syndrome. Because of the single-oval twins, there may be blood circulation between the placenta, including inter-arterial, inter-venous, and arteriovenous anastomosis.

Cause

Mainly due to twin-transfusion syndrome. Because of the single-oval twins, there may be blood circulation between the placenta, including inter-arterial, inter-venous, and arteriovenous anastomosis. The first two types are uniform in blood distribution, and no abnormalities occur. The arteries are in an anastomosis with the veins of the veins. The blood circulation of the two fetuses causes arteriovenous communication, which leads to blood communication between the fetuses, through the arteriovenous anastomosis between the fetuses, and blood from the arteries. One-way shunt to the vein, causing one fetus to become a donor, and the other fetus to be a recipient, causing blood loss, dehydration, and lack of nutrition to cause death; while recipients may have increased blood volume, cardiac hypertrophy, and liver Complications such as kidney enlargement.

an examination

Related inspection

Obstetric B-ultrasound amniotic fluid amniotic fluid examination interventional intrauterine material examination

(1) Prenatal examination and diagnosis

1. Determination of single-oval twins: TTTs are generally single chorionic twins, so it is an important condition for the diagnosis of single-chorionic twins by B-ultrasound. Barss and others have seen what they saw under the B-ultrasound:

(1) A single placenta.

(2) Fetus of the same sex.

(3) There is a fine longitudinal mediastinum between the fetuses, which is determined to be a single chorionic double-twist, which has a higher diagnostic accuracy. Gender differences can rule out the diagnosis of TTTs. Nores et al reported that of the 37 TTTs, 33 were women with a male to female ratio of 1:9. She cited 74% of 384 single-chorionic twins such as James as females, and 74 of the 96 consecutive twins were female. The issue of female predominance in TTTs remains to be seen.

2. Differences in fetal weight and fetal performance: At present, among the parameters for estimating the weight of the fetus by B-ultrasound, the most accurate abdominal circumference is calculated by a single item. Many scholars believe that the difference in abdominal circumference is 20 mm, and the difference in body weight At around 20%. Blickstein et al found that the difference in fetal abdominal circumference 18 mm, the difference in body weight will be > 15%. In addition, the developmental delay of one fetus in the twins is less due to too little amniotic fluid, and it is in a stuck state. It is also a unique state in TTTs. Brown et al confirmed 6 fetuses in 10 pregnant women by B-ultrasound. Have the above performance.

3. Differences in amniotic fluid: Excessive amniotic fluid and the presence of oligohydramnios are one of the important diagnostic conditions for TTTs. Chescheir et al found 6 cases of B-ultrasound in 7 cases of TTTs with excessive amniotic fluid or oligohydramnios. Achirhon et al found that if a series of B-ultrasound examinations were performed at 18 to 22 weeks of gestation, the fetal bladder was often filled with the possibility of excessive amniotic fluid. Rosen et al. compared the urinary output of TTTs in the fetus, and 3 suspected TTTs. B-ultrasound showed that the small fetus had almost zero urine output, while the large fetus had a 95-percent urine output.

4. Difference between umbilical cord and placenta: In the B-ultrasound, the umbilical cord of the recipient is thicker than the donor, and sometimes the umbilical cord of the recipient is accompanied by a single umbilical artery. Strong studied the number of laps of TTTs in the umbilical cord. Within a certain length, the number of rotations of the recipient is twice that of the blood donor. In addition to the diagnosis, the author also believes that this may be one of the pathological basis of TTTs.

Color Doppler ultrasonography of the placenta may be helpful in determining the traffic branch of the placental vessels of TTTs. Hecher et al. performed color Doppler ultrasound examination on 18 TTTs (two of which were combined with non-cardiac malformations). It was found that the blood supply of blood donors to the recipients of 6 cases of placenta was observed in the middle of the fetal membrane. One case combined with non-cardiac malformation, blood From the normal fetus to the unintentional malformation, this phenomenon disappears after laser treatment, so Hecher considers this to be an important diagnostic method.

5. Differences between the two fetal viscera: Zosmer et al. observed that most of the recipients of TTTs may have cardiac dysfunction, from 5 cases of TTTs before the 25th week of pregnancy combined with amniotic fluid recipients in color Doppler Mild to severe pulmonary stenosis or fatal heart disease was found in B-ultrasound.

Lachapalle et al. In 5 cases of twins confirmed as TTTs after delivery, the ventricular wall of the 5 cases of the recipients was thickened during pregnancy, and the left ventricular part of the donor was shortened, and the cardiac output was significantly increased, indicating myocardial Being overactive, and comparison of the various fetal parameters of the two fetuses, especially the shortening of the left ventricle, may be helpful in diagnosis.

Roberts et al. performed liver measurements on 14 fetuses of 14 TTTs and found that the liver size of the recipients and donors was greater than the normal average. The length of the liver was significantly larger than that of the double chorionic twins as a control, so the diagnosis of TTTs was performed. Have a certain value.

At present, due to the continuous advancement of ultrasound instruments, it is expected that more discoveries will be provided for the recipients of TTTs and the heart and other organs of blood donors.

6. Umbilical puncture: Blickstein believes that puncture of the umbilical blood vessels under the guidance of B-ultrasound to obtain blood samples is of great help in diagnosing TTTs. First, blood samples can be used to confirm that they are single-oval twins; secondly, hemoglobin levels between the two fetuses can be understood; third, the blood donors can be informed of anemia. Okamura had extracted cord blood from two fetuses with single chorionic twins under the guidance of B-ultrasound, confirming that the hemoglobin level of the donor was 9.2 g/dl, and that of the recipient was 15.4 g/dl, due to the damage of the method. Sex, so there are certain difficulties in practical operation, and no more literature reports have been reported so far.

(2) Postpartum examination

1. Placenta: The placenta of the blood donor is pale and edematous, showing atrophy, edema and vasoconstriction of the villi, and amniotic nodules on the amniotic membrane due to oligohydramnios. The recipients have a lot of research on the vascular anastomosis between the placenta, such as injection dyes, radioactive angiography, etc., but because of its complicated steps and clinical significance, this article will not repeat them.

2. Hemoglobin level: The difference in hemoglobin levels between the recipients of the TTTs and the donors is usually above 5 g/dl, even at 27.6 g/dl to 7.8 g/dl, so the current difference is 5 g/dl. . However, some reports mention that the difference is less than 5 g / dl, especially in the mid-term pregnancy, Saunders et al reported that 4 cases of mid-term pregnancy occurred TTTs through the umbilical cord puncture, the difference between the blood and the blood donor's hemoglobin levels did not exceed 2.7 g/dl. As for the short-term after the death of the donor, the anemia of the recipient can be described above.

3. Weight difference: The standard of weight difference between the two fetuses is generally set at 20%, but Blickstein et al. think that 15% is appropriate. In addition, when the gestational age is small, the difference in body weight is small, and the weight of individual blood donors is greater than that of the recipient.

Differential diagnosis

According to the medical history, obstetric examination, the diagnosis of multiple pregnancy is not difficult to establish, in case of doubt, it can be assisted by means of B-mode ultrasound imaging.

There is a history of multiple births in the family of both sides of the medical history; the treatment of ovulation induction drugs before the pregnancy; the early pregnancy reaction is heavier; after the second trimester, the weight gain is more, and the lower abdomen is discomfort.

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