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Twin reversed arterial perfusion (TRAP) sequence is a rare (1/35.000 pregnancies) and severe complication specific to monochorionic twin pregnancies, involving the presence of an acardiac twin and a structurally normal co-twin (pump twin). The normal twin has a high mortality rate (50- 70%), especially due to congestive heart failure. We report on the case of a IIG IIIP 33 year-old patient who was referred to our institution form another service with the initial diagnosis of multiple pregnancy with one dead twin. Ultrasound revealed 24 gestational weeks intrauterine biamniotic monochorionic twin pregnancy with TRAP sequence and polyhydramnios. Therapeutic amniocentesis was performed for polyhydramnios, evacuating 500 ml of amniotic fluid. A fetoscopic intervention was decided, with the occlusion of the umbilical cord of the acardiac twin, followed by the evacuation of another 700 ml amniotic fluid. The patient was readmitted to our institution at 34 gestational weeks for preterm premature rupture of membranes and vaginal bleeding. Ultrasound revealed intrauterine growth restriction of the living twin, corresponding to 30 gestational weeks and retroplacentar hematoma, reaching 8,5/5 cm. The patient gave birth through cesarean section to a living female fetus, weighing 1480 g, Apgar score 6, 7, 8 at 1, 2 and respectively 5 minutes. In conclusion, TRAP sequence is a rare entity, requiring early diagnosis and careful ultrasound monitoring, in order to select the best management option for the pump twin. To the best of our knowledge, this is the first case reporting a twin pregnancy with TRAP sequence complicated with retroplacentar hematoma. [ABSTRACT FROM AUTHOR]

Amniocentesis is the most commonly performed invasive prenatal diagnostic procedure. The relative simplicity of the method has made amniocentesis available in a large number of centres. Amniocentesis may increase the risk of fetomaternal hemorrhage (FMH) due to needle transfixation of the maternal abdomen skin to the amniotic membrane and sometimes the placenta. There is an increase in FMH after performing amniocentesis, but there is no consensus regarding the best method to monitor the safety of these procedure. Flow cytometry immunophenotyping, using a monoclonal antibody against fetal hemoglobin, has become an interesting alternative to classical Kleihauer test to measuring FMH. Blood contamination of amniotic fluid (AF) during amniocentesis correlates directly with: needle thickness, physician experience, number of puncture points taken for sample acquisition, placental location. The puncture needle is recommended to have a thickness between 20-23 gauge (G).. Maternal cell contamination is prevented by discharging the first 2 ml of each sample. Another factor affecting safety of amniocentesis is the volume of procedures performed by the operator. High volume experience is reported to have decisive impact on rates of procedure-related adverse outcomes The impossibility of AF extraction at the first puncture requires its repetition, which increases the risk of AF contamination. From this point of view, it is extremely important to identify before the procedure the most voluminous AF bags, but also to choose a tract that avoids the transplacental passage. Placement of the placenta on the anterior wall increases the risk of AF contamination compared to the back or posterior wall location. Regarding the isoimunisation risc after amniocentesis, when a FMH occurs with less than 0.1 ml, isoimmunization at six months after delivery is 3%. Amniocentesis is safe to be carried out in fetal medicine when is followed by standard methods and conducted by trained professionals. [ABSTRACT FROM AUTHOR]

Fetal growth restriction(FGR) represents a challenge because diagnostic certainty of its cause is difficult to reach. The purpose of the obstetricians is to identify early FGR and plan the management according to the severity of the condition and the gestational age. Umbilical artery(UA) Doppler study has significant diagnostic efficacy in identifying fetal compromise, representing the gold standard in managing FGR. An increased Doppler index above the 95th percentile for the gestational age, absent or reversed end-diastolic flow, is nonassuring. Doppler study of the uterine artery(Ut. A), performed in low risk-women, can be a valuable predictior for FGR if an increased pulsatility index(PI), alone or combined with notching, is found. In high-risk patients, an increased resistivity index(RI) alone is considered better predictor for FGR. Changes in the cerebral blood flow can be detected by Doppler sonography of the middle cerebral artery(MCA). Abnormal cerebral vasodilation and consequent decrease in vascular resistance are depicted by a decrease in the PI or RI below the 5th percentile. Ductus venosus(DV) Doppler is used in the assessment of FGR when UA Doppler is abnormal. A PI greater than 1 between the 2nd trimester and term is considered abnormal. Absence or reversal of flow during fetal atrial contraction is suggestive for inadequate supply of oxygen to vital organs. The progression of multi-vessel Doppler studies indicating placental dysfunction points out the following events: elevated UA sistole/diastole ratio, MCA PI < 5th percentile, UA - absent followed by reversed diastolic flow, DV - elevated PI followed by reversed a-wave, umbilical vein double/triple pulsations. Multi-vessel Doppler ultrasonography may be the starting point in establishing the management algorithm for FGR. The combined use of fetal biometry, cardiotocographic patterns, amiotic fluid volume, biophysical profile is complementary in detecting fetal compromise. [ABSTRACT FROM AUTHOR]