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Case Reports
. 2020 Aug 8;14(1):123.
doi: 10.1186/s13256-020-02444-3.

Intestinal volvulus in the pump twin of a twin reversed arterial perfusion (TRAP) sequence after laser therapy at 18 weeks: a case report

Tania T Herrera  1   2 , Katia Rueda  3 , Honorina Espinosa  4   5 , Gabrielle B Britton  6
Affiliations
Case Reports

Intestinal volvulus in the pump twin of a twin reversed arterial perfusion (TRAP) sequence after laser therapy at 18 weeks: a case report

Tania T Herrera et al. J Med Case Rep. .

Abstract

Background: Twin reversed arterial perfusion sequence is a rare and potentially lethal condition affecting approximately 1% of monochorionic twin pregnancies and 1 in 35,000 pregnancies overall. An apparently normal (pump) twin perfuses its severely malformed cotwin with deoxygenated blood via retrograde flow in direct arterioarterial anastomoses between the umbilical arteries of each twin. Fetal intestinal volvulus is a rare condition usually manifesting after birth. We report a unique case of twin reversed arterial perfusion sequence in association with intestinal volvulus in the surviving pump twin.

Case presentation: A 32-year-old Hispanic primigravida was referred to our clinic after a fetoscopy procedure of laser photocoagulation of anastomoses at 18 weeks of gestation. Follow up scans in the ex-pump twin revealed dilated bowel loops and a typical "whirlpool sign" at 26 weeks of gestation, and intrauterine intestinal volvulus was suspected. At 29 weeks of gestation, preterm premature rupture of membranes occurred, and an emergency cesarean section was performed. The newborn was diagnosed in the early neonatal period with intestinal perforation. The diagnosis was postnatally confirmed by surgery and histopathology.

Conclusions: The type of fetal intervention and late gestational age of the procedure increase the risk of complications. This case alerts health providers to be vigilant in the follow-up of patients with complicated monochorionic pregnancies.

Keywords: Fetal therapies; Intestinal volvulus; Prenatal diagnosis; TRAP sequence; Twin pregnancy.

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Conflict of interest statement

We have no conflicts of interest to declare.

Figures

Fig. 1
Fig. 1
Ultrasound images of a twin reversed arterial perfusion (TRAP) sequence. a Transverse view of both the pump and acardiac twin, white arrows. bWhite arrow, longitudinal view of the acardiac twin
Fig. 2
Fig. 2
Ultrasound image of fetal volvulus in pump twin. Transverse view of the fetal abdomen with white arrows pointing to the (a) dilated bowel loop segments and (b) dilated bowel loop in a whirlpool configuration
Fig. 3
Fig. 3
Ultrasound images comparing normal intestines and different signs of fetal bowel obstruction. a Normal intestines at 26 weeks of gestation, white arrows. b Ileal atresia in a fetus with gastroschisis at 30 weeks of gestation. c Double bubble sign (white arrows; S, stomach; D, duodenum) in a fetus with duodenal atresia at 28 weeks of gestation. dWhite arrows, ascites and meconium pseudocyst at 22 weeks of gestation
See this image and copyright information in PMC

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