Twin reversed arterial perfusion (TRAP) sequence managed at 20 weeks
Varam, the dedicated women’s super-specialty center at MGM Healthcare, is pleased to announce the successful treatment of a high-risk pregnant patient from Bangladesh with a very rare Twin Reversed Arterial Perfusion (TRAP) sequence. The Rh Isoimmunized mother delivered a live, healthy baby, overcoming the loss of three previous infants due to this condition.
In September 2023, 25-year-old Mrs. Zeenat (name changed) from Bangladesh sought assistance at Varam, MGM Healthcare, due to multiple complications in her pregnancy. At 20 weeks pregnant with twins, she had a history of recurrent miscarriages and the heartbreaking loss of two infants within one or two days of delivery. In 2016, a miscarriage occurred at 19 weeks; in 2017, a baby with a birth weight of 1.7 kg was delivered at 32 weeks, succumbing to preterm premature rupture of membranes (PPROM). In 2019, another baby, with a birth weight of 2.5 kg, was delivered at 36 weeks and lived for only two days.
Despite her history of losses, Mrs. Zeenat (name changed) conceived identical twins spontaneously this year. Due to her previous losses, she traveled to India for proper guidance and treatment. When she visited MGM Healthcare during her 20th week of pregnancy, Dr. Vanitha Shri R., Senior Consultant, Obstetrics, Gynecology, and Fertility Specialist, at VARAM by MGM Healthcare, observed that one of the foetuses was abnormal during the scan. She confirmed Twin Reversed Arterial Perfusion (TRAP) through a series of tests.
Twin Reversed Arterial Perfusion (TRAP)
Twin Reversed Arterial Perfusion (TRAP) Sequence, or Acardiac twinning, is a very rare problem, occurring in approximately 1 in 35,000 pregnancies where one of the foetuses is anatomically normal and the other is an abnormal mass of tissue, consisting usually of legs and a lower body but no upper body, head, or heart. Because of the absent heart, the term ‘Acardiac twin’ has been used to describe this state. The normal foetus is referred to as the ‘pump twin’ because its heart is used to pump blood to the abnormal mass. The ‘Acardiac twin’ has no chance of survival.
Arteries usually carry blood away from the foetus and toward the placenta to receive oxygen from the mother’s circulation in normal pregnancies. Due to the absence of a beating heart, the acardiac foetus does not send blood to any portion of the placenta, and all of its blood supply comes from and goes back to the circulation of the pump twin (Normal foetus) through some unique vascular connections on the surface of the shared placenta. When there is an “Acardiac twin foetus”, the unique vascular connections allow blood in the artery to flow in the reverse direction (toward the Acardiac foetus rather than away from it). Thus, the phrase “twin reversed arterial perfusion” (TRAP) sequence has been used to describe this condition.
The normal ‘pump twin’ faces the excess burden of having to send and receive blood to the Acardiac foetus as well as to its own growing tissues. As such, the normal twin’s heart has to work extra hard and is under a lot of stress. This can result in heart failure for the normal twin. When left untreated, up to 50% of these otherwise normal twins may die in utero (stillbirth) or die shortly after birth.
Treatment at VARAM by MGM Healthcare
Dr. Vanitha Shri R, devised a treatment plan that saved the normal twin. A Radio-Frequency Ablation (RFA) was performed at Mediscan along with Dr. S. Sudarshan, Fetal Medicine Specialist, Mediscan Systems Private Limited to stop the blood flow into the Acardiac twin. The RFA device was placed into the Acardiac’s abdomen through the maternal abdomen and uterus, and energy was deployed through the tip of the device, which cuts the vessels supplying blood to the Acardiac twin.
Explaining the procedure in details Dr. S. Sudarshan, Fetal Medicine Specialist, Mediscan Systems Private Limited, said, “In a Radio-Frequency Ablation (RFA) technique, we use a small 14 G needle and using ultrasound guidance introduce the needle into the acardiac mass. Through this method, the blood flow to the Acardiac mass was stopped, so that the normal pump twin is protected and is at a significantly lesser risk of heart failure or death. In addition, the pregnancy was complicated by severe anaemia in the normal twin due to Rhesus isoimmunisation which required three intrauterine blood transfusions to the baby after the radio frequency ablation procedure. This was unique due to the fact that, two major, diverse complications have been handled in a single pregnancy at the same time.”
Explaining further, Dr. Vanitha Shri R, Senior Consultant, Obstetrics, Gynecology, and Fertility Specialist at VARAM by MGM Healthcare, she added, “The patient had several other complications, including auto-immune haemolytic anemia, anti- phospholipid and antibody positive, and was also Rh-negative. Anti- phospholipid and antibody positive syndrome causes clots in arteries and veins which might leads blockage of blood supply to the baby, hence the patient was on blood thinners till the delivery. All these complications added to our challenge; hence, the baby was monitored week-on-week through an MCA Doppler scan. Since the baby had a decrease in foetal hemoglobin, we performed three rounds of intrauterine blood transfusions on the child in the womb itself at Mediscans.”
The mother also developed a huge abscess in her lower abdomen which ended in sepsis which altered her liver functions, she was treated for the same. Considering all these complications, the baby was delivered in 32 weeks through a cesarean. Post-birth, the baby was under continuous observation and was also treated for jaundice by exchange transfusion (in which the blood from the baby was transfused totally) by Prof. Dr. Binu Ninan, Senior Consultant, Paediatrics & Neonatology, MGM Healthcare, and his team. They were key in performing the exchange transfusion and stabilizing the baby post-delivery for more than two weeks. Both the mother and the girl child have been stabilized and discharged.
Dr. Urjitha Rajagopalan, Director, MGM Healthcare, said, “Mrs. Zeenat’s (name changed) inspiring journey, guided by the dedicated hands of Dr. Vanitha Shri R showcases the remarkable resilience and innovation of our medical team. Overcoming the challenges of a rare Twin Reversed Arterial Perfusion (TRAP) Sequence, our team, through compassionate care and cutting-edge technologies, ensured the safe delivery of a healthy baby. This achievement is a testament to the unwavering commitment of VARAM to delivering excellence in women’s healthcare, marking a moment of hope and triumph for both the patient and our dedicated medical professionals. I extend my sincere appreciation to Dr. Vanitha Shri R. and the entire medical team, including Prof. Dr. Binu Ninan and his team in Paediatrics & Neonatology, for their tireless efforts in making this success possible. This heartening outcome underscores our commitment to advancing healthcare with compassion and innovation, reaffirming MGM Healthcare as a beacon of excellence in women’s health.”
‘Varam’, which is a dedicated women’s super-specialty center combines the values that MGM Healthcare stands for with cutting-edge technology and unparalleled care. Encompassing everything from adolescent health, gynaecological health, obstetric services to menopausal health and gynaec-oncology, Varam strives to be the one-stop center for comprehensive and holistic care the city needs. ‘Varam’ aims to deliver exceptional healthcare for women of all ages with abundant empathy, expertise and excellence.
For more details on mother & child care, one may reach out to Varam at MGM Healthcare at +91 44 4524 2407 or [email protected].
About MGM Healthcare
Born out of a need for altruism, MGM Healthcare is obsessed with bettering patient experiences and improving clinical outcomes through expertise, passion and technology. The manifestation of this dedication to superlative health-caring is a state-of-the-art hospital on Nelson Manickam Road having 400 beds, 50 out-patient consultation rooms, over 100 critical care beds, 250+ Doctors, 12 Centers of excellence, 30+ Clinical Departments, 12 state-of-the-art Operating Theatres and 24 x 7 comprehensive Emergency Care. Here, a host of eminent surgeons and physicians wield a potent combination of skill and cutting-edge technology to elevate care and outcomes to new levels. MGM Healthcare is the first hospital in Asia with the highest rated USGBC LEED Platinum-certified Green Hospital.
Over the past year, the team of clinical experts at MGM Healthcare have performed many innovative and complex surgeries in the pursuit of establishing trust and clinical excellence. MGM Healthcare designed and equipped with the latest in technology and equipment is poised to drive patient centricity and clinical excellence of both the domestic and international patients.