Twin Reversed Arterial Perfusion (TRAP) Syndrome or acardiac twin: a case report in Madagascar

TRAP syndrome is a rare complication of monochorionic twin pregnancy. It is characterized by the association of an acardiac twin with a healthy twin. The acardiac twin is a parasite who put the healthy twin at high risk of cardiac failure. We report a case in a 25-year-old Malagasy woman, primigravida, who had a consultation at gestational week 31 for significant dyspnea and a threat of premature delivery. Ultrasound scans discovered an acute polyhydramnios, fetus with anasarca and low cardiac activity, and a para-fetal mass. She gives birth to a male newborn and an acardiac twin without head an upper body. The first twin died short time after birth.

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A Case of Trap Sequence with Immense Acardiac Twin

Folia Medica ◽

10.2478/folmed-2014-0019 ◽

2014 ◽

Vol 56 (2) ◽

pp. 129-132

Author(s):

Georgi I. Amaliev ◽

Maria L. Malinova ◽

Blagovest K. Pehlivanov ◽

Hristina A. Ivancheva

Keyword(s):

Twin Pregnancy ◽

Rare Complication ◽

Arterial Perfusion ◽

Acardiac Twin ◽

Trap Sequence ◽

Complicated Pregnancy ◽

Twin Reversed Arterial Perfusion ◽

Normal Twin ◽

Pump Twin

Abstract Twin-reversed arterial perfusion sequence is a rare complication of monochorionic twin pregnancy in which an anomalous acardiac fetus is hemodynamically dependent on its structurally normal “pump” twin. Early diagnosis is essential for improving perinatal prognosis for the normal twin. In this case report we present a case of TRAP sequence with immense acardiac twin with favorable outcome, emphasizing the importance of ultrasound imaging, follow-up and timing of delivery in this complicated pregnancy.

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Acardiac Twin

Delta Medical College Journal ◽

10.3329/dmcj.v2i2.20529 ◽

2014 ◽

Vol 2 (2) ◽

pp. 77-80 ◽

Cited By ~ 1

Author(s):

MS Maherunnessa ◽

Rahima Begum ◽

Samsad Jahan ◽

Shamsunnahar Bela ◽

Syeda Riffat Binta Habib ◽

...

Keyword(s):

Twin Pregnancy ◽

Umbilical Artery ◽

Rare Complication ◽

Multiple Pregnancy ◽

The Body ◽

Reverse Direction ◽

Arterial Perfusion ◽

Blood Flows ◽

Acardiac Twin ◽

Pump Twin

Acardiac anomaly is a rare complication of multiple pregnancies. It is a hemodyamically disadvantaged nonviable twin which occurs in association with a twin reversed arterial perfusion sequence (TRAP). In TRAP, blood flows from an umbilical artery of the pump twin in reverse direction into umbilical artery of the perfused (or acardiac) twin via an arterial to arterial (AA) anastomosis. Its blood is poorly oxygenated and results in variable degrees of deficient development of the head, heart, and upper limb structures. The lower half of the body is usually better developed, which may be explained by the mechanism of perfusion. The pump twin is at risk of heart failure and problems related to preterm birth with a reported mortality of 50-75%. We present a case of multiple pregnancy with acardiac twin in a 26 year old lady with gestational diabetes mellitus. During ante natal check up several ultrasonographic (USG) screening showed twin pregnancy with one healthy fetus and the other fetus with inconspicuous anatomy and structure. Repeat USG at 36th week of gestation diagnosed twin pregnancy with acardiac twin. Strikingly the pump twin did not develop the usual complications and was delivered by cesarean section at 37th week of gestation. DOI: http://dx.doi.org/10.3329/dmcj.v2i2.20529 Delta Med Col J. Jul 2014; 2(2): 77-80

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Is it correct to trust each ultrasonography report blindly? a case report on misdiagnosis, diagnosis and management of acardiac twin pregnancy

International Journal of Reproduction Contraception Obstetrics and Gynecology ◽

10.18203/2320-1770.ijrcog20202363 ◽

2020 ◽

Vol 9 (6) ◽

pp. 2628

Author(s):

Pooja Chandak ◽

Shobha Toshniwal

Keyword(s):

Case Report ◽

Twin Pregnancy ◽

Rare Complication ◽

Fetal Medicine ◽

Monochorionic Twin ◽

Arterial Perfusion ◽

Acardiac Twin ◽

Risk Pregnancy ◽

Twin Pregnancies ◽

Multifetal Pregnancy

Multifetal gestation is often a high-risk pregnancy and especially the monochorionic twin pregnancy significantly contributes to fetal morbidity and mortality. Acardiac twinning, earlier known as chorioangiopagus parasiticus, is the most extreme manifestation of this condition. An acardiac twin is a rare complication of multifetal pregnancy, in the literature reported at an incidence of 1% of monochorionic twin pregnancies, i.e. 1 of 35,000 pregnancies. Often results from abnormal placental vascular anastomoses. This leads to twin reversal arterial perfusion with complex pathophysiology. Here authors present a case of acardiac twin pregnancy presented at 26 weeks with the ultrasonography report suggested?? Placental teratoma of size 11×11×13 cm with polyhydramnios as there was no reason to suspect something else as the picture described in the USG report with the polyhydramnios was fitting with the diagnosis of placental teratoma but as the scan was done at taluka place and the images provided were not clear authors decided to confirm the diagnosis from fetal medicine specialist as MTP was not the option for the patient as she was 28 weeks who confirmed that as a case of acardiac twin pregnancy and the case was managed accordingly.

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Twin reversed arterial perfusion sequence in a monochorionic monoamniotic twin pregnancy: a very rare condition

Egyptian Journal of Radiology and Nuclear Medicine ◽

10.1186/s43055-020-00350-8 ◽

2020 ◽

Vol 51 (1) ◽

Author(s):

Abolfazl Abouie ◽

Nima Rakhshankhah ◽

Ladan Younesi ◽

Zeinab Safarpour ◽

Ayda Roostaee ◽

...

Keyword(s):

Twin Pregnancy ◽

Cardiac Activity ◽

Rare Condition ◽

Case Presentation ◽

Arterial Perfusion ◽

Trap Sequence ◽

Fetal Surveillance ◽

History Of ◽

Twin Reversed Arterial Perfusion ◽

Pump Twin

Abstract Background Twin reversed arterial perfusion sequence (TRAP) is a very rare congenital anomaly. We present sonographic findings of TRAP sequence in the case of a multiparous woman with a monochorionic monoamniotic twin pregnancy who was referred to our unit for blood sugar control. Case presentation The patient had a history of co-twin demise at 13 weeks of gestation without appropriate fetal surveillance afterwards. We found a monochorionic placentation with a normal appearing pump twin, an abnormal appearing co-twin without obvious cardiac activity and reversed arterial flow toward instead of away from the anomalous acardiac fetus. Therefore, the sonographic diagnosis of TRAP sequence was confirmed. Conclusions We recommend considering the potential rare complications of monochorionic twin pregnancy which necessitates proper surveillance and intervention to monitor suitable growth of pump twin.

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Acardia anceps: the monster twin; twin reversed arterial perfusion (TRAP) syndrome

International Journal of Reproduction Contraception Obstetrics and Gynecology ◽

10.18203/2320-1770.ijrcog20184547 ◽

2018 ◽

Vol 7 (11) ◽

pp. 4775

Author(s):

Shazia Khan ◽

Tina Singh ◽

Gunadhar Maiti

Keyword(s):

Imaging Techniques ◽

Rare Complication ◽

Cardiac Activity ◽

Well Being ◽

Reverse Direction ◽

Arterial Perfusion ◽

Trap Sequence ◽

Twin Reversed Arterial Perfusion ◽

Live Baby ◽

Pump Twin

Twin reversed arterial perfusion (TRAP) sequence is an extremely rare complication of monochorionic multi-foetal pregnancy, occurring once in 35,000 births. It is characterized by a malformed foetus without a heart being perfused by a structurally normal (pump) twin via an artery-to-artery anastomosis in a reverse direction. We report one such case where ultrasound imaging revealed monochorionic twin pregnancy with a viable, normal-appearing first twin and a structurally aberrant second twin with absent cardiac activity. The patient was monitored with two weekly ultrasonography and Doppler ultrasound examination to ascertain the well-being of the pump twin. She delivered successfully at term a normal live baby and an acardius anceps foetus. The perinatal mortality of the pump twin ranges from 35 to 55%; making it essential to diagnose the presence of a pump twin at an early gestational age through improved imaging techniques to plan effective intervention at appropriate time.

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Monochorionic-diamniotic twin pregnancy complicated by twin reversed arterial perfusion sequence and retroplacental hematoma – a case report

Medical Ultrasonography ◽

10.11152/mu-1486 ◽

2018 ◽

Vol 20 (3) ◽

pp. 396

Author(s):

Andrei Mihai Malutan ◽

Marina Dudea ◽

Camelia Albu ◽

Razvan Ciortea ◽

Doru Diculescu ◽

...

Keyword(s):

Twin Pregnancy ◽

Female Fetus ◽

Monochorionic Twin ◽

Arterial Perfusion ◽

Acardiac Twin ◽

Trap Sequence ◽

First Case ◽

Retroplacental Hematoma ◽

Twin Pregnancies ◽

Twin Reversed Arterial Perfusion

Twin reversed arterial perfusion (TRAP) sequence is a rare and severe complication specific to monochorionic twin pregnancies, involving the presence of an acardiac twin and a structurally normal co-twin (pump twin). We report on the case of a33-year-old female with a biamniotic monochorionic twin pregnancy complicated with TRAP sequence and polyhydramnios. The patient underwent fetoscopic termination of the acardiac twin and at 34 gestational weeks (GW) was readmitted with aretroplacental hematoma. The patient gave birth through caesarean section to a living female fetus, weighing 1480 g. To the best of our knowledge, this is the first case reporting a twin pregnancy with TRAP sequence complicated with retroplacental hematoma.

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Acardiac Acephalus Twin Pregnancy

Anwer Khan Modern Medical College Journal ◽

10.3329/akmmcj.v10i1.43669 ◽

2019 ◽

Vol 10 (1) ◽

pp. 89-91

Author(s):

Shamim Rima ◽

Gule Tajkia ◽

Sharmin Siddika ◽

Md Tarik Aziz ◽

Rumana Amin ◽

...

Keyword(s):

Blood Supply ◽

Umbilical Artery ◽

Monozygotic Twins ◽

The Body ◽

Upper Body ◽

Arterial Perfusion ◽

Medical College ◽

Acardiac Twin ◽

Twin Reversed Arterial Perfusion ◽

Pump Twin

Occurrence of acardiac twin is due to twin reversed arterial perfusion sequence (TRAP) occurring early in embryogenesis. There is vascular communication between the twins in monozygotic twins. The vascular communication in acardiac twin is different, in that, the acardiac twin receives blood supply from other twin pump through umbilical artery. The blood in the umbilical artery is mostly deoxygenated. Hence it leads to secondary organ atrophy. Upper body does not develop at all, hence missing heart and head. All the blood supply to the acardiac twin is derived from the pump twin. The acardiac twin develops only lower part of the body or just a mass of tissue. Hence, the mortality for acardiac twin is 100%. Anwer Khan Modern Medical College Journal Vol. 10, No. 1: Jan 2019, P 89-91

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Acardia anceps- A case report

Indian Journal of Obstetrics and Gynecology Research ◽

10.18231/j.ijogr.2021.083 ◽

2021 ◽

Vol 8 (3) ◽

pp. 408-410

Author(s):

Shital Lad ◽

Mangala Shinde

Keyword(s):

Case Report ◽

Twin Pregnancy ◽

Clinical Case ◽

Preterm Labour ◽

Large Artery ◽

Arterial Perfusion ◽

Acardiac Twin ◽

Trap Sequence ◽

Twin Reversed Arterial Perfusion

Twin-Reversed Arterial Perfusion(TRAP) sequence or Acardia twin refers to a unique complication of mono-chorionic twin pregnancy in which a twin with an absent or rudimentary non functioning heart (acardiac twin) is perfused by its co-twin (pumping twin) through a large artery to artery placental shunt, often accompanied by a vein to vein shunt. Here we discussed about a clinical case of TRAP sequence came in established preterm labour and its management.

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Conservative management of a case of a cardiac anceps twin reversed arterial perfusion sequence misdiagnosed as vanishing twin: a case report

International Journal of Reproduction Contraception Obstetrics and Gynecology ◽

10.18203/2320-1770.ijrcog20205805 ◽

2020 ◽

Vol 10 (1) ◽

pp. 385

Author(s):

Jharna Behura ◽

Ayushi Sinha ◽

Aafreen Naaz ◽

Soni Bharti

Keyword(s):

Conservative Management ◽

Multiple Pregnancy ◽

Cardiac Activity ◽

Laser Coagulation ◽

Variable Degree ◽

Arterial Perfusion ◽

Acardiac Twin ◽

Trap Sequence ◽

Twin Reversed Arterial Perfusion ◽

Pump Twin

Twin reversed arterial perfusion (TRAP) sequence is a specific, rare and severe complication of monochorionic multiple pregnancy, which is characterized by one normal fetus (pump twin) and another with no cardiac activity and variable degree of deficient development of the head and upper limbs. The management of these pregnancies are a real challenge due to the parasitic hemodynamic dependence of the acardiac twin on the pump twin. The aim of management is to maximize the chances of survival of the pump twin with some intervention. The preferred management suggested is elective ultrasound-guided laser coagulation or radiofrequency ablation of the umbilical cord vessels at 11-13 weeks when the survival is 70-75%. Delay in intervention until 16-18 weeks is associated with spontaneous cessation of blood flow in the acardiac twin in 60% of cases and in about 50% of these there is death or brain damage in the pump twin. However, pregnancies diagnosed late need to follow a tailored approach with expectant management. The authors report a case of TRAP twin sequence which on ultrasound was diagnosed as a case of vanishing twin at 20 weeks. Subsequently on follow up ultrasound, it was diagnosed as a trap sequence with the pump twin developing polyhydramnios at 30 weeks. She was counselled regarding the prognosis of the pump twin and she opted for conservative management. Weekly ultrasound and color doppler were done. The amniotic fluid index (AFI) decreased gradually at 33 and 35 weeks, there were no signs of congestive cardiac failure of the pump twin on Doppler studies and she had a spontaneous delivery of a healthy male child and an acardiac anceps fetus at 36weeks and 5 days. The perinatal mortality of a pump twin managed conservatively ranges from 35 to 55%. It is essential to diagnose the presence of trap sequence at an early gestational age through improved imaging techniques to plan a timely and effective intervention to salvage most of the pump twins.

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