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org Doppler Assessment, Fetus, Neonatology, Prematurity Poster Session III

429 Twin-twin transfusion syndrome: response to

428 Apoptosis pathway is involved in hemolysis, elevated
liver enzyme, and low platelet (HELLP) syndrome
and intrauterine growth restriction (IUGR)
Monia Cecati1, Stefano R. Giannubilo1, Valentina Pozzi1,
Davide Sartini1, Piergiorgio Stortoni1, Franca Saccucci2,
Andrea L. Tranquilli1, Monica Emanuelli1
1
Universita’ Politecnica Marche, Ancona, 2Polytechnic
University of Marche, Ancona
OBJECTIVE: The neurotrophin family comprises molecules involved in
growth, differentiation, survival, regeneration, normal functions of
the neuronal system, and in angiogenesis. We investigate the expres-
sion pattern of neurotrophic signaling molecules in pregnancies com-
plicated by HELLP (Hemolysis, Elevated Liver enzymes and Low
Platelet count) syndrome and IUGR.
STUDY DESIGN: Placentas from normal term pregnancies (n⫽10),
from pregnancies complicated by HELLP syndrome (n⫽10) and
intrauterine growth restriction (IUGR) (n⫽10) were collected.
Macroarray analyses were performed with GEArray Q Series Human
Neurotrophin and Receptors Gene Array HS-018. The data were con-
firmed by quantitative Real-Time PCR. The Mann-Whitney test was
used for statistical analysis. Differences were considered significant at
p ⬍ 0.05.
RESULTS: Gene expression measurements (HELLP vs normal and
IUGR vs normal), confirmed by real-time PCR technique, revealed a
significant down-regulation for Interleukin 6, STAT3␣, STAT3␤, and
Bcl-2. The expression of Mcl1 isoform 1 (long) was significantly in-
creased. The Mcl1 isoform 2 (short) expression levels did not show
statistically significant differences between normal and pathological
pregnancies.
CONCLUSIONS: Decreased expression of IL-6 could mean that abnor-
malities in the immunological system function involve inflammatory
cytokines other than IL-6 in pregnancies complicated by HELLP syn-
drome and IUGR. The STAT3␣ and STAT3␤ downregulation lead to
a marked reduction of cellular transcriptional activity. Decreased ex-
pression of IL-6 is associated with a down-regulation of Bcl-2 but not
amnioreduction with selective fetoscopic laser
photocoagulation (SFLP) salvage therapy for progression
Mounira Habli1, Jeffery Livingston2, Foong Yen Lim3, James
Vanhook4, William Polzin3, Sundeep Keswani3, James Cnota3,
Erik Michelfelder1, Beth Kline-fath1, Timothy Crombleholme3
1
Cincinnati Childrens Hospital, Cincinnati, OH, 2University of South
Carolina, Charlotte, SC, 3Cincinnati Children’s Hospital Medical
Center, Cincinnati, OH, 4University of Cincinnati
College of Medicine, Cincinnati, OH
OBJECTIVE: No published study has examined the use of AR to treat
TTTS with SFLP used as salvage therapy for cases which fail to respond
to AR. The aim of this study is to evaluate the outcomes with sequen-
tial therapy in early stage TTTS using a trial of AR with salvage SFLP in
cases which fail to respond.
STUDY DESIGN: A retrospective study of early TTTS cases managed
with a trial of AR with SFLP reserved as salvage therapy from 2005-
2010. Early TTTS stage was defined as no or mild recipient cardiomy-
opathy (RTCM) based on the Cincinnati staging system(stages
I-IIIA). These patients were offered SFLP or an initial trial of either AR
or observation (OBS) with serial echocardiography to detect progres-
sion of TTTS. In “non-responders,” progression was defined as an
increase in severity of RTCM or recurrence/progression of amniotic
fluid discordance. Progression was treated with SFLP. Outcome data
included ultrasound and echocardiographic data, treatment, and sur-
vival to birth.
RESULTS: Among 182 TTTS, 32 (18%) were stage I, 17 (9%)stage II, 37
(20%)stage III (all with Doppler abnormality of umbilical artery flow
only), and 96 (53%)stage IIIA (mild RTCM). 97 (53%) elected AR, 33
(18%) OBS, and 48 (26%)SFLP. 4 patients (2%) underwent RFA due
to severe placental insufficiency. Among 130 treated with AR(n⫽97)
or OBS(n⫽33), 44.6%(n⫽49 AR and n⫽9 OBS) progressed within
1.9⫾1.8 weeks and then had SFLP. Among 97 patient treated with AR
chorioamnio-separation occurred in 7 (7%) of which 4 (4%) only
were SFLP candidates. As compared to patients treated primarily by
SFLP, responders treated with AR had a significantly higher survival
(93 vs. 78%, p⫽0.004). Non-responders treated by AR/OBS then sub-
sequent SFLP had similar survival to primary SFLP (78% vs. 79%, p⫽
1.0)(table).
CONCLUSIONS: In early stage TTTS up to 49% may respond to AR, with
significantly better survival than with primary SFLP. Salvage SFLP for
non-responders to AR is associated with excellent survival, compara-
ble to primary SFLP. Such management can minimize risks of major
operative procedure in 40% of early stage TTTS.
AR or OBS
followed
Amnioreduction Observation by SFLP SFLP
Outcome nⴝ48 nⴝ24 (nⴝ58) nⴝ48
Gestational age at 30.6 ⫾ 4.0 32.8 ⫾ 4.8 30.3 ⫾ 4.1 31.2 ⫾ 8.2
delivery-wks
...........................................................................................................................................................................................................
Pregnancies with 47 23 56 48
complete survival
data-n
...........................................................................................................................................................................................................
Overall survival-n(%) 90/97 (93)** 41/46 (89) 88/112 (79) 75/96 (78)
...........................................................................................................................................................................................................
Double demise-n(%) 1 (2) 2 (9) 4 (7) 3 (6)
...........................................................................................................................................................................................................

of Mcl-1 isoform 1, suggesting that these two anti-apoptotic proteins At least one-n(%) 46/47 (98) 21/23 (91) 52/56 (93) 45/48 (94)
...........................................................................................................................................................................................................
may function independently and that Mcl1 may have a distinct role in Reference group is SFLP, **P⬍0.01.
controlling apoptotic pathway.

Supplement to JANUARY 2011 American Journal of Obstetrics & Gynecology S173