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Twin Reversed Arterial Perfusion
Priyanka Jha, MBBS
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KEY FACTS

  • Terminology

    • Imaging

      • Top Differential Diagnoses

        • Clinical Issues

          • Diagnostic Checklist

            TERMINOLOGY

            • Abbreviations

              • Twin reversed arterial perfusion (TRAP)
            • Synonyms

              • Acardiac monster
              • Cardiac regression sequence
            • Definitions

              • Anomalous twin (TRAP twin) perfused by deoxygenated blood from pump twin
              • Blood enters TRAP fetus via umbilical artery (UA)
                • Reversed perfusion → selective development of torso/lower extremities
                • Lack of umbilical vein flow into heart → impaired/absent cardiac development

            IMAGING

            • General Features

              • Ultrasonographic Findings

                • MR Findings

                  • Imaging Recommendations

                    DIFFERENTIAL DIAGNOSIS

                      PATHOLOGY

                      • General Features

                        • Staging, Grading, & Classification

                          • Gross Pathologic & Surgical Features

                            CLINICAL ISSUES

                            • Presentation

                              • Demographics

                                • Natural History & Prognosis

                                  • Treatment

                                    DIAGNOSTIC CHECKLIST

                                    • Image Interpretation Pearls

                                      Selected References

                                      1. Gabby LC et al: Risk factors for co-twin fetal demise following radiofrequency ablation in multifetal monochorionic gestations. Fetal Diagn Ther. 1-7, 2020
                                      2. Shanahan MA et al: Placental anatomy and function in twin gestations. Obstet Gynecol Clin North Am. 47(1):99-116, 2020
                                      3. Shettikeri A et al: Outcome of pregnancies diagnosed with TRAP sequence prenatally: a single-centre experience. Fetal Diagn Ther. 47(4):301-6, 2020
                                      4. Tavares de Sousa M et al: First-trimester intervention in twin reversed arterial perfusion sequence. Ultrasound Obstet Gynecol. 55(1):47-9, 2020
                                      5. Ting YH et al: Outcomes of radiofrequency ablation for selective fetal reduction in complicated monochorionic pregnancies performed before 16 gestational weeks and thereafter. Ultrasound Obstet Gynecol. ePub, 2020
                                      6. Jha P et al: US Evaluation of twin pregnancies: Importance of chorionicity and amnionicity. Radiographics. 39(7):2146-66, 2019
                                      7. Expert Panel on Women's Imaging:. et al: ACR Appropriateness Criteria® multiple gestations. J Am Coll Radiol. 14(11S):S476-89, 2017
                                      8. Roethlisberger M et al: First-trimester intervention in twin reversed arterial perfusion sequence: does size matter? Ultrasound Obstet Gynecol. 50(1):40-4, 2017
                                      9. Mone F et al: Intervention versus a conservative approach in the management of TRAP sequence: a systematic review. J Perinat Med. 44(6):619-29, 2016
                                      10. Sugibayashi R et al: Forty cases of twin reversed arterial perfusion sequence treated with radio frequency ablation using the multistep coagulation method: a single-center experience. Prenat Diagn. 36(5):437-43, 2016
                                      11. van Gemert MJ et al: Acardiac twin pregnancies part III: model simulations. Birth Defects Res A Clin Mol Teratol. 106(12):1008-15, 2016
                                      12. van Gemert MJ et al: Hypothesis acardiac twin pregnancies: pathophysiology-based hypotheses suggest risk prediction by pump/acardiac umbilical venous diameter ratios. Birth Defects Res A Clin Mol Teratol. 106(2):114-21, 2016
                                      13. Stephenson CD et al: Microwave ablation for twin-reversed arterial perfusion sequence: a novel application of technology. Fetal Diagn Ther. 38(1):35-40, 2015
                                      14. Takano M et al: Experience of fetoscopic laser photocoagulation and cord transection for twin-reversed arterial perfusion sequence. J Obstet Gynaecol Res. 41(9):1326-9, 2015
                                      15. van Gemert MJ et al: Twin reversed arterial perfusion sequence is more common than generally accepted. Birth Defects Res A Clin Mol Teratol. 103(7):641-3, 2015
                                      16. Berg C et al: Twin reversed arterial perfusion (TRAP) sequence--does monoamniocity preclude early intervention? Ultrasound Obstet Gynecol. 44(2):241-2, 2014
                                      17. Chaveeva P et al: Optimal method and timing of intrauterine intervention in twin reversed arterial perfusion sequence: case study and meta-analysis. Fetal Diagn Ther. 35(4):267-79, 2014
                                      18. Peeters SH et al: Fetal surgery in complicated monoamniotic pregnancies: case series and systematic review of the literature. Prenat Diagn. 34(6):586-91, 2014
                                      19. Prefumo F et al: Fetoscopic cord transection for treatment of monoamniotic twin reversed arterial perfusion sequence. Ultrasound Obstet Gynecol. 43(2):234-5, 2014
                                      20. Oliver ER et al: Twin reversed arterial perfusion sequence: a new method of parabiotic twin mass estimation correlated with pump twin compromise. J Ultrasound Med. 32(12):2115-23, 2013
                                      Related Anatomy
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                                      Related Differential Diagnoses
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                                      References
                                      Tables

                                      Tables

                                      KEY FACTS

                                      • Terminology

                                        • Imaging

                                          • Top Differential Diagnoses

                                            • Clinical Issues

                                              • Diagnostic Checklist

                                                TERMINOLOGY

                                                • Abbreviations

                                                  • Twin reversed arterial perfusion (TRAP)
                                                • Synonyms

                                                  • Acardiac monster
                                                  • Cardiac regression sequence
                                                • Definitions

                                                  • Anomalous twin (TRAP twin) perfused by deoxygenated blood from pump twin
                                                  • Blood enters TRAP fetus via umbilical artery (UA)
                                                    • Reversed perfusion → selective development of torso/lower extremities
                                                    • Lack of umbilical vein flow into heart → impaired/absent cardiac development

                                                IMAGING

                                                • General Features

                                                  • Ultrasonographic Findings

                                                    • MR Findings

                                                      • Imaging Recommendations

                                                        DIFFERENTIAL DIAGNOSIS

                                                          PATHOLOGY

                                                          • General Features

                                                            • Staging, Grading, & Classification

                                                              • Gross Pathologic & Surgical Features

                                                                CLINICAL ISSUES

                                                                • Presentation

                                                                  • Demographics

                                                                    • Natural History & Prognosis

                                                                      • Treatment

                                                                        DIAGNOSTIC CHECKLIST

                                                                        • Image Interpretation Pearls

                                                                          Selected References

                                                                          1. Gabby LC et al: Risk factors for co-twin fetal demise following radiofrequency ablation in multifetal monochorionic gestations. Fetal Diagn Ther. 1-7, 2020
                                                                          2. Shanahan MA et al: Placental anatomy and function in twin gestations. Obstet Gynecol Clin North Am. 47(1):99-116, 2020
                                                                          3. Shettikeri A et al: Outcome of pregnancies diagnosed with TRAP sequence prenatally: a single-centre experience. Fetal Diagn Ther. 47(4):301-6, 2020
                                                                          4. Tavares de Sousa M et al: First-trimester intervention in twin reversed arterial perfusion sequence. Ultrasound Obstet Gynecol. 55(1):47-9, 2020
                                                                          5. Ting YH et al: Outcomes of radiofrequency ablation for selective fetal reduction in complicated monochorionic pregnancies performed before 16 gestational weeks and thereafter. Ultrasound Obstet Gynecol. ePub, 2020
                                                                          6. Jha P et al: US Evaluation of twin pregnancies: Importance of chorionicity and amnionicity. Radiographics. 39(7):2146-66, 2019
                                                                          7. Expert Panel on Women's Imaging:. et al: ACR Appropriateness Criteria® multiple gestations. J Am Coll Radiol. 14(11S):S476-89, 2017
                                                                          8. Roethlisberger M et al: First-trimester intervention in twin reversed arterial perfusion sequence: does size matter? Ultrasound Obstet Gynecol. 50(1):40-4, 2017
                                                                          9. Mone F et al: Intervention versus a conservative approach in the management of TRAP sequence: a systematic review. J Perinat Med. 44(6):619-29, 2016
                                                                          10. Sugibayashi R et al: Forty cases of twin reversed arterial perfusion sequence treated with radio frequency ablation using the multistep coagulation method: a single-center experience. Prenat Diagn. 36(5):437-43, 2016
                                                                          11. van Gemert MJ et al: Acardiac twin pregnancies part III: model simulations. Birth Defects Res A Clin Mol Teratol. 106(12):1008-15, 2016
                                                                          12. van Gemert MJ et al: Hypothesis acardiac twin pregnancies: pathophysiology-based hypotheses suggest risk prediction by pump/acardiac umbilical venous diameter ratios. Birth Defects Res A Clin Mol Teratol. 106(2):114-21, 2016
                                                                          13. Stephenson CD et al: Microwave ablation for twin-reversed arterial perfusion sequence: a novel application of technology. Fetal Diagn Ther. 38(1):35-40, 2015
                                                                          14. Takano M et al: Experience of fetoscopic laser photocoagulation and cord transection for twin-reversed arterial perfusion sequence. J Obstet Gynaecol Res. 41(9):1326-9, 2015
                                                                          15. van Gemert MJ et al: Twin reversed arterial perfusion sequence is more common than generally accepted. Birth Defects Res A Clin Mol Teratol. 103(7):641-3, 2015
                                                                          16. Berg C et al: Twin reversed arterial perfusion (TRAP) sequence--does monoamniocity preclude early intervention? Ultrasound Obstet Gynecol. 44(2):241-2, 2014
                                                                          17. Chaveeva P et al: Optimal method and timing of intrauterine intervention in twin reversed arterial perfusion sequence: case study and meta-analysis. Fetal Diagn Ther. 35(4):267-79, 2014
                                                                          18. Peeters SH et al: Fetal surgery in complicated monoamniotic pregnancies: case series and systematic review of the literature. Prenat Diagn. 34(6):586-91, 2014
                                                                          19. Prefumo F et al: Fetoscopic cord transection for treatment of monoamniotic twin reversed arterial perfusion sequence. Ultrasound Obstet Gynecol. 43(2):234-5, 2014
                                                                          20. Oliver ER et al: Twin reversed arterial perfusion sequence: a new method of parabiotic twin mass estimation correlated with pump twin compromise. J Ultrasound Med. 32(12):2115-23, 2013