Imaging
equipment, providing fine detail and high- resolution images, is extremely important. Several reports, including consensus statements from the College of Intensive Care Medicine, NHS England, and the British Medical Ultrasound Society (BMUS) cite five years as the optimal lifespan for all ultrasound equipment.10
While
this is just a guideline, implementing the latest imaging technologies should be a priority, not only for the effective monitoring of multiple pregnancies but across all clinical applications.
Delving deeper with SMI technology Ultimately, high-quality 2D ultrasound, right from the beginning of the pregnancy through to the later stages, is critical when monitoring for any potential complications – such as TTTS. However, should a growth restriction or other abnormality be identified, then the use of colour Doppler imaging (CDI) technology can enable the sonographer to take a closer look and interrogate the tiny vessels in the umbilical cord and placenta. Superb Micro-vascular Imaging (SMI) is an award-winning Doppler
technology11
technology and is proving to be extremely effective in this area. Unlike traditional colour Doppler imaging, which removes clutter from images by suppressing low-velocity components, SMI expands the range of visible blood flow from low to high velocities with incredible sensitivity. During the examination, clinicians can easily
choose SMI with the press of a button. SMI separates blood flow from overlaying tissue motion effectively, while preserving even the subtlest low-flow components with superior
While entry-level 2D ultrasound equipment is sufficient in determining multiple pregnancies, and the type of placentation (chorionicity and amnionicity), a high-end ultrasound machine providing optimal clarity and high-resolution detail is recommended to efficiently identify symptoms associated with any complications or abnormalities.
detail and definition – meaning that clarity needn’t be sacrificed. Compared with other colour Doppler, SMI is found to be superior in terms of high frame rate, high sensitivity, high resolution, and less motion artifact – making blood flow easier to analyse, especially when visualising the microvasculature flow of the placenta.
Predicting risk with existing ultrasound technologies Advanced ultrasound capabilities, such as SMI, along with the Myocardial Performance Index (MPI), and Speckle Tracking Echocardiography (STE), have enabled research that has led to a better understanding of fetal and maternal physiology and pathophysiology of many conditions, and has provided focus for further studies. Prof. Christoph Lees is currently conducting
research, funded by the Medical Research Council and the Wiseman Trust,12
whether existing ultrasound technology, to understand
including SMI, can be used to look at the blood vessels within the placenta of MCDA twins. The study aims to understand how and where they join to predict the risk of developing TTTS, along with other serious complications. This ongoing research consists of a study carried out in London in May 2019, which used a Canon Aplio i-series ultrasound machine to map placental angioarchitecture (the arrangement and distribution of blood vessels)13 in MC pregnancies using different colour Doppler filters. According to Lees, placental angioarchitecture is important to determine the vascular connections in an MCDA twin pregnancy but, until now, it is rarely examined prenatally. He argues, however, that the detection and characterisation of placental anastomoses (a connection between two structures)14
within the angioarchitecture could
be key to identifying conditions such as TTTS or other risks.
When examining the placental vessels
through the different colour Doppler modalities the results varied. While traditional CDI was impacted by sonographic “noise”, Advanced Dynamic Flow (ADF), which combined a broadband frequency with a high frame rate, allowed for a more precise depiction of blood circulation, and blood flow to be characterised. With SMI and ADF, Lees was able to view microscopic blood flow, suggesting its potential for identifying risk earlier in the future. Overall, the study concluded that a “multi-filter”
approach to angioarchitecture sonographic examination (using different colour Doppler techniques) is of fundamental assistance when characterising anastomoses and determining vascular equator in twin MC placentas.
Benefits of early identification According to guidance provided by Dr. Surabhi Nanda, for Twins Trust UK,15
as soon as there
are signs that TTTS has progressed, the mother will be referred to their regional fetal medicine unit to discuss treatment options. While the options available will depend on the stage
24
www.clinicalservicesjournal.com I January 2025
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