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Suggest Treatment For Elevated Alpha-fetoprotein

Posted on Wed, 19 Nov 2014

Question: Hi, we are currently having twins through a surrogate. Our quadruple marker came back with an elevated AFP of corrected MoM of 3.23 for both twins. The rest of the markers said very low risk. In the follow up anomaly scan, they diagnosed Twin 2 with mild borderline ventriculomegaly. The report said "Lateral ventricle measures 1.0 cm. The cavum septum and cerebellum appear normal. Fetal spine appears normal. No other abnormality is seen. No obvious anatomical anomalies are seen in twin 1. Normal fetal cardiac activity and fetal biophysical profile is seen in both the fetuses." Yet, my doc recommended an amniocentesis that was performed yesterday.

I have two questions:
(a) what is the prognosis for Twin 2? Over the last three scans conducted at 16, 18 and 20 weeks, the vP has grown 6.53, 8.11 and 8.61mm. In the last scan they recorded three measures - 8.61, 8.88 and 10 and reported 10mm. In contrast, the other twin has 6.29, 7.79 and 6.47mm. When do these measures normally stabilize?
(b) If there is a problem with Twin 2, can it be addressed without affecting Twin 1? How should we progress?

Answered by Dr. Dalia Muraleedharan (1 hour later)

Brief Answer:
Dont worry

Detailed Answer:
Hi,
Thanks for writing..
I understand your concern..

(a) You need to follow up monthly with scan to see the lateral ventricle.. Value greater than 10 is mild ventriculomegaly.. Borderline ventriculomegaly not associated with other anomalies have a good prognosis.. Some resolve spontaneously.. The value will stabilize by 32 -34 weeks as the fetal brain keeps growing.. Amniocentasis report is required to see whether there is any problem associated with it..

(b) If the lateral ventricle keeps increasing in size, it can compress the brain matter and affect brain development in twin 2..This occurs only if LV>15mm..If amniocentasis is normal, twin 1 is unlikely to be affected.. No need to intervene at this moment.. Get a follow up scan monthly to see the lateral ventricles and growth of the fetus..

Hope I have answered your query.. Feel free to ask any doubts.. Good day..

Above answer was peer-reviewed by : Dr. Yogesh D

Follow up: Dr. Dalia Muraleedharan (5 hours later)

Yes, they will be scanning every two weeks. Had a few doubts:

(a) I had attached three scan reports - one from a previous scan and two from the current scan. The previous one shows 8.11 and the second one shows 8.61 and 10 at two different points. Is it possible to tell whether the 8.11 has grown to 8.61 or it has grown to 10?

(b) What will the amniocentesis tell us if the quadruple marker test is already indicative of low risk for trisomy 18 and 21?

(c) Also, if something goes wrong with Twin 2, will it affect Twin 1 too at this stage?

Thanks much!

Answered by Dr. Dalia Muraleedharan (25 hours later)

Brief Answer:
Dont worry

Detailed Answer:
Hi,
Thanks for writing..

(a) Yes, from the previous 8.11, it has grown to 10mm.. 10mm is considered more reliable than 8.61 from the picture provided..

(b)Amniocentasis confirms that there is no chromosomal abnormality in the fetus.. Veticulomegaly might be associated with chromosomal abnormality..

(c) Is it monochorionic monoamniotic or dichorionic diamniotic pregnancy? If it is DD pregnancy it is unlikely to affect the twin 1 if amniocentasis is normal.. But close monitoring 2 weekly is advisable to see furthur increase of the lateral ventricle size..

Hope I have answered your query.. Feel free to ask any doubts.. Good day..

Above answer was peer-reviewed by : Dr. Vinay Bhardwaj

Follow up: Dr. Dalia Muraleedharan (1 hour later)

Thanks for your response! In your opinion and experience, what is the prognosis given this rapid rise from 8 to 10mm but absent any other anomalies? Is there a good chance it will stabilize or resolve itself in the future? They are doing a scan after the amnio this Wed. Thanks!

Answered by Dr. Dalia Muraleedharan (5 hours later)

Brief Answer:
HI

Detailed Answer:
Hi,
Thanks for writing..

In my opinion, I would suggest to wait and watch.. There were many cases where the Lv size has stabilized to 10mm and resolved after birth where no other anomaly detected.. But a few cases the size has increased drastically and they have opted for termination in the fear of mental retardation in the newborn..

In your case, it is a precious pregnancy with 1 normal fetus and other with only borderline ventriculomegaly.. So close follow up is the best option.. Always hope for the best and the mother should never be given any stress or worry as it can affect the babies..

Hope I have answered your query.. Good day..

Above answer was peer-reviewed by : Dr. Vinay Bhardwaj

Follow up: Dr. Dalia Muraleedharan (2 days later)

Hi,
They did a scan today and found it has grown to 11.3mm. Should we be concerned?

Thanks!

Answered by Dr. Dalia Muraleedharan (34 minutes later)

Brief Answer:
Hi

Detailed Answer:
Hi,
Thanks for writing..

It is mild ventriculomegaly as the lateral ventricle size between 10-15 mm. Since there is no other abnormalies detected, if amniocentesis report is normal, it is a good prognosis.

I would suggest to get a fetal MRI to see the fetal brain in detail. Get ultrasound 2 weekly.

Hope I have answered your query. Good day.

Above answer was peer-reviewed by : Dr. Vaishalee Punj