\r\n\tRisk management aims to develop an efficient organizational development environment through risk planning, assessment, analysis, and control. This process will apply in all areas of activity, and the evaluation framework is the same regardless of the field. This volume will aim to appeal to chapters that address methods, models, evaluation frameworks, benefits, barriers, and other dimensions of risk management.
\r\n\tSustainability and the circular economy are approaches approached by many companies and have become activities of global interest. Protecting the environment, streamlining the consumption of organizational resources, reducing the amount of waste generated, and other activities are objectives of these efforts. The circular economy contributes to the sustainable development of the company or country and the achievement of the global objectives of sustainable development. This book will aim to collect various studies for organizational and global sustainability.
\r\n\tLeadership has become a globally desirable approach that can help improve organizational competitiveness and reduce organizational risks. Risks and barriers in risk-free management can be well managed through effective organizational leadership. This book will aim to bring together chapters that explore different areas of leadership.
The cheetah,
As an animal built for speed, all parts of its body have evolved for precision and agility. Because of its small, aerodynamic head, lean body, long legs, flexible backbone and tail that works like a boat’s rudder, the cheetah can change direction in a split second and reach speeds of up to 113 km/h while turning 180° [6, 7, 8]. With each stride, the cheetah covers 6 m with just one foot touching the ground at a time; at two points in the stride, all four feet are in the air. The cheetah’s flexible spine acts like a spring as it doubles up with feet under its body to clench the earth with powerful, semi-non-retractable claws, thrusting it forward with great speed and maximum distance. The cheetah is not only the fastest running land mammal; it is also known for its rapid acceleration, as it can go from zero to 96 km/h in just 3 s [6].
\nWith less than 7100 adults and adolescents remaining [9], the cheetah is one of the most endangered big cat species. Cheetah numbers have declined primarily due to increased human-wildlife conflict, loss of habitat and loss of prey, and the illegal wildlife trade. In addition to these threats, cheetahs lack genetic variation due to a historic population bottleneck, approximately 12,000 years ago, which makes the cheetah more vulnerable to ecological and environmental changes [10, 11, 12].
\nToday, nearly 80% of the remaining world’s cheetahs are found outside of protected areas living near rural livestock farming communities [9]. Protected areas, such as wildlife reserves or national parks typically have higher densities of larger or more aggressive predator species that can outcompete cheetahs, making it difficult for cheetahs to survive. Despite being one of the best hunter species on the savanna, cheetahs often lose their kills to larger predators. In protected areas, cheetahs have been found to lose 10–15% of their kills to lions (
Living outside protected areas prevents threats by other predators but puts the cheetah in direct conflict with commercial and subsistence livestock farmers [18, 19]. These farmers often perceive cheetahs to be a threat to their livestock, which leads into economic and emotional issues. The Rangewide Cheetah and Wild Dog program, an IUCN Cat Specialist endorsed program, brings together conservation organizations across the cheetah’s range to work on a more sustainable future for cheetahs and farmers. Cheetah Conservation Fund (CCF), Cheetah Conservation Botswana (CCB), and the Ruaha Carnivore Project work with other stakeholders, such as community members, local and national governments, conservancies and scientists to develop and implement action plans for cheetah conservation throughout its range [9, 20, 21, 22, 23].
\nAs human populations grow, so do the chances of conflict with cheetahs. Simultaneously, available rangeland will shrink, along with the wild prey base, hastening the decline of the cheetah [24, 25]. If the observed trends of decline among cheetah population continues, the world’s fastest land mammal could become extinct within the next 15–20 years [26].
\nThe cheetah was once one of the most widely distributed of all land animals. Through the course of time the cheetah was found from North America to China, throughout Asia, India, Europe, and Africa. About 20,000 years ago, it settled into its current range [3, 27].
\nA century ago, approximately 100,000 cheetahs were found in at least 44 countries throughout Africa and Asia. Today, the current free-ranging populations of cheetahs are restricted to 10% of their former range, found only in small, fragmented areas spread across 23 countries in Africa (in North Africa, the Sahel, East Africa and southern Africa), however, two thirds of these countries’ cheetah populations number less than 200 individuals [9, 28]. It is estimated that fewer 50 wild cheetahs remaining in Iran, the last of the Asiatic population [9, 29].
\nToday, viable populations may be found in less than half the countries where cheetahs still exist. Cheetahs are particularly difficult to census due to their large home ranges, which average more than 1500 km2 [14, 30, 31, 32], and their shy nature, an instinct that has been reinforced because of persecution on farmlands, where they are shot, trapped and chased [19, 22, 33, 34]. As a result of persecution and due to their naturally large home ranges, wherever they live they occur in low densities [34].
\nAll populations of cheetahs are listed on the Convention on International Trade in Endangered Species of Fauna and Flora (CITES) Appendix 1 and are classified as Vulnerable or Endangered by the International Union for Conservation of Nature (IUCN) [35]. All cheetah populations are threatened due to habitat reduction and declines in prey populations, which bring them into increased contact (and ultimately conflict) with farmers and livestock [14, 20, 21, 22, 23, 33].
\nDue to its declining numbers and genetic lack of diversity, it is important to protect remaining wild cheetah populations to ensure the species chances for survival. An evaluation of conservation priorities in each country where the cheetah is found has been conducted to better understand the issues involved in achieving this goal [20, 21, 22, 23, 33, 36]. The remaining strongholds for cheetahs are Namibia and Botswana, in southern Africa; and Kenya and Tanzania in East Africa (see Figure 1). With approximately 20% of the world’s remaining wild cheetahs and successful efforts to conserve its wild population, Namibia is popularly known as “The Cheetah Capital of the World.”
\nHistoric and current: cheetah range map [
As a result of habitat fragmentation over time, there are currently four genetically confirmed subspecies of cheetah, three African and one Asiatic subspecies [4, 12, 37]. These subspecies are physically distinct from one another, and research is still ongoing to determine the genetic uniqueness of each. One previously-accepted subspecies, the Northeastern African Cheetah,
Cheetahs have evolved for speed and are not built to fight other predators. Because of this, they are shy in nature and will often abandon their kills in the presence of more robust predators, such as lions, leopards and hyenas [14, 39]. To combat this, cheetahs are typically diurnal hunters, as opposed to other large predator species, such as lions, hyena, and leopards, which are nocturnal [39, 40]. Their lack of defense against these predators has led to 80% of the current cheetah range being on farmland habitat [28, 41].
\nFemale cheetahs live solitary lives and do not form coalitions. After a 93 to 95-day gestation, solitary female cheetahs give birth to two to six cubs, with 3.5 being the average litter [13, 28, 42]. Cubs stay in the den for the first 6 weeks, with females moving their cubs to different nest sites for protection [39, 43].
\nAt 6 weeks of age, the cubs leave the den and follow their mother. At first, cubs will stay hidden while their mother begins to stalk prey. While the cubs are on their own, they may chase after inappropriate prey animals, such as jackals or birds [13]. To teach them how to catch appropriate prey, their mother will capture and release prey for the cubs to play with to practice their hunting skills [13]. The cubs will begin to chase the prey and trip it before the mother eventually comes and kills it for them [43]. Cubs start initiating their own hunts at about 1 year of age but are not proficient until they are independent [13]. Cubs stay with their mother for about 18–22 months. Even after they become independent, it can take cubs up to 3.5 years to master hunting [13]. Female cubs establish their home ranges within their mother’s larger home range, so there is familiarity among female cheetahs that are related [44].
\nOnce the young males disperse they will not maintain a territory until they are 4–5 years of age [13, 18]. Male cheetahs remain with their other male siblings from birth, forming a coalition for life. This behavior increases hunting success and is a defense against predators. By sticking together, they can hold and defend a better territory, where wildlife prey is abundant [39]. This also increases the chances of a greater number of desirable females coming into the territory for breeding.
\nMembers of a coalition are very bonded to one another. If separated, they do a lot of vocalizations. Cheetahs have a variety of unusual vocalizations including a dog-like bark and a bird-like chirp for calling between each other [13, 39]. Other sounds they make include a bubble or “uhun” sound, a hiss, and a growl. They are also very affectionate to each other. They purr and lick each other’s faces. Male coalitions work together when hunting and are able to hunt larger prey together. Cheetah coalitions are very stable, and the bond of brotherhood is permanent.
\nCheetahs require vast expanses of land with prey and other resources [9, 45]. Research in Namibia shows that cheetahs have an average home range of 1500 km2 with individuals covering 20–40 km in a week, but live in low densities throughout their range [14, 39, 45, 46]. Most cheetahs live in open grasslands and savanna, which are arid environments [35]. Throughout the cheetahs range, cheetahs are known to use tall trees for greater visualization as well as territorial markings. In Namibia, these trees have been called “playtrees,” as cubs are often seen climbing into them, or “newspaper tree,” as male cheetahs use these trees for leaving their territorial scent marks, urine and feces [14, 47]. However, in many ecosystems throughout the cheetah ranges, bush encroachment, a form of desertification caused by overgrazing arid landscapes as well as the decline of many of the large mega-herbivores, has caused a problem for cheetah hunting ability as well as altering the mix of wildlife [47]. Bush encroachment results in the prolific growth of a native plant species,
Changes in the arid ecosystems in favor of human needs have also created problems, mainly from overgrazing of livestock leading to desertification, leaving limited grazing for wildlife. Further compounding this issue, forces of nature that are unpredictable and difficult to manage such as climate change, negatively affect agriculture and wildlife as rangelands become drier and vegetation is altered [50]. This also affects distribution and abundance of prey [14, 45]. And, as the human population grows, air and water become more polluted, habitat is lost to development, and the climate crisis deepens. Ultimately, the cheetah’s chances for survival depend greatly on the re-balancing of the ecosystem and the restoration of habitat so it will support sufficient natural prey [26].
\nLearning to hunt is the most critical survival skill that the cubs must develop [13]. At 1-year-old cubs are participating in hunts and the mother, while assuring enough kills for the family’s survival, will allow the cubs to join in. Cheetahs hunt in the early morning and early evening and capture their prey by stalking to within 10–30 yards or as far as 80 yards before beginning the chase [13]. During a hunt, cheetahs usually catch their prey after an average 200-yard sprint [13]. Although fast, their ability to accelerate at a high speed is most critical, and their maneuverability enabling them to turn rapidly is more important than their speed. Most hunts take place at a slower speed, as prey are dodging in efforts to flee [39]. Successful hunters need not only speed but stealth as well. They move slowly and remain low in the grass, staying downwind, sometimes hiding behind small mounds to obscure their approach, taking advantage of their coloring to camouflage their appearance and blend into their surroundings [13].
\nOnly 10% of cheetah chases are successful, and diet depends largely on where the cheetah lives [13]. Medium-sized and smaller prey, such as antelope and gazelles, hare and the young of larger antelope like wildebeest (
Threats from other predators is one of the main reasons why nearly 80% of wild cheetahs today are found outside of protected areas (like national parks or wildlife reserves) and living alongside human communities [9, 28, 39]. In protected areas, cheetahs often lose their kill to larger and more aggressive predators. Cheetahs tend to lose 10–15% of their kills to other predators [39]. Cheetahs are apex predators and the best hunters on the savanna, they feed many species with their kills’ thus increasing biodiversity of the ecosystem in which they live [14]. Without this balance, other species within the ecosystem will also be adversely affected, ultimately resulting in negative consequences for the human population.
\nConservation research shows that the greatest conservation problems are not biological but have more to do with humans. Climate change and human population growth compounds these threats to an already genetically compromised species [19, 25, 33, 35, 45, 50]. Human-wildlife conflict, habitat loss and illegal wildlife trade have become the biggest threats to long-term cheetah survival [9, 26, 51, 52].
\nThe majority of people who live alongside cheetahs are rural subsistence farmers whose livelihoods depend on the health and wellbeing of their livestock. These farmers have traditionally viewed cheetah as worthless vermin, a nuisance and a threat. Some governments have sanctioned herd protection programs that allow for cheetahs on farmlands to be trapped and removed or killed on sight [51]. Culling of cheetahs in Namibia during the 1980s resulted in losses of nearly 7000 cheetahs due to real and perceived conflict with livestock and game farmers [18, 53]. While these programs were popular during the 1970s and 1980s, this led to a rapid, widespread reduction in the numbers of wild cheetah, which fortunately has been stemmed by the intervention of conservationists and the introduction of non-lethal predator control techniques [19].
\nIn Northern Africa, the rarity of the Saharan or desert cheetah is directly linked to the rarity of the prey species, as the IUCN Red List lists both predator and prey as critically endangered species [28]. The Saharan cheetah can still be found in small numbers in Algeria (Ahaggar and Tassili N’Ajjer), Niger (Termit and Aïr), and possibly also in Mali, Chad and Mauritania [9, 28]. Due to the decline of prey, mainly from poaching and overhunting, these cheetahs are living primarily on hare (
Habitat destruction across Africa and Iran is one of the biggest problems threatening cheetah survival. As wild lands are being destroyed and fragmented by human expansion, landscapes across Africa that once supported thousands of cheetahs now support only a few. With habitat loss comes the decline in wild game species that provide prey for the cheetah [45]. As the human population continues to grow exponentially, there is an every-increasing demand for land rights. This affects the cheetah, as increased agricultural pressure and subdivision of land mean a decrease in available habitat for the cheetah and other wildlife species [25].
\nFor many African wildlife species, living within a protected national park or private game reserve such as the Maasai Mara in Kenya, the Serengeti National Park in Tanzania, or Kruger National Park in South Africa is the difference between life and death. Animals that live on protected lands are guarded by rangers and photographed by tourists, which makes them less likely to be poached. But for some species, including the cheetah, living in protected areas results in greater competition with other larger and more aggressive predators that will steal their kills and kill their cubs. There is a high cub mortality (up to 90% in protected areas), mainly due to predation [15]. Consequently, nearly 80% of all cheetahs throughout their range are found living outside of protected parks and reserves [9, 28].
\nThe lifespan of an adult cheetah is between 8 and 10 years [18, 42]. Adult mortality is one of the most significant limiting factors for cheetah population growth and survival [18, 54, 55].
\nBecause of in-depth,
Genetic homogeneity can make a species more susceptible to ecological and environmental changes to which the world is subjected now and has been interpreted in the context of two potential risks: the expression of recessive deleterious alleles and increased vulnerability to viral and parasitic epizootics that can affect genetically uniform populations [11, 12]. Cheetahs are known to be very susceptible to several feline diseases and are possibly more vulnerable due to the lack of heterogeneity in the population [11, 56, 57]. As cheetahs transverse the farmlands where more villages occur, the potential for disease transmission increases. Given the species lack of genetic diversity, monitoring the overall health of cheetah populations is an important component of understanding and promoting its long-term viability.
\nAnother major threat is the trafficking of live cheetahs for the illegal pet trade. Wildlife trafficking is one of the top five transnational crimes and it is impacting affecting the survival of many species (U.N. Office on Drugs and Crime). While cheetahs are not poached at the same high rates as elephants and rhinoceros in Africa, an estimated 300 cheetah cubs are being smuggled out of the continent each year to supply the illegal pet trade [52] (Figure 2). Illegal capture is occurring mostly in Ethiopia, Somalia and northern Kenya, with most cases being reported in Somaliland [52]. Although trade in wildlife species products is regulated by both international and national laws, the illegal wildlife trade is estimated to be worth between $50–150 billion USD annually. Cheetahs, listed as an Appendix 1 species under CITES, are removed from the wild for the pet trade and for their body parts.
\nA caged cheetah cub confiscated from illegal wildlife trafficking. Cheetahs are often illegally sold as pets to the Middle East and for everyone that makes it live into the trade, 5 die in transport.
Because the cheetah is light and built for speed and has a flight versus fight instinct. For this reason, the cheetah is a sought-after pet in multiple regions of the world [52]. In the Gulf States, cheetahs are one of the most popular exotic pets and are a status symbol [52]. Photos posted on social media show cheetahs with gem-studded collars posing in luxury vehicles beside their owners, or riding in speedboats, or in other outlandish depictions.
\nKeeping a wild cheetah as an exotic pet undermines the species, as its numbers are so low it cannot sustain regular losses and still hope to survive. The illegal pet trade is decimating cheetah populations that are already small and nearly unsustainable [9, 52]. Five out of six cubs poached die before being sold into the pet trade. Cheetah cubs that survive long enough to be sold most likely will not make it beyond 2 years of age. All will become sick, disabled and die prematurely. Improper diet, environment and lack of veterinary care result in a myriad of debilitating health problems [52].
\nAnother human issue impacting the cheetah is tourism. Everyone who visits Africa on safari wants to see a cheetah. While tourism helps bring international attention to the cheetah and instills economic value in species survival, crowds of multiple vehicles surrounding cheetahs can have a negative impact [20, 58, 59]. Cheetahs hunt in the early morning and late afternoon when most game drives take place. Vehicles sometimes move between the cheetah and its prey so tourists can get a better view. This interferes with the cheetah’s ability to catch its prey and can separate mothers from cubs [20, 58, 59].
\nPredators are exceptionally aware of tourists and their vehicles and sometimes use them to their advantage. If a cheetah has made a kill it will most certainly lose it if vehicles are present, since other predators, particularly the hyena, lion or jackal are alerted by the tourists. If the cheetah has cubs, this is a very dangerous situation for them, as they are made more vulnerable by the interference of the vehicles. Research conducted in the Maasai Mara recorded that nearly 30% of cheetah sightings had more than 20 vehicles surrounding it, and of these, more than 50% were less than 30 yards from the animal [58]. Nearly 60% were reported as being noisy (hooting and engine revving) with tourists and drivers shouting or talking very loudly [20]. The busiest time for the tourist vehicles was found to be between 4:40 and 6:30 pm coinciding with the high times for hunting by cheetahs [20].
\nIn the Maasai Mara, a high incidence in sarcoptic mange in cheetahs has been linked to stress caused by tourism vehicles. Chronic stress induces immuno-suppression, which in cheetahs has been found to contribute to a high occurrence of uncommon diseases, like mange, gastritis and amyloidosis [56, 57, 58, 61].
\nSolving cheetah conservation crisis involves addressing a complex web of social, environmental and economic issues. Although people are the root of most of the problems facing the cheetah in today’s world, they are also the solution as well. Over the past several years, conservation professionals have come together to look closely at the crisis for the cheetah and devise strategies for cheetah survival [9, 24].
\nThough the situation for the wild cheetah is dire with less than 7100 wild adult and adolescents remaining, there is hope for species’ long-term survival. Efforts to educate communities living alongside cheetah through awareness building media campaigns and to obtain government buy-in have been successful [60]. Range-wide strategies for the cheetah have been developed and implementation is underway through eastern, southern, north, west and central Africa [9, 14, 36]. Capacity building for range country conservation scientist and agriculture extension officers is an ongoing process, using the “train the trainer” approach [26, 60]. Committed conservationists are focusing on the bigger picture, encouraging community participation in finding solutions that alleviate conflict. The bigger picture allows for a global perspective and a multi-species, integrated approach to cheetah conservation.
\nAt the 2003 World Park’s Conference, conservation practitioners agreed there was need for community ownership and responsibility over assessing and addressing human wildlife conflict (HWC). To be successful, improved communication on a local level between stakeholders and on a global level between experts, practitioners, local communities and international conservation organizations would be required. Guidance manuals, processes and systems needed to be developed, and HWC mitigation needed to be supported by international political and legal institutions.
\nIn 2007 and again in 2012, government representatives, non-government organizations (NGOs) and the International Union for Conservation of Nature (IUCN) Species Survival Commission’s (SSC) Cat Specialist Group met to develop regional strategies for the survival of cheetahs [20, 21, 22]. Since then, strategies for the three regions of Africa have been developed: central, west, and southern, eastern and north. The Range Wide Conservation Plan is a joint initiative of the Wildlife Conservation Society and the Zoological Society of London, in partnership with the Cat and Canid Specialist Groups of the IUCN/SSC. These strategies have created a structure under which government programs could be developed, thus enabling conservation action on a national level. Subsequently, National Action Plans have been developed in 13 cheetah range countries [14, 20, 21, 22, 23].
\nToday, cheetah research and conservation programs are found in Botswana, Iran, Kenya, Namibia, Tanzania, South Africa, and Zimbabwe [14]. Furthermore, cheetah research and training has been conducted in countries such as Algeria, Angola, Benin, Ethiopia, Mozambique, Niger, Zambia and Somaliland [26].
\nCommunity-based, natural resource management NGOs are also working with many communities throughout Africa to develop integrated programs incorporating tourism development and economic incentives to diversify livelihoods for its citizens [62]. Through outreach programs focusing on agricultural education, farmers are being taught about livestock health and management along with grasslands, wildlife and basic principles of ecology [19, 60]. Conservancies—collaborative partnerships of neighboring farms united by common operating principles—are being formed to implement standardized land management techniques that benefit people, livestock and wildlife [33, 49, 63, 64]. Examples of successful conservancies are being used to provide the basis for developing large-scale trans-boundary land management plans for the future [64].
\nConservation biologists increasingly underscore that national parks and reserves alone are not large enough to sustain the wildlife they were created to protect. This is particularly true for the cheetah [25, 65]. Therefore, the focus on conservation of private land is crucial. Conservancies are one of the most important solutions for cheetah survival as they promote sustainable management of natural resources and development of responsible eco-tourism [64]. Conservancies give communities a vested interest in the welfare of local wildlife by giving them control over the economic benefits from wildlife populations. As a result, fewer problems with poaching are experienced and human-wildlife conflict is reduced [49].
\nWith populations dwindling through most cheetah-range countries, cheetah survival depends on people using an informed, integrated approach to conservation. Education is the foundation and must include communication, information sharing and capacity building [60, 66]. In 2005, CCF began conducting month-long courses to bring together conservation managers, scientists, and community representatives from African cheetah-range countries and Iran [66]. The courses build capacity, with a goal of stabilizing cheetah populations. More than 300 participants are now managing cheetah and wildlife conservation programs in their own countries.
\nAt the same time, research into ways to conserve and restore habitat for cheetahs and farmers is also important by working with local livestock farming communities, to help improve their livelihoods. Assigning economic value to cheetahs and having a thriving population on the landscape is key. Training programs have been developed by the Cheetah Conservation Fund that address human-wildlife conflict called Future Farmers of Africa (FFA) [66]. FFA teaches best agricultural practices to rural farmers to help them manage integrated wildlife and livestock farmlands. FFA also teaches how non-lethal predator control methods can reduce predation losses. The use of livestock guarding dogs is included in this course. CCF has helped develop similar programs throughout the cheetah’s range. Many of these methods of reducing predator conflict are also applicable or adaptable to other animals such as mountain lions, jaguars and wolves, and have been used as models elsewhere in the world.
\nFFA covers topics like livestock health, veterinary care, husbandry, and valuation as well as wildlife and rangeland management, methods of non-lethal predator control, predator identification and best practices to reduce livestock losses including the use of kraals, birthing camps as well as seasonal, coordinated breeding. The use of a livestock guarding dog has been shown to be a very effective tool and is included in training [67] (see Figure 3). The Anatolian shepherd or Kangal dogs have been used for thousands of years in the Turkish region of Anatolia as livestock guarding dogs, where they were formidable guardians of livestock against bears and wolves [69, 70, 71].
\nA goat herd protected by a livestock guardian dog in Namibia. Turkish Anatolian shepherd and Kangal dogs are bred and placed with livestock through the Cheetah Conservation Fund in Namibia.
Since 1994, the Cheetah Conservation Fund (CCF) in Namibia, has bred and placed these dogs with livestock farmers to reduce conflict with livestock and reduce the killing of cheetahs and other predators. Farmers who use CCF LGDs report a decrease in predation rates ranging over 80% [70, 72]. Simultaneously, LGDs reduce the killing and capture of cheetahs and other predators [72, 73]. The dogs have been so successful, similar programs in South Africa, Botswana and in Tanzania [68].
\nIncreasingly, today’s consumers rely on product labels to guide their purchases, and at the same time, are willing to pay a premium price to ensure a product’s providence. In 2000, CCF conceptualized the Cheetah Country—Eco-Labeling Program to encourage predator-friendly farming techniques in producing beef, goat cheese, crafts, honey and wine [49, 62]. Under the brand
The outlook for the cheetah is today in human’s hands. Cheetah populations can rebound. But humans also have the capacity to save them. In many parts of Africa, cheetahs and other large predators are viewed as threats to human livelihoods, rather than species vital to maintaining healthy, balanced ecosystems. Good livestock management can protect herds while allowing prey and room for cheetahs and other predators. Having thriving cheetah populations also brings economic value to land as they and other predator species help drive tourism.
\nImplementation of more programs now is critical, so future generations will benefit from having cheetahs on earth. Continuing to expand our scientific research will be important (Figure 4), while collaborating with international institutions in fields such as cheetah health, genetics, reproduction, ecology to establish population numbers, as well as expanding training and capacity building programs will be key in cheetah conservation, while expanding efforts to stop the illegal cheetah trafficking. If we wait much longer, we will lose this amazing feline icon of speed and grace. A holistic approach that considers all stakeholders is critical to balance the needs of people, wildlife and the land and try to make their efforts sustainable. This way, the communities are more likely to be good stewards of wildlife. The end goal to save the cheetah is to achieve coexistence. This is the only way to ensure a permanent place for cheetahs on Earth.
\nSatellite collars allow monitoring of cheetahs movements. Through understand the cheetah’s use of their large home ranges (ave. 1500 km2) allows for management plans can be used with rural communities to plan for the cheetahs’ survival in the future.
Education and outreach are key in building awareness for the cheetah’s plight and for developing sustainable practices that alleviate pressure on the species. Looking to the future, teaching conservation and instilling a high regard for the environment among young learners will help cheetahs secure a permanent place on Earth.
\nCreative approaches are also necessary. The future of the cheetah will require enhancing the livelihoods of the human communities that live alongside them. These include developing alternative income sources, such as eco-tourism, economic incentives for predator-friendly products. The concept is that farmers in cheetah range areas can be monitored and certified as practicing predator-friendly livestock management. In return for being good stewards to the cheetahs on their land, these farmers can be certified with the Cheetah Country eco-label and receive premium prices for their products [49, 62]. A program in development, its model could serve to protect all of the world’s predators, each of whom are threatened by conflict with humans and yet are vital to maintaining the health and biodiversity of their ecosystem.
\nDespite all of the problems facing the cheetah, including genetic uniformity, competition with other large predators, destruction of habitat and conflict with humans, this iconic animal has survived for thousands of years. Cheetahs continue to fulfill their ecological role as the fastest mammalian apex predator on land. With integrated conservation programs across large landscapes, survival of cheetahs for future generations can be attained [26].
\nThanks to the Cheetah Conservation Fund for their support of long-term research (www.cheetah.org), Susan Yannetti and Natalie Minor for their assistance with editing of this Chapter.
\nThe incidence of twin pregnancy in the United States in recent times is approximately 3% [1]. With advancing age, different ethnic populations and advanced use of assisted reproduction technology, the incidence of dizygotic twins is far more common and accounts for 70% of all twin gestations. However, the incidence of monozygotic twins remains mostly constant worldwide and accounts for 3–5 per thousand births. The incidence of monochorionic twins is 1 in 300 pregnancies. In about 15% of these twins, there is an imbalance in foetal circulation. This results in conditions like twin-to-twin transfusion syndrome (TTTS), twin anaemia polycythaemia syndrome (TAPS), twin reversed arterial perfusion syndrome (TRAP), selective intrauterine growth restriction (sIUGR) and death of a co-twin.
In this chapter, we discuss the latest updates in the management of monochorionic twin pregnancy.
The most essential component of foetal well-being in twin pregnancy is the determination of the placental chronicity. Placental physiology has a vital impact on foetal and neonatal outcomes. Monozygotic twins develop when a single sperm fertilises with a single ovum during conception. Post conception, if the splitting of the egg occurs 2–3 days post fertilisation, it results in dichorionic, diamniotic twins. Approximately 30% of monozygotic twins are diamniotic and dichorionic. A splitting of egg 3–8 days post-conception results in monochorionic and diamniotic twins. About 70% of monozygotic twins are monochorionic diamniotic. If splitting occurs 9–12 days after fertilisation, it results in monoamniotic monochorionic twins. The incidence of these twins is only 1%. There is a well-documented increased incidence of second-trimester loss, congenital anomalies, and prematurity in these twins. A splitting after 12 days fertilisation can result in conjoined twins (Figure 1).
Courtesy—Google images.
As a result of a single placenta, monochorionic twins have substantial vascular communications between the two foetal circulations. In 80% of cases, the vascular anastomosis is bidirectional, which rarely leads to a haemodynamic imbalance between foetal circulations. However, it allows a direct vascular connection between the twins with an increased risk of foetal death [2, 3].
In 15% of monochorionic pregnancies, the placenta has have a predominance of unidirectional vascular anastomosis which results in twin-to-twin transfusion syndrome (TTTS) [2]. Other morbidities exclusive to monochorionic pregnancies are:
Intrauterine growth restriction (sIUGR)
Twin anaemia polycythaemia sequence (TAPS)
Neurodevelopmental morbidity
Trap reversal arterial perfusion syndrome (TRAP)
The death of a single twin and its effects on the second twin
It is vital that all women with twin pregnancies should be offered an ultrasound examination between 11 + 0 and 13 + 6 weeks of gestation (crown-rump length 45–84 mm [2]. This is crucial to assess foetal viability, gestational age and chronicity. In monochorionic diamniotic pregnancies, the intertwin membrane becomes progressively thin after 9 weeks. A characteristic ‘T’ sign is seen on ultrasound with a 100% sensitivity and greater than 98% specificity for detecting monochorionic diamniotic gestation [4]. On the other hand, in dichorionic diamniotic pregnancies, a ‘twin peak’ or lambda sign is characteristic with a sensitivity greater than 97% and specificity of 100% in predicting chronicity [4]. It is a good practice to determine the amnionicity at the same time and document it as well (Figure 2).
Courtesy: (obgyn.onlinelibrary.wiley.com).
Other sonographic signs to determine chronicity, especially when women present after 14 weeks of gestation, include number of placental masses, number of gestational sacs and concordant sex of the foetuses but the most valuable sign is the intertwin membrane using 2-dimensional ultrasound which is considered as highly accurate with very high sensitivity and specificity. The reliability of the number of placental masses may become arguable, as it is not unusual for dichorionic placentae to be commonly adjacent to each other and give appearance of a single mass. It is also noted that 3% of monochorionic twin pregnancies may have two placental masses on ultrasound, the presence of which does not prevent the presence of vascular anastomoses. It is likely that using a combination of ultrasound features, rather than one, would be more accurate [5].
Several studies have reported a comparison of increased nuchal translucency versus normal nuchal translucency in both dichorionic and monochorionic twins. However, a recent study has demonstrated that monochorionic twin pregnancies with increased nuchal translucency, but no chromosomal abnormalities had a higher incidence of structural anomalies and twin-specific complications. The most likely cause of increased nuchal translucency in these twins could be because of their unique vascular anastomoses which can lead to conditions like cardiac dysfunction, anaemia and possibly twin-to-twin transfusion syndrome. The studies indicated that detection of increased nuchal translucency is important in the early prediction of twin-specific complications although the appropriate intervention in such cases remains controversial [6]. Similarly, a discordance in nuchal translucency measurements of more than 20% is often seen in those cases of monochorionic diamniotic twin pregnancies that develop early twin to twin transfusion than those with normal outcomes [7]. The risk of TTTS and early intrauterine death in such cases is up to 30%. Such cases should be discussed with the foetal medicine expert and should be offered a detailed ultrasound and karyotyping [5].
As for the chromosomal screening, it is recommended in monochorionic twins when aneuploidy sceening is offered nuchal translucency should be used in conjunction with first-trimester serum markers (combined screening test) at 11 + 0 weeks to 13 + 6 weeks of gestation (crown–rump length 45–84 mm). Studies have shown that although non-invasive prenatal testing has a high screening efficiency in a singleton pregnancy, its performance in twin pregnancies remains unstable. Hence, it should be carefully used in the screening of chromosomal abnormalities in twins [8].
As it is well recognised that screening and diagnostic testing in twins are more complex than in singleton pregnancy, hence comprehensive counselling should be provided by health care experts before tests are taken. Health care providers should inform couples regarding the complex decisions which may be potentially required especially in cases of monochorionic twin pregnancy.
With regards to performing amniocentesis in monochorionic twins, if monochorionicity has been confirmed before 14 weeks of gestation and there is no gross discordant in growth of foetuses, it is acceptable to sample only one amniotic sac. Otherwise, both amniotic sacs need to be sampled as the rare possibility of discordant chromosomal anomalies in monochorionic pregnancy cannot be ruled out. Chorionic villus sampling (CVS) in monochorionic pregnancy will sample only the single placenta. This could miss the rare discordant chromosomal anomalies. Discordance for most of the common human aneuploidies (trisomy’s 13, 18 and 21, Turner syndrome and triploidy) has been reported in monochorionic twin pairs. In the event of such a case, a selective reduction by umbilical cord occlusion can be offered from 16 weeks onwards, with a survival rate of more than 80% for the healthy twin. It is extremely important to provide detailed counselling in such complex cases to the parents by foetal medicine experts [5].
It is recommended that the pregnancy should be dated according to the crown-rump length of the larger twin. Dating should take place when the crown-rump length is between 45 mm and 84 mm (equivalent to 11 + 0 to 13 + 6 weeks of gestation). Twins, if seen after 14 weeks, should be dated according to the head circumference of the larger twin [9].
Labelling of twins should follow a reliable and steady strategy with options according to their site; for example right or left, upper or lower or according to the insertion of cord in relation to placental membrane insertion as recorded during first trimester scans. If there is a discordance in the twins, a description such as ‘potential recipient’ can be used for labelling. It is important to note that twins as seen on ultrasound may not be delivered in the same sequence especially during a caesarean section. Thus, it is strongly recommended to rescan the women just before performing a caesarean especially in cases of twin congenital abnormality like cardiac defects or diaphragmatic hernia and before any surgical intervention [5].
It is recommended that monochorionic diamniotic pregnancy should have hospital-based care. If any complications arise, then tertiary care should be advised. Women with monochorionic diamniotic twin pregnancy require a good and strong emotional support throughout the pregnancy bearing in mind the foetal morbidity and mortality associated with the twins. All efforts should be made to reduce their anxiety, and comprehensive counselling should be done at the booking visit. The screening and diagnostic tests and their complexity should also be discussed at the initial visit.
General advice regarding diet and lifestyle should be given [10]. It should be emphasised that women with twin pregnancies are more prone to anaemia, preeclampsia, gestational diabetes, varicose veins as well as increased risk of venous thromboembolism, antepartum and postpartum haemorrhage. All usual antenatal screening blood tests should be advised as singleton pregnancy. If anaemia is detected, iron should be commenced in early pregnancy along with folic acid. Vitamin D should also be started from early pregnancy if a woman is deficient in vitamin D.
A prophylaxis dose of Aspirin 100–150 mg is recommended from 12 weeks to 36 weeks of pregnancy if other risk factors are present such as:
Previous history of hypertensive disorders in pregnancy; chronic hypertension in pregnancy; chronic kidney disease; history of Type 1 or type 2 diabetes; primigravida; history of autoimmune conditions such as antiphospholipid syndrome or systemic lupus erythematosus; age greater than 40 years; family history of pre-eclampsia or obesity greater than 35 at first visit [10].
The antenatal and ultrasound visit schedule for monochorionic diamniotic twins (Figure 3).
Reproduced from Google image (Cambridge University Press).
Most recent studies suggest a structured ultrasound schedule for the antenatal management of monochorionic twin pregnancy. It is now generally accepted that after the first visit and ultrasound at 12 weeks, monochorionic pregnancies should have antenatal visits every 2 weeks from 16 weeks onwards. At every visit, an ultrasound should be performed for the early detection of twin transfusion syndrome and twin anaemia polycythaemia syndrome, as early detection of these conditions results in a better perinatal outcome.
At 16 and 18 weeks scan, it is recommended to measure foetal biometry and deepest vertical pocket (DVP) of amniotic fluid in each twin. At 20 weeks, a detailed anomaly scan should be performed along with biometry. The umbilical artery Doppler pulsatile index (UA PI) should also be recorded from this visit onwards along with the middle cerebral artery peak systolic velocity (MCA PSV). The MCA PSV helps in the early diagnosis of twin anaemia polycythaemia syndrome (TAPS) and is recommended to be done routinely from 20 weeks onwards [5]. Amniotic fluid measurements should be continued at this visit and a cervical length screening is also recommended at this stage. Antenatal visits should continue every 2 weeks until 36 weeks. At each visit, foetal biometry, umbilical artery Dopplers, middle cerebral artery peak systolic velocity and deepest vertical pocket of amniotic fluid in each sac should continue. A decision on delivery should be taken at 36 weeks.
Twin foetuses should be assessed for the presence of any major anomalies at the first-trimester scan, and a routine second-trimester (anomaly) scan should be performed at around 20 (18–22) weeks of gestation as in singleton pregnancy.
Apart from this, a cardiac screening assessment should be performed in monochorionic twins. The cardiac scan should be performed according to standard ultrasound guidelines including laterality, situs and four-chamber, ventricular outflow tract and aortic arch. The abnormalities of the brain and cardiac abnormalities are more common in monochorionic twins. Other abnormalities associated with twins include neural tube defects, anterior abdominal wall defects, facial clefts, brain abnormalities, cardiac defects and gastrointestinal anomalies. Every 1 in 15 monochorionic pregnancies may have a risk of a major congenital anomaly. By doing a regular screening, the parents get a chance to prepare for the birth of a baby with a potential problem, offering them the option of termination. This also allows the transfer of the pregnancy to a tertiary care with special intervention facilities [5].
Cervical length assessment should be considered the optimal method of screening for preterm birth in a monochorionic pregnancy. A transvaginal scan visualises the cervix more objectively and the 2D modality is considered the most appropriate imaging modality.
The ratio of a curved/straight cervix decreases with a decrease in length, and this does not have important clinical implications [11]. Serial measurements should be done, and the shortest result should be taken. A short cervical length is a good predictor of preterm births even in later gestations. It is considered more accurate than digital exams and foetal fibronectin in the prediction of preterm birth (Figure 4) [12].
Twin pregnancy with a short cervix. Courtesy: (mfmync.com).
A cervical length of <20 mm at 20–24 weeks is the most accurate predictor of preterm labour with high sensitivity and specificity [12]. A higher rate of preterm birth is common in monochorionic twins and could be reflected and predicted by an increased rate of a short cervix.
The use of progesterone, bed rest, Arabin cervical pessary, antibiotics or oral tocolytics has not shown to reduce the risk of preterm labour in these cases. The use of vaginal progesterone in twin pregnancy with a TVS cervical length of <20–25 mm has been shown to reduce the incidence of preterm birth at <34 and <32 weeks in some studies [13]. However, the results were not conclusive. Progesterone may reduce the risk of neonatal morbidity and mortality [5].
The rates of preterm birth at <24 weeks, <28 weeks, <32 weeks and < 34 weeks have shown to be reduced by placement of a first-trimester cervical cerclage in twins only with a previous history of preterm birth [13].
A course of antenatal corticosteroids may reduce the risk of respiratory morbidity, necrotising enterocolitis and intraventricular haemorrhage but this should be timed and not given untargeted [14].
There is an increased number of arteriovenous (AV) anastomoses deep in the placenta in twin-to-twin transfusion syndrome. These are mainly capillary connections that happen in the cotyledon portion of the placenta. Unidirectional flow can occur in these AV anastomoses and result in shunting of blood towards one twin and away from the other, when the arteriovenous anastomoses are unbalanced. Bidirectional flow is usually maintained by arterioarterial (AA) and venovenous (VV) anastomosis. These are found more superficially on the placenta. AA anastomoses are thought to be protective against TTTS. There is apparently a reduction in AA anastomosis in monochorionic diamniotic twins and thus these twins are more susceptible to TTTS. On the other hand, monochorionic monoamniotic twins are thought to have more AA anastomoses, which is a theoretical reason why rates are lower in these twins than in MCDA twins [15, 16].
Due to the hypovolemia experienced by the donor twin, the renin-angiotensin-aldosterone system (RAAS) gets stimulated in that twin. This leads to oliguria and oligohydramnios. On the contrary, the other twin experiences hypervolemia which causes a cardiac stretch. This leads to an increase in atrial natriuretic peptide and brain natriuretic peptide release in the recipient twin. This inhibits the RAAS and leads to polyuria and polyhydramnios [17, 18, 19]. The consequences are atrioventricular valve insufficiency, diastolic dysfunction and pulmonary stenosis or atresia in the recipient twin.
Based upon data from referral centres, the Society for Maternal-Fetal Medicine (SMFM) estimates a prevalence of:
Stage I: 11–15%
Stage II: 20–40%
Stage III: 38–60%
Stage IV: 6–7%
Stage V: 2% [20]
It is now well recognised that from 16 weeks onwards all women with monochorionic pregnancies should have a fortnightly ultrasound to diagnose TTTS. Literature suggests ultrasound-based signs as more reliable in the diagnosis of TTTS than physical examination or symptoms.
The ultrasound criteria recommended for the diagnosis of TTS are as follows:
Other studies suggest using hydrops fetalis (a condition associated with ascites, pleural, pericardial effusion and skin oedema) of the recipient twin as the criteria for ultrasound diagnostic features as well as growth restriction which can happen in 50% of donor twins as ultrasound criteria of TTTS along with the above standards. The foetal growth restriction is defined as an estimated foetal weight of <10% of normal or an abdominal circumference (AC) of <5% of normal in the setting of otherwise normal foetal growth [21].
The staging system is most utilised for TTTS is the Quintero Staging System, which is based upon two-dimensional ultrasound and Doppler study findings and is as follows:
Stage I: oligohydramnios and polyhydramnios sequence, donor twin bladder is visible, Doppler studies of UA/UV/DV are normal in both twins.
Stage II: oligohydramnios and polyhydramnios sequence, donor twin bladder is not visible, Doppler studies of UA/UV/DV are normal in both twins.
Stage III: oligohydramnios and polyhydramnios sequence and abnormal Doppler study (only one of the following is required in either twin) [absent/reversed end-diastolic flow in UA, pulsatile flow in UV, or reversed a-wave flow in DV].
Stage IV: oligohydramnios and polyhydramnios sequence, and one or both foetuses have hydrops.
Stage V: oligohydramnios and polyhydramnios sequence, and one or both foetuses have died.
The above staging has been adopted from the Society of Maternal Fetal Medicine (Figure 5) [20].
Twin to twin transfusion syndrome. Courtesy (Springer open.com).
Management recommendations differ based on the stage of TTTS and gestational age and are outlined below [15].
Stage I: The management of stage 1 is controversial. Expectant management is considered a recommended option. Similar outcomes comparing expectant management to amnioreduction and foetoscopic laser photocoagulation have been noted. Consider weekly ultrasounds for follow-up. Up to 25% of Stage I TTTS may progress to another stage. Expectant management is usually associated with a high survival chance of at least one twin in most pregnancies.
Stage II, III, IV: The recommended treatment for these three stages is foetoscopic laser photocoagulation when the gestational age is <26 weeks. Laser photocoagulation has shown to have better outcomes than serial amnioreductions, including increased survival rates of one or both twins, delivery at greater gestational ages, and superior neurological outcomes. TTTS diagnosed before 26 weeks of gestation is best treated by laser ablation, as the evidence suggests that it leads to better outcomes compared with amnioreduction or septostomy. It is generally accepted that Quintero stages II and above will require treatment, and many centres will manage Quintero stage I conservatively. However, if laser ablation expertise is not available, amnioreduction is an acceptable alternative in pregnancies diagnosed after 26 weeks of gestation. There are some evidences that laser ablation is still the best form of treatment for TTTS, regardless of whether it is diagnosed early (before 16 weeks) or late (after 26 weeks of gestation).
Stage V: No interventions have been evaluated at this stage.
Foetoscopic laser photocoagulation is the most well-known procedure for the management of TTTS. The rate of twin survival increases significantly after treatment with foetoscopic laser therapy up to 88% for at least one twin and 62% for the survival of both twins [22]. It should be performed under ultrasound guidance typically between 15 and 26 weeks of gestation. The aim of the procedure is to create 2 chorions which will individually supply blood to each twin. Although the procedure can be performed even earlier or later, there are drawbacks when performed at different times than recommended. If done below 16 weeks, the risk of PPROM is high while the risk of difficulty in coagulation exists after 25 weeks. This is mainly due to the increase in the size of blood vessels after 25 weeks.
The following are the various kinds of foetoscopic laser procedures used [23]:
In this procedure, at first, abnormal vessels are mapped by following them from origin to termination. A vessel that starts from one foetus, incorporates into a cotyledon and then journeys through the other foetus. This is considered pathologic, and it is this vessel which is photocoagulated. On the contrary, the vessel that leaves the cord as an artery, enters a cotyledon and returns to the same foetus as a vein is not pathologic and not treated. This procedure is called selective photocoagulation [21, 24].
Laser coagulation of the anastomoses is done through bursts of energy over 3–4 seconds from 1 cm. The laser energy can be tailored to the working distance, type and size of the vessels. If larger vessels are involved, multiple shots may be required to coagulate the vessels. Higher laser energy can be more efficient to prevent perforation of foetal vessels, bleeding and may lead to less placental damage. Typically (Nd: YAG: wavelenth 1066 nm are used).
Caution should always be taken to avoid contact between the laser fibre and tissue. In case, the targeted vessel is behind the membrane, the laser energy can be fired through the membrane.
The coagulation in this procedure is done in the following way order of type of connections [21].
Donor artery—recipient vein
Recipient artery—donor vein
Artery-artery
Vein-vein
AAs and VVs are usually called superficial anastomosis, whereas arteriovenous (AV) anastomosis typically involves an anastomosis between the artery and the vein and is called deep anastomosis. In an uncompensated case, the blood supply from the artery of one will twin will drain into the vein of the other twin. Sequential lasering involves grouped coagulation of AA, AV and VV anastomosis. In this technique, at first AV (donor to recipient) is coagulated, followed by VA (recipient to donor) [25]. Several studies (non-randomised) have shown better survival rates with this method. Technically, such a procedure reduces the risk of hypotension in the donor twin.
The Solomon technique was developed as an advancement of coagulation techniques. The ‘Solomon technique’ involves initially completing coagulation of all visible anastomoses and then performing coagulation to connect the anastomoses ablation sites from one edge of the placenta to the other [22, 26]. This method enables the monochorionic placenta to be dichorionised by coagulating placental vessels and the surface of placenta. Although this technique results in fewer TTTS recurrences, decreased development of TAPS and increased perinatal survival, the risk of PPROM and placental abruption is high. This could be due to the increased exposure of the placental tissue to laser energy. This technique was found to be superior to the conventional technique in a randomised controlled study (Figure 6) [27].
Solomon technique: Courtesy—(google images-researchgate.net).
An initial follow-up a day after the procedure to rule out complications such as intrauterine death of one or both twins and cervical length.
The pregnancy can then be followed every two weeks as per the usual schedule. A weekly ultrasound is also recommended post-operatively [28]. The complications that could occur may be from procedure-related surgical complications to recurrences, brain, cardiac and limb abnormalities. As the procedure is associated with a risk of neurological damage, some centres perform a follow-up MRI, but this is still not a routine recommendation [27, 29].
Delivery is recommended in treated cases at around 35 weeks after giving steroids.
Illustrative diagrams of various laser techniques (Figures 7 and 8).
Courtesy: Gautier Scientific Illustrations.
Placental Anastomosis in TTTS (Courtesy: e-medicine.com).
Short-term early complications could include foetal demise of one or both twins. The risk is higher when the procedure is performed before 17 weeks. Similarly, the rates of preterm premature rupture of membranes (PPROM) may be higher when performed earlier than 17 weeks. TAPS may occur after missed small anastomosis in up to 3% of cases after dichoronisation.
Other complications could be a persisting or recurrent TTTS. This could happen in up to 1% of cases due to technical difficulties. A second laser could be a possibility but could be complicated by a haemorrhagic amniotic fluid due to a previous procedure.
Long-term foetal outcome shows that the survival of at least one or both twins is high. The survival rate of both twins is reported as 35–65%, whereas the survival of at least one twin is reported as between 70 and 88% [30]. Long-term neurodevelopment impairment was reported as 10% [31]. Neurological damage in TTTS may occur because of antenatal injury secondary to hemodynamic and haematological imbalance and/or from postnatal injury associated with prematurity [32] and low birth weight. Thermal injury damages may happen infrequently if unexpected foetal movements happen. A rare but serious complication could be vascular limb occlusion. This could vary from mild skin damage to total limb amputation and happens usually in the lower limbs.
This could vary from mild peritoneal irritation due to leakage of fluid or blood in abdominal cavity, to other complications such as preterm labour, iatrogenic PPROM and delivery. Other complications could include infection, haemorrhage and placental abruption.
In the past, amnioreduction was the only treatment available for TTTS, but not anymore. Although foetal laser coagulation is now considered a gold standard for TTTS, a certain group of patients may still benefit from amnioreduction. Amnioreduction is also a more suitable option when TTTS is diagnosed after 26 weeks of gestation.
Amnioreduction is useful in the setting of TTTS when the criteria for laser surgeries are not met and when laser surgery is not technically possible in certain cases and in some cases of post-laser coagulation is a relatively simple treatment which does not require high-tech equipment [32].
Reduction of elevated amniotic fluid volume in polyhydramnios decreases the amniotic pressure which may lead to increased flow from the placenta to the foetus, as well as increases placental perfusion provided all other characteristics are unchanged. Controlled amnioreduction is considered a better option than random drainage of amniotic fluid [33].
Complications could include PPROM, infections, death of one or both twins (survival rates following this procedure range from 50 to 65%), need for serial amnioreductions, preterm labour, placental abruption, infection and decreased success of potential future foetoscopic laser photocoagulation. [15] The neurological impairments associated with amnioreduction are comparable with foetal laser therapy indicating that the predictor for neurological impairment is gestational age irrespective of management [32].
Septostomy is a procedure when an intentional rupture of the intertwin septum is done under ultrasound guidance. The aim of the procedure is to balance the amniotic fluid pressure in the two sacs. This may lead to a correction of the placental circulation, mainly in the donor twin’s vessels. As the amniotic sac of the donor twin is filled, it reduces cord compression and improves foetal haemodynamics. As a result, the urine production of donor twin is improved [34].
Complications of septostomy are same as for serial amnioreduction, such as preterm labour and premature rupture of membranes. An additional risk is represented by the creation of a monoamniotic pregnancy that can lead to cord entanglement. The survival rates following septostomy for TTTS vary widely from 36 to 83%. Gestational age is increased in cases of septostomy compared with amnioreduction. Survival rates between septostomy and amnioreduction are comparable and septostomy offered the advantage of requiring a single procedure [34]. Another potential risk associated with septostomy is the presence of membrane flaps which may induce an amniotic band syndrome, a potentially dangerous complication. Experience with septostomy is limited and there is a need for further evaluation of this technique (Figure 9).
Illustrative diagram of Septostomy (Courtesy: Semanticsscholar.org).
Twin anaemia polycythaemia sequence (TAPS) is defined by significant intertwin haemoglobin discordance. It does not have the amniotic fluid discordance that characterises twin-twin transfusion syndrome (TTTS) in monochorionic twin pregnancies. This difference clearly distinguishes TAPS from TTTS.
TAPS is a rare disorder and can occur spontaneously (3–5%) or following foetoscopic laser ablation for TTTS (13–15%). This complication is thought to result from chronic transfusion through very small placental anastomoses. The pathogenesis of TAPS is not known.
A small number of usually very tiny and mostly unidirectional, arteriovenous placental anastomoses are seen in this condition. TAPS that follow laser surgery is associated with a smaller number of recurrent placental anastomoses than when it occurs spontaneously. The slow, and likely low volume, blood transfusion, which does not cause a great impact on the recipient’s plasma volume (as the classic TTTS does), could be the possible explanation for there being no discordance in amniotic fluid volumes [35]. As a result of their extremely small size, these anastomoses can be missed during coagulation; thereby, Solomon technique is considered a better technique to prevent TAPS. The condition can be diagnosed both in antenatal and postnatal periods [36].
Middle cerebral artery peak systolic velocity (PSV) should be performed routinely following post-laser treatment to detect TAPS. The sensitivity of middle cerebral artery PSV to diagnose TAPS is more than 90%. Anaemia and polycythaemia both can be diagnosed using middle cerebral artery PSV antenatally. A middle cerebral PSV > 1.5 multiples of the median (MoM) for the donor twin and < 0.8 MoM in the recipient is proposed for antenatal diagnosis [37].
TAPS classification Antenatal stage Findings at Doppler ultrasound examination [37]:
Stage 1—MCA-PSV donor >1.5 MoM and MCA-PSV recipient<1.0 MoM, without other signs of foetal compromise
Stage 2—MCA-PSV donor >1.7 MoM and MCA-PSV recipient<0.8MoM, without other signs of foetal compromise
Stage 3—as stage 1 or 2, with cardiac compromise of donor, defined as critically abnormal flow
Stage 4—hydrops of donor
Stage 5—intrauterine demise of one or both foetuses preceded by TAPS
Postnatal stage Intertwin Hb difference, g/dl
Stage 1 > 8.0
Stage 2 > 11.0
Stage 3 > 14.0
Stage 4 > 17.0
Stage 5 > 20
Apart from the inter-twin haemoglobin difference of more >8 g/dl and one of the two following criteria should also be there; either a reticulocyte count ratio of >1.7 or the presence of only small vascular anastomoses (diameter 1 mm) on placental inspection (Figure 10) [37].
The illustrative difference between TTTS and TAPS (courtesy—hopkinsmedicine.org).
Treatment options in utero include expectant management, intra-uterine transfusion both (intraperitoneal or intravascular) in the donor with or without partial exchange transfusion (PET) in the recipient, selective foeticide and laser therapy. Despite all options, laser remains the only treatment option that can resolve the possible causal mechanism. The preferred laser coagulation in TAPS should be the Solomon technique as this technique diminishes the risk of residual anastomoses and recurrent TAPS [38].
Intrauterine transfusions and partial exchange transfusions can temporarily stabilise the hemodynamic situation in severely affected foetuses. Overall, different management options may improve survival and perinatal outcomes like respiratory morbidities in affected foetuses [35, 39].
Some cases of intrauterine transfusions have been reported to be successful in prolonging the pregnancy. Even though the only pivotal treatment for TAPS is foetoscopic laser coagulation of the residue vascular anastomoses, this can be technically trickier than in TTTS. The reason for this is the absence of polyhydramnios and a stuck twin. This situation makes the visualisation of the vascular equator more difficult. The other reason is placental anastomoses in TAPS are known to be only few and minute. As a result, this may be missed during foetoscopy because of their size.
The precise perinatal mortality and morbidity frequency in TAPS is not known yet, probably because of the oddity of the condition. Spontaneous resolution of antenatal TAPS has also been described [40].
The results from recent studies suggest that spontaneous TAPS may have a better prognosis than post laser TAPS. As for mortality and morbidity, no differences were observed when comparing different management options for TAPS. Caution should be applied when interpreting these results due to scarcity of literature. A tailored antenatal management, considering the severity of TAPS and gestational age, is currently the recommended strategy [39].
Haematological complications are commonly seen in TAPS donors and recipients. This may require postnatal blood transfusions or partial exchange transfusions. Another condition that the recipient can develop is polycythaemia hyper viscosity syndrome, which could possibly lead to necrosis of the skin and multiple limb ischemia. The recipient twin is also more at risk of thrombocytopenia due to impaired production because of tissue hypoxia [38].
Because of anaemia in donor twin and polycythaemia in recipient twin, cerebral injury can theoretically occur and cases of reported cerebral injuries have been reported in both twins. Recent studies show that long-term neurodevelopmental outcome in post-laser TAPS, not indicate mild to moderate cognitive delay in 9% and 17% of TAPS survivors, respectively. No difference in neurological impairment was found between donors and recipients. The rate of neurological impairment in TAPS seems to be comparable to the rate of impairment in children with TTTS after laser surgery. Risk factors may include early gestational age at delivery and smaller babies (Figure 11) [38].
Twin Anaemia Polycythaemia Syndrome—Courtesy:(en.wikepedis.org).
This condition affects approximately 10–15% of monochorionic (MC) twin pregnancies. Selective intrauterine growth restriction is diagnosed when the estimated foetal weight (EFW) in one twin of <3rd percentile or an intertwin EFW discordance ≥25% is observed on ultrasound.
The main complications are the possible risk of intrauterine death of one twin or neurological damage of both twins. Unequal sharing of the placenta is the main cause of this condition, and the clinical outcome is closely related to the placental vascular anastomosis [41].
The risks of foetal demise of one or both foetuses
Preterm delivery
Subsequent development of TTTS
Increased risk for neurodevelopmental impairment, with poorer outcome of the smaller twin
Diagnosis of sIUGR is typically made in the second trimester based on foetal biometric measurements, growth discordance and umbilical artery (UA) Doppler parameters. sIUGR is defined as [42]:
Estimated foetal weight (EFW) <3rd percentile of one foetus [5] or
At least two of the four following criteria:[42]
EFW <10th percentile for one twin
Abdominal circumference < 10th percentile for one twin
Weight discordance ≥25%
UA pulsatility index >95th percentile for the smaller twin
It is recommended that from 20 weeks of gestation (at 2-weekly intervals) onwards at each scan the estimated foetal weight discordance should be calculated using two or more biometric parameters. The percentage EFW discordance should be calculated using the following formula:
([larger twin EFW – smaller twin EFW]/larger twin EFW) × 100. Liquor volumes as DVP should be measured and recorded (to differentiate from TTTS) [2].
As the EFW discordance of greater than 20% is associated with an increase in perinatal risks, these pregnancies should be referred to the specialist centres for further evaluation and management. One parameter that best reflects the differences in intrauterine growth restriction (IUGR) in monochorionic pregnancy with respect to singletons or dichorionic twins is umbilical artery (UA) Doppler flow. The characteristics of UA Doppler flow may be strongly affected by the existence of intertwin vascular connections.
In MC twin pregnancies complicated by sIUGR, UA Doppler waveforms represent the combined effect of placental insufficiency and placental vascular anastomoses.
Three main wave form patterns of diastolic flow in umbilical artery of smaller twin have been recognised. Hence, sIUGR is classified as [43]:
Type 1—It is characterised by persistently forward UA end-diastolic velocity without variation in the waveform with normal or elevated resistance. This type has the best prognosis and the mean gestational age at delivery was after 35 weeks. It has the lowest risk of intrauterine foetal death and survival rates are high. Usually, late-onset sIUGR are type 1 and their prognosis is good as well, although they are at increased risk of TAPS.
Type 2—It is characterised by fixed absent or fixed reversed UA end-diastolic velocity without any alteration of the waveform in the smaller twin. Affected foetuses will have worsening conditions in mid-trimester and the delivery is usually required at an average gestational age of 30 plus weeks.
Although pregnancies with type 2 sIUGR are anticipated to have a predictable pattern of deterioration and a longer latency period between diagnosis and deterioration than type 3 sIUGR, in terms of risk of death of one twin and preterm delivery, their prognosis is worst among all 3 types of sIUGR. Interestingly, there is usually no neurological damage seen in majority of survivors.
Type 3—It is characterised by a pathognomonic UA waveform that has a variable flow pattern that cycles between forward, absent, and reversed flow over a short interval, which is termed intermittent absent/reversed end-diastolic flow. This happens due to a large artery-to-artery anastomosis on the placental surface and signifies the bidirectional volume flow across these vessels. It is more commonly observed in the UA of the smaller foetus since the interface of the two waveforms is shifted toward the smaller twin. An artery-to-artery anastomosis allows perfusion of oxygen and nutrients from the larger foetus to a portion of the smaller twin’s placenta; consequently, type 3 sIUGR is associated with the largest degree of placental territory discordance (Figure 12) [44].
The three types of selective intrauterine growth restriction (courtesy: isug.org).
These pregnancies have unpredictable diagnosis, and foetal death can occur even shortly after a satisfactory ultrasound assessment. There is a high risk of neurologic morbidity as well, particularly of the larger twin. Survival rate has been reported up to 61%.
A detailed ultrasound anatomic survey of both twins to rule out structural anomalies.
Maternal viral serology or ultrasound markers to rule out foetal viral infections.
Evaluation of amniotic fluid of both twins to rule out coexisting TTTS and
Evaluation of middle cerebral artery peak systolic velocity to rule out coexisting TAPS.
sIUGR type 1—Expectant management
Weekly ultrasound surveillance of (umbilical artery [UA], middle cerebral artery [MCA]).
Weekly biophysical profile scoring (BPP) from 28 to 32 weeks.
If the UA pulsatility index increases to >95th percentile or the MCA pulsatility index falls below the 5th percentile, a twice weekly surveillance is recommended with additional monitoring of abnormalities in the ductus venosus (DV) waveform.
If foetal status remains reassuring, as it usually does, it is recommended to deliver delivery at 34 + 0 to 35 + 6 weeks (after steroids) as in pregnancies with sIUGR the risk of unexpected foetal death is higher than uncomplicated monochorionic pregnancies. Earlier delivery is indicated if deemed necessary for any maternal or foetal indications.
sIUGR types 2 and 3—Due to the complexity of the condition the approach to these cases is more complicated. Death of one twin is high in these cases and can result in acute foetal transfusion and volume shifts, which leads to the double foetal demise or neurologic damage in the surviving co-twin in up to 30% of cases.
The recommended approach may include either selective foetal reduction or foetoscopic laser ablation of intertwin placental vascular anastomoses (before the lower limit of viability), especially when there is foetal deterioration (progression from type 2 to type 3 sIUGR, venous Doppler abnormalities or oligohydramnios in the growth-restricted foetus.
Foetoscopic laser ablation can result in high mortality rate of the smaller twin and does not guarantee the survival of the normal twin but may protect the normally grown twin from the consequences of co-twin demise. The procedure may be more technically challenging compared with foetoscopic laser ablation for the treatment of twin-twin transfusion syndrome.
Weekly Doppler surveillance of UA, MCA and DV should commence from the diagnosis.
Perform weekly biophysical profile (BPPs) at 28 weeks.
If Doppler findings remain stable and BPPs are reassuring, they can be followed up as outpatients on a weekly basis.
If Doppler findings worsen increase surveillance with Dopplers/BPP to two to three times weekly and advise hospital admission for daily foetal monitoring with nonstress tests. Delivery should be considered between 32 and 34 week and earlier if indicated. Steroids should be given prior to deliver.
Selective foeticide in monochorionic twins is performed by cord occlusion, intrafoetal laser ablation or radiofrequency ablation. The risk of miscarriage and or preterm birth may be influenced by the timing. A higher risk of these complications occurs when the procedure is performed in second trimester. When the diagnosis is made in the second trimester, a late selective termination in the third trimester can be offered to the woman, as the law permits. The risk of preterm birth in third trimester is less compared to the risk in second trimester. For selective foeticide of one twin of a monochorionic pair injection of intracardiac potassium chloride is not an option (unlike in dichorionic twin) due to the risk involved to the healthy co-twin. Instead, cord occlusion, intrafoetal laser ablation or radiofrequency ablation should be done. This procedure does not cause the healthy twin to lose its circulating blood volume in the terminating twin. The survival rate of the co-twin is approximately 80% in such cases [5].
Premature rupture of the membranes and preterm birth in up to 20% of cases prior to 32 weeks.
Miscarriages in second trimester.
Increased risk of neurological damage in surviving twins.
Single intrauterine foetal demise (sIUFD) is a rare but exceptional perinatal problem in twin pregnancies. Monochorionicity and gestational age at the time of stillbirth seem to be decisive factors in terms of long-term neurologic outcome prediction for the survivor [45]. Monochorionic pregnancies are at particular risk of sIUFD due to bidirectional inter-twin placental vascular anastomoses. The intertwin blood flow becomes unbalanced and can lead to acute and chronic inter-twin transfusion and profound anaemia secondary to foetal exsanguination into the low-pressure circulation of the dead foetus [42]. The co-twin is at increased risk of preterm delivery, long-term neurological complications, and death especially when the condition occurs after 14 weeks of gestation.
The increased risk of neurological damage in the surviving twin could be due is to the bidirectional inter-twin vascular anastomoses that are found in monochorionic placentation. This results in unbalanced inter twin blood flow and leading to acute and chronic inter-twin transfusion and profound anaemia, which are seen in conditions such as TTTS, twin-anaemia-polycythaemia sequence (TAPS) and twin-oligo-polyhydramnios sequence (TOPS) [42]. As a result of these conditions, a multi-organ injury may occur causing significant hypoperfusion of the surviving twin. This may have been initiated by acute foetal exsanguination leading to low-pressure circulation of the dead foetus. The end results are hypoxic-ischaemic injury to the central nervous system of the surviving twin (up to 36%) and subsequent brain injury, or intrauterine death of the surviving twin [42, 46]. The other proposed theory is that “thromboplastic materials” from the dead twin to the surviving twin through the placental anastomosis which in turn causes disseminated intravascular coagulation (DIC) in the surviving twin. This results in renal, pulmonary, hepatic, splenic and neurological infarcts in surviving twin. But there are doubts as to the fact that the DIC can occur so fast; hence, it may be unlikely to be a causative mechanism [47].
The most accurate diagnosis can be made by Magnetic resonance imaging (MRI). Diffusion weighted imaging (DWI) has recently been shown to add to the accuracy of the diagnosis with a timelier diagnosis [45].
Ultrasound detection of brain damage is possible in later stages of foetal brain injury. Also, ultrasound lesions may identify lesions like atrophic and necrotic cystic lesions or ventriculomegaly but not those associated with hypoxic ischemic injuries. This is due to the technical difficulty of the acoustic bone shadowing of skull bones. An early diagnosis and multidisciplinary counselling must be provided to the parents to make an informed choice.
Three types of injuries have been identified:
Ischemic hypoxic lesions of white matter which is irrigated by middle cerebral artery.
This leads to porencephaly, multicystic encephalomalacia, microcephaly and hydranecephaly.
Haemorrhagic lesions isolated or associated with ischemic lesions leading to post haemorrhagic hydrocephalus.
Anomalies secondary to vascular disruption leading to neural tubal defects and optic nerve hypoplasia.
The best time to identify these injuries on MRI is usually considered between 1 and 3 weeks. The use of DWI is unanimously accepted as superior with respect to the precocity of diagnosis. DWI signal changes occurring in cerebral ischemia may be detected early, within the first day of co-twin demise. Its usefulness is restricted to the first week after the death of the co-twin, interval after which pseudo normalisation occurs [45]. Decision to terminate pregnancy should be reserved for foetuses with severe ischemic injury (Figure 13).
MRI changes in the brain of the surviving twin after the death of co twin. Courtesy-(pubs.rsna.org).
A multidisciplinary team with maternal foetal medicine specialist, neonatologist, paediatric neurologist and neurosurgeon should be involved in counselling. Parents should be given accurate information to make a final decision. Should parents opt for continuing the pregnancy the risks of cerebral palsy and iatrogenic preterm delivery should be explained. Foeticide is not legally accepted in all countries. Social, cultural, and religious beliefs also add up in deciding.
Management of such cases will also depend upon any maternal or foetal infections or conditions that could impair the survival of the other twin. DIC could also happen in rare cases because of the release of tissue thromboplastin from dead foetus in maternal circulation activating extrinsic coagulopathy. However, this is not very common (25%). As it occurs usually 3–5 weeks following foetal demise, clotting profiles should be performed in week 1 and repeat in 2–3 weeks [48].
In the short term, the surviving twin should be assessed for evidence of ongoing foetal compromise using CTG or MCA Doppler to assess for foetal anaemia. If conservative management is chosen, foetal biometry and assessment of umbilical and MCA Doppler should be scheduled every 2–4 weeks. Delivery should be considered at 34–36 weeks, after a course of maternal steroids. If the MCA-PSV is normal in the first few days, foetal anaemia is unlikely to occur later [5].
Twin reversed arterial perfusion (TRAP) sequence, also named as acardiac malformation, is an exclusive complication of monochorionic multiple pregnancy. In this condition, one of the twins has no cardiac structure (and so is called ‘acardiac’), while a morphologically normal co-twin (called ‘pump twin’) supplies both circulations. Historically, the first case was described by Benedetti in 1533, and the first cases had been reported in the international literature in the 1950s; the first description of prenatal diagnosis of an acardiac twin was reported by Lehr and Dire in 1978 [49].
Pathogenesis involves two pathways. First is that an unequal blood flow between the twins is noticed. The pump twin predominates due to its high-pressure flow, while the perfused twin receives a reversed deoxygenated blood flow. This leads to compromised morphogenesis. As there is no functioning heart developed the acardiac twin relies on the circulation of pump twin in a parasitic fashion.
The second pathogenesis proposed is that there is an embryogenic defect with a failure in heart formation, due to chromosome abnormality or environmental factors. Hence the single perfusion support for the acardiac foetus is received through anastomoses between the umbilical vessels. The acardiac twin is not viable but keeps getting vascular support from the pumped twin, which supplies deoxygenated blood to the acardiac twin. It has a well-developed body and upper extremities and a big size; hence, it remains a danger during the intrauterine period and is dangerous for the whole pregnancy.
The well-being of the pump twin can also be compromised through at least three mechanisms [49]:
Congestive heart failure (30%) and polyhydramnios of the pump twin (40%0, caused by a risen cardiac work due to the increased blood flow.
Preterm premature rupture of membranes (pPROM), preterm labour and preterm delivery (90%), caused by uterine overdistension, since the acardiac twin is often bigger than pump twin and it can reach a considerable size (acardiac twin to pump twin ratio > 70%).
Hypoxia and intrauterine growth restriction of the pump twin, caused by the deoxygenated blood that comes back to the pump twin through vascular anastomosis.
The perinatal mortality rate of this twin is 55%. The risk of demise of the pump twin in TRAP sequence if managed conservatively is up to 30% by 18 weeks.
The diagnosis is made by ultrasound. Features noticed on ultrasound are:
Gross discrepancies in biometrical measurements of twins, regarding abdominal circumference.
Absence of a morphologically normal heart in one twin associated with several other malformations in head, trunk, upper and lower extremities: presence of subcutaneous oedema and fluid collections in the anomalous twin (Figure 14) [49].
Illustrative and ultrasound images of TRAP (courtesy—google image).
Based on the morphology of the acardiac foetus, 4 different types have been described: acardiac acephalus; acardiac anceps; acardiac acormus; acardiac amorphous. However, they have no prognostic value and no difference in management options.
A classification based on prenatal ultrasound findings as acardius size and signs of impaired cardiac function of the pump twin have been proposed. This classification may help in identifying the most severe cases and those that need prenatal interventions [49].
Acardiac anomalies are divided into:
Type I: small or medium-sized acardiac twins, identified by an abdominal circumference ratio < 50%.
Type II: large acardiac twins, in which the abdominal circumference ratio is ≥50%.
Each type can be further divided into a ‘subtype a and b’, if pump-twin does not show signs of cardiovascular failure, or into a subtype.
The main goals in the management of the TRAP sequence are preserving the survival of the pump twin and reaching the term for delivery. It is observed that the prognosis of the pump twin in Type Ia, acardiac foetus is quite reassuring. This allows a conservative management of pregnancy through periodic ultrasound. This approach is associated with a good outcome in 88% of cases. In the presence of an acardius Type Ib, it is reasonable to repeat ultrasound to identify a spontaneous resolution or a worsening that requires invasive treatment.
The Type IIa acardiac foetus can be large because of subcutaneous oedema or hydrops, and even if now of diagnosis, the pump foetus shows no signs of cardiac failure, the large size could threat the whole pregnancy due to an increased risk of preterm labour. In this case, a prenatal treatment is required. The detection of a Type IIb acardius requires a prompt intervention [49].
The best timing of intervention is not clear. It should be performed preferably before 16 weeks [5]. A pump-twin loss rate of 33% in the time elapsed from the first-trimester diagnosis and the elective intervention at 16–18 weeks, highlights an important disadvantage of delayed intervention. A multicentre, open-label, randomised controlled trial currently ongoing (ClinicalTrails.gov: NCT02621645), named the TRAP Intervention Study (TRAPIST), comparing treatment at 13–15 weeks vs. treatment from 16 weeks, is expected to define the optimal timing of treatment.
Different minimally invasive techniques, such as cord coagulation, cord ligation and photocoagulation of the anastomoses, as well as intrafoetal methods, such as Radiofrequency Ablation and intrafoetal laser therapy, are performed as a means of preventing the demise of the pump twin. The survival rate of the pump twin using these treatment modalities is approximately 80%. TRAP sequence pregnancies should be monitored serially. The aim is to take intrauterine therapy as an option if cardiac strain becomes evident in the pump twin or there is increased perfusion (including the occurrence of polyhydramnios) and growth of the TRAP mass. Hence, these cases should be managed in a tertiary level centre [5].
Parents should be informed that usually a planned birth is recommended at 36 completed weeks and this does not increase the risk of any neonatal morbidity [10]. It is well documented that continuing pregnancy beyond 36 weeks is associated with increased risk of still births in monochorionic pregnancies. With an uncomplicated monochorionic twin pregnancy, vaginal birth and planned caesarean section are both safe choices for them, and vaginal delivery can be offered if the following criteria are met [10]:
The pregnancy was uncomplicated throughout and has progressed beyond 32 weeks.
There are no obstetric contraindications to labour.
The first baby is in a cephalic (head-first) presentation.
There is no significant size discordance between the twins.
If the first twin is not cephalic at the time of birth, a caesarean section should be offered. Corticosteroids should be offered prior to the planned delivery at 36 weeks.
During labour continuous, cardiotocography (CTG) should be commenced. A dual channel cardiotocography monitor should be used to allow simultaneous monitoring of both foetal hearts. As labour progresses, a foetal scalp electrode can be used for the first twin if no contraindications. If there is foetal dress and foetal blood sampling cannot be done, caesarean section should be performed after the birth of the first baby.
Once the first twin is delivered, continue to monitor the second baby using CTG. If the CTG shows a ‘suspicious’ or ‘pathological’ pattern, and vaginal birth is not possible within 20 minute a caesarean section should be offered. Epidural should be offered for vaginal birth and regional anaesthesia for caesarean section.
Third stage should be managed actively with controlled cord traction and oxytocin (Active management). In a vaginal birth, active management consists of 10 IU of oxytocin by intramuscular injection immediately after the birth of the last baby and before the cord is clamped and cut. In a caesarean section, it consists of 5 IU of oxytocin by intravenous injection immediately after the birth of the last baby and before the cord is clamped and cut [10].
MCDA twins are associated with several well-known complications. Updated guidelines and basic standards should be adhered to for a better outcome of these complications. Challenging cases may need individual care, but basic principles of early screening, diagnosis, accurate follow-up, and timely intervention should be the best approach. Poor or suboptimal care may directly be related to lack of observance to updated guidelines and non-accessibility of advances in management. The advanced role of ultrasound and relatively newer technologies such as laser photocoagulation for the treatment of severe TTTS, radiofrequency ablation and cord occlusion for selective reduction have significantly enhanced the outcomes for many of the complications of MCDA twins. Screening for these conditions is of paramount significance for the early diagnosis with timely intervention to improve neonatal morbidity and mortality. A first-trimester ultrasound to evaluate the interface of the intertwin membrane with the placenta, timely detection of chorionicity and antenatal surveillance of these pregnancies is the key to improved outcomes in MCDA twins. Future researches are required to further improve the overall survival rate and reduce the incidence of neurological impairment associated with intervention procedures.
These Terms and Conditions outline the rules and regulations pertaining to the use of IntechOpen’s website www.intechopen.com and all the subdomains owned by IntechOpen located at 5 Princes Gate Court, London, SW7 2QJ, United Kingdom.
',metaTitle:"Terms and Conditions",metaDescription:"These terms and conditions outline the rules and regulations for the use of IntechOpen Website at https://intechopen.com and all its subdomains owned by Intech Limited located at 7th floor, 10 Lower Thames Street, London, EC3R 6AF, UK.",metaKeywords:null,canonicalURL:"/page/terms-and-conditions",contentRaw:'[{"type":"htmlEditorComponent","content":"By accessing the website at www.intechopen.com you are agreeing to be bound by these Terms of Service, all applicable laws and regulations, and agree that you are responsible for compliance with any applicable local laws. Use and/or access to this site is based on full agreement and compliance of these Terms. All materials contained on this website are protected by applicable copyright and trademark laws.
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\n\nThe following terminology applies to these Terms and Conditions, Privacy Statement, Disclaimer Notice, and any or all Agreements:
\n\n“Client”, “Customer”, “You” and “Your” refers to you, the person accessing this website and accepting the Company’s Terms and Conditions;
\n\n“The Company”, “Ourselves”, “We”, “Our” and “Us”, refers to our Company, IntechOpen;
\n\n“Party”, “Parties”, or “Us”, refers to both the Client and ourselves, or either the Client or ourselves.
\n\nAll Terms refer to the offer, acceptance, and consideration of payment necessary to provide assistance to the Client in the most appropriate manner, whether by formal meetings of a fixed duration, or by any other agreed means, for the express purpose of meeting the Client’s needs in respect of provision of the Company’s stated services/products, and in accordance with, and subject to, the prevailing laws of the United Kingdom.
\n\nAny use of the above terminology, or other words in the singular, plural, capitalization and/or he/she or they, are taken as interchangeable.
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\n'}]},successStories:{items:[]},authorsAndEditors:{filterParams:{},profiles:[{id:"396",title:"Dr.",name:"Vedran",middleName:null,surname:"Kordic",slug:"vedran-kordic",fullName:"Vedran Kordic",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/396/images/7281_n.png",biography:"After obtaining his Master's degree in Mechanical Engineering he continued his education at the Vienna University of Technology where he obtained his PhD degree in 2004. He worked as a researcher at the Automation and Control Institute, Faculty of Electrical Engineering, Vienna University of Technology until 2008. His studies in robotics lead him not only to a PhD degree but also inspired him to co-found and build the International Journal of Advanced Robotic Systems - world's first Open Access journal in the field of robotics.",institutionString:null,institution:{name:"TU Wien",country:{name:"Austria"}}},{id:"441",title:"Ph.D.",name:"Jaekyu",middleName:null,surname:"Park",slug:"jaekyu-park",fullName:"Jaekyu Park",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/441/images/1881_n.jpg",biography:null,institutionString:null,institution:{name:"LG Corporation (South Korea)",country:{name:"Korea, South"}}},{id:"465",title:"Dr.",name:"Christian",middleName:null,surname:"Martens",slug:"christian-martens",fullName:"Christian Martens",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Rheinmetall (Germany)",country:{name:"Germany"}}},{id:"479",title:"Dr.",name:"Valentina",middleName:null,surname:"Colla",slug:"valentina-colla",fullName:"Valentina Colla",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/479/images/358_n.jpg",biography:null,institutionString:null,institution:{name:"Sant'Anna School of Advanced Studies",country:{name:"Italy"}}},{id:"494",title:"PhD",name:"Loris",middleName:null,surname:"Nanni",slug:"loris-nanni",fullName:"Loris Nanni",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/494/images/system/494.jpg",biography:"Loris Nanni received his Master Degree cum laude on June-2002 from the University of Bologna, and the April 26th 2006 he received his Ph.D. in Computer Engineering at DEIS, University of Bologna. On September, 29th 2006 he has won a post PhD fellowship from the university of Bologna (from October 2006 to October 2008), at the competitive examination he was ranked first in the industrial engineering area. He extensively served as referee for several international journals. He is author/coauthor of more than 100 research papers. He has been involved in some projects supported by MURST and European Community. His research interests include pattern recognition, bioinformatics, and biometric systems (fingerprint classification and recognition, signature verification, face recognition).",institutionString:null,institution:null},{id:"496",title:"Dr.",name:"Carlos",middleName:null,surname:"Leon",slug:"carlos-leon",fullName:"Carlos Leon",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Seville",country:{name:"Spain"}}},{id:"512",title:"Dr.",name:"Dayang",middleName:null,surname:"Jawawi",slug:"dayang-jawawi",fullName:"Dayang Jawawi",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Technology Malaysia",country:{name:"Malaysia"}}},{id:"528",title:"Dr.",name:"Kresimir",middleName:null,surname:"Delac",slug:"kresimir-delac",fullName:"Kresimir Delac",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/528/images/system/528.jpg",biography:"K. Delac received his B.Sc.E.E. degree in 2003 and is currentlypursuing a Ph.D. degree at the University of Zagreb, Faculty of Electrical Engineering andComputing. His current research interests are digital image analysis, pattern recognition andbiometrics.",institutionString:null,institution:{name:"University of Zagreb",country:{name:"Croatia"}}},{id:"557",title:"Dr.",name:"Andon",middleName:"Venelinov",surname:"Topalov",slug:"andon-topalov",fullName:"Andon Topalov",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/557/images/1927_n.jpg",biography:"Dr. Andon V. Topalov received the MSc degree in Control Engineering from the Faculty of Information Systems, Technologies, and Automation at Moscow State University of Civil Engineering (MGGU) in 1979. He then received his PhD degree in Control Engineering from the Department of Automation and Remote Control at Moscow State Mining University (MGSU), Moscow, in 1984. From 1985 to 1986, he was a Research Fellow in the Research Institute for Electronic Equipment, ZZU AD, Plovdiv, Bulgaria. In 1986, he joined the Department of Control Systems, Technical University of Sofia at the Plovdiv campus, where he is presently a Full Professor. He has held long-term visiting Professor/Scholar positions at various institutions in South Korea, Turkey, Mexico, Greece, Belgium, UK, and Germany. And he has coauthored one book and authored or coauthored more than 80 research papers in conference proceedings and journals. 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He is the author of several scientific articles, book chapters, and books.",institutionString:"University of Hassan II Casablanca",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"7",totalChapterViews:"0",totalEditedBooks:"2",institution:{name:"University of Hassan II Casablanca",institutionURL:null,country:{name:"Morocco"}}},equalEditorTwo:null,equalEditorThree:null},{type:"book",id:"7060",title:"Gingival Disease",subtitle:"A Professional Approach for Treatment and Prevention",coverURL:"https://cdn.intechopen.com/books/images_new/7060.jpg",slug:"gingival-disease-a-professional-approach-for-treatment-and-prevention",publishedDate:"October 23rd 2019",editedByType:"Edited by",bookSignature:"Alaa Eddin Omar Al Ostwani",hash:"b81d39988cba3a3cf746c1616912cf41",volumeInSeries:4,fullTitle:"Gingival Disease - A Professional Approach for Treatment and Prevention",editors:[{id:"240870",title:"Ph.D.",name:"Alaa Eddin Omar",middleName:null,surname:"Al Ostwani",slug:"alaa-eddin-omar-al-ostwani",fullName:"Alaa Eddin Omar Al Ostwani",profilePictureURL:"https://mts.intechopen.com/storage/users/240870/images/system/240870.jpeg",institutionString:"International University for Science and Technology.",institution:{name:"Islamic University of Science and Technology",institutionURL:null,country:{name:"India"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null},{type:"book",id:"7572",title:"Trauma in Dentistry",subtitle:null,coverURL:"https://cdn.intechopen.com/books/images_new/7572.jpg",slug:"trauma-in-dentistry",publishedDate:"July 3rd 2019",editedByType:"Edited by",bookSignature:"Serdar Gözler",hash:"7cb94732cfb315f8d1e70ebf500eb8a9",volumeInSeries:3,fullTitle:"Trauma in Dentistry",editors:[{id:"204606",title:"Dr.",name:"Serdar",middleName:null,surname:"Gözler",slug:"serdar-gozler",fullName:"Serdar Gözler",profilePictureURL:"https://mts.intechopen.com/storage/users/204606/images/system/204606.jpeg",institutionString:"Istanbul Aydin University",institution:{name:"Istanbul Aydın University",institutionURL:null,country:{name:"Turkey"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null},{type:"book",id:"7139",title:"Current Approaches in Orthodontics",subtitle:null,coverURL:"https://cdn.intechopen.com/books/images_new/7139.jpg",slug:"current-approaches-in-orthodontics",publishedDate:"April 10th 2019",editedByType:"Edited by",bookSignature:"Belma Işık Aslan and Fatma Deniz Uzuner",hash:"2c77384eeb748cf05a898d65b9dcb48a",volumeInSeries:2,fullTitle:"Current Approaches in Orthodontics",editors:[{id:"42847",title:"Dr.",name:"Belma",middleName:null,surname:"Işik Aslan",slug:"belma-isik-aslan",fullName:"Belma Işik Aslan",profilePictureURL:"https://mts.intechopen.com/storage/users/42847/images/system/42847.jpg",institutionString:"Gazi University Dentistry Faculty Department of Orthodontics",institution:null}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null},{type:"book",id:"6668",title:"Dental Caries",subtitle:"Diagnosis, Prevention and Management",coverURL:"https://cdn.intechopen.com/books/images_new/6668.jpg",slug:"dental-caries-diagnosis-prevention-and-management",publishedDate:"September 19th 2018",editedByType:"Edited by",bookSignature:"Zühre Akarslan",hash:"b0f7667770a391f772726c3013c1b9ba",volumeInSeries:1,fullTitle:"Dental Caries - Diagnosis, Prevention and Management",editors:[{id:"171887",title:"Prof.",name:"Zühre",middleName:null,surname:"Akarslan",slug:"zuhre-akarslan",fullName:"Zühre Akarslan",profilePictureURL:"https://mts.intechopen.com/storage/users/171887/images/system/171887.jpg",institutionString:"Gazi University",institution:{name:"Gazi University",institutionURL:null,country:{name:"Turkey"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null}]},subseriesFiltersForPublishedBooks:[{group:"subseries",caption:"Prosthodontics and Implant Dentistry",value:2,count:3},{group:"subseries",caption:"Oral Health",value:1,count:6}],publicationYearFilters:[{group:"publicationYear",caption:"2022",value:2022,count:3},{group:"publicationYear",caption:"2020",value:2020,count:2},{group:"publicationYear",caption:"2019",value:2019,count:3},{group:"publicationYear",caption:"2018",value:2018,count:1}],authors:{paginationCount:229,paginationItems:[{id:"318170",title:"Dr.",name:"Aneesa",middleName:null,surname:"Moolla",slug:"aneesa-moolla",fullName:"Aneesa Moolla",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/318170/images/system/318170.png",biography:"Dr. Aneesa Moolla has extensive experience in the diverse fields of health care having previously worked in dental private practice, at the Red Cross Flying Doctors association, and in healthcare corporate settings. She is now a lecturer at the University of Witwatersrand, South Africa, and a principal researcher at the Health Economics and Epidemiology Research Office (HE2RO), South Africa. Dr. Moolla holds a Ph.D. in Psychology with her research being focused on mental health and resilience. In her professional work capacity, her research has further expanded into the fields of early childhood development, mental health, the HIV and TB care cascades, as well as COVID. She is also a UNESCO-trained International Bioethics Facilitator.",institutionString:"University of the Witwatersrand",institution:{name:"University of the Witwatersrand",country:{name:"South Africa"}}},{id:"419588",title:"Ph.D.",name:"Sergio",middleName:"Alexandre",surname:"Gehrke",slug:"sergio-gehrke",fullName:"Sergio Gehrke",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000038WgMKQA0/Profile_Picture_2022-06-02T11:44:20.jpg",biography:"Dr. Sergio Alexandre Gehrke is a doctorate holder in two fields. The first is a Ph.D. in Cellular and Molecular Biology from the Pontificia Catholic University, Porto Alegre, Brazil, in 2010 and the other is an International Ph.D. in Bioengineering from the Universidad Miguel Hernandez, Elche/Alicante, Spain, obtained in 2020. In 2018, he completed a postdoctoral fellowship in Materials Engineering in the NUCLEMAT of the Pontificia Catholic University, Porto Alegre, Brazil. He is currently the Director of the Postgraduate Program in Implantology of the Bioface/UCAM/PgO (Montevideo, Uruguay), Director of the Cathedra of Biotechnology of the Catholic University of Murcia (Murcia, Spain), an Extraordinary Full Professor of the Catholic University of Murcia (Murcia, Spain) as well as the Director of the private center of research Biotecnos – Technology and Science (Montevideo, Uruguay). Applied biomaterials, cellular and molecular biology, and dental implants are among his research interests. He has published several original papers in renowned journals. In addition, he is also a Collaborating Professor in several Postgraduate programs at different universities all over the world.",institutionString:null,institution:{name:"Universidad Católica San Antonio de Murcia",country:{name:"Spain"}}},{id:"342152",title:"Dr.",name:"Santo",middleName:null,surname:"Grace Umesh",slug:"santo-grace-umesh",fullName:"Santo Grace Umesh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/342152/images/16311_n.jpg",biography:null,institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"333647",title:"Dr.",name:"Shreya",middleName:null,surname:"Kishore",slug:"shreya-kishore",fullName:"Shreya Kishore",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/333647/images/14701_n.jpg",biography:"Dr. Shreya Kishore completed her Bachelor in Dental Surgery in Chettinad Dental College and Research Institute, Chennai, and her Master of Dental Surgery (Orthodontics) in Saveetha Dental College, Chennai. She is also Invisalign certified. She’s working as a Senior Lecturer in the Department of Orthodontics, SRM Dental College since November 2019. She is actively involved in teaching orthodontics to the undergraduates and the postgraduates. Her clinical research topics include new orthodontic brackets, fixed appliances and TADs. She’s published 4 articles in well renowned indexed journals and has a published patency of her own. Her private practice is currently limited to orthodontics and works as a consultant in various clinics.",institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"323731",title:"Prof.",name:"Deepak M.",middleName:"Macchindra",surname:"Vikhe",slug:"deepak-m.-vikhe",fullName:"Deepak M. Vikhe",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/323731/images/13613_n.jpg",biography:"Dr Deepak M.Vikhe .\n\n\t\n\tDr Deepak M.Vikhe , completed his Masters & PhD in Prosthodontics from Rural Dental College, Loni securing third rank in the Pravara Institute of Medical Sciences Deemed University. He was awarded Dr.G.C.DAS Memorial Award for Research on Implants at 39th IPS conference Dubai (U A E).He has two patents under his name. He has received Dr.Saraswati medal award for best research for implant study in 2017.He has received Fully funded scholarship to Spain ,university of Santiago de Compostela. He has completed fellowship in Implantlogy from Noble Biocare. \nHe has attended various conferences and CDE programmes and has national publications to his credit. His field of interest is in Implant supported prosthesis. Presently he is working as a associate professor in the Dept of Prosthodontics, Rural Dental College, Loni and maintains a successful private practice specialising in Implantology at Rahata.\n\nEmail: drdeepak_mvikhe@yahoo.com..................",institutionString:null,institution:{name:"Pravara Institute of Medical Sciences",country:{name:"India"}}},{id:"204110",title:"Dr.",name:"Ahmed A.",middleName:null,surname:"Madfa",slug:"ahmed-a.-madfa",fullName:"Ahmed A. Madfa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/204110/images/system/204110.jpg",biography:"Dr. Madfa is currently Associate Professor of Endodontics at Thamar University and a visiting lecturer at Sana'a University and University of Sciences and Technology. He has more than 6 years of experience in teaching. His research interests include root canal morphology, functionally graded concept, dental biomaterials, epidemiology and dental education, biomimetic restoration, finite element analysis and endodontic regeneration. Dr. Madfa has numerous international publications, full articles, two patents, a book and a book chapter. Furthermore, he won 14 international scientific awards. Furthermore, he is involved in many academic activities ranging from editorial board member, reviewer for many international journals and postgraduate students' supervisor. Besides, I deliver many courses and training workshops at various scientific events. Dr. Madfa also regularly attends international conferences and holds administrative positions (Deputy Dean of the Faculty for Students’ & Academic Affairs and Deputy Head of Research Unit).",institutionString:"Thamar University",institution:null},{id:"210472",title:"Dr.",name:"Nermin",middleName:"Mohammed Ahmed",surname:"Yussif",slug:"nermin-yussif",fullName:"Nermin Yussif",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/210472/images/system/210472.jpg",biography:"Dr. Nermin Mohammed Ahmed Yussif is working at the Faculty of dentistry, University for October university for modern sciences and arts (MSA). Her areas of expertise include: periodontology, dental laserology, oral implantology, periodontal plastic surgeries, oral mesotherapy, nutrition, dental pharmacology. She is an editor and reviewer in numerous international journals.",institutionString:"MSA University",institution:null},{id:"204606",title:"Dr.",name:"Serdar",middleName:null,surname:"Gözler",slug:"serdar-gozler",fullName:"Serdar Gözler",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/204606/images/system/204606.jpeg",biography:"Dr. Serdar Gözler has completed his undergraduate studies at the Marmara University Faculty of Dentistry in 1978, followed by an assistantship in the Prosthesis Department of Dicle University Faculty of Dentistry. Starting his PhD work on non-resilient overdentures with Assoc. Prof. Hüsnü Yavuzyılmaz, he continued his studies with Prof. Dr. Gürbüz Öztürk of Istanbul University Faculty of Dentistry Department of Prosthodontics, this time on Gnatology. He attended training programs on occlusion, neurology, neurophysiology, EMG, radiology and biostatistics. In 1982, he presented his PhD thesis \\Gerber and Lauritzen Occlusion Analysis Techniques: Diagnosis Values,\\ at Istanbul University School of Dentistry, Department of Prosthodontics. As he was also working with Prof. Senih Çalıkkocaoğlu on The Physiology of Chewing at the same time, Gözler has written a chapter in Çalıkkocaoğlu\\'s book \\Complete Prostheses\\ entitled \\The Place of Neuromuscular Mechanism in Prosthetic Dentistry.\\ The book was published five times since by the Istanbul University Publications. Having presented in various conferences about occlusion analysis until 1998, Dr. Gözler has also decided to use the T-Scan II occlusion analysis method. Having been personally trained by Dr. Robert Kerstein on this method, Dr. Gözler has been lecturing on the T-Scan Occlusion Analysis Method in conferences both in Turkey and abroad. Dr. Gözler has various articles and presentations on Digital Occlusion Analysis methods. He is now Head of the TMD Clinic at Prosthodontic Department of Faculty of Dentistry , Istanbul Aydın University , Turkey.",institutionString:"Istanbul Aydin University",institution:{name:"Istanbul Aydın University",country:{name:"Turkey"}}},{id:"256417",title:"Associate Prof.",name:"Sanaz",middleName:null,surname:"Sadry",slug:"sanaz-sadry",fullName:"Sanaz Sadry",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/256417/images/8106_n.jpg",biography:null,institutionString:null,institution:{name:"Istanbul Aydın University",country:{name:"Turkey"}}},{id:"240870",title:"Ph.D.",name:"Alaa Eddin Omar",middleName:null,surname:"Al Ostwani",slug:"alaa-eddin-omar-al-ostwani",fullName:"Alaa Eddin Omar Al Ostwani",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/240870/images/system/240870.jpeg",biography:"Dr. Al Ostwani Alaa Eddin Omar received his Master in dentistry from Damascus University in 2010, and his Ph.D. in Pediatric Dentistry from Damascus University in 2014. Dr. Al Ostwani is an assistant professor and faculty member at IUST University since 2014. \nDuring his academic experience, he has received several awards including the scientific research award from the Union of Arab Universities, the Syrian gold medal and the international gold medal for invention and creativity. Dr. Al Ostwani is a Member of the International Association of Dental Traumatology and the Syrian Society for Research and Preventive Dentistry since 2017. He is also a Member of the Reviewer Board of International Journal of Dental Medicine (IJDM), and the Indian Journal of Conservative and Endodontics since 2016.",institutionString:"International University for Science and Technology.",institution:{name:"Islamic University of Science and Technology",country:{name:"India"}}},{id:"42847",title:"Dr.",name:"Belma",middleName:null,surname:"Işik Aslan",slug:"belma-isik-aslan",fullName:"Belma Işik Aslan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/42847/images/system/42847.jpg",biography:"Dr. Belma IşIk Aslan was born in 1976 in Ankara-TURKEY. After graduating from TED Ankara College in 1994, she attended to Gazi University, Faculty of Dentistry in Ankara. She completed her PhD in orthodontic education at Gazi University between 1999-2005. Dr. Işık Aslan stayed at the Providence Hospital Craniofacial Institude and Reconstructive Surgery in Michigan, USA for three months as an observer. She worked as a specialist doctor at Gazi University, Dentistry Faculty, Department of Orthodontics between 2005-2014. She was appointed as associate professor in January, 2014 and as professor in 2021. Dr. Işık Aslan still works as an instructor at the same faculty. She has published a total of 35 articles, 10 book chapters, 39 conference proceedings both internationally and nationally. Also she was the academic editor of the international book 'Current Advances in Orthodontics'. She is a member of the Turkish Orthodontic Society and Turkish Cleft Lip and Palate Society. She is married and has 2 children. Her knowledge of English is at an advanced level.",institutionString:"Gazi University Dentistry Faculty Department of Orthodontics",institution:null},{id:"202198",title:"Dr.",name:"Buket",middleName:null,surname:"Aybar",slug:"buket-aybar",fullName:"Buket Aybar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/202198/images/6955_n.jpg",biography:"Buket Aybar, DDS, PhD, was born in 1971. She graduated from Istanbul University, Faculty of Dentistry, in 1992 and completed her PhD degree on Oral and Maxillofacial Surgery in Istanbul University in 1997.\r\nDr. Aybar is currently a full-time professor in Istanbul University, Faculty of Dentistry Department of Oral and Maxillofacial Surgery. She has teaching responsibilities in graduate and postgraduate programs. Her clinical practice includes mainly dentoalveolar surgery.\r\nHer topics of interest are biomaterials science and cell culture studies. She has many articles in international and national scientific journals and chapters in books; she also has participated in several scientific projects supported by Istanbul University Research fund.",institutionString:null,institution:{name:"Marmara University",country:{name:"Turkey"}}},{id:"178412",title:"Associate Prof.",name:"Guhan",middleName:null,surname:"Dergin",slug:"guhan-dergin",fullName:"Guhan Dergin",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178412/images/6954_n.jpg",biography:"Assoc. Prof. Dr. Gühan Dergin was born in 1973 in Izmit. He graduated from Marmara University Faculty of Dentistry in 1999. He completed his specialty of OMFS surgery in Marmara University Faculty of Dentistry and obtained his PhD degree in 2006. In 2005, he was invited as a visiting doctor in the Oral and Maxillofacial Surgery Department of the University of North Carolina, USA, where he went on a scholarship. Dr. Dergin still continues his academic career as an associate professor in Marmara University Faculty of Dentistry. He has many articles in international and national scientific journals and chapters in books.",institutionString:null,institution:{name:"Marmara University",country:{name:"Turkey"}}},{id:"178414",title:"Prof.",name:"Yusuf",middleName:null,surname:"Emes",slug:"yusuf-emes",fullName:"Yusuf Emes",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178414/images/6953_n.jpg",biography:"Born in Istanbul in 1974, Dr. Emes graduated from Istanbul University Faculty of Dentistry in 1997 and completed his PhD degree in Istanbul University faculty of Dentistry Department of Oral and Maxillofacial Surgery in 2005. He has papers published in international and national scientific journals, including research articles on implantology, oroantral fistulas, odontogenic cysts, and temporomandibular disorders. Dr. Emes is currently working as a full-time academic staff in Istanbul University faculty of Dentistry Department of Oral and Maxillofacial Surgery.",institutionString:null,institution:{name:"Istanbul University",country:{name:"Turkey"}}},{id:"192229",title:"Ph.D.",name:"Ana Luiza",middleName:null,surname:"De Carvalho Felippini",slug:"ana-luiza-de-carvalho-felippini",fullName:"Ana Luiza De Carvalho Felippini",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/192229/images/system/192229.jpg",biography:null,institutionString:"University of São Paulo",institution:{name:"University of Sao Paulo",country:{name:"Brazil"}}},{id:"256851",title:"Prof.",name:"Ayşe",middleName:null,surname:"Gülşen",slug:"ayse-gulsen",fullName:"Ayşe Gülşen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/256851/images/9696_n.jpg",biography:"Dr. Ayşe Gülşen graduated in 1990 from Faculty of Dentistry, University of Ankara and did a postgraduate program at University of Gazi. \nShe worked as an observer and research assistant in Craniofacial Surgery Departments in New York, Providence Hospital in Michigan and Chang Gung Memorial Hospital in Taiwan. \nShe works as Craniofacial Orthodontist in Department of Aesthetic, Plastic and Reconstructive Surgery, Faculty of Medicine, University of Gazi, Ankara Turkey since 2004.",institutionString:"Orthodontist, Assoc Prof in the Department of Aesthetic, Plastic and Reconstructive Surgery, Faculty of Medicine, University of Gazi",institution:null},{id:"255366",title:"Prof.",name:"Tosun",middleName:null,surname:"Tosun",slug:"tosun-tosun",fullName:"Tosun Tosun",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/255366/images/7347_n.jpg",biography:"Graduated at the Faculty of Dentistry, University of Istanbul, Turkey in 1989;\nVisitor Assistant at the University of Padua, Italy and Branemark Osseointegration Center of Treviso, Italy between 1993-94;\nPhD thesis on oral implantology in University of Istanbul and was awarded the academic title “Dr.med.dent.”, 1997;\nHe was awarded the academic title “Doç.Dr.” (Associated Professor) in 2003;\nProficiency in Botulinum Toxin Applications, Reading-UK in 2009;\nMastership, RWTH Certificate in Laser Therapy in Dentistry, AALZ-Aachen University, Germany 2009-11;\nMaster of Science (MSc) in Laser Dentistry, University of Genoa, Italy 2013-14.\n\nDr.Tosun worked as Research Assistant in the Department of Oral Implantology, Faculty of Dentistry, University of Istanbul between 1990-2002. \nHe worked part-time as Consultant surgeon in Harvard Medical International Hospitals and John Hopkins Medicine, Istanbul between years 2007-09.\u2028He was contract Professor in the Department of Surgical and Diagnostic Sciences (DI.S.C.), Medical School, University of Genova, Italy between years 2011-16. \nSince 2015 he is visiting Professor at Medical School, University of Plovdiv, Bulgaria. \nCurrently he is Associated Prof.Dr. at the Dental School, Oral Surgery Dept., Istanbul Aydin University and since 2003 he works in his own private clinic in Istanbul, Turkey.\u2028\nDr.Tosun is reviewer in journal ‘Laser in Medical Sciences’, reviewer in journal ‘Folia Medica\\', a Fellow of the International Team for Implantology, Clinical Lecturer of DGZI German Association of Oral Implantology, Expert Lecturer of Laser&Health Academy, Country Representative of World Federation for Laser Dentistry, member of European Federation of Periodontology, member of Academy of Laser Dentistry. Dr.Tosun presents papers in international and national congresses and has scientific publications in international and national journals. He speaks english, spanish, italian and french.",institutionString:null,institution:{name:"Istanbul Aydın University",country:{name:"Turkey"}}},{id:"260116",title:"Dr.",name:"Mehmet",middleName:null,surname:"Yaltirik",slug:"mehmet-yaltirik",fullName:"Mehmet Yaltirik",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/260116/images/7413_n.jpg",biography:"Birth Date 25.09.1965\r\nBirth Place Adana- Turkey\r\nSex Male\r\nMarrial Status Bachelor\r\nDriving License Acquired\r\nMother Tongue Turkish\r\n\r\nAddress:\r\nWork:University of Istanbul,Faculty of Dentistry, Department of Oral Surgery and Oral Medicine 34093 Capa,Istanbul- TURKIYE",institutionString:null,institution:{name:"Istanbul University",country:{name:"Turkey"}}},{id:"171887",title:"Prof.",name:"Zühre",middleName:null,surname:"Akarslan",slug:"zuhre-akarslan",fullName:"Zühre Akarslan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/171887/images/system/171887.jpg",biography:"Zühre Akarslan was born in 1977 in Cyprus. She graduated from Gazi University Faculty of Dentistry, Ankara, Turkey in 2000. \r\nLater she received her Ph.D. degree from the Oral Diagnosis and Radiology Department; which was recently renamed as Oral and Dentomaxillofacial Radiology, from the same university. \r\nShe is working as a full-time Associate Professor and is a lecturer and an academic researcher. \r\nHer expertise areas are dental caries, cancer, dental fear and anxiety, gag reflex in dentistry, oral medicine, and dentomaxillofacial radiology.",institutionString:"Gazi University",institution:{name:"Gazi University",country:{name:"Turkey"}}},{id:"272237",title:"Dr.",name:"Pinar",middleName:"Kiymet",surname:"Karataban",slug:"pinar-karataban",fullName:"Pinar Karataban",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/272237/images/8911_n.png",biography:"Assist.Prof.Dr.Pınar Kıymet Karataban, DDS PhD \n\nDr.Pınar Kıymet Karataban was born in Istanbul in 1975. After her graduation from Marmara University Faculty of Dentistry in 1998 she started her PhD in Paediatric Dentistry focused on children with special needs; mainly children with Cerebral Palsy. She finished her pHD thesis entitled \\'Investigation of occlusion via cast analysis and evaluation of dental caries prevalance, periodontal status and muscle dysfunctions in children with cerebral palsy” in 2008. She got her Assist. Proffessor degree in Istanbul Aydın University Paediatric Dentistry Department in 2015-2018. ın 2019 she started her new career in Bahcesehir University, Istanbul as Head of Department of Pediatric Dentistry. In 2020 she was accepted to BAU International University, Batumi as Professor of Pediatric Dentistry. She’s a lecturer in the same university meanwhile working part-time in private practice in Ege Dental Studio (https://www.egedisklinigi.com/) a multidisciplinary dental clinic in Istanbul. Her main interests are paleodontology, ancient and contemporary dentistry, oral microbiology, cerebral palsy and special care dentistry. She has national and international publications, scientific reports and is a member of IAPO (International Association for Paleodontology), IADH (International Association of Disability and Oral Health) and EAPD (European Association of Pediatric Dentistry).",institutionString:null,institution:null},{id:"172009",title:"Dr.",name:"Fatma Deniz",middleName:null,surname:"Uzuner",slug:"fatma-deniz-uzuner",fullName:"Fatma Deniz Uzuner",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/172009/images/7122_n.jpg",biography:"Dr. Deniz Uzuner was born in 1969 in Kocaeli-TURKEY. After graduating from TED Ankara College in 1986, she attended the Hacettepe University, Faculty of Dentistry in Ankara. \nIn 1993 she attended the Gazi University, Faculty of Dentistry, Department of Orthodontics for her PhD education. After finishing the PhD education, she worked as orthodontist in Ankara Dental Hospital under the Turkish Government, Ministry of Health and in a special Orthodontic Clinic till 2011. Between 2011 and 2016, Dr. Deniz Uzuner worked as a specialist in the Department of Orthodontics, Faculty of Dentistry, Gazi University in Ankara/Turkey. In 2016, she was appointed associate professor. Dr. Deniz Uzuner has authored 23 Journal Papers, 3 Book Chapters and has had 39 oral/poster presentations. She is a member of the Turkish Orthodontic Society. 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Thus proteomics, an area of research that detects all protein forms expressed in an organism, including splice isoforms and post-translational modifications, is more suitable than genomics for a comprehensive understanding of the biochemical processes that govern life. The most common proteomics applications are currently in the clinical field for the identification, in a variety of biological matrices, of biomarkers for diagnosis and therapeutic intervention of disorders. From the comparison of proteomic profiles of control and disease or different physiological states, which may emerge, changes in protein expression can provide new insights into the roles played by some proteins in human pathologies. Understanding how proteins function and interact with each other is another goal of proteomics that makes this approach even more intriguing. Specialized technology and expertise are required to assess the proteome of any biological sample. 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Since then, he has been working as an Adjunct Professor in the same Department at the University of Pavia. His research activity during the first years was primarily focused on the purification and structural characterization of enzymes from animal and plant sources. During this period, Prof. Iadarola familiarized himself with the conventional techniques used in column chromatography, spectrophotometry, manual Edman degradation, and electrophoresis). Since 1995, he has been working on: i) the determination in biological fluids (serum, urine, bronchoalveolar lavage, sputum) of proteolytic activities involved in the degradation processes of connective tissue matrix, and ii) on the identification of biological markers of lung diseases. In this context, he has developed and validated new methodologies (e.g., Capillary Electrophoresis coupled to Laser-Induced Fluorescence, CE-LIF) whose application enabled him to determine both the amounts of biochemical markers (Desmosines) in urine/serum of patients affected by Chronic Obstructive Pulmonary Disease (COPD) and the activity of proteolytic enzymes (Human Neutrophil Elastase, Cathepsin G, Pseudomonas aeruginosa elastase) in sputa of these patients. More recently, Prof. Iadarola was involved in developing techniques such as two-dimensional electrophoresis coupled to liquid chromatography/mass spectrometry (2DE-LC/MS) for the proteomic analysis of biological fluids aimed at the identification of potential biomarkers of different lung diseases. He is the author of about 150 publications (According to Scopus: H-Index: 23; Total citations: 1568- According to WOS: H-Index: 20; Total Citations: 1296) of peer-reviewed international journals. 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The applications of this research cover many related fields, such as biotechnology and medicine, where, for example, Bioinformatics contributes to faster drug design, DNA analysis in forensics, and DNA sequence analysis in the field of personalized medicine. Personalized medicine is a type of medical care in which treatment is customized individually for each patient. Personalized medicine enables more effective therapy, reduces the costs of therapy and clinical trials, and also minimizes the risk of side effects. Nevertheless, advances in personalized medicine would not have been possible without bioinformatics, which can analyze the human genome and other vast amounts of biomedical data, especially in genetics. The rapid growth of information technology enabled the development of new tools to decode human genomes, large-scale studies of genetic variations and medical informatics. 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Dr. Koprowski has authored more than a hundred research papers with dozens in impact factor (IF) journals and has authored or co-authored six books. Additionally, he is the author of several national and international patents in the field of biomedical devices and imaging. Since 2011, he has been a reviewer of grants and projects (including EU projects) in biomedical engineering.",institutionString:null,institution:{name:"University of Silesia",institutionURL:null,country:{name:"Poland"}}},subseries:[{id:"7",title:"Bioinformatics and Medical Informatics",keywords:"Biomedical Data, Drug Discovery, Clinical Diagnostics, Decoding Human Genome, AI in Personalized Medicine, Disease-prevention Strategies, Big Data Analysis in Medicine",scope:"Bioinformatics aims to help understand the functioning of the mechanisms of living organisms through the construction and use of quantitative tools. The applications of this research cover many related fields, such as biotechnology and medicine, where, for example, Bioinformatics contributes to faster drug design, DNA analysis in forensics, and DNA sequence analysis in the field of personalized medicine. Personalized medicine is a type of medical care in which treatment is customized individually for each patient. Personalized medicine enables more effective therapy, reduces the costs of therapy and clinical trials, and also minimizes the risk of side effects. Nevertheless, advances in personalized medicine would not have been possible without bioinformatics, which can analyze the human genome and other vast amounts of biomedical data, especially in genetics. The rapid growth of information technology enabled the development of new tools to decode human genomes, large-scale studies of genetic variations and medical informatics. The considerable development of technology, including the computing power of computers, is also conducive to the development of bioinformatics, including personalized medicine. In an era of rapidly growing data volumes and ever lower costs of generating, storing and computing data, personalized medicine holds great promises. Modern computational methods used as bioinformatics tools can integrate multi-scale, multi-modal and longitudinal patient data to create even more effective and safer therapy and disease prevention methods. Main aspects of the topic are: Applying bioinformatics in drug discovery and development; Bioinformatics in clinical diagnostics (genetic variants that act as markers for a condition or a disease); Blockchain and Artificial Intelligence/Machine Learning in personalized medicine; Customize disease-prevention strategies in personalized medicine; Big data analysis in personalized medicine; Translating stratification algorithms into clinical practice of personalized medicine.",annualVolume:11403,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/7.jpg",editor:{id:"351533",title:"Dr.",name:"Slawomir",middleName:null,surname:"Wilczynski",fullName:"Slawomir Wilczynski",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000035U1loQAC/Profile_Picture_1630074514792",institutionString:null,institution:{name:"Medical University of Silesia",institutionURL:null,country:{name:"Poland"}}},editorTwo:null,editorThree:null,editorialBoard:[{id:"5886",title:"Dr.",name:"Alexandros",middleName:"T.",surname:"Tzallas",fullName:"Alexandros Tzallas",profilePictureURL:"https://mts.intechopen.com/storage/users/5886/images/system/5886.png",institutionString:"University of Ioannina, Greece & Imperial College London",institution:{name:"University of Ioannina",institutionURL:null,country:{name:"Greece"}}},{id:"257388",title:"Distinguished Prof.",name:"Lulu",middleName:null,surname:"Wang",fullName:"Lulu Wang",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRX6kQAG/Profile_Picture_1630329584194",institutionString:"Shenzhen Technology University",institution:{name:"Shenzhen Technology University",institutionURL:null,country:{name:"China"}}},{id:"225387",title:"Prof.",name:"Reda R.",middleName:"R.",surname:"Gharieb",fullName:"Reda R. Gharieb",profilePictureURL:"https://mts.intechopen.com/storage/users/225387/images/system/225387.jpg",institutionString:"Assiut University",institution:{name:"Assiut University",institutionURL:null,country:{name:"Egypt"}}}]},{id:"8",title:"Bioinspired Technology and Biomechanics",keywords:"Bioinspired Systems, Biomechanics, Assistive Technology, Rehabilitation",scope:'Bioinspired technologies take advantage of understanding the actual biological system to provide solutions to problems in several areas. Recently, bioinspired systems have been successfully employing biomechanics to develop and improve assistive technology and rehabilitation devices. The research topic "Bioinspired Technology and Biomechanics" welcomes studies reporting recent advances in bioinspired technologies that contribute to individuals\' health, inclusion, and rehabilitation. Possible contributions can address (but are not limited to) the following research topics: Bioinspired design and control of exoskeletons, orthoses, and prostheses; Experimental evaluation of the effect of assistive devices (e.g., influence on gait, balance, and neuromuscular system); Bioinspired technologies for rehabilitation, including clinical studies reporting evaluations; Application of neuromuscular and biomechanical models to the development of bioinspired technology.',annualVolume:11404,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/8.jpg",editor:{id:"144937",title:"Prof.",name:"Adriano",middleName:"De Oliveira",surname:"Andrade",fullName:"Adriano Andrade",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRC8QQAW/Profile_Picture_1625219101815",institutionString:null,institution:{name:"Federal University of Uberlândia",institutionURL:null,country:{name:"Brazil"}}},editorTwo:null,editorThree:null,editorialBoard:[{id:"49517",title:"Prof.",name:"Hitoshi",middleName:null,surname:"Tsunashima",fullName:"Hitoshi Tsunashima",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYTP4QAO/Profile_Picture_1625819726528",institutionString:null,institution:{name:"Nihon University",institutionURL:null,country:{name:"Japan"}}},{id:"425354",title:"Dr.",name:"Marcus",middleName:"Fraga",surname:"Vieira",fullName:"Marcus Vieira",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y00003BJSgIQAX/Profile_Picture_1627904687309",institutionString:null,institution:{name:"Universidade Federal de Goiás",institutionURL:null,country:{name:"Brazil"}}},{id:"196746",title:"Dr.",name:"Ramana",middleName:null,surname:"Vinjamuri",fullName:"Ramana Vinjamuri",profilePictureURL:"https://mts.intechopen.com/storage/users/196746/images/system/196746.jpeg",institutionString:"University of Maryland, Baltimore County",institution:{name:"University of Maryland, Baltimore County",institutionURL:null,country:{name:"United States of America"}}}]},{id:"9",title:"Biotechnology - Biosensors, Biomaterials and Tissue Engineering",keywords:"Biotechnology, Biosensors, Biomaterials, Tissue Engineering",scope:"The Biotechnology - Biosensors, Biomaterials and Tissue Engineering topic within the Biomedical Engineering Series aims to rapidly publish contributions on all aspects of biotechnology, biosensors, biomaterial and tissue engineering. We encourage the submission of manuscripts that provide novel and mechanistic insights that report significant advances in the fields. Topics can include but are not limited to: Biotechnology such as biotechnological products and process engineering; Biotechnologically relevant enzymes and proteins; Bioenergy and biofuels; Applied genetics and molecular biotechnology; Genomics, transcriptomics, proteomics; Applied microbial and cell physiology; Environmental biotechnology; Methods and protocols. Moreover, topics in biosensor technology, like sensors that incorporate enzymes, antibodies, nucleic acids, whole cells, tissues and organelles, and other biological or biologically inspired components will be considered, and topics exploring transducers, including those based on electrochemical and optical piezoelectric, thermal, magnetic, and micromechanical elements. Chapters exploring biomaterial approaches such as polymer synthesis and characterization, drug and gene vector design, biocompatibility, immunology and toxicology, and self-assembly at the nanoscale, are welcome. Finally, the tissue engineering subcategory will support topics such as the fundamentals of stem cells and progenitor cells and their proliferation, differentiation, bioreactors for three-dimensional culture and studies of phenotypic changes, stem and progenitor cells, both short and long term, ex vivo and in vivo implantation both in preclinical models and also in clinical trials.",annualVolume:11405,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/9.jpg",editor:{id:"126286",title:"Dr.",name:"Luis",middleName:"Jesús",surname:"Villarreal-Gómez",fullName:"Luis Villarreal-Gómez",profilePictureURL:"https://mts.intechopen.com/storage/users/126286/images/system/126286.jpg",institutionString:null,institution:{name:"Autonomous University of Baja California",institutionURL:null,country:{name:"Mexico"}}},editorTwo:null,editorThree:null,editorialBoard:[{id:"35539",title:"Dr.",name:"Cecilia",middleName:null,surname:"Cristea",fullName:"Cecilia Cristea",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYQ65QAG/Profile_Picture_1621007741527",institutionString:null,institution:{name:"Iuliu Hațieganu University of Medicine and Pharmacy",institutionURL:null,country:{name:"Romania"}}},{id:"40735",title:"Dr.",name:"Gil",middleName:"Alberto Batista",surname:"Gonçalves",fullName:"Gil Gonçalves",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYRLGQA4/Profile_Picture_1628492612759",institutionString:null,institution:{name:"University of Aveiro",institutionURL:null,country:{name:"Portugal"}}},{id:"211725",title:"Associate Prof.",name:"Johann F.",middleName:null,surname:"Osma",fullName:"Johann F. 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