Cord Occlusion intrapartum : Why on earth someone will do this?

Cord Occlusion

intrapartum : Why on earth someone will do this?

Sounds Bizarre is it not .read further and you will know why

What is Cord Occlusion?

Refers to a procedure where the umbilical cord circulation is stops to interrupt blood supply to an abnormal identical twin (monochorionic pregnancy). In fraternal twins (dichorionic) where selective feticide is performed or indicated, Potassium chloride is typically the agent used. Due to concern to communicating vessels across the placenta in identical twin pregnancies, this procedure is not performed, and other cord occlusive methods must be applied.

Currently, there are many different procedures described in the literature such as:

• Bipolar cord ligation:This procedure is done inside the uterus, through a sheath or large bore needle placed by ultrasound guidance in the sac of one twin, usually the donor (smaller) twin. Special bipolar tweezers grasp the cord and an electric current passes between the jaws of the tweezers, coagulating the blood vessels of that twin’s cord. This stops the flow of blood in the cord and that fetus will die.
• Laser cord occlusion: A laser fiber is used either through a scope inside the uterus or a large bore needle. Under direct US guidance, the laser fibre is threaded through the needle or through the scope. A power output between 20-100 watts is required to achieve complete occlusion, depending on gestation and cord size. In this group, an amnioreduction is usually performed.
• Unipolar cord ligation:This procedure is done inside the uterus, through a large bore needle placed by ultrasound guidance in the sac of one of the affected twins. A wire electrode is wrapped around the cord, and an electric current passes coagulating the blood vessels of that twin’s cord. This stops the flow of blood in the cord and that fetus will die.
• Cord ligation: Under continuous ultrasound (US) guidance, a cannula is introduced into the amniotic cavity, and a large needle passed through it. Blood can be sampled from the “pump” twin’s placental cord root and a medication can be used to paralyze both twins. An operating trocar is then placed into the amniotic sac approximately 10 cm from the previous needle site. Using both access points, a suture is placed around the acardiac (parasitic twin) twin’s cord under US guidance and tied, resulting in interruption of blood flow in the cord. An amnioreduction is sometimes performed.
• Radiofrequency ablation 
  

For what conditions is Cord Occlusion performed?

Cord occlusion is considered an option in identical twin pregnancies (Monochorionic) where there are complications:

• Severe Twin-to-twin transfusion where there is concern for death of one twin or severe brain damage.
• Severe cases of growth discordances with abnormal Dopplers or brain anomalies.
• Severe discordant anomaly both for parental decision or impending damage to normal fetus.
• Acardiac fetus or TRAP Sequence with polyhydramnios or cardiac overload (1% monozygotic twins).   An acardiac twin is a parasitic twin, who fails to develop a normal heart, and relies on an abnormal circuit with a normal twin to survive. This twin is not able to survive without this circuit, and there is concern for the normal twin’s survival due to cardiac failure.

What are the risks of Cord Occlusion to fetus?

As with any intrauterine invasive procedure, there may be short term complications, including preterm labor, rupture of membranes, infection or bleeding. This means that not all such procedures result in one living baby. But, in about 60-85% of cases (depending on procedure), the procedure results in one living baby, born near term, with no permanent handicaps. The optimal technique has not yet been established, although a few reports report good survival and less complications with RFA.

Because the umbilical cord is completely blocked, this procedure means survival of both babies can never occur.

What are the risks of Cord Occlusion to mother?

For an experienced team, this procedure is technically feasible and usually not long, so maternal operative complications are very unusual. There may be risks related to anesthetic use.

Twins / Multiples | Twin-reversed arterial perfusion (TRAP)

Twin-reversed arterial perfusion (TRAP) sequence (or Acardiac twin) is a very rare complication, seen in twins that share a single placenta (monochorionic twins). In TRAP sequence, one twin (called the “pump twin”) develops normally, but the other (called the “acardiac twin”) is very abnormal and has no chance of surviving outside the womb.

Essential Information

• Twin-reversed arterial perfusion (TRAP) sequence is a very rare condition that only occurs in identical twins. This condition is also referred to as Acardiac Twinning.
• In this condition, one of the fetuses, called the “acardiac twin”, does not have a normally-functioning heart and has no chance of surviving outside the womb.
• The fetus with the normal heart function (called the “pump twin”) sends blood to the acardiac fetus, which causes it to grow. This places increased demand on the pump twin’s heart and may lead to heart failure or death.
• The fetal intervention in severe cases of twin-reversed arterial perfusion includes closing off the blood source to the acardiac fetus, allowing the pump fetus to thrive.

Twin reversed arterial perfusion (TRAP) sequence is a complication specific to identical twins who share a single placenta (monochorionic twins). In this condition, one of the fetuses (referred to as the “acardiac twin”) does not have a normally-functioning heart, and as a result, is unable to survive after birth. During pregnancy, however, this acardiac twin receives its blood supply from the normal, ‘pump’ twin through blood vessel connections at the level of the placenta and through backward flow in the umbilical cord. As such, the acardiac fetus may grow before birth.

The acardiac fetus places an increased demand on the heart of the pump twin. If the acardiac fetus grows very large, this can cause heart failure and death in the pump twin.

TRAP sequence can be diagnosed by ultrasound. The acardiac twin may resemble an abnormal mass of tissue or a very abnormal, under-developed fetus with no heart beat. If heart failure is present in the pump twin, this may result in a condition called “hydrops”, which refers to abnormal fluid collections under the fetus’ skin, in the chest or in the abdomen, as well as excess amniotic fluid.

In cases where the acardiac twin remains small, and the pump twin does not develop heart failure, the outcomes for the pump twin can be excellent. However, when the acardiac twin becomes large, its blood flow must be interrupted so as to improve the survival chances of the pump twin.

Treatment

No treatment is necessary in cases where the acardiac fetus remains small and heart failure does not develop in the pump twin. However, if the acardiac fetus grows large, and there is an excess of amniotic fluid and hydrops, fetal therapy is necessary to improve the survival chances of the pump fetus.

Prenatal therapy aims to stop the blood flow towards the acardiac fetus. This is done by closing off the umbilical cord of the acardiac mass (termed “cord occlusion”) or by closing off the large blood vessels within the acardiac fetus using either radiofrequency energy (termed “radiofrequency ablation (RFA)”), bipolar cord occlusion or interstitial laser. Outcomes are similar with all techniques, with survival of the pump twin in approximately 85% of cases. The average gestation at delivery after such procedures is 34-35 weeks’ of pregnancy. Developmental delay in survivors is rare, occurring in approximately 2 per cent of cases. If developmental delay occurs, it is most often a result of prematurity.

Abbreviation Galore

AB Ayushmaan Bharat
ACA Affordable Care Act
ACO Affordable Care Organizations
AHRQ Agency for Healthcare Quality and
Research
AI Artificial Intelligence
AIIMS All India Institute of Medical Sciences
ALOS Average Length of Stay
ANM Auxiliary Nurse Midwife
APL Above Poverty Line
ASHA Accredited Social Health Activist
AYUSH Ayurveda, Yoga & Naturopathy, Unani,
Siddha
BoD Burden of Disease
BPJS Badan Penyelenggara Jaminan Sosial,
Indonesia
BPL Below Poverty Line
BPSSBY Bhagat Puran Singh Sehat Bima Yojana
BSBY Bhamashah Swasthya Bima Yojana
CAPEX Capital Expenditure
CBHI Central Bureau for Health Intelligence
CD Communicable Diseases
CDAC Centre for Development of Advanced
CDSS Clinical Decision-Support Systems
CDSS Clinical Decision Support Systems
CEA Clinical Establishments Act
CGHI Central Government Health Scheme
CGHR Centre for Global Health Research
CHA Cambridge Health Alliance
CHC Community Health Center
CHD Center for Healthy Development
CHIAK Comprehensive Health Insurance Agency
of Kerala
CMCHIS Chief Minister's Comprehensive Health
Insurance Scheme
CMIE Centre for Monitoring Indian Economy
COPD Chronic Obstructive Pulmonary Disease
CPA Consumer Protection Act
CPHC Comprehensive Primary Healthcare
CVD Cardiovascular Diseases
DHAF Digital Health Architecture Framework
DMRC Delhi Metro Rail Corporation
DOTS Directly Observed Treatment, Short-course
DRG Diagnosis Related Grouping
EAG Empowered Action Group
EHRs Electronic Health Records
EMRI Emergency Management Research
Institute
EPH Essential Health Package
ESI Employee State Insurance
ESIC Employee State Insurance Corporation
ESIS Employee State Insurance Scheme
eVIN Electronic Vaccine Intelligence Network
FFS Fee for Service
FHIR Fast Healthcare Interoperability
Resources
FRU First Referral Unit
GDP Gross Domestic Product
GIPSA General Insurance Public Sector
Association
GoI Government of India
GP General Physician
GR Grievance
GSHIS Government Sponsored Health
Insurance Scheme
GST Goods and Services Tax H&WC
Health and Wellness Centre
HAAD Health Authority of Abu Dhabi
HDD Health Data Dictionary
HIC High Income Countries
HIIP Health Information and Intelligence
Platform
HIIS Health Insurance Information System
HIS Health Information System
HIT Health information technology
HIV Human Immunodeficiency Virus
HLFPPT Hindustan Latex Family Planning
Promotion Trust
HMIS Health Management Information System
HMO Health Management Organization
HR Human Resources
HRH Human resources for health
HRIS Human Resources Information System
HTA Health Technology Assessment
IAS Indian Administrative Services
IBEF India Brand Equity Foundation
Health System for a New India: Building Blocks
xvii
ABBREVIATIONS
ICD International Classification of Diseases
ICHSS International Center for Health Systems
Strengthening
ICMR Indian Council for Medical Research
ICT Information and Communications
Technology
ID Identity
IDSP Integrated Disease Surveillance Program
IEC Information, Education and
Communication
IFC International Finance Corporation
IHI Institute for Healthcare Improvement
IHME Institute for Health Metrics and
Evaluation
ILO International Labour Organization
IMA Indian Medical Association
IMS Inventory Management System
IOM Institute of Medicine
IP In Patient
IPA Independent Practice Associations
IPHS Indian Public Health Standards
IPs Informal Providers
IQWiG Institute for Quality and Efficiency in
healthcare
IRCTC Indian Railways Catering and Tourism
Corporation
IRDA Insurance Regulatory and Development
Authority
IT Information Technology
JCAHO Joint Commission on Accreditation of
Healthcare Organizations
JHM Johns Hopkins Medicine
JLN Joint Learning Network
LIS Laboratory Information System
LMIC Low and middle-income countries
MCI Medical Council of India
MIC Middle Income Countries
MCTS Mother and Child Tracking System
MDDS Meta Data and Data Standards for Health
MHIS Meghalaya Health Insurance Scheme
MHN Merrygold Health Network
MIS Management Information Systems
MMR Maternal Mortality Ratio
MNCH Maternal, New-born and Child Health
MoF Ministry of Finance
MoHFW Ministry of Health and Family Welfare
MoU Memorandum of Understanding
MSQH Malaysian Society for Quality in Health
NABH National Accreditation Board for
Hospitals & Healthcare Providers
NAMMIS National Anti-Malaria Management
Information System
NACO National AIDS Control Organization
NCD Noncommunicable diseases
NCMH National Centre for Mental Health
NDHA National Digital Health Authority
NDHM National Digital Health Mission
NFHS National Family Health Survey
NHA National Health Authority
NHM National Health Mission
NHRR National Health Resource Registry
NHS National Health Service, United
Kingdom
NHS National Health Stack
NHSRC National Health Systems Resource
Centre
NIC National Informatics Centre
NICE National Institute for Health and Care
Excellence
NID National Identification
NIPI Norway India Partnership Initiative
NITI National Institution for Transforming
India
NPCDCS National Programme for Prevention and
Control of Cancers, Diabetes,
Cardiovascular Diseases and Stroke
NSS National Sample Survey
NSSO National Sample Survey Organization
NWH Network Hospital
OECD Organisation for Economic Cooperation
and Development
OOD Object-Oriented Design
OOP Out-Of-Pocket
OOPs Out-Of-Pocket Payments
OP Outpatient
OPD Outpatient Department
Abbreviations
xviii Abbreviations
ORS Oral Rehydration Solution
OT Operating Theatre
P4P Pay-for-Performance
PC Primary Care
PCR Pure Claims Ratio
PDSA Plan, Do, Study, Act
PFMS Public Financial Management System
PHC Primary Health Centres
PHFI Public Health Foundation of India
PHR Personal Health Records
PHSC Punjab Health Systems Corporation
PM-JAY Pradhan Mantri Jan Arogya Yojana
PPD Public-Private Dialogue
PPP Public Private Partnership
PRP Performance-Related Pay
PSF Brazil's Programma Saúde da Família
(Family Health Programme)
QCI Quality Council of India
QOF Quality and Outcomes Framework
RBSNY Rajya Bimaari Sahayta Nidhi Yojana
RFP Request For Proposals
RIS Radiology Information System
RSBY Rashtriya Swasthya Bima Yojana
SAST Suvarna Aarogya Suraksha Trust
SDG Sustainable Development Goals
SECC Socio Economic Caste Census
SHI Social Health Insurance
SIMS State Information Management Systems
SNA State Nodal Agency
SNCU Special Newborn Care Unit
SQAU State Quality Assurance Units
SRS Sample Registration System
SSI Surgical Site Infection
STGs Standard Treatment Guidelines
SUS Brazil’s Sistema Único de Saúde
TA Technical Assistance
TB Tuberculosis
TFR Total Fertility Rate
THE Total Health Expenditure
TPA Third Party Administrator
UAE United Arab Emirates
UHC Universal Health Coverage
UK United Kingdom
UNCTAD United Nations Conference on Trade
and Development
UNICEF United Nations Children's Fund
UNDP United Nations Development Program
UPID Unique Patient Identifier
US/USA United States of America
USAID United States Agency for International
Development
VAS Vajpayee Arogyashree Scheme
VAT Value Added Tax
WHO World Health Organization
WMS World Management Survey
WPI Wholesale Price Index

Common Abbreviations

2D                          two dimensional

3D                          three dimensional

A1c                         glycated/glycosylated hemoglobin

AAA                       abdominal aortic aneurysm

ABO                       three of human blood antigen groups (for transfusion compatibility)

ACE                       angiotensin converting enzyme

AcG                        accelerator globulin

ACI                        autologous chondrocyte implantation

ACTH                    adrenocorticotropic hormone

ADH                       antidiuretic hormone

AFB                        acid fast bacilli

AFP                        alpha-fetoprotein

AHG                      antihemophilic globulin

AKD                       acetone-killed dried

ALA                       aminolevulinic acid

ALT                       alanine amino

AMP                       adenosine monophosphate

ANA                       antinuclear antibodies

AP                          abdominal voiding pressure

APC                       activated protein C

ARB                       angiotensin receptor blocker

ART                       automated reagin test

ASPE                      allele-specific primer extension

AST                        aspartate aminotransferase

AUDIT                   alcohol use disorders identification test

AV                          arteriovenous

BCG                       Bacille Calmette-Guerin

BUN                       blood urea nitrogen

CA                          community-acquired bacterial

CAD                       computer-aided detection

CAD                       coronary artery disease

CAT                       computed axial tomography

CBC                       complete blood count

CCP                       cyclic citrullinated peptide

CCU                       critical care unit

CEA                       carcinoembryonic antigen

CHr                        reticulocyte hemoglobin content

CH50                     complement (blood protein)

CK                         creatine kinase

CMG                      cystometrogram

CMRI                     cardiac magnetic resonance imaging

CMT                      chiropractic manipulative treatment

CMV                      cytomegalovirus

CMV-IgV               cytomegalovirus immune globulin, intravenous

CNP                       continuous negative pressure

CNPB                     continuous negative pressure breathing

CNS                        central nervous system

CO2                       carbon dioxide

COPD                    chronic obstructive pulmonary disease

CPAP                     continuous positive airway pressure

CPK                       creatine phosphokinase

CPPD                     chronic obstructive pulmonary disease

CPR                       cardiopulmonary resuscitation

CRH                       corticotropic releasing hormone

CSF                        cerebrospinal fluid

CT                          computed tomography

D and C                  dilation and curettage

D and E                  dilation and evacuation

DAST                     drug abuse screening test

DFA                       direct fluorescent antibody

DGGE                    denaturing gradient gel electrophoresis

DHEA                    dehydroepiandrosterone

DHT                       dihydrotestosterone

DM                         diabetes mellitus

DNA                       deoxyribonucleic acid

DNAse                    deoxyribonuclease

DRIL                      distal revascularization and interval ligation

DT                          diphtheria and tetanus toxoids

DTaP                      diphtheria, tetanus toxoids, and acellular pertussis

DXA                       dual energy X-ray absorptiometry

EA                          Epstein-Barr (virus), early antigen

EB                          Epstein-Barr (virus)

EBNA                     Epstein-Barr (virus), nuclear antigen

ECG                       electrocardiogram

ECLS                     extracorporeal life support

ECMO                   extracorporeal membrane oxygenation

EDTA                     ethylene-diamine-tetra-acetic acid

EEG                       electroencephalography

EGD                       esophagogastroduodenoscopy

EKG                       electrocardiogram

E/M                        evaluation and management

EMG                      electromyography

ENT                       ear, nose, and throat

EOG                       electrooculogram

ePTFE                    expanded polyetra-fluorethylene

ERCP                     endoscopic retrograde cholangiopancreatography

ESRD                     end-stage renal disease

Fc                           portion of antibody molecule bound by membrane receptors

FDA                       Food and Drug Administration

FDP                        fibrin degradation products

FEV                        forced expiratory volume

FISH                      fluorescent in-situ hybridization

FSF                         fibrin stabilizing factor

FSH                        follicle-stimulating hormone

FSP                         fibrinogram split products

FT-4                       free thyroxine

FTA-abs                 fluorescent treponemal antibody absorption

FVC                       forced vital capacity

GAIL                     breast cancer risk assessment model

G-CSF                    granulocyte colony stimulating factors

GERD                    gastroesophageal reflux disease

GGT                       glutamyltransferase, gamma

GLC                       gas liquid chromatography

GM-CSF                granulocyte macrophage colony stimulating factors

GTT                       glucose tolerance test

HAA                       hepatitis-associated antigen

HAAb                     hepatitis A antibody

HAI                        hemagglutination inhibition

HAST                     high altitude simulation test

HBA                       hyaluronan binding assay

HBcAb                   hepatitis B core antibody

HBcAg                   hepatitis B core antigen

HBeAb                   hepatitis Be antibody

HBeAg                   hepatitis Be antigen

HbIg                       hepatitis B immune globulin

HBsAb                   hepatitis B surface antibody

HBsAg                   hepatitis B surface antigen

hCG                       human chorionic gonadotropin

HCO2                    bicarbonate

HDL                               high density lipoprotein HER-2/neu                               breast cancer-related gene HF                               heart failure

Hgb                        hemoglobin

hGH                       human growth hormone

HIAA                     hydroxyindoleacetic acid

Hib                         haemophilus influenzae b

Hib-HepB               hepatitis B and haemophilus influenzae b

HIV                        human immunodeficiency virus

HLA                       human leukocyte antigen

HLA DR                human leukocyte antigen DR allele (an alternative form of gene on a chromosome)

HLA DQ                human leukocyte antigen DQ allele (an alternative form of gene on a chromosome)

HP                          haptoglobin

hPL                        human placental lactogen

HPLC                     high performance liquid chromatography

HPV                       human papillomavirus

HTLV                    human T-lymphotropic virus

HTN                       hypertension

HVA                       homovanillic acid

ICF                         intermediate care facilities

IDH                        isocitric dehydrogenase

IgIV                       immune globulin (human) intravenous

IGRT                     image guided radiation therapy

IMRT                     intensity modulated radiation therapy

INH                        isonicotinic acid hydrazide

INR                        international normalized ratio

IPPB                       intermittent positive pressure breathing

IPV                         inactivated polio virus

IRF                         immature reticulocyte fraction

ISH                         in-situ hybridization

IUD                        intrauterine device

IV                           intravenous

IVC                        intravenous cholangiography, inferior vena cava

IVF                         in vitro fertilization

KIA                        Kligler iron agar

KOH                      potassium hydroxide

L/S                          lecithin/sphingomyelin ratio

LAP                        leucine aminopeptidase

LATS                     long-acting thyroid stimulation hormone

LD                          lactic dehydrogenase

LDH                       lactate dehydrogenase

LDL                       low density lipoproteins

LEEP                     loop electrode excision procedure

LH                          luteinizing hormone

LHR                       leukocyte histamine release test

LIA                        lysine iron agar

LMP                       last menstrual period

LRH                       luteinizing releasing factor

LSD                        lysergic acid diethylamide

LVEF                     left ventricular ejection fraction

LVF                        left ventricular function

LVSD                     left ventricular systolic dysfunction

MEG                      magnetoencephalography

MER                      microelectrode recording

MIC                       minimum inhibitory concentration

MIF                        migration inhibitory factor

MLC                      mixed lymphocyte culture

MLC                      multi-leaf collimator

mm                         millimeters

MMPI                    Minnesota Multiphasic Personality Inventory

MMR                     measles, mumps, and rubella

MMRV                   measles, mumps, rubella, and varicella

MN                         two red cell antigens determined for +B82 blood typing

MRA                      magnetic resonance angiography

MRI                       magnetic resonance imaging

MRV                      mean reticulocyte volume

MS                          mass spectrometry

MSLT                     multiple sleep latency testing

MTMS                    medication therapy management services

MUGA                   multiple gated acquisition

NCPAP                  nasal continuous positive airway pressure

NCQA                    National Committee on Quality Assurance

NCV                       nerve conduction volume

NG                         nasogastric tube

NK                         natural killer [cells]

NSAID                   nonsteroidal antiinflammatory drug

NSD                        nominal standard dose

NTD                       nitroblue tetrazolium dye test

OA                         osteoarthritis

OG                         orogastric tube

OLA                       oligonucleotide ligation assay

OMT                      osteopathic manipulative treatment

OTC                       over-the-counter

PAD                       peripheral arterial disease

PAO2                     arterial blood partial oxygen pressure PAPP-A  pregnancy-associated plasma protein-A pCO2                     partial pressure exerted by carbon dioxide

PCP                        phencyclidine

PCR                       polymerase chain reaction

PET                        positron emission tomography

pH                          hydrogen ion concentration

PI                           prescribing information

PICC                      peripherally inserted central venous catheter

PKU                       phenylalanine

PLC                        primed lymphocyte culture

pO2                        partial pressure of oxygen

PORD                    partial ossicular replacement prosthesis

PPD                        purified protein derivative

PRA                       plasma renin activity

PSA                        prostate specific antigen

PTA                        platelet thromboplastin antecedent

PTB                        patella tendon bearing

PTC                        plasma thromboplastin component

PTCA                     percutaneous transluminal angioplasty

PUVA                     psoralens and ultraviolet A

QST                        quantitative sensory testing

RBC                       red blood cell

RFA                       radiofrequency ablation

Rh                          red blood cell antigen

RhIg                       red cell immune globulin (human)

RhIgIV                   red cell immune globulin (human) intravenous

Rho (D)                  red cell antigen

RIg                         rabies immune globulin

RIg-HT                  rabies immune globulin-heat treated

RIA                        radioimmunoassay

RPR                       rapid plasma reagin

RSV                        respiratory syncytial virus

RSV-IgIM                               respiratory syncytial virus immune globulin, intramuscular RSV-IgIV                               respiratory syncytial virus immune globulin, intravenous SAVER                               surgical anterior ventricular restoration

SBCE                     single base chain extension

SBI                         screening and brief intervention

SBRT                     stereotactic body radiation therapy

SCIg                       immune globulin (human) subcutaneous

SEPS                      subfascial endoscopic perforator surgery

SGOT                     serum glutamic oxaloacetic transaminase

SGPT                     serum glutamic pyruvate transaminase

SHBG                     sex hormone binding globulin

SIS                          saline infusion sonohysterography

SIS                          small intestine submucosa

SISI                        short increment sensitivity index

SLAP                      superior labral anterior posterior

SMAS                     superficial musculoaponeurotic system SPECT               single-photon emission computed tomography SRS                        stereotactic radiosurgery

SSCP                      single strand conformational polymorphism

STS                         serologic test for syphilis

SVR                        surgical ventricular restoration

T3                           thyroid hormone

T4                           thyroid hormone

TB                          tuberculosis

TBG                       thyroxine binding globulin

TBS                        Bethesda system

TBSA                     total body surface area

Td                           tetanus and diphtheria toxoids

TDF                        time, dose, fractionation

TENS                     transcutaneous electrical nerve stimulation

THBR                    thyroid hormone binding ratio

TIg                         tetanus immune globulin

TIPS                       transvenous intrahepatic portosystemic shunt

TLC                       thin-layer chromatography

TLD                       thermoluminescent dosimeters

TMJ                       temporomandibular joint

TNS                        transcutaneous nerve stimulation

TORCH                 toxoplasmosis, rubella, cytomegalovirus, and herpes virus serology

TORP                     total ossicular replacement prosthesis

TRAM                    transverse rectus abdominis myocutaneous flap

TRH                       thyrotropin releasing hormone

TSH                        thyroid stimulating hormone

TSI                         thyroid stimulating immunoglobin

TT3                        triiodothyronine T3 total

UFR                       uroflowmetry

UPP                        urethral pressure profile

VAR                       varicella

VCA                       viral capcid antigens

VDRL                    venereal disease research laboratory; test for syphilis

VEP                        visual evoked potential

VIP                         vasoactive intestinal peptide

VLDL                     very low density lipoprotein

VMA                      vanillylmandelic acid

VP                          voiding pressure

VZIg                      varicella zoster immune globulin

WAIS                     Wechsler Adult Intelligence Scale

WBC                      white blood count

YAG                       yttrium-aluminum-garnet