223: Outcomes after Solomon fetoscopic laser as the primary treatment for twin-twin-transfusion syndrome

Abstract

Treatment of twin-twin-transfusion syndrome (TTTS) includes fetoscopic laser occlusion (FLOC), cord occlusion and even pregnancy termination. Since the Solomon FLOC technique achieves more complete separation of the twin circulations (Solomon-RCT, Slaghekke et al., 2014), we have adopted this as the primary treatment of TTTS irrespective of disease severity. We aimed to evaluate the outcomes using this treatment approach. Patients with TTTS had detailed anatomy ultrasound, Quintero staging, middle cerebral artery peak systolic velocity and cervical length (CL) measurement. When TTTS criteria were met, Solomon FLOC was offered (including coexisting selective intrauterine growth restriction (sIUGR), complete anterior placenta or cervical shortening). Obstetric comorbidities were managed independently. We ascertained and compared preoperative characteristics in a clinical training program with 2 attending physicians and 2 fellows to procedure-related outcomes in the Solomon-RCT. 144 consecutive TTTS patients managed in 3 years had similar stage distribution to the Solomon-RCT. Twin size discordance >25% and sIUGR was present in 52 (36.1%) and 22 (15.2%), respectively. 7 (4.8%) had a preoperative cervical length (CL) <25mm. All patients elected Solomon FLOC; complete outcome was obtained for 140 pregnancies. Intraoperative intentional septostomy was less frequent in our cohort (7 (5%) vs. 17 (12%); p=0.024) but rupture of membranes (PPROM) within 2 weeks of FLOC was similar (6 (4%) vs 4 (3%); p=0.27). PPROM at birth was seen in 26 (18%) (vs. 57 (42%); p<0.005, Table). Recurrent TTTS (n=2, 1%) and Twin anemia polycythemia sequence (n=3, 2%) requiring repeat FLOC was similar to the Solomon-RCT rate. Median FLOC to delivery interval was 78.5 days (0-141) resulting in a delivery gestational age of 32.2 weeks (range 18+5 – 38+0). Pre-FLOC CL was unrelated to the interval to delivery (Pearson 0.12, p=0,331; median interval 61 vs 82 days for CL<25 and above respectively, p=0.492). Overall twin survival was significantly higher due to a larger proportion of double twin survival at birth (104 74% vs 87 (64%), p<0.05, Table). Solomon FLOC offered in a clinical setting performs at least as well as anticipated from the randomized trial with superior outcomes compared to any other treatment. In the absence of any absolute contraindication Solomon FLOC should be offered to all TTTS patients irrespective of disease severity.View Large Image Figure ViewerDownload Hi-res image Download (PPT)