Effects and outcomes of septostomy in twin-to-twin transfusion syndrome after fetoscopic laser therapy

Wen-Fang Li,Lan-Yan Yang,An-Shine Chao,Po-Jen Cheng,Shuenn-Dyh Chang,Yao-Lung Chang

doi:10.1186/s12884-019-2555-5

Abstract

BackgroundTo evaluate the incidence and outcomes of septostomy in twin-to-twin transfusion syndrome (TTTS) after fetoscopic laser therapy.MethodsA retrospective analysis of TTTS postlaser septostomy between 2005 and 2018 was performed. Postlaser septostomy was diagnosed using both (1) a free-floating intertwin membrane flap visible on ultrasound examination and (2) the rapid equalization of amniotic fluid maximum vertical pocket in the donor and recipient amniotic sacs observed after laser therapy. Perinatal survival, neonatal brain image anomaly, gestational age at operation and birth, incidence of premature rupture of membranes (PROM) within 3 weeks after operation, pseudoamniotic band syndrome, and cord entanglement were evaluated.ResultsIn the 159 TTTS cases included, 12 had postlaser septostomy. Relative to the group without septostomy, the septostomy group had a lower total fetal survival rate (54.2% vs 73.6%, p = 0.041), an earlier mean gestational age at delivery (27.8 vs 34.4 weeks, p = 0.009), a higher risk of PROMs within 3 weeks after operation (33.3% vs 5.4%, p = 0.004), a higher cord entanglement rate (16.7% vs 0%, p = 0.005), and a higher brain image anomaly rate (23.0% [3/13] vs 5.0% [11/218], p = 0.035). After considering the severe Quintero stages (stage III and IV), postlaser septostomy was the only variable [p = 0.003, odds ratio = 5.1] to predict neonatal brain image anomaly. Postlaser septostomy combined with severe Quintero stages could predict PROMs within 3 weeks after laser therapy [p = 0.001, odds ratio = 14.1 and p = 0.03, odds ratio = 5.4, respectively] and delivery before the gestational age of 28 weeks [p = 0.017, odds ratio = 4.5 and p = 0.034, odds ratio = 2.3, respectively]. The risk of pseudoamniotic band syndrome was not increased by postlaser septostomy in this case series.ConclusionsPostlaser septostomy in TTTS was associated with poorer fetal survival and more adverse perinatal outcomes even after considering severe Quintero stages before laser therapy. Efforts should be made to prevent septostomy during laser therapy, and septostomy as the primary method to treat TTTS is not advisable.

Highlights

To evaluate the incidence and outcomes of septostomy in twin-to-twin transfusion syndrome (TTTS) after fetoscopic laser therapy
From October 2005 to November 2018, 159 TTTS cases diagnosed before the gestational age of 26 weeks and who received fetoscopic laser therapy at our hospital were included in this study
In 58.3% (7/12) of the cases, the operator was already aware of the perforation during the procedure, and in 41.7% (5/12), septostomy was observed the day after the operation through ultrasound examination

Summary

Introduction

To evaluate the incidence and outcomes of septostomy in twin-to-twin transfusion syndrome (TTTS) after fetoscopic laser therapy. Septostomy designates the perforation of the membrane separating the twins that can occur after laser therapy for TTTS [1, 6,7,8,9]. Septostomy after laser therapy for TTTS can be caused by the perforation of the donor’s collapsed membrane at the trocar insertion site, laser photocoagulation through the dividing membrane, or mechanical rupture of the membrane during the operation by the laser fiber tip or trocar tip. The reported incidence of septostomy after laser therapy for TTTS ranges from 1.6 to 25.0% [1, 6, 7, 9, 10]. Postlaser septostomy is associated with higher risks of early delivery [1, 7, 9], intrauterine fetal demise (IUFD) [7], and cerebral injury in the surviving fetus [9]

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Discussion

Conclusion