Endoscopic laser surgery versus serial amniocenteses in the treatment of severe twin-twin transfusion syndrome

Abstract

Objective: Severe twin-twin transfusion can be treated by either serial amniocenteses with removal of large volumes of amniotic fluid or by endoscopic laser coagulation of the communicating vessels. We investigated the benefit of laser surgery in comparison to serial amniocenteses in terms of pregnancy outcome. Study Design: The data used in this comparative study were collected from 116 patients with severe twin-twin transfusion syndrome between 17 and 25 weeks’ gestation. The patients were grouped according to the treatment center. The first group comprised 73 patients (median gestational age 20.7 weeks) treated in Hamburg by fetoscopic laser coagulation of the vascular placental anastomoses between January 1995 and May 1997. The second group comprised 43 patients (median gestational age 20.4 weeks), fulfilling identical diagnostic criteria and treated in Bonn by serial amniocenteses between 1992 and 1996. Results: The overall fetal survival rate was not significantly different (61%, 89/146, vs 51%, 44/86; P = .239). There was a significantly higher proportion of pregnancies with ≥1 survivor in the laser-treated group (79%, 58/73, vs 60%, 26/43; P = .033). The number of cases with spontaneous intrauterine fetal death of both fetuses was significantly lower in the laser-treated group (3%, 2/73, vs 19%, 8/43; P = .003). The incidence of abnormal ultrasonographic findings in the brain was significantly lower among surviving neonates after laser surgery than after amniocenteses (6%, 5/89, vs 18%, 8/44; P = .03). For pregnancies with ≥1 live-born baby, a significantly longer interval between first intervention and delivery (median 90 vs 72 days, P = .022) leading to a significantly higher gestational age at delivery (median 33.7 vs 30.7 weeks, P = .018) was observed for the laser-treated group. The birth weights of the donor fetuses were significantly higher in the laser-treated group (median 1750 vs 1145 g, P = .034), and a trend toward higher birth weight was also found for recipient fetuses (median 2000 vs 1560 g, P = .076). Conclusions: These findings indicate that endoscopic laser coagulation of placental vascular anastomoses offers a more effective alternative to serial amniocenteses as a treatment of severe second-trimester twin-twin transfusion syndrome. (Am J Obstet Gynecol 1999;180:717-24.)