Abstract
Selective fetoscopic laser coagulation of the intertwin anastomotic chorionic vessels is the first-line treatment for twin-twin transfusion syndrome. However, in stage 1 twin-twin transfusion syndrome, the risks of intrauterine surgery may be higher than those of the natural progression of the condition. This study aimed to compare immediate surgery and expectant follow-up in stage 1 twin-twin transfusion syndrome. We conducted a multicentric randomized trial, which recruited from 2011 to 2018 with a 6-month postnatal follow-up. The study was conducted in 9 fetal medicine centers in Europe and the Unites States. Asymptomatic women with stage 1 twin-twin transfusion syndrome between 16 and 26 weeks' gestation, a cervix of >15 mm, and access to a surgical center within 48 hours of diagnosis were randomized between expectant management and immediate surgery. In patients allocated to immediate laser treatment, percutaneous laser coagulation of anastomotic vessels was performed within 72 hours. In patients allocated to expectant management, a weekly ultrasound follow-up was planned. Rescue fetoscopic coagulation of anastomoses was offered if the syndrome worsened as seen during a follow-up, either because of progression to a higher Quintero stage or because of the maternal complications of polyhydramnios. The primary outcome was survival at 6 months without severe neurologic morbidity. Severe complications of prematurity and maternal morbidity were secondary outcomes. The trial was stopped at 117 of 200 planned inclusions for slow accrual rate over 7 years: 58 women were allocated to expectant management and 59 to immediate laser treatment. Intact survival was seen in 84 of 109 (77%) expectant cases and in 89 of 114 (78%) (P=.88) immediate surgery cases, and severe neurologic morbidity occurred in 5 of 109 (4.6%) and 3 of 114 (2.6%) (P=.49) cases in the expectant and immediate surgery groups, respectively. In patients followed expectantly, 24 of 58 (41%) cases remained stable with dual intact survival in 36 of 44 (86%) cases at 6 months. Intact survival was lower following surgery than for the nonprogressive cases, although nonsignificantly (78% and 71% following immediate and rescue surgery, respectively). It is unlikely that early fetal surgery is of benefit for stage 1 twin-twin transfusion syndrome in asymptomatic pregnant women with a long cervix. Although expectant management is reasonable for these cases, 60% of the cases will progress and require rapid transfer to a surgical center.
Highlights
Twin-twin transfusion syndrome (TTTS) complicates 10% to 15% of monochorionic pregnancies, and it is a major contributor to perinatal mortality and morbidity.[1,2]
We included patients with Quintero stage 1 TTTS defined by a visible bladder in the donor twin and the absence of Doppler anomalies in either twins, which is a positive end-diastolic flow in the umbilical arteries and a positive “A” wave in the ductus venosus.[10]
The data monitoring committee made the decision to stop the trial in May 2018 when 117 of 164 eligible cases consented to inclusion between April 2011 and March 2018, showing the increasing difficulties to recruit (Supplemental Figure)
Summary
Twin-twin transfusion syndrome (TTTS) complicates 10% to 15% of monochorionic pregnancies, and it is a major contributor to perinatal mortality and morbidity.[1,2] Its prenatal diagnosis is defined by oligohydramnios in 1 twin and polyuric polyhydramnios in the cotwin and is well standardized.[3]. This study aimed to determine if stage 1 twin-twin transfusion syndrome (TTTS) should be managed primarily with intrauterine fetoscopic photocoagulation of placental anastomosis or expectantly. OBJECTIVE: This study aimed to compare immediate surgery and expectant follow-up in stage 1 twin-twin transfusion syndrome. Asymptomatic women with stage 1 twin-twin transfusion syndrome between 16 and 26 weeks’ gestation, a cervix of >15 mm, and access to a surgical center within 48 hours of diagnosis were randomized between expectant management and immediate surgery. Rescue fetoscopic coagulation of anastomoses was offered if the syndrome worsened as seen during a follow-up, either because of progression to a higher Quintero stage or because of the maternal complications of polyhydramnios. RESULTS: The trial was stopped at 117 of 200 planned inclusions for slow accrual rate over 7 years: women were allocated to expectant management and to immediate laser treatment. Expectant management is reasonable for these cases, 60% of the cases will progress and require rapid transfer to a surgical center
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