Laparoscopically Guided Uterine Entry for Fetoscopy in Twin-to-Twin Transfusion Syndrome with Completely Anterior Placenta: A Novel Technique

Abstract

Objective: Laser coagulationof anastomotic vessels on the placental surface is the treatment of choice in severe second trimester twin-to-twin transfusion syndrome (TTTS). This procedure is associated with technical difficulties when the placenta is located on the anterior side of the uterus. We describe a novel technique for fetoscopy in TTTS with completely anterior placenta where laparoscopy is used to guide safe percutaneous insertion of the fetoscope through the lateral abdominal wall and the dorsal side of the uterus. Methods: Prospective controlled series of 16 TTTS pregnancies with completely anterior placenta (study group) treated with this novel technique. Studied outcomes were technical result of the procedure and perinatal survival. Outcome in the study group was compared with outcome of 49 TTTS pregnancies treated with conventional percutaneous fetoscopic laser without laparoscopy, 9 of these with partially anterior placenta (control group A) and 40 with lateral or posterior placenta (control group B). Results: In the study group, the procedure-related complication rate was 25% (4/16). In 1 case, uterine entry of the fetoscope from the lateral abdominal wall was not possible due to complex bowel adhesions. In 3 patients, intra-amniotic haemorrhage occurred after fetoscopic entry, preventing complete laser coagulation of anastomoses. One of these patients required 2 units of blood transfusion. The procedure-related complication rate in control groups A and B was 22% (2/9) and 5% (2/40), respectively (intra-amniotic haemorrhage n = 3, severe leakage of amniotic fluid into the peritoneal cavity, n = 1). Perinatal survival in the study group, control group A and control group B was 63% (20/32), 78% (14/18) and 70% (56/80), respectively. Conclusion: Combined laparoscopy and fetoscopy is a novel technique that enables safe uterine entry and creates optimal visualisation for laser coagulation of inter-twin anastomoses in TTTS pregnancies with completely anterior placenta. The procedure-related complication rate and perinatal survival rate were similar compared to the conventional percutaneous technique. Procedure-related complications occur more often with partially or completely anterior placenta.