P343a: Fetoscopic laser treatment in monochorionic and dichorionic triplets

Abstract

To report on feasibility and outcome of 7 consecutive fetoscopic laser procedures in monochorionic (MC) or dichorionic (DC) triamniotic (TA) triplets. Consecutive case series. Variables were principal indication, gestational age (GA) at diagnosis, preoperative decision making in terms of technical limitations and clinical presentation, performed procedure, success rate, delivery, survival rate, birth weight, duration of follow-up and long-term outcome. Indications were TRAP in 3 MCTA triplets and severe TTTS in 3 DCTA triplets and 1 MCTA triplet. Median GA at diagnosis in TRAP was 16.2 wks (range 16–18) and 17 wks (range: 15–22) in TTTS. Cord coagulation was done in all cases of TRAP. In cases with TTTS cord coagulation was performed in 3 cases, in 1 case because of ventriculomegaly in the donor, in the 2 remaining because of an anterior placenta, limiting the chances for successful inspection of the vascular equator, and poor Doppler examination (“stage III”). In one case of TTTS (“stage III”) with posterior placenta and involvement of all 3 fetuses (1 recipient, 2 donors), laser coagulation of the vascular anastomoses was performed. Each procedure was done percutaneously by a single port and successful in arresting flow in the target cord or TTTS. All patients delivered beyond 30 weeks (range: 30.3–38 weeks), except for one. This patient underwent cord coagulation for TTTS at 22 wks, and developed PPROM within 3 weeks postoperatively. She delivered at 25 wks leading to 2 early neonatal deaths. There was 1 unexplained IUFD within 24 hours in a case of TRAP. One pregnancy is still ongoing without problems so far. Overall survival rate and survival of at least 1 fetus were respectively 77% (10/13) and 83% (5/6). Median birth weight of liveborn children was 1688 g (range: 700–2804). All surviving children had an uneventful neonatal course and of the children more than 1 yr of age (range: 1–6) (n = 5), all are developing normally. In this small case series of fetoscopic laser procedures in complicated MC or DC triplets, overall survival rate was 77% with favourable outcome. For cord occlusion, this is comparable with the outcome in twins. Fetoscopic surgery seems feasible. Technical restrictions and clinical presentation may influence the choice of procedure.