Permanent feto-fetal transfusion from the recipient to the donor twin. A complication of laser surgery in twin-to-twin transfusion syndrome

Abstract

A COMPLICATION OF LASER SURGERY IN TWIN-TO-TWIN TRANSFUSION SYNDROME ROMAINE ROBYR, LIESBETH LEWI, MASAMI YAMAMOTO, JAN DEPREST, YVES VILLE, Universite Paris Ouest SQY-V CHI Poissy St Germain en Laye, Poissy, France, University Hospital Gasthuisberg, Leuven, Belgium OBJECTIVE: Laser ablation of placental anastomoses is an effective treatment of severe midtrimester twin-to-twin transfusion syndrome (TTTS). We report on recipient to donor exsanguination as a iatrogenic complication. STUDY DESIGN: Cases of severe TTTS treated by laser proceeding with two survivors after surgery. Weekly follow–up scans performed after hospital discharge included Doppler measurement of mid-cerebral artery peak systolic velocity (MCA PSV) and suspicion of anemia led to fetal blood sample (FBS) and intrauterine transfusion (IUT) when indicated. RESULTS: 120 consecutive cases led to 55 ongoing pregnancies with 2 survivors 2 days after surgery. MCA PSV increased (mean: 2.02 MoM (1.54.1). In 8/55 recipient-twins 3 to 28 days after laser without any other ultrasound feature of anemia or recurrence of TTTS. All recipients were anemic on FBS with a mean hemoglobin concentration of 4.5 (2.5 9) g/dL and were given IUT. All donors showed low MCA PSV mean 0.55 (0.43-0.78) MoM suggesting polycythemia as confirmed (19 and 24 g/dL) in two that were sampled. Kleihauer Betke test was negative in maternal blood but showed adult red cells in the donor’s blood following transfusion of its co-twin confirming the mechanism of feto-fetal transfusion. Depending on gestational age and fetal consequences, subsequent management included repeat laser, elective delivery, serial IUT and selective cord coagulation for fetal anomaly in 2, 2, 2, and 4 cases respectively. Four patients delivered two live babies and 4 had only one survivor None showed persistant hematological dysfunction. Examination of the placentae in cases with 2 survivors, showed remaining uncoagulated anastomoses. CONCLUSION: Incomplete coagulation of chorionic plate anastomoses and subsequent exsanguination of a hypervolemic recipient into a hypovolemic donor can be seen up to 4 weeks after surgery in up to 10% of double survival. Follow-up of double survivors with MCA PSV Doppler measurement should therefore be recommended.