Abstract
Fetoscopic laser photocoagulation (FLP) of placental anastomoses is the preferred treatment for twin-to-twin transfusion syndrome (TTTS). Iatrogenic septostomy (IOS) during FLP is associated with increased risk of neonatal morbidity and mortality. We sought to identify risk factors for IOS and quantify the resultant outcomes. This is a secondary analysis of prospectively collected cases of TTTS in monochorionic diamniotic twins following FLP at a single center. Pre-operative ultrasound characteristics and operative technique (i.e., cannula size, total energy used) were compared between cases with vs. without IOS. Pregnancy and neonatal outcomes were also compared. Of 475 patients that had FLP, 33 (7%) were complicated by IOS. There was no association between operative technique and IOS. IOS was more common with later diagnosis, but less likely when selective fetal growth restriction (sFGR) was present. Survival was similar between groups (76% vs. 76% dual survivors, p = 0.95); however, IOS was associated with earlier delivery (29.7 vs. 32.0 wks, p < 0.01) and greater composite neonatal morbidity (25% vs. 8% in both twins, p = 0.02). Risks of IOS at greater gestational ages without sFGR may be related to a larger collapsed intervening membrane area and the resulting increased risk of puncture on entry.
Highlights
Twin-to-twin transfusion syndrome (TTTS) is a complication affecting 10–15% of monochorionic diamniotic (MCDA) twin pregnancies [1,2,3]
Fetoscopic laser photocoagulation (FLP) is associated with several complications related to the intervening and surrounding fetal membranes including preterm premature rupture of membranes (PPROM), chorion amnion separation (CAS), and inadvertent iatrogenic septostomy (IOS) [6,7]
The present study includes several important findings: (1) Iatrogenic septostomy (IOS) occurred in 6.9% of TTTS cases treated with FLP. (2) IOS was more likely to occur in TTTS treated at later gestational ages with greater recipient MVPs, larger Estimated fetal weights (EFWs), and greater growth discordance between twins
Summary
Twin-to-twin transfusion syndrome (TTTS) is a complication affecting 10–15% of monochorionic diamniotic (MCDA) twin pregnancies [1,2,3]. FLP is associated with several complications related to the intervening and surrounding fetal membranes including preterm premature rupture of membranes (PPROM), chorion amnion separation (CAS), and inadvertent iatrogenic septostomy (IOS) [6,7]. The reported incidence of IOS is 1.3–20% [6,8,9,10,11] It has been associated with increased rates of preterm delivery and PPROM at earlier gestational ages, development of an iatrogenic pseudo-monoamniotic pregnancy with associated cord entanglement, amniotic band syndrome, decreased survival, and increased neonatal morbidity [8,9,10,11]. IOS is thought to occur either by heat degeneration during ablation of anastomoses located behind the intervening membrane
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