Stage-based treatment of twin-twin transfusion syndrome

Abstract

Objective: The purpose of this study was to compare the outcomes of patients with twin-twin transfusion syndrome who were treated with either serial amniocentesis or selective laser photocoagulation of communicating vessels according to disease severity (stage). Study Design: Centers that were experienced in the treatment of twin-twin transfusion syndrome were invited to share stage-based perinatal outcome data. All patients met basic standard sonographic criteria for twin-twin transfusion syndrome (polyhydramnios maximum vertical pocket, ≥8 cm; oligohydramnios maximum vertical pocket, ≤2 cm). Gestational age at first treatment was <27 weeks of gestation. Results: Three centers submitted stage-based data, for a total of 173 patients (serial amniocentesis, 78 patients from all 3 centers) and 95 selective laser photocoagulation of communicating vessels (1 center). The distribution of patients by stage was similar in the two groups. Successful pregnancy outcome (at least 1 surviving infant) was correlated inversely with stage in the serial amniocentesis but not in the selective laser photocoagulation of communicating vessels group and was significantly lower in the serial amniocentesis (66.7%) than in the selective laser photocoagulation of communicating vessels group (83.2%). Neurologic morbidity was related directly to stage in the serial amniocentesis group but not in the selective laser photocoagulation of communicating vessels group and was significantly higher in the serial amniocentesis (24.4%) than in the selective laser photocoagulation of communicating vessels (4.2%) group. Intact neurologic survival (at least 1 surviving infant without neurologic morbidity) was significantly lower in the serial amniocentesis group than in the selective laser photocoagulation of communicating vessel group (51.3% vs 78.9%), particularly in stage III and stage IV (23.5% vs 72.7% in stage IV). Patients who were treated with selective laser photocoagulation of communicating vessels were 2.4 times more likely to have at least one survivor than those treated with serial amniocentesis. Conclusion: Our study suggests a relationship between perinatal morbidity and mortality rates and stage in serial amniocentesis but not in selective laser photocoagulation of communicating vessel-treated twin-twin transfusion syndrome patients. These findings could be used to tailor the treatment of twin-twin transfusion syndrome. A clinical trial to confirm these results is being organized by our research groups. (Am J Obstet Gynecol 2003;188:1333-40.)