Abstract
As twin-twin transfusion syndrome (TTTS) and selective fetal growth restriction (sFGR) are both prevalent complications of monochorionic (MC) twin pregnancies, its coexistence is not uncommon. The aim of this study is to evaluate the short and long-term outcome in TTTS with and without sFGR prior to fetoscopic laser coagulation. All TTTS cases treated with laser surgery at our center between 2001–2019 were retrospectively reviewed for the presence of sFGR, defined as an estimated fetal weight (EFW) <10th centile. We compared two groups: TTTS-only and TTTS + sFGR. Primary outcomes were perinatal survival and long-term severe neurodevelopmental impairment (NDI). Of the 527 pregnancies eligible for analysis, 40.8% (n = 215) were categorized as TTTS-only and 59.2% (n = 312) as TTTS + sFGR. Quintero stage at presentation was higher in the TTTS + sFGR group compared to the TTTS-only group (57% compared to 44% stage III). Separate analysis of donors showed significantly lower perinatal survival for donors in the TTTS + sFGR group (72% (224/311) compared to 81% (173/215), p = 0.027). Severe NDI at follow-up in long-term survivors in the TTTS-only and TTTS + sFGR group was present in 7% (13/198) and 9% (27/299), respectively (p = 0.385). Both sFGR (OR 1.5;95% CI 1.1–2.0, p = 0.013) and lower gestational age at laser (OR 1.1;95% CI 1.0–1.1, p = 0.001) were independently associated with decreased perinatal survival. Thus, sFGR prior to laser surgery is associated with a more severe initial presentation and decreased donor perinatal survival. The long-term outcome was not affected.
Highlights
Twin-twin transfusion syndrome (TTTS) is a disorder arising from inter-twin blood flow imbalances caused by vascular anastomoses on the surface of the shared placenta in monochorionic (MC) twins [1]
After exclusion according to the aforementioned criteria, 527 pregnancies were eligible for analysis, of which 40.8% (n = 215) were categorized as TTTS-only and 59.2% (n = 312) as TTTS + selective fetal growth restriction (sFGR)
Our study shows that the donor perinatal survival is significantly decreased (72% compared to 81%) in TTTS cases with coexistent sFGR prior to laser surgery, mainly caused by an increased donor fetal death rate (24% compared to 17%). sFGR prior to laser surgery appeared to be an independent predictor of decreased perinatal survival
Summary
Twin-twin transfusion syndrome (TTTS) is a disorder arising from inter-twin blood flow imbalances caused by vascular anastomoses on the surface of the shared placenta in monochorionic (MC) twins [1]. The donor transfers blood to the recipient, resulting in hypovolemia in the donor and hypervolemia in the recipient. Due to the decreased blood volume, the donor may present with growth restriction, next to the oliguria and oligohydramnios, while the recipient suffers from polyhydramnios [2]. TTTS has a high perinatal mortality rate [3]. Fetoscopic laser surgery is the preferred treatment for TTTS, coagulating the placental vascular equator after selective coagulation of the anastomoses, called the Solomon technique [5,6]
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