Fetoscopic Selective Laser Coagulation Research Articles

OP24.04: Early changes in fetal cardiac function following fetoscopic selective laser coagulation of placental anastomoses for severe twin–twin transfusion syndrome

OP24.04: Early changes in fetal cardiac function following fetoscopic selective laser coagulation of placental anastomoses for severe twin–twin transfusion syndrome

OP24.05: Management of high‐order multiples complicated by TRAP sequence

Objectives: To describe early changes in fetal cardiac function after laser treatment in severe twin–twin transfusion syndrome (TTTS). Methods: A prospective study was conducted over a fivemonth period. Cardiac function was assessed in 49 consecutive monochorionic pregnancies presenting with severe TTTS and referred for fetoscopic selective laser coagulation (FSLC) of placental anastomoses as first-line treatment. Echocardiography was performed on admission and after laser treatment (median = 1 day, IQR = 1–3). The studied parameters included cardiac output, myocardial performance index, shortening fraction (SF), and heart dimensions. Results: Median gestational age was 21 weeks (IQR = 19–23). Distribution across Quintero stages was as follow: 32.7%, 18.4%, 46.9% and 2.0% for stages 1, 2, 3 and 4 respectively. Cardiac output significantly increased after laser treatment in both donor (+33%) and recipient twins (+24%). In the recipient twin, a significant increase in LV SF was also found. The increase in cardiac output was not significantly correlated with Quintero stage, the volume of amniotic fluid drained, or gestational age. Conclusions: As early as 24 h after laser treatment, a significant increase in systolic function was found in both twins. These changes seem to be unrelated to initial severity of the syndrome.

Fetoscopic Laser Surgery in 100 Pregnancies with Severe Twin-to-Twin Transfusion Syndrome in the Netherlands

Objective: In this prospective cohort study, we evaluated the initial results of fetoscopic laser surgery for severe second trimester twin-to-twin transfusion syndrome (TTTS) treated at our centre. Method: A total of 100 consecutive pregnancies with severe second trimester TTTS treated at our centre with selective fetoscopic laser coagulation of vascular anastomoses on the placental surface between August 2000 and November 2004 were included in the study. Perinatal survival was analysed in relation to Quintero stage. Results: Median gestational age was 20 weeks at fetoscopy (range: 16–26) and 33 weeks at delivery (range: 18–40). Perinatal survival rate was 70% (139/200). The treatment resulted in at least one survivor at the age of 4 weeks in 81% of pregnancies. Perinatal survival was significantly higher when treatment was performed in the early Quintero stages (95% in stage 1, 76% in stage 2, 70% in stage 3, 50% in stage 4) (p = 0.02). Conclusion: Results of fetoscopic laser surgery for TTTS in our centre are similar to those in specialised centres in other countries. Diagnosis and treatment in the early Quintero stages resulted in significantly higher perinatal survival.

Endoscopic laser surgery versus serial amnioreduction for severe twin-to-twin transfusion syndrome*

BACKGROUND: Monochorionic twin pregnancies complicated by severe twin to twin transfusion syndrome at midgestation can be treated by either serial amnioreduction(removal of large volumes of amniotic fluid) or selective fetoscopic laser coagulation of the communicating vessels on the chorionic plate. We conducted a randomized trial to compare the efficacy and safety of these two treatments. METHODS: Pregnant women with severe twin to twin transfusion syndrome before 26 weeks of gestation were randomly assigned to laser therapy or amnioreduction. We assessed perinatal survival of at least one twin (a prespecified primary outcome),survival of at least one twin at six months of age, and survival without neurologic complications at six months of age on the basis of the number of pregnancies or the number of fetuses or infants, as appropriate. RESULTS:The study was concluded early, after 72 women had been assigned to the laser group and 70 to the amnioreduction group, because a planned interim analysis demonstrated a significant benefit in the laser group. As compared with the amnioreduction group, the laser group had a higher likelihood of the survival of at least one twin to 28 days of age (76 percent vs. 56 percent; relative risk of the death of both fetuses, 0.63; 95 percent confidence interval, 0.25to 0.93; P=0.009) and 6 months of age (P=0.002). Infants in the laser group also had a lower incidence of cystic periventricular leukomalacia (6 percent vs. 14 percent,P=0.02) and were more likely to be free of neurologic complications at six months of age (52 percent vs. 31 percent, P=0.003). CONCLUSIONS: Endoscopic laser coagulation of anastomoses is a more effective first linetreatment than serial amnioreduction for severe twin totwin transfusion syndrome diagnosed before 26 weeks of gestation.

OC119: Prognostic factors for preterm delivery in twin‐to‐twin transfusion syndrome (TTTS) treated by laser coagulation

Background: Monochorionic twin pregnancies complicated by severe twin-to-twin transfusion syndrome at midgestation can be treated by either serial amnioreduction (removal of large volumes of amniotic fluid) or by selective fetoscopic laser coagulation of the communicating vessels on the chorionic plate. We conducted a randomized trial to compare the efficacy and safety of these two methods of treatment. Methods: Pregnant women with severe twin-to-twin transfusion syndrome before 26 weeks of gestation were randomly assigned to laser therapy or amnioreduction. We assessed perinatal survival of at least one twin (a prespecified primary outcome), survival of at least one twin at 6 months of age, and survival without neurologic morbidity at 6 months of age. Results: The study was concluded early, after randomization of 72 women to the laser group and 70 to the amnioreduction group, based on results of a planned interim analysis demonstrating a significant benefit in the laser group. As compared with the amnioreduction group, the laser group had a higher likelihood of survival of at least one twin both in the perinatal period (76.4 percent vs. 55.7 percent; relative risk = 1.37 [95 percent confidence interval: 1.07–1.75]; P = 0.009) and at 6 months of age (P = 0.002). As compared with the amnioreduction group, infants in the laser group had a lower incidence of periventricular leukomalacia (5.6 percent vs. 14.3 percent; P = 0.02), and were more likely to be alive without neurological morbidity at 6 months (52.1 percent vs. 31.4 percent; P = 0.003). Conclusion: Endoscopic laser coagulation of anastomoses is a more effective first-line treatment of severe twin-to-twin transfusion syndrome diagnosed before 26 weeks’ of gestation than serial amnioreduction.