Laser Ablation Of Placental Anastomoses Research Articles

The impact of fetal surgical procedures on perinatal anxiety and depression

BackgroundPerinatal mental illness imparts a significant health burden to both patients and families. Many factors are hypothesized to increase the incidence of perinatal depression and anxiety in the fetal surgical population, including uncertain fetal prognosis and the inherent risks of surgery and preterm delivery. ObjectiveThe aim of this study was to determine the incidence and disease course of postpartum depression and anxiety in the fetal surgery population. Study DesignA retrospective chart review was conducted of fetal surgery patients delivering between November 2016 – November 2021 at an academic level IV perinatal health care center. Demographics and surgical, obstetric, and psychiatric diagnoses were abstracted. Standard descriptive analyses were performed. ResultsEligible patients were identified (n=119). Fetal surgery was performed at a mean gestational age of 22.8 weeks (SD: 4.11) weeks. Laser ablation of placental anastomoses (n=51) and in utero myelomeningocele repair (n=22) were the most common procedures. 28.6% (34/119) of patients carried the diagnosis of pre-existing depression or anxiety, with 55.9% (19/34) and 50.0% (17/34) of those on a baseline medication for depression or anxiety, respectively, prior to surgery. 27.1% (23/85) of patients without a history of anxiety or depression had new identification of one or both postpartum. Two patients experienced suicidal ideation postpartum.6.7% (8/119) and 10.1% (12/119) initiated a new psychiatric medication during or post-pregnancy, respectively. 16.0% (19/119) received a therapy referral. Among patients with baseline anxiety or depression, 58.8% (20/34) experienced an exacerbation postpartum with 26.5% (9/34) referred for therapy, and 26.5% (9/34) changing dose or medication for anxiety and 32.4% (11/34) for depression. 20.2% (24/119) of patients experienced new or worsening depression or anxiety after the standard 6-week postpartum visit. ConclusionAmong patients undergoing fetal surgery, a high incidence of postpartum depression and anxiety was identified, with most patients with pre-pregnancy anxiety or depression experiencing exacerbation postpartum. The timeframe to clinical presentation with depression or anxiety symptoms may be delayed beyond the traditional six-week postpartum period and into the first postpartum year. This observation could be attributed to de novo postpartum exacerbation or a lack of standardized treatment approaches earlier in the disease course or antepartum period. Understanding effective longitudinal supportive interventions is an essential next step.

Effect of Fetal Surgery on Maternal Mental Health [ID: 1376946

INTRODUCTION: Perinatal mental illness imparts a significant health burden. A multitude of factors are hypothesized to increase the incidence of perinatal mood and anxiety disorders (PMADs) in the fetal surgical population, including uncertain fetal prognosis and the inherent risks of surgery and preterm delivery. We sought to determine the disease course of PMADs in the fetal surgery population. METHODS: A retrospective chart review was conducted of fetal surgery patients from 2017 to 2021 at a tertiary care center. Demographics, surgical, obstetric, and psychiatric diagnoses were recorded. Standard descriptive analyses were performed. RESULTS: One hundred nineteen eligible patients were identified. Fetal surgery was performed at a median gestational age of 23.0 (range 16.0–34.0) weeks. Laser ablation of placental anastomoses (n=51) and in utero myelomeningocele repair (n=22) were the most common procedures. 26.8% (32/119) had preexisting mood disorders, with 59.3% (19/32) and 53.1% (17/32) on a baseline medication for depression or anxiety, respectively, prior to surgery. 26.4% (23/87) of patients without a history of anxiety or depression had a new diagnosis of PMAD. Two patients experienced suicidal ideation. 6.7% (8/119) and 10.1% (12/119) initiated a new psychiatric medication during or post-pregnancy, respectively. 19.8% (21/113) received a therapy referral. Among patients with baseline anxiety or depression, 62.5% (20/32) experienced an exacerbation postpartum with 25.0% (8/32) referred for therapy, and 34.3% (11/32) changing dose or medication for anxiety and 37.5% (12/32) for depression. CONCLUSION: Among patients undergoing fetal surgery, a high incidence of PMAD was identified. Most patients with prepregnancy anxiety or depression experienced an exacerbation postpartum. Further research into effective supportive interventions is warranted.

Spotlight on… multiple pregnancy

Multiple pregnancy has received increasing attention over the last decade, with the National Institute for Health and Care Excellence (NICE) guideline on multiple pregnancy already in its second edition.1 The first review article about multiple pregnancy in The Obstetrician and Gynaecologist (TOG) was published in 2000 by Taylor and Fisk (TOG 2000;2:4–10). Looking again at this article and seeing the photograph of a young Myles Taylor (as all TOG articles featured the authors’ photos then!) brought back fond (…) memories of reading this for the MRCOG examination. It is interesting to compare the older article with a 2010 Review by Devaseelan and Ong (TOG 2010;12:179–85). Most aspects of care were largely unchanged, but the Eurofoetus trial2 had proven that endoscopic laser ablation of placental anastomoses was the treatment of choice for severe twin-to-twin transfusion syndrome (TTTS). Soon after the publication of the Eurofoetus study,2 Smith and Denbow wrote a comprehensive review on TTTS (TOG 2006;8:1–6) and its evolving management in light of the landmark trial. The complex management of TTTS has also been reviewed in the two Advances in fetal therapy articles published in 2005 (TOG 2005;7:183–9) by O’Brien and Kumar and in 2010 (TOG 2010;12:94–102) by Morris et al. Monoamniotic twin pregnancies are rare and challenging to manage. Dias et al. reviewed the pathophysiology, outcomes and management of these pregnancies in 2012 (TOG 2012;14:71–8). Even more challenging is the management of higher order multiple pregnancies and multiple pregnancies where one fetus has severe genetic or congenital abnormalities. Beriwal et al. summarised elegantly Multifetal pregnancy reduction and selective termination in 2020 (TOG 2020;22:284–92). Importantly, the authors highlighted the ethical, legal and psychological considerations for women, couples and doctors in these difficult cases. Beyond the rare multiple pregnancy cases that are mainly managed in fetal medicine units, the major challenge and source of neonatal mortality and morbidity in multiple pregnancies is preterm birth. Effective prevention strategies are still not available, but the most recent evidence was finely appraised by Murray et al. in 2018 (TOG 2018;20:57–63). For both preterm and term births, mode of delivery can be a difficult decision. Breeze and Smith reviewed the evidence for mode of delivery in twins in 2004 (TOG 2004;6:222–6). The Twin Birth Study has been published since then3 and has answered some questions about the safety of vaginal birth and caesarean section and actual mode of delivery depending on original intention. Overall, TOG has published a comprehensive selection of articles on the management of multiple pregnancy. As it is now 11 years since the last general multiple pregnancy review article (TOG 2010;12:179–85), perhaps it is time for another up-to-date review incorporating the latest evidence from the Twin Birth Study,3 the STOPPIT-2 trial4 and other relevant studies.

Fetoscopic laser ablation therapy in monochorionic diamniotic twin pregnancies with twin-to-twin transfusion syndrome treated at a single centre over 10 years: a retrospective study.

To review experience with fetoscopic laser ablation of placental anastomoses to treat monochorionic diamniotic (MCDA) twin pregnancies complicated by twin-to-twin transfusion syndrome (TTTS) in a single centre over a ten-year period. A retrospective study on 142 MCDA twin pregnancies complicates by TTTS treated with equatorial laser ablation of placental anastomoses (2008-2018). Solomon technique was also applied after 2013. Survival rates, neonatal outcome, intraoperative and post-laser complications were recorded, and prognostic factors analysed. A total of 133 cases were included in the final analysis; 41 patients were at stage II (30.8%), 73 were at stage III (62.9%), while only 12 (9%) at stage I and two patients (1.7%) at stage IV. Solomon technique was applied in 39 cases (29.3%). Survival of both twins was 51.1% (68/133), of a single twin 20.3% (27/133), and of at least one 71.5% (95/133), with an overall survival of 61.3% (163/266). TAPS and recurrent TTTS occurred in 8 (6%) and 15 (11.3%) patients. Survival of both fetuses increased over time (44.6 vs. 57.3%). A posterior placenta (p<0.003) and the use of the Solomon technique (p<0.02) were more frequent in cases with survival of both fetuses, while TTTS recurrence was significantly associated to the loss of one or two fetuses (p<0.01). Such associations were confirmed at logistic regression analysis. Survival of both twins can improve over time and seems to be favourably associated with a placenta in the posterior location and the use of the Solomon technique.

Perioperative Care of Patients Diagnosed With Twin-to-Twin Transfusion Syndrome Undergoing Laparoscopic-Assisted Fetoscopic Placental Laser Photocoagulation.

Twin-to-twin transfusion syndrome (TTTS) is a condition that results in unbalanced blood flow between two fetuses. Patients diagnosed with TTTS can experience maternal or fetal morbidity and mortality. Depending on the severity of TTTS, laser ablation of placental anastomoses may be the most effective treatment. The preferred treatment method requires percutaneous entry to the uterus; however, some patient circumstances (eg, placenta location) require a laparoscopic-assisted procedure. During the preoperative appointments, clinicians assess the condition of the fetuses and patients may participate in genetic counseling. Intraoperative care involves an interdisciplinary team that may include a pediatric general surgeon, maternal-fetal medicine specialists, an RN circulator, a scrub person, and an anesthesia professional. Perioperative nurses should have knowledge of the pathophysiology of TTTS, including its natural progression. They also should understand preoperative and intraoperative patient care requirements to provide safe and effective care for patients undergoing laparoscopic-assisted fetoscopic placental laser photocoagulation procedures.

A novel "video-game" simulator for training fetoscopic laser coagulation of anastomoses in twin-to-twin transfusion syndrome.

: We have developed a high-fidelity interactive "video-game" simulator in order to teach fetoscopic laser ablation of placental anastomoses for twin-twin transfusion syndrome This simulator may be used by teachers in order to provide metrics-based simulator education to multiple trainees, in both hands-on and distanced learning settings WHAT IS ALREADY KNOWN ABOUT THIS TOPIC?: The use of simulation improves training of the fetoscopic laser techniques utilized in the treatment of twin-twin transfusion syndrome A number of mannequins have been developed to aid this education WHAT DOES THIS STUDY ADD?: Two new simulators are described for twin-twin transfusion syndrome training-silicone and digital The digital simulator is a novel digital video game virtual format This new format has enhanced interactivity and has the potential to enable distance learning.

420: Differences in impedance to blood flow in the umbilical arteries determine infant survival in TTTS

Unequal placental sharing is associated with inter-twin size discordance, twin-to-twin transfusion syndrome (TTTS) and reduced infant survival in monochorionic twin pregnancies. This study explores if inter-twin differences in impedance to blood flow (IDIBF) in the umbilical arteries influences infant survival in TTTS. All women who underwent laser ablation of placental anastomoses for the management of TTTS between January 2012 and May 2018 at a single institution were included. Laser surgery was performed in all cases with Quintero stages II or greater and in women with Quintero stage I with either symptomatic polyhydramnios, cervix shortening or preterm labor. IDIBF in the umbilical arteries was estimated by substracting the pulsatility index (PI) of the umbilical artery of the donor twin from that of the recipient twin, prior to surgery. Outcomes included dual infant survival or survival of at least one fetus at delivery and at 30 days of age. Logistic regression analyses were perfomed to determine the relationship of IDIBF in the umbilical arteries with the study outcomes, while controling for gestational age (GA) at surgery, GA at delivery, Quintero stage, cervical length prior to surgery, inter-twin size discordance ≥25% and/or EFW<10 percentile for GA, advanced maternal age (≥35 years old), maternal obesity (BMI>35), and number of placental anastomoses. A total of 230 consecutive TTTS cases met study the inclusion criteria. TTTS Quintero stages I, II, III and IV were present in 10%, 31.3%, 50.9% and 7.8% of all cases, respectively. Inter-twin size discordance ≥25% and/or EFW<10 percentile for gestational age was present in 72.4% of cases. Two live births or at least one live birth was present in 68.3% and 88.3% of cases, respectively. Two infants or al least one infant was alive by 30 days in 70.8% and 96.4% of cases, respectively. 27% (n=62) were lost to follow-up by 30 days or have not reached this age yet. Logistic regression analysis demonstrated that IDIBF in the umbilical arteries is an independent factor for the survival of one (p=0.004) or both infants (p<0.001) at birth as well as for the survival of both infants at 30 days of age (p=0.01). In contrast, neither Quintero staging nor inter-twin size discordance were associated with these outcomes (see Table). Differences in impedance to blood flow in the umbilical arteries may influence infant survival in TTTS cases following laser ablation of placental anastomoses.

Short-Time Impact of Laser Ablation of Placental Anastomoses on Myocardial Function in Monochorionic Twins with Twin-to-Twin Transfusion Syndrome.

Purpose To evaluate pre- and post-procedure myocardial function in monochorionic twins with TTTS who underwent laser ablation of placental anastomoses using pulsed wave tissue Doppler imaging (pw TDI). Materials and Methods 20 monochorionic twin gestations with TTTS were included and underwent laser ablation at our center between 2011 and 2014. Prior to and after the intervention, cardiac function was assessed by measuring the mitral annular plane systolic excursion (MAPSE), the tricuspid annular plane systolic excursion (TAPSE), Tei index, isovolumetric contraction time (ICT), ejection time (ET), isovolumetric relaxation time (IRT) for the left ventricle in pulsed wave Doppler (pw D) ultrasound as well as ICT, ET, IRT and Tei index in pw TDI for the left and right ventricle. E-, A-, E´- and A´-wave peak velocity and the systolic downward motion (S´) were measured for both ventricles and the E/A, E/E´ and E´/A´ ratios were calculated. In a mean of 1.3 (SD 0.6) days after laser ablation, this measurement protocol was repeated. Results Pre-intervention recipients had longer ICT, ET and IRT in pw D and pw TDI compared to donors not reaching statistical significance for most parameters. Statistically significant were prolonged ICT in pw D (p 0.01) and ET (p 0.01) in pw TDI in recipients. In donor fetuses preoperative myocardial function did not differ significantly from postoperative myocardial function except in increased left ventricular ejection time of the left ventricle in pw TDI (p 0.04) and an increased E´/A´ratio (p 0.01). After laser coagulation, myocardial function was slightly altered in recipients as ICT and IRT shortened and Tei indices decreased but only reaching statistical significance in shortened IRTs in pw TDI for both ventricles. Conclusion Laser ablation of placental anastomoses in TTTS might influence myocardial function in the postoperative period. Shortened IRT intervals may reflect an improvement of diastolic function in recipients.

OC18.01: Stage‐based outcomes for 400 cases of TTTS managed with fetoscopic laser ablation of placental anastomoses

OC18.01: Stage‐based outcomes for 400 cases of <scp>TTTS</scp> managed with fetoscopic laser ablation of placental anastomoses

OC26.06: Short‐time impact of laser ablation of placental anastomoses on myocardial function in monochorionic twins with twin–twin transfusion syndrome (TTTS)

<scp>OC</scp>26.06: Short‐time impact of laser ablation of placental anastomoses on myocardial function in monochorionic twins with twin–twin transfusion syndrome (<scp>TTTS</scp>)

P07.20: Peri‐operative changes in fetal cardiac function with fetoscopic laser ablation of placental anastomoses in twin‐to‐twin transfusion syndrome

<scp>P</scp>07.20: Peri‐operative changes in fetal cardiac function with fetoscopic laser ablation of placental anastomoses in twin‐to‐twin transfusion syndrome

Reply

We note the comments made by Moise and colleagues regarding our study, ‘Fetoscopic laser ablation of placental anastomoses in twin–twin transfusion syndrome using ‘Solomon technique’, published in this journal last year1, and welcome the opportunity to provide further information about our study. Moise et al. stated that their esteemed colleagues at Leiden University (Enrico Lopriore et al.) described the Solomon method 3 years earlier than did Chalouhi et al.. We would like to point out that there was never a claim of primacy regarding the Chalouhi et al. study2 made in our article. Enrico Lopriore et al.3 may well have been the first to use the term. Moise et al. make the statement that: ‘Most laser centers in such large countries as the USA and Brazil serve a large referral population base with great geographic distribution. As such, complete perinatal follow-up is difficult.’ While we cannot make sweeping statements about the type of follow-up offered by their center or that offered by ‘most laser centers in large countries’, we do pride ourselves on our own efforts to obtain this information for our patients, regardless of their geographic origin. While it may be difficult, it can certainly be done, and we follow all our post-laser patients closely with Doppler studies after surgery, in some cases performed by the referring physicians, and in others (more local) by ourselves. In the patients involved in our study none was lost to follow-up. As requested, in Table 1, we have provided further information about the six cases that developed twin anemia-polycythemia sequence (TAPS). The ‘Solomon technique’ was not performed in any of these patients. As demonstrated in Table 1, all had Doppler studies confirming the diagnosis of TAPS4. Three of these patients had an anterior placenta and three had a posterior placenta. Intrauterine fetal blood transfusion was performed in one case (Case 1). In four of the six cases, the TAPS was diagnosed late and all four were delivered by preterm Cesarean section. One patient had twin demise in utero and the classic features of anemia and plethora were confirmed at delivery but no hemoglobin values could be obtained. The remaining five twin sets had postnatal confirmation of an intertwin hemoglobin difference > than 8 g/dL. Regarding the number of ‘unsuccessful’ cases of complete ‘Solomonization’, we did not receive all of the placentae for pathological examination and so cannot be sure. This was, unfortunately, one of the limitations of our study. Moise et al. stated that: ‘The dual neonatal survival rate in the control group was 46%, a rate that is lower than that reported by other experienced centers’. We note that Moise and his colleagues have not supplied us with their dual fetal survival prior to their adoption of the Solomon technique, but we are reasonably sure that it was very similar to that reported in our paper, and that reported by another USA center (50.7%)5. The surgeons who operated on the cases in our study were experienced and were not new to laser surgery6. Thus, we feel that the improvement in dual survival that we, and others7, have shown following adoption of the Solomon technique is most probably due to the benefits of the technique itself, and not due to increasing experience of the operators. In fact, the results of one of our trainees, who learned to perform laser therapy using only the Solomon technique, show dual survival of 70% (14/20) for his first 20 cases (pers. comm.), which suggests that good results are possible even during the learning curve using this technique. His cases were all performed after July 2012. This result compares favorably with that reported by the experienced operators in Moise's group (75%)8. Given that our study was not a randomized controlled trial, and that the two techniques were employed sequentially in our study, the question is still valid, and is one that, hopefully, will be answered soon by the randomized controlled trial that is underway. R. Ruano*†, C. Rodo‡, J. L. Peiro‡, A. A. Shamshirsaz†, S. Haeri†, M. L. Nomura§, E. M. A. Salustiano§, K. K. De Andrade§, H. Sangi-Haghpeykar†, E. Carreras‡ and M. A. Belfort† †Baylor College of Medicine and Texas Children's Hospital, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Houston, TX, USA; ‡Hospital Universitari Vall d'Hebron and University Autonoma de Barcelona, Fetal Surgery Program, Barcelona, Spain; §Maternal-Fetal Institute in Campinas, Campinas, Brazil *Correspondence. Pavilion for Women – Texas Children's Fetal Center, 6651 Main Street, Suite F1020, Houston, TX 77030, USA (e-mail: ruano@bcm.edu; rodrigoruano@hotmail.com)

Fetoscopic laser ablation of placental anastomoses in twin–twin transfusion syndrome using ‘Solomon technique’

To document perinatal outcomes following use of the 'Solomon technique' in the selective photocoagulation of placental anastomoses for severe twin-twin transfusion syndrome (TTTS). Between January 2010 and July 2012, data were collected from 102 consecutive monochorionic twin pregnancies complicated by severe TTTS that underwent fetoscopic laser ablation at four different centers. We compared outcomes between subjects that underwent selective laser coagulation using the Solomon technique (cases) and those that underwent selective laser coagulation without this procedure (controls). Of the 102 pregnancies examined, 26 (25.5%) underwent the Solomon technique and 76 (74.5%) did not. Of the 204 fetuses, 139 (68.1%) survived up to 30 days of age. At least one twin survived in 82 (80.4%) pregnancies and both twins survived in 57 (55.9%) pregnancies. When compared with the control group, the Solomon-technique group had a significantly higher survival rate for both twins (84.6 vs 46.1%; P < 0.01) and a higher overall neonatal survival rate (45/52 (86.5%) vs 94/152 (61.8%); P < 0.01). Use of the Solomon technique remained independently associated with dual twin survival (adjusted odds ratio (aOR), 11.35 (95% CI, 3.11-53.14); P = 0.0007) and overall neonatal survival rate (aOR, 4.65 (95% CI, 1.59-13.62); P = 0.005) on multivariable analysis. There were no cases of recurrent TTTS or twin anemia-polycythemia sequence (TAPS) in the Solomon-technique group. Use of the Solomon technique following selective laser coagulation of placental anastomoses appears to improve twin survival and may reduce the risk of recurrent TTTS and TAPS. Our data support the idea of performing a randomized controlled trial to evaluate the effectiveness of the Solomon technique.

Fetal cardiac function in recipient twins undergoing fetoscopic laser ablation of placental anastomoses for Stage IV twin–twin transfusion syndrome

Cardiac dysfunction is common in the recipient fetus of twin-twin transfusion syndrome (TTTS). In this study, we aimed to document the severity of fetal cardiac dysfunction in Stage IV TTTS (fetal hydrops) and assess evolution of cardiac function longitudinally after fetoscopic laser surgery. We reviewed obstetric ultrasound examination data, pre- and postoperative echocardiograms and neonatal outcomes for 22 cases of Stage IV TTTS undergoing fetoscopic laser ablation of placental anastomoses between 1998 and 2011. Myocardial performance index, atrioventricular valve flow patterns, ventricular shortening fraction, ventricular hypertrophy, outflow tract obstruction and venous Doppler waveforms were assessed. Nineteen fetuses (86.4%) had ascites, eight (36.4%) had pleural effusions, nine (40.9%) had a pericardial effusion and 12 (54.5%) had subcutaneous edema at presentation. Preoperatively, cardiac function was grossly abnormal in all. Eight fetuses (36.4%) had functional pulmonary atresia and one (4.5%) had functional aortic atresia. Seventy-seven percent of recipient fetuses survived until birth. Postoperative echocardiographic follow-up (mean, 26 days) showed that indices of fetal cardiac function improved considerably, but never completely normalized. Six of the eight fetuses with functional pulmonary atresia (75.0%), as well as the fetus with functional aortic atresia, survived to birth. In all cases, the functional atresia resolved within 48 h of laser ablation therapy and none had structural valve anomalies at birth. All fetal effusions resolved after the laser. Fetoscopic laser ablation of placental anastomoses reverses cardiac dysfunction and valvulopathy, even in the most severe cases of TTTS. However, recovery takes longer than in early stage disease.

Outcome after fetoscopic selective laser ablation of placental anastomoses vs equatorial laser dichorionization for the treatment of twin-to-twin transfusion syndrome

The objective of the study was to compare the outcome in women with twin-twin transfusion syndrome (TTTS) who were managed by selective laser ablation of placental anastomoses (S-LASER) vs equatorial dichorionization of the anastomoses and chorionic plate (ED-LASER). We conducted an analysis of 2 consecutive cohorts with TTTS treated with S-LASER and ED-LASER. Preoperative, procedural, delivery, and outcome details were compared between treatment groups. A total of 147 twin pregnancies had laser (S-LASER, n = 71; ED-LASER, n = 76). Obstetric history, Quintero stage, placental location, individual arterial and venous Doppler parameters, and gestational age at laser and delivery did not differ. Use of lens fetoscope (96.1% vs 50.7%), coagulated anastomosis count (11 vs 15, P < .001), complete equatorial plate visualization (77.5% vs 92.1%, P = .019), and amniotic fluid transparency (80.3% vs 94.7%, P = .011) was greater during ED-LASER. Procedure-related complications, gestational age at delivery, and perinatal details were comparable between groups. ED-LASER was associated with significantly lower recurrence of TTTS (3.9% vs 8.5%), twin anemia polycythemia sequence (2.6% vs 4.2%), and amniotic fluid abnormalities (0% vs 5.6%, P < .05 for all comparisons). Logistic regression identified complete visualization of the equator as the primary determinant for successful TTTS treatment and coagulation of the chorionic plate as an independent cofactor. Double survival at age 6 months was significantly higher after ED-LASER (68.4% vs 50.7%, P < .05), attributable to a lower postlaser and neonatal mortality rates. In patients with TTTS, photocoagulation of causative anastomoses and the chorionic plate along the vascular equator decreases recurrence without increasing adverse outcome and improves survival compared with the selective technique.

Laser ablation of placental anastomoses in twin‐to‐twin transfusion syndrome: preoperative predictors of death by recursive partitioning

The aim of this study was to develop a simple clinical algorithm for prediction of donor and recipient death using 'yes'or 'no' questions through the process of recursive partitioning for patients undergoing laser therapy for twin to twin transfusion syndrome (TTTS). The intent was to identify a subset of patients with very high specificity to whom clinical decisions would be simplified. Secondary analysis of data retrospectively collected from laser procedures was performed for TTTS at NAFTNet centers from 2002 to 2009. Preoperative factors associated with donor and recipient death were identified by recursive partitioning regression analysis. Classification And Regression Trees (CARTs) were developed to refine specificity for prediction of death. There were 466 TTTS patients from eight centers. CARTs were obtained for prediction of donor death. Improved specificity was achieved through recursive partitioning as demonstrated in receiver operator characteristic curves for prediction of death of the donor. There was less than optimal predictive ability for prediction of death in the recipient, as demonstrated by lack of generation of CARTs. Recursive partitioning improves the specificity and refines the prediction of donor fetal and neonatal demise in TTTS treated with laser therapy. This has the potential to improve therapeutic choices and refine counseling regarding outcomes.

OP06.09: Maternal transient tachycardia following treatment of twin‐to‐twin transfusion syndrome by laser ablation of placental vascular anastomoses

Objectives: A significant subset of patients presents with new-onset maternal tachycardia (heart rate >100 beats per minute) 24 hours after laser coagulation of placenta anastomoses for twin-to-twin transfusion syndrome (TTTS). The clinical and pathophysiologic implications of this tachycardia are unknown. We thus investigated the relation between maternal clinical, surgical and laboratory findings and postoperative maternal tachycardia after fetoscopic laser for TTTS. Methods: Demographic data, surgical characteristics, maternal perioperative vital signs as well as hematologic, coagulation and biochemistry blood work were retrospectively reviewed in 311 patients undergoing fetoscopic laser ablation of placental anastomoses for TTTS. Results: Fifty-four women (17.4%) had new-onset persistent tachycardia 24 hours after laser. Simultaneously, a significant drop of both systolic (9mmHg) and diastolic (−8 mmHg) blood pressure (BP) was observed (P 3,000 mL (Odds Ratio [OR] 2.0, 95% Confidence Interval [95% CI] 1.1–3.9) and indomethacin use in the post-laser period (OR 0.3, 95% CI 0.1–0.6) as the only variables independently associated with maternal postoperative tachycardia. Maternal tachycardia did not lead to any changes in clinical management. Conclusions: Feto-maternal volume shifts as well as changes in intraabdominal pressure after fetoscopic laser cause a drop in maternal BP and an increase in maternal HR. These changes may be affected by the use of Indomethacin through its effects on maternal pain and diuresis.

Estudio de la función cardiaca en el síndrome de transfusión feto fetal

IntroductionTwin to twin transfusion syndrome (TTTS) leads to cardiac dysfunction, mainly in the recipient twin. After laser ablation of placental anastomoses, an improvement has been described. ObjectivesTo assess cardiac function in both recipient and donor twins in TTTS, its association with Quintero stages, and the impact of intrauterine therapy. Material and methodsProspective study based on 58 consecutive TTTS referred to a single centre (March 2008-March 2012). Assessment of cardiac function was performed on the recipient and donor fetuses before and 48-72h after the procedure (laser photocoagulation of placental anastomoses or cord occlusion). ResultsA complete cardiovascular examination was possible in 88% (51/58). Up to 90% of stage i and ii recipients showed a left ventricle Tei index >3Z-Score. After intrauterine treatment of TTTS, the right heart function improved in recipient fetuses. No differences were found in left ventricle Tei index. In donor twins, there was a significant decrease in pathological blood flow velocity waveform in the umbilical artery and a trend to a worse right cardiac function. ConclusionsIn TTTS, cardiac dysfunction commonly affects the recipient twin. This is already present at early stages of Quintero. Intrauterine therapy induces changes in cardiac function. Shortly after the procedure, right heart function improves in recipient twins but it worsens in the donors.

387: Importance of monitoring for twin anemia-polycythemia sequence (TAPS) in MC/DA twins without TTTS

TAPS is a recently described rare but serious complication of monochorionic/diamniotic (MC/DA) twins. It can occur spontaneously or in twin-to-twin transfusion syndrome (TTTS) following incomplete fetocopic laser ablation of placental anastomoses.

Preoperative predictors of death in twin-to-twin transfusion syndrome treated with laser ablation of placental anastomoses

To determine preoperative predictive factors for donor and recipient death after laser ablation of placental vessels in twin-to-twin transfusion syndrome. Retrospective analysis of North American Fetal Therapy Network center laser procedures, 2002-2009. Factors associated with donor and recipient death were identified by regression analysis. There were 466 patients from 8 centers. Factors significantly associated with donor fetal death were low donor estimated fetal weight (odds ratio [OR], 0.69; 95% confidence interval [CI], 0.55-0.87) and reversed end diastolic velocity in the umbilical artery (OR, 4.0; 95% CI, 1.54-10.2); for recipient fetal death-low recipient estimated fetal weight (OR, 0.65; 95% CI, 0.44-0.95), recipient reversed "a" wave in the ductus venosus (OR, 2.39; 95% CI, 1.27-4.51) and hydrops (OR, 3.7; 95% CI, 1.1-12.7); for recipient neonatal death-low donor estimated fetal weight (OR, 0.54; 95% CI, 0.30-0.95), high recipient estimated fetal weight (OR, 1.55; 95% CI, 1.06-2.26) and recipient reversed end diastolic velocity in the umbilical artery (OR, 7.8; 95% CI, 1.03-59.3). Preoperative findings predict fetal and neonatal demise in twin-to-twin transfusion syndrome treated with laser therapy.