Treatment Of Twin-twin Transfusion Syndrome Research Articles

Fetoscopic laser versus amnioreduction, septostomy, and expected management for the treatment of twin-twin transfusion syndrome (TTTS): an economic evaluation analysis in Iran

BackgroundTwin-twin transfusion syndrome (TTTS) affects 10–15% of monochorionic twin pregnancies. Without treatment, their mortality rates would be considerable. There are differences in survival rate between different therapeutic modalities. This study aims to compare the cost-effectiveness of Fetoscopic laser versus amnioreduction, septostomy, and expected management in the treatment of twin-to-twin transfusion syndrome (TTTS).MethodsThis is a cost-effectiveness analysis of the treatment strategies in patients with TTTS. A decision tree model was used to estimate the clinical and economic outcomes with a pregnancy period time horizon. Medical direct costs were extracted in a quantitative study, and survival rates were determined as effectiveness measures based on a review. A probabilistic sensitivity analysis was used to measure the effects of uncertainty in the model parameters. The TreeAge, Excel and R software were used for analyzing data.ResultsIn the first phase, 75 studies were included in the review. Based on the meta-analysis, a total of 7183 women treated with Fetoscopic laser, the perinatal survival of at least one twin-based pregnancy was 69%. In the second phase, the results showed that expected management and amnioreduction have the lowest (791.6$) and highest cost (2020.8$), respectively. Based on the decision model analysis, expected management had the lowest cost ($791.67) and the highest rate in at least one survival (89%), it was used only in early stages of TTTS. Fetoscopic laser surgery, with the mean cost 871.46$ and an overall survival rate of 0.69 considered the most cost-effectiveness strategy in other stages of TTTS.ConclusionOur model found Fetoscopic laser surgery in all stages of TTTS to be the most cost-effective therapy for patients with TTTS. Fetoscopic laser surgery thus should be considered a reasonable treatment option for TTTS.

Consensus protocol for management of early and late twin-twin transfusion syndrome: Delphi study.

Fetoscopic laser photocoagulation (FLP) is a well-established treatment for twin-twin transfusion syndrome (TTTS) between 16 and 26 weeks' gestation. High-quality evidence and guidelines regarding the optimal clinical management of very early (prior to 16 weeks), early (between 16 and 18 weeks) and late (after26 weeks) TTTS are lacking. The aim of this study was to construct a structured expert-based clinical consensus for the management of early and late TTTS. A Delphi procedure was conducted among an international panel of experts. Participants were chosen based on their clinical expertise, affiliation and relevant publications. A four-round Delphi survey was conducted using an online platform and responses were collected anonymously. In the first round, a core group of experts was asked to answer open-ended questions regarding the indications, timing and modes of treatment for early and late TTTS. In the second and third rounds, participants were asked to grade each statement on a Likert scale (1, completely disagree; 5, completely agree) and to add any suggestions or modifications. At the end of each round, the median score for each statement was calculated. Statements with a median grade of 5 without suggestions for change were accepted as the consensus. Statements with a median grade of 3 or less were excluded from the Delphi process. Statements with a median grade of 4 were modified according to suggestions and reconsidered in the next round. In the last round, participants were asked to agree or disagree with the statements, and those with more than 70% agreement without suggestions for change were considered the consensus. A total of 122 experts met the inclusion criteria and were invited to participate, of whom 53 (43.4%) agreed to take part in the study. Of those, 75.5% completed all four rounds. A consensus on the optimal management of early and late TTTS was obtained. FLP can be offered as early as 15 weeks' gestation for selected cases, and can be considered up to 28 weeks. Between 16 and 18 weeks, management should be tailored according to Doppler findings. A consensus-based treatment protocol for early and late TTTS was agreed upon by a panel of experts. This protocol should be modified at the discretion of the operator, according to their experience and the specific demands of each case. This should advance the quality of future studies, guide clinical practice and improve patient care. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

The Arabin cervical pessary for the prevention of preterm birth in twin-to-twin transfusion syndrome treated by fetoscopic laser coagulation: a multicenter randomized controlled trial

BackgroundMiscarriage and preterm birth are leading causes of loss and disability in monochorionic twins following laser treatment for twin-twin transfusion syndrome. ObjectiveWe investigated the use of the cervical pessary to reduce preterm birth before 32 weeks in monochorionic diamniotic twin pregnancies after fetal surgery for twin-twin transfusion syndrome. Study designIn this open-label multicenter randomized trial pregnant women carrying monochorionic diamniotic twins requiring fetoscopic laser coagulation for twin-twin transfusion syndrome were randomly assigned in a 1:1 ratio to pessary placement or conservative management. The primary outcome was birth before 32 weeks. Secondary outcomes were birth before 28, 30, 34 or 37 weeks, preterm rupture of membranes, fetal and neonatal survival, and a composite of maternal and neonatal complications. The estimated sample size was 364 patients, with 182 cases in each arm of the study. The analysis was performed according to the intention-to-treat principle. Two interim analyses were planned. ResultsThe trial was stopped prematurely after the first planned interim analysis for futility. One hundred thirty-seven women were included in the analysis, 67 in the pessary and 70 in the conservative management group. A preterm birth before 32 weeks occurred in 27/67 women (40.3%) in the pessary group and in 25/70 women (35.7%) in the conservative management group (aOR, 1.19; 95%CI, 0.58-2.47, P=.63). No significant differences between groups were observed in the rate of deliveries before 28, 30, 34 and 37 weeks, respectively. Overall survival to delivery was 91.2% (125/137) for at least one twin and 70.8% (97/137) for both twins, with no differences between groups. Neonatal survival at 30 days was 76.5% (208/272). There were no differences between groups in maternal or neonatal morbidity. ConclusionIn monochorionic diamniotic twin pregnancies requiring fetal therapy for twin-twin transfusion syndrome, routine use of cervical pessary did not reduce the rate of preterm delivery before 32 weeks.

Solomon technique of fetoscopic laser ablation is associated with improved perinatal outcomes

Fetoscopic laser ablation of pathogenic vascular connections between twin circulations is the mainstay of treatment for twin-twin transfusion syndrome (TTTS). Laser photocoagulation can be performed in either a selective manner or by utilizing the Solomon technique. The purpose of this study was to assess differences in perinatal and neonatal outcomes between fetuses undergoing either selective laser ablation or laser photocoagulation using the Solomon technique for treatment of TTTS.

Antepartum hemorrhage at delivery after Solomon laser for Twin-Twin Transfusion Syndrome

The Solomon fetoscopic laser (FLS) technique for treatment of Twin-Twin transfusion syndrome (TTTS) aims to coagulate the chorionic plate along the entire vascular equator. The higher laser energy required has been implicated in subsequent placental abruption (PA) often presenting with antepartum hemorrhage (APH) at delivery. We sought to determine the relationship between Solomon FLS and antepartum hemorrhage (APH). Retrospective single center study of patients delivered after Solomon FLS. Histologically confirmed placental abruption (HCPA), and other causes of APH at delivery were related to perioperative details using nonparametric, univariate and logistic regression analyses. Between 2014-22, 368 patients met criteria. APH occurred in 50 (13.5%) patients and was due to HCPA in 15 (30%), clinically suspected PA in 25 (50%), other obstetric causes in 7 (14%), and idiopathic in 3 (6%). Patients with APH delivered earlier (29.2 weeks [27.5-31.3], p< 0.001) and at a shorter interval to delivery after FLS (9.3 weeks [7.3-10.8], p< 0.001) compared to those without APH. Preoperative fetal size discordance (p=0.032) and selective fetal growth restriction (p=0.008) was more common in patients with APH. Applied laser energy, duration of laser activation, and number of anastomoses requiring coagulation were not associated with APH at delivery. Myometrial bleeding (intrauterine or intra-abdominal) at the time of laser was the primary determinant of APH (p < 0.001, R2 = 0.37). Patients who had APH after Solomon FLS experienced poorer obstetric outcomes. Myometrial bleeding at the time of laser was the primary surgical risk factor for APH.

Perinatal and neonatal outcomes for fetoscopic laser ablation for the treatment of twin twin transfusion syndrome at a single center

ObjectiveTo describe the perinatal and neonatal outcomes of fetal laser ablation (FLA) for the treatment of twin-twin transfusion syndrome (TTTS) in our single center institution.Study designRetrospective study of 76 treated pregnant women. Procedural complications, perinatal and neonatal outcomes analyzed. Differences in outcomes between two procedural techniques, selective and Solomon, compared.ResultsFLA occurred at median gestational age (GA) of 20.8 weeks (IQR 18.1–22.9) with low incidence of procedural complications (5.3%). High survival rate with delivery of at least one neonate (96%) [95% CI: 88.9–99.2%]; 73.7% [95% CI: 62.3–83.1%] were twins. Median GA at birth was 33.1 weeks (IQR 28.0–35.0). Neonatal mortality and morbidities were 9.4% and 48.3% of cases respectively, and associated with lower GA. Solomon cases had comparatively higher median GA, and lower incidences of neonatal morbidities.ConclusionOur small single center study showed favorable outcomes for using the Solomon technique in the treatment of TTTS.

Correction of fetal umbilical vein flow imbalance following laser surgery for twin-twin transfusion syndrome.

Twin-twin transfusion syndrome (TTTS) is characterized by unequal hemodynamics between the twins. We aimed to assess preoperatively the difference in umbilical vein flow (UVF) between the recipient and donor monochorionic diamniotic twins and evaluate the change in UVF following laser surgery in both twins. This was a retrospective cohort study of differences in UVF that occurred following laser surgical treatment of TTTS. Sonographic assessment of the umbilical vein before and 24 h after fetoscopic laser surgery for TTTS was performed. Umbilical vein diameter and time-averaged maximum velocity were measured, and UVF per kg (UVF/kg) was converted into a Z-score by a calculator created using gestational age as an independent variable. Z-score values were converted into centiles, which were evaluated statistically. Median differences in UVF/kg centile values were adjusted for TTTS stage and presence of arterioarterial anastomoses. The study population consisted of 363 TTTS patients. The adjusted preoperative median difference in UVF/kg centile between the recipient vs donor twin was 17.9% (-17.1% to 57.6%), P < 0.0001. The adjusted median difference in UVF/kg centile between the postoperative vs preoperative period among recipients was 2.2% (-10.8% to 13.8%), P < 0.0001, while the adjusted median difference among donors was 27.3% (8.2%-34.6%), P < 0.0001. The preoperative difference in UVF between the recipient and donor twins confirms the pathophysiology of TTTS. Postoperatively, the substantial increase in UVF of the donor twin and the relatively small increase in UVF of the recipient twin confirm that ablation of the vascular communications resulted in rapid improvement in perfusion of the donor twin. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Treatment of twin-twin transfusion syndrome: "They also serve who only stand and wait".

Linked article : This is a mini commentary on Bartin et al., pp. 2028–2037. in this issue. To view this article visit https://doi.org/10.1111/1471‐0528.17228

The Efficacy of Fetoscopic Laser Surgery in Twin-Twin Transfusion Syndrome: A Preliminary Vietnamese Study.

Twin-twin transfusion syndrome (TTTS) is a severe prenatal complication of monochorionic diamniotic twins (MCDA). If left untreated, TTTS is associated with a high risk of neonatal death and neurological complications. Various treatment methods for TTTS have been proposed, but fetoscopic laser surgery (FLS) is currently the primary treatment for TTTS in global fetal medicine centers. The objective of this study was to evaluate the outcome of TTTS following FLS treatment at Hanoi Obstetrics and Gynecology Hospital (HOGH), a new fetal medicine center in Vietnam. A prospective study of a series of 33 consecutive TTTS cases prior to 26 weeks of gestation subjected to FLS at HOGH in Vie-tnam between September 2019 to July 2021. Neonates were monitored for at least six months after birth. The survival rate of at least one fetus reached 84.85%. No short-term neurological complications have been reported upon follow-up of the newborn up to six months after birth. There were three stillbirth cases (9.09%), one case of preterm ruptured membra-nes (PROM) (3.03%) after seven days of surgery and three cases of recurrent TTTS after surgery using the Solomon technique (25%). No maternal complications were observed. The mean gestational age at birth was 33.76 ± 4.52 weeks, with a mean interval of 12.24 ± 6.67 weeks between intervention and delivery. Nine cases (30%) were born prematurely before 32 weeks. Additionally, 60% of recipients and nearly 90% of donors weighed less than 2500 grams. FLS leads to high survival rates for fetuses with TTTS. FLS seems to be an effective therapeutic option for TTTS before 26 weeks of gestation.

Association of amnioinfusion and adverse outcomes at the time of surgery for TTTS

To evaluate if the volume of Ringer’s lactate amnioinfusion (AI) used during selective fetoscopic laser photocoagulation (SFLP) for treatment of twin-twin transfusion syndrome (TTTS) is associated with adverse pregnancy outcome.

Call to action: long‐term neurodevelopment in monochorionic twins

Call to action: long‐term neurodevelopment in monochorionic twins

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.

985 Influence of gestational age of treatment of twin-twin transfusion syndrome on latency-to-delivery and outcomes

The average latency to delivery after selective fetoscopic laser photocoagulation (SFLP) for treatment of pregnancies complicated by twin-twin transfusion syndrome (TTTS) has been reported as 10 weeks. We sought to determine the influence of the gestational age (GA) at the time of SFLP on latency to delivery and neonatal survival in patients with TTTS. This was a retrospective cohort study evaluating latency to delivery and survival of infants after SFLP in pregnancies complicated by TTTS at a single center from 4/2010 to 6/2019. A total of 637 patient were included. Latency was evaluated for each week that SFLP was performed. Primary and secondary outcomes were compared between three groups (16 0/7-17 6/7, 18 0/7-22 6/7, and 23 0/7-28 6/7 weeks) at time of SFLP. Primary outcomes were latency to delivery and neonatal survival after SFLP. Secondary outcomes were postoperative and pregnancy complications after SFLP. Data were analyzed using linear regression, ANOVA, and Chi2 as appropriate. Advancing GA is inversely related to latency from SFLP to delivery (See figure). Latency to delivery was longer the earlier SFLP was performed, mean (±SD) of 11.7 (±4.9) weeks at 16 0/7-17 6/7 weeks, 10.2 (±4) weeks at 18 0/7-22 6/7 weeks, and 6.3 (±3.4) weeks at 23 0/7-28 6/7 weeks (Table 1). Linear regression demonstrated an inverse relationship (coefficient -0.73, R2 0.19, p<0.001). Composite complications were increased the earlier SFLP was performed 55.6%, 40.3%, and 30.8% at 16 0/7-17 6/7, 18 0/7-22 6/7, and 23 0/7-28 6/7 weeks respectively (p=0.001). Neonatal survival for at least one twin to day of life 30 was 85.6%, 92.3%, and 94.7% (p=0.042) and dual neonatal survival to day of life 30 was 67.0%, 79.2%, and 81.2% (p=0.02) for the same groups. SFLP performed at earlier gestational age demonstrates longer latency until delivery. Despite this, SFLP at earlier gestational age is associated with an increase in complications and decreased neonatal survival for one or both twins.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

546 Natural history of previable and periviable rupture of membranes after treatment of twin-twin transfusion syndrome

We aim to describe the natural history and outcomes of pre/periviable prelabor rupture of membranes (PROM) in TTTS after selective fetoscopic laser photocoagulation (SFLP). Retrospective cohort study at a single fetal center which included pregnancies from April 2010-June 2019 complicated by TTTS and were treated with SFLP and subsequently had PROM. Primary outcomes were latency from PROM to delivery and fetal survival. Exposure groups were pregnancies that developed PROM between 16-19 6/7 weeks, 20 -22 6/7 weeks, 23- 25 6/7 weeks and ≥ 26 weeks (referent group). Comparisons were made with t-test, Mann-Whitney U, Kruskall-Wallis, and chi-squared as appropriate, with significance reported as p < 0.05. A total of 33% (N=221/678) of patients had PROM post-SFLP. The average latency from SFLP to PROM was 7.5 weeks (95% CI 7.0 – 8.1) with overall 86% survival in setting of PROM. Eighteen patients (2.7%) experienced PROM within 7 days of surgery, with the mean gestational age (GA) at delivery of 23.4 weeks (95% CI 21.2-25.6 weeks) and 44% (8/18) of those patients delivering within 48 hrs. Baseline characteristic among those that experienced PROM < 26 weeks vs ≥ 26 weeks were non-significant except for GA at the time of surgery (19.5 ± 2.1 vs 20.6 ± 2.8 weeks respectively, p=0.005). The rates of PROM by GA were 0.7%, 2.7% and 6.1% at 16-19 6/7, 20-22 6/7, and 23-25 6/7 weeks, respectively. Linear regression demonstrated inverse correlation between GA at PPROM and latency, R = 0.25. Despite this longer latency, those with PROM after SFLP at less than 23 weeks demonstrated lower survival rates as delivery was more likely to occur in the periviable period (Table). These findings remained true when patients who delivered within 48 hours of PROM were excluded. GA at PROM after SFLP is inversely correlated with latency to delivery, however later GA at PROM is associated with improved live birth rates. When latency after PROM exceeds 48 hours, rates of live birth are significantly improved, with live birth of one or more fetuses exceeding 70% even with PROM < 20 weeks.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Maternal vascular endothelial growth factor receptor and interleukin levels in pregnant women with twin-twin transfusion syndrome.

Twin-twin transfusion syndrome (TTTS) is an unusual and serious condition that occurs in twin pregnancies when identical twins share a placenta but develop discordant amniotic fluid volumes. TTTS is associated with an increased risk of fetal death and birth defects if untreated. This study investigated the soluble levels of biomarkers including growth factors and interleukins in pregnant women with and without TTTS during pregnancy. We quantified plasma levels of VEGF-R1, VEGF-R2, IL-1β, IL-6 and IL-8 in twin pregnant women with (n=53) and without TTTS (n=72) and in women with single pregnancy (n=30) by ELISA and analyzed the association of maternal circulating biomarker levels with TTTS. Our results showed that maternal VEGF-R1 levels were significantly higher in twins compared to single pregnancy (P<0.05) and were decreased in the second trimester compared to the first trimester (P = 0.065, 0.019 and 0.072 for twins with and without TTTS and single pregnancy, respectively). VEGF-R2 levels had a trend to be lower in twins compared to single pregnancy. In addition, soluble VEGF-R1 and VEGF-R2 levels were significantly decreased while IL-6 levels were increased after surgical treatment with laser in twin pregnant women with TTTS (P = 0.016, 0.041 and 0.04, respectively). These results suggest that IL-6, VEGF-R1 and VEGF-R2 are involved in vascular regulation and stabilization in twin pregnancies and may contribute to the pathogenesis of TTTS and thus play a prognostic role in the surgical treatment of TTTS.

Perioperative maternal complications of twin-twin transfusion syndrome after fetoscopic laser photocoagulation

Objective: To analyze the perioperative maternal complications of twin-twin transfusion syndrome (TTTS) after fetolascopic laser photocoagulation (FLP). Methods: A retrospective study was conducted among 182 cases with TTTS received FLP in Shanghai First Maternity and Infant Hospital from January 2010 to December 2018. The types, incidence and related factors of perioperative maternal complications as well as the changes of maternal laboratory parameters before and after FLP were analyzed. Results: The age of 182 TTTS pregnant women was (29.8±3.9) years old, body mass index (BMI) before pregnancy was (21.3±2.9) kg/m2. The median gestational week of FLP treatment was 22.0 weeks, the preoperative cervical length was (34.1±9.0) mm, and the median preoperative maximum vertical pocket was 12.0 cm. During the perioperative period of FLP treatment, 22 cases (12.1%, 22/182) presented maternal complications, among which 4 cases (2.2%, 4/182) presented severe postoperative maternal complications, including 3 cases of pulmonary edema and 1 case of pulmonary embolism accompanied with right cardiac insufficiency. There were 18 cases (9.9%, 18/182) of common maternal complications during the perioperative period, including 6 cases (3.3%, 6/182) of intraoperative hemorrhage, 5 cases (2.7%, 5/182) of intraoperative amniotic fluid leakage into the pelvic cavity, 5 cases (2.7%, 5/182) of premature rupture of membrane 72 hours after the operation, 1 case (0.5%, 1/182) of inevitable abortion, and 1 case (0.5%, 1/182) of infection. The analysis of related risk factors found that maternal complications were only related to BMI before pregnancy, and the BMI of TTTS pregnant women with complications was lower than that of those without complications, the difference was statistically significant (P<0.01). The hemoglobin level, hematocrit and albumin level of TTTS pregnant women were significantly decreased at 4-6 hours and 24 hours after FLP respectively, compared with those before surgery (P<0.01), and there were no significant correlations with the amount of amniodrainage during surgery (P>0.05 for all). Conclusions: The overall incidence of perioperative maternal complications in the treatment of TTTS by FLP is not high, among which the serious complications mainly include pulmonary edema and pulmonary embolism. Timely correction of maternal hemodilution that may occur in TTTS pregnant women could achieve a good prognosis after FLP.

Study on the expression of interleukins in patients with twin-twin transfusion syndrome

Twin-twin transfusion syndrome (TTTS) is an unusual and serious condition that occurs in twin pregnancies when identical twins share a placenta but develop discordant amniotic fluid volumes. The TTTS has a high risk of fetal death and birth defects if left untreated. IL-1β, IL-6 and IL-8 have been shown to play an important role in preterm birth in twin pregnancies, which is one of the consequences of TTTS. This study quantified plasma levels of IL-1β, IL-6 and IL-8 in twin pregnant women with (n = 52) and without TTTS (n = 73) by ELISA and analyzed the association of interleukin expression levels with TTTS. The results showed that plasma concentrations of IL-1β and IL-8 were low and not significantly different between the first trimester and the second trimester of pregnancy, between the patients with and without TTTS or between patients with TTTS before and after treatment. IL-6 levels showed no significant difference between first trimester and second trimester of pregnancy or between patients with and without TTTS. Importantly, IL-6 levels were significantly elevated in TTTS patients after surgical treatment compared to those before surgical treatment. In conclusion, IL-6 may be considered as a potential marker for the prognosis of surgical treatment of TTTS.

Intrauterine fetoscopic laser surgery versus expectant management in stage 1 twin-to-twin transfusion syndrome: an international randomized trial

Selective fetoscopic laser coagulation of the intertwin anastomotic chorionic vessels is the first-line treatment for twin-twin transfusion syndrome. However, in stage 1 twin-twin transfusion syndrome, the risks of intrauterine surgery may be higher than those of the natural progression of the condition. This study aimed to compare immediate surgery and expectant follow-up in stage 1 twin-twin transfusion syndrome. We conducted a multicentric randomized trial, which recruited from 2011 to 2018 with a 6-month postnatal follow-up. The study was conducted in 9 fetal medicine centers in Europe and the Unites States. Asymptomatic women with stage 1 twin-twin transfusion syndrome between 16 and 26 weeks' gestation, a cervix of >15 mm, and access to a surgical center within 48 hours of diagnosis were randomized between expectant management and immediate surgery. In patients allocated to immediate laser treatment, percutaneous laser coagulation of anastomotic vessels was performed within 72 hours. In patients allocated to expectant management, a weekly ultrasound follow-up was planned. Rescue fetoscopic coagulation of anastomoses was offered if the syndrome worsened as seen during a follow-up, either because of progression to a higher Quintero stage or because of the maternal complications of polyhydramnios. The primary outcome was survival at 6 months without severe neurologic morbidity. Severe complications of prematurity and maternal morbidity were secondary outcomes. The trial was stopped at 117 of 200 planned inclusions for slow accrual rate over 7 years: 58 women were allocated to expectant management and 59 to immediate laser treatment. Intact survival was seen in 84 of 109 (77%) expectant cases and in 89 of 114 (78%) (P=.88) immediate surgery cases, and severe neurologic morbidity occurred in 5 of 109 (4.6%) and 3 of 114 (2.6%) (P=.49) cases in the expectant and immediate surgery groups, respectively. In patients followed expectantly, 24 of 58 (41%) cases remained stable with dual intact survival in 36 of 44 (86%) cases at 6 months. Intact survival was lower following surgery than for the nonprogressive cases, although nonsignificantly (78% and 71% following immediate and rescue surgery, respectively). It is unlikely that early fetal surgery is of benefit for stage 1 twin-twin transfusion syndrome in asymptomatic pregnant women with a long cervix. Although expectant management is reasonable for these cases, 60% of the cases will progress and require rapid transfer to a surgical center.

Complications of Monochorionic Diamniotic Twins: Stepwise Approach for Early Identification, Differential Diagnosis, and Clinical Management

AbstractOne in three monochorionic twins may develop complications during pregnancy. Monochorionic twins, especially monochorionic diamniotic (MCDA), present specific problems caused by the presence of interfetal placental anastomoses. The first critical step in the management of MCDA twins is identification in the first trimester. Secondly, close follow-up every 2 weeks is mandatory to allow early diagnosis and timely treatment of twin-twin transfusion syndrome. Other potentially severe complications include selective fetal growth restriction, twin anemia polycythemia syndrome or single fetal death. Thirdly, a correct differential diagnosis is critical to establish the best therapy. This may represent a clinical challenge since MCDA twin complications often overlap. A simple diagnostic algorithm may be of great help to establish the right diagnosis and management option. In this review we summarize the main steps for the clinical follow-up, differential diagnosis, and targeted management of MCDA twins complications.

Survival Outcomes by Fetal Weight Discordance after Laser Surgery for Twin-Twin Transfusion Syndrome Complicated by Donor Fetal Growth Restriction

Introduction: Management options for treatment of twin-twin transfusion syndrome (TTTS) with severe donor intrauterine growth restriction (IUGR) include fetoscopic laser surgery and umbilical cord occlusion (UCO). We studied perinatal survival outcomes in this select group after laser surgery, stratifying patients by preoperative estimated fetal weight (EFW) discordance. Methods: In this retrospective study of monochorionic diamniotic twin gestations with TTTS and selective donor IUGR who underwent laser surgery (2006–2017), preoperative EFW discordance was calculated ([(larger twin – smaller twin)/(larger twin)] × 100) and cases were divided into discordance strata. Severe EFW discordance was defined as >35%. The primary outcome was 30-day donor twin neonatal survival. Results: The 371 cases were distributed by discordance strata: ≤20% (74 [19.9%]), 21–25% (49 [13.2%]), 26–30% (68 [18.3%]), 31–35% (53 [14.3%]), 36–40% (51 [13.7%]), 41–45% (38 [10.2%]), >45% (38 [10.2%]). Donor 30-day survival declined as the discordance strata increased: 86.5, 85.7, 83.8, 75.5, 64.7, 63.2, and 65.8% (p = 0.0046); 30-day survival was inversely associated with severe discordance (>35%) (64.6 vs. 83.2%, p < 0.0001). Discussion: In TTTS cases complicated by donor IUGR with severe growth discordance, laser surgery was associated with donor survivorship greater than 60% suggesting that, in this setting, laser surgery remains a reasonable alternative treatment to UCO.