Vessels For Twin-twin Transfusion Syndrome Research Articles

Impact of Obesity on Pregnancies Undergoing Laser Therapy for Twin-Twin Transfusion Syndrome

Introduction: We sought to determine if maternal obesity, defined by body mass index (BMI) 30–34.9 or BMI ≥35, negatively impacts the technical aspects and pregnancy outcomes in women treated with selective laser photocoagulation of placental communicating vessels for twin-twin transfusion syndrome (TTTS). Methods: Retrospective review of women undergoing laser for TTTS from January 2010 to December 2021. Outcomes were stratified based on maternal BMI <30, 30–34.9, and ≥35. Data obtained included maternal age, parity, ethnicity, gestational age at laser, placental location, Quintero stage, CHOP cardiovascular score, operative and anesthesia times, procedure-to-delivery interval, gestational age at delivery, survival to birth, survival to discharge, and the presence of residual anastomoses. Statistical analysis included the χ² or Fisher’s exact test for categorical variables and the Mann-Whitney U test for continuous variables with p < 0.05 being significant. Results: A total of 434 women underwent laser for TTTS during the study period. Of those, 274 (63%) had a BMI of <30, 92 (21.2%) had a BMI between 30 and 34.9, and 68 (15.7%) had a BMI ≥ 35. There were no differences in maternal age, parity or ethnicity, Quintero stage, CHOP cardiovascular score, placental location, operative time, laser-to-delivery interval, gestational age at delivery, survival outcomes, or the presence of residual anastomoses between the three groups. Patients with a BMI of 30–34.9 were operated on at a slightly later gestational age, and those with a BMI > 35 had longer operative and anesthesia times. There were no technical failures as a result of BMI ≥ 30 or 35. Conclusion: Using appropriate technical adjustments, outcomes for obese women undergoing laser for TTTS are similar to nonobese women, although patients with BMI ≥35 have longer operative and anesthesia times.

Selective vs complete fetoscopic coagulation of vascular equator: a matched comparative study

Complete coagulation of the vascular equator (asin the Solomon technique) has been suggested to reduce postoperative complications such as twin anemia polycythemia syndrome and the recurrence of twin-twin transfusion syndrome following fetoscopic laser coagulation of chorionic vessels for twin-twin transfusion syndrome. We aimed to evaluate the benefit of this technique on perinatal outcomes compared with selective ablation of anastomoses. We conducted a monocentric retrospective study comparing selective laser coagulation of anastomoses to the Solomon technique from January 2006 to August 2020. To adjust for potential confounders, the cases operated by selective surgery were matched to the cases operated with the Solomon technique according to the gestational age at laser therapy, placental localization, and Quintero stage using propensity score matching. With a total of 994 cases, 399 matched pairs were included in the analysis. Compared with selective ablation, the Solomon technique was associated with significantly improved survival: the overall twin survival at delivery and discharge was 72% vs 79% (P=.003) and 69% vs 75% (P=.006), respectively; the double twin survival rate at discharge was 55% vs 65% (P=.02), respectively, and the rate of intrauterine death dropped from 18% to 12% (P=.003), respectively. The Solomon technique significantly reduced the rate of twin anemia polycythemia syndrome (10% vs 4%; P=.02), leading to fewer secondary rescue procedures (13% vs 7.3%; P=.01). However, the Solomon technique was associated with an increased risk of preterm rupture of membranes, especially at early gestational ages (3.8% vs 11%; P<.001 for preterm rupture of membranes <24 weeks). Among the survivors at delivery, both the groups had similar gestational ages at birth. Both neonatal mortality and severe neurologic morbidity were similar in both the groups. However, an increased risk of bronchopulmonary dysplasia was found in the Solomon group (4.5% vs 12%; P<.001). Although the risk of preterm premature rupture of membranes has increased, the introduction of the Solomon technique has significantly improved perinatal outcomes in pregnancies affected with twin-twin transfusion syndrome.

Endoscopic laser coagulation of the communicating placental vessels for twin-twin transfusion syndrome of monochorionic triamniotic triplet pregnancy conceived by IVF and ICSI

Endoscopic laser coagulation of the communicating placental vessels for twin-twin transfusion syndrome of monochorionic triamniotic triplet pregnancy conceived by IVF and ICSI

416: Maternal obesity and outcomes with laser therapy for twin twin transfusion syndrome

To determine if maternal obesity, as defined by BMI ≥ 30, negatively impacts the technical aspects and pregnancy outcomes in women treated with selective laser photocoagulation of placental communicating vessels for twin-twin transfusion syndrome (TTTS). Retrospective review of women undergoing laser for TTTS from June 1, 2005 – March 31, 2010. Outcomes were stratified based on maternal BMI < 30 and ≥ 30. Data obtained included gestational age at laser, placental location, Quintero stage and CHOP cardiac score at laser, operative and anesthesia times, procedure to delivery interval, gestational age at delivery, survival to birth and to discharge. Women with increased BMI were assessed intraoperatively for the need to alter technical approach. Technical changes included adjustments in patient positioning, lighter conscious sedation and longer introducers when the abdominal wall to amniotic sac distance was measured to be > 4.5 cm. Statistical analysis included chi-square for categorical variables and student's t test for continuous variables with p< 0.05 being significant. A total of 153 women underwent laser for TTTS during the study period. Of those, 100 (65%) had a BMI of < 30 and 53 (35%) had a BMI ≥ 30. There were no differences in the gestational age at laser, Quintero stage, CHOP cardiac score, anesthesia or operative times, laser to delivery interval, gestational age at delivery or survival outcomes between the two groups, as represented in the table. There were no technical failures as a result of BMI ≥ 30.Tabled 1All patientsBMI < 30 N=100BMI ≥ 30 N=53P valuePlacenta Location0.97Anterior58 (38%)38 (38%)20 (37.7%)Posterior95 (62%)62 (62%)33 (62.3%)TTTS Stage 285 (55.6%)51 (51%)34 (64.2%)0.20Stage 361 (39.9%)43 (43%)18 (34%)Stage 47 (4.6%)6 (6%)1 (1.8%)CHOP cardiac score6.9 (± 4.5)6.9 (± 4.5)6.8 (± 4.5)0.93Gestational age at laser (weeks)20.9 (± 2.0)20.8 (± 2.1)21.1 (± 1.8)0.41Anesthesia time (minutes)117.9 (± 27.8)120.3 (± 28)113.8 (± 27.2)0.14Operative time (minutes)72.5 (± 23.1)73.6 (± 24)70.4 (± 21.3)0.41Gestational age at delivery (weeks)32.6 (± 4.7)32.6 (± 4.6)32.7 (± 4.9)0.94Procedure to delivery interval (days)82.5 (± 35.8)82.9 (± 34.6)81.6 (± 38.2)0.84Survivors to Live Birth0.7808 (5.2%)5 (5%)3 (5.7%)126 (17%)18 (18%)8 (15.1%)2118 (77%)76 (76%)42 (79.3%)31 (0.65%)1 (1%)0 (0%)Survivors to Discharge0.51014 (9.5%)8 (8.33%)6 (11.7%)127 (18.4%)20 (20.83%)7 (13.7%)2105 (71.4%)67 (69.8%)38 (74.5%)31 (0.68%)1 (1.04%)0 (0%) Open table in a new tab Using appropriate technical adjustments, outcomes for obese women undergoing laser for TTTS are similar to non-obese women.

Residual Vascular Communications in Twin-twin Transfusion Syndrome Treated With Sequential Laser Surgery: Frequency and Clinical Implications

Unbalanced sharing of blood through vascular communications in the common placenta is thought to be responsible for the development of twin-twin transfusion syndrome (TTTS) in monochorionic diamniotic twins. Fetoscopic laser surgery treats TTTS in utero by ablating placental vascular communications. The resulting separation of the fetal circulatory systems improves perinatal survival and neurological outcome. Several studies have demonstrated that, after laser surgery, residual vascular communications (RVC) may be present in up to one-third of cases, and may be associated with persistent TTTS or twin anemia-polycythemia sequence (TAPS) and other adverse perinatal outcomes. A wide range of RVC rates (from 32% to 75% of cases) have been reported in similar patient populations. This variability in RVC rates has been attributed to the laser technique used and the method of placental evaluation. The primary aim of this study was to determine the frequency of residual RVC in a large series of placentas treated in utero for TTTS using preferential sequential selective laser photocoagulation of communicating vessels. A secondary aim was to investigate potential clinical risk factors associated with RVC and perinatal outcomes of cases complicated by RVC. The study subjects were pregnant women who underwent preferential sequential selective laser photocoagulation of communicating vessels for TTTS from 2006 through 2009 at an academic medical center. After delivery, placentas were submitted for examination and water and/or milk injections were used to assess the patency of vascular communications between the twins. Cases with placental disruption and intrauterine fetal demise were excluded from the analysis. Perinatal outcomes of cases with and without RVC were compared. Over the 3 years of the study, 174 women with TTTS were treated by preferential sequential selective laser photocoagulation of communicating vessels. Of the 174 cases, 133 (76%) resulted in survival of both twins at birth, and 105 (79%) of these submitted an intact placenta for pathological evaluation. Injection studies showed the presence of RVC in 5 of the 105 placentas (4.8%). One of the 5 RVC cases (20%) had neonatal findings consistent with TAPS, whereas none of the no-RVC cases had TAPS. There was one case of persistent TTTS in the no-RVC group. The gestational age, estimated fetal weights, and amniotic fluid volumes in each sac at the time of the procedure were similar in RVC and no-RVC cases. There was a trend toward a longer operative time in RVC cases (63.4 vs. 44.4 min; P = 0.057), but this did not reach statistical significance. Outcomes of RVC and no-RVC cases were also similar: gestational age at delivery = 28.7 ± 6.5 versus 33.4 ± 3.3 weeks (P = 0.178), and donor birth weight = 1429 ± 1369 versus 1653 ± 715 g (P = 0.518). The only differences between the groups were that the no-RVC group had a higher recipient birth weight (1287 ± 1061 vs. 1973 ± 610 g; P = 0.020), and the donor in the RVC cases was more likely to have central or eccentric placental cord insertion (80% vs. 17%; P = 0.006). No histological differences were found between the placentas with and without RVC. These findings show that the frequency of RVC among gestations with dual survivors after preferential sequential selective laser photocoagulation of communicating vessels treatment for TTTS was less than 5%.

105: Amniotic fluid volume normalization post sequential selective laser photocoagulation of communicating vessels for twin-twin transfusion syndrome

105: Amniotic fluid volume normalization post sequential selective laser photocoagulation of communicating vessels for twin-twin transfusion syndrome

Sequential selective laser photocoagulation of communicating vessels in twin-twin transfusion syndrome

Objective. We have previously described the selective laser photocoagulation of communicating vessels (SLPCV) technique for the treatment of twin–twin transfusion syndrome (TTTS). Because TTTS is t...

Individual placental territories after selective laser photocoagulation of communicating vessels in twin-twin transfusion syndrome

Intrauterine fetal death of one or both twins after laser therapy (selective photocoagulation of communicating vessels) may occur, in part, from insufficient individual placental mass. The objective of this study was to assess the percentage of individual placental mass (individual placental territory) that is associated with fetal survival in twin-twin transfusion syndrome after selective photocoagulation of communicating vessels. Placentas from 72 patients with selective photocoagulation of communicating vessels-treated twin-twin transfusion syndrome without intrauterine fetal death and from 61 monochorionic pregnancies without twin-twin transfusion syndrome (control subjects) were assessed. The placentas were weighed fresh (total placental mass) and cut along the vascular equator, which yielded the individual placental mass and the individual placental territory. Patency of anastomoses was ruled out with air-injection. The individual fetoplacental ratio was obtained by dividing birth weight by the corresponding individual placental mass. The 5th percentile individual placental territory that was associated with fetal survival was 27% in control subjects and 18% in cases with twin-twin transfusion syndrome, with a minimum of 10% to 14%, respectively. There were no differences in total placental mass, individual placental mass, individual placental territory, or individual fetoplacental ratio between pregnancies with twin-twin transfusion syndrome and control subjects. However, corrected for gestational age, the birth weight of recipient and donor twins were significantly smaller than control subjects. The individual placental territory of donors was statistically smaller than that of recipients. Individual placental territories were not different within control subjects. Fetal survival typically is associated with at least 18% of individual placental territory after selective photocoagulation of communicating vessels for twin-twin transfusion syndrome, but it can occur with as little as 10% to 14% individual placental territory. Decreased birth weight of the donor twin could result from relative decreased percentage of individual placental territory or from the loss of nutrients to the recipient twin. Decreased birth weight of the recipient twin could result from partial deprivation of functional placental tissue after surgery. Our findings may contribute to the understanding of normal and pathologic monochorionic twin gestations, in the counseling of patients, and potentially to the improvement of surgical treatment of twin-twin transfusion syndrome.

Selective photocoagulation of placental vessels in twin-twin transfusion syndrome: evolution of a surgical technique.

Selective photocoagulation of placental vessels in twin-twin transfusion syndrome: evolution of a surgical technique.

Doppler assessment of the effect of laser photocoagulation of communicating vessels in twin-twin transfusion syndrome

Doppler assessment of the effect of laser photocoagulation of communicating vessels in twin-twin transfusion syndrome

Color Doppler Ultrasonography in the Identification of Communicating Vessels in Twin-Twin Transfusion Syndrome and Acardiac Twins

Color Doppler Ultrasonography in the Identification of Communicating Vessels in Twin-Twin Transfusion Syndrome and Acardiac Twins

Color Doppler ultrasonography in the identification of communicating vessels in twin-twin transfusion syndrome and acardiac twins.

This study evaluates the role of color Doppler ultrasonography in the identification of the communicating placental vessels in pregnancies with twin-twin transfusion syndrome and acardiac twins. In 18 pregnancies with twin-twin transfusion syndrome and two with an acardiac twin, color Doppler studies of the placental vasculature were performed before fetoscopy for laser coagulation of the communicating vessels. In six cases of twin-twin transfusion syndrome the placental attachment of the intertwin membrane could be visualized. Pulsatile arterial blood flow was observed from the donor to the recipient twin that disappeared after laser therapy. In both cases of acardiac twins, one communicating vessel with pulsatile and another vessel with nonpulsatile blood flow in the opposite direction could be identified. Color Doppler imaging is unlikely to play a major role in assisting endoscopic laser separation of chorioangiopagus in patients with acute polyhydramnios, but it may prove to be useful in the early identification of pregnancies at risk of developing twin-twin transfusion syndrome.