1
|
Tchirikov M, Zühlke A, Schlabritz-Lutsevich N, Entezami M, Seliger G, Bergner M, Li W, Köninger A, Wienke A, Yusupbaev R, Ebert AD. Fetoscopic laser coagulation for twin-to-twin transfusion syndrome: a comparison of flexible 1.0/1.2 mm fetoscopes with curved sheaths of 2.7/3.3 mm 2 vs. 2 mm fetoscopic lens technique with sheaths of 6.6/11.3 mm 2. J Perinat Med 2024; 52:530-537. [PMID: 38536953 DOI: 10.1515/jpm-2023-0328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 02/19/2024] [Indexed: 06/02/2024]
Abstract
OBJECTIVES Fetoscopic laser coagulation of placental anastomoses is usually performed for a treatment of twin-to-twin transfusion syndrome (TTTS). A common complication of fetoscopic laser coagulation for TTTS is preterm preliminary rupture of fetal membranes (PPROM) aggravating the neonatal outcome significantly. However, use of an flexible 1 mm fetoscope with an curved sheath could reduce iatrogenic damage of the amniotic membrane and improve neonatal outcomes after laser treatment. The aim of this study was to compare neonatal outcomes using this flexible fetoscope with curved sheath vs. use of a standard lens technique. METHODS Outcomes were retrospective analyzed after use of a standard lens fetoscope of 2 mm (sheath 6.63 mm2 or 11.27 mm2 for anterior placenta) and a flexible fetoscope of 1 mm or 1.2 mm (sheath 2.65 mm2 or 3.34 mm2) in two German centers of fetal surgery, performed during 2006-2019. RESULTS Neonatal outcome of 247 TTTS patients were analyzed including the rates of double and single fetal survival. The survival of at least one fetus was 97.2 % in the group with the ultrathin technique (n=154) compared to 88.3 % (n=93) in the group with the standard lens fetoscope (p=0.008). Survival of both fetuses was not different between groups (81.0 vs. 75.3 %). The procedure to delivery interval was significantly increased using the ultrathin fetoscope (89.1±35.0 d vs. 71.4±35.4 d, p=0.001) resulting in an increased gestational age at delivery by 11 days on average (231.9±28.1 d vs. 221.1±32.7 d, p=0.012). CONCLUSIONS Fetal survival can be significantly increased following TTTS using flexible fetoscope of 1 mm or 1.2 mm (sheath 2.65 mm2 or 3.34 mm2).
Collapse
Affiliation(s)
| | - Anja Zühlke
- Clinic of Anesthesiology, Martha-Maria Clinic, Halle-Dölau, Germany
| | - Natalia Schlabritz-Lutsevich
- School of Medicine at the Permian Basin, Texas Tech University, Health Sciences Center (TTUHSC), Odessa, TX, USA
| | - Michael Entezami
- Center of Prenatal Diagnostic and Human Genetic Kudamm-199, Berlin, Germany
| | - Gregor Seliger
- Martin-Luther University Halle-Wittenberg, Halle, Germany
| | | | - Weijing Li
- EWK, Clinic of Obstetrics and Gynecology, Berlin, Germany
| | - Angela Köninger
- University Clinic of Obstetrics and Gynecology, St. Hedwig, Barmherzige Brüder, Regensburg, Germany
| | - Andreas Wienke
- Institute of Medical Epidemiology, Biostatistics and Informatics, Martin-Luther University Halle-Wittenberg, Halle, Germany
| | - Rustem Yusupbaev
- Republican Scientific and Practical Medical Center for Obstetrics and Gynecology, Tashkent, Uzbekistan
| | | |
Collapse
|
2
|
Liu S, Xu Q, Liu D, Li Q, Qian J, Zhang B, Chen X. Pregnancy and obstetric outcomes of dichorionic triamniotic triplet pregnancies with selective foetal reduction after assisted reproductive technology. Reprod Biol Endocrinol 2024; 22:30. [PMID: 38491531 PMCID: PMC10941449 DOI: 10.1186/s12958-024-01199-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 02/27/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND It is generally beneficial and recommended that dichorionic triamniotic (DCTA) triplet pregnancies be reduced to monochorionic (MC) twin or singleton pregnancies after assisted reproductive technology (ART). However, some infertile couples still have a firm desire to retain twins. For this reason, the best foetal reduction strategies need to be available for infertile couples and clinicians. Given that data on the elective reduction of DCTA triplet pregnancies to twin pregnancies are scarce, we investigated the outcomes of elective reduction of DCTA triplet pregnancies through the retrospective analysis of previous data. METHOD Patients with DCTA triplet pregnancies who underwent elective foetal reduction between January 2012 and June 2020 were recruited. A total of 67 eligible patients with DCTA triplet pregnancies were divided into two groups: a DCTA-to-dichorionic diamniotic (DCDA) twin group (n = 38) and a DCTA-to-monochorionic diamniotic (MCDA) twin group (n = 29); the basic clinical data of the two groups were collected for comparison. RESULTS Compared with the DCDA-to-MCDA twin group, the DCTA-to-DCDA twin group had lower rates of complete miscarriage (7.89% versus 31.03%, p = 0.014), early complete miscarriage (5.26% versus 24.14%, p = 0.034), late preterm birth (25.71% versus 65.00%, p = 0.009) and very low birth weight (0 versus 11.11%, p = 0.025). In addition, the DCTA-to-DCDA twin group had higher rates of full-term delivery (65.71% versus 25.00%, p = 0.005), survival (92.11% versus 68.97%, p = 0.023), and taking the babies home (92.11% versus 68.97%, p = 0.023) than did the DCTA-to-MCDA twin group. In terms of neonatal outcomes, a significantly greater gestational age (38.06 ± 2.39 versus 36.28 ± 2.30, p = 0.009), average birth weight (3020.77 ± 497.33 versus 2401.39 ± 570.48, p < 0.001), weight of twins (2746.47 ± 339.64 versus 2251.56 ± 391.26, p < 0.001), weight of the larger neonate (2832.94 ± 320.58 versus 2376.25 ± 349.95, p < 0.001) and weight of the smaller neonate (2660.00 ± 345.34 versus 2126.88 ± 400.93, p < 0.001) was observed in the DCTA-to-DCDA twin group compared to the DCTA-to-MCDA twin group. CONCLUSION The DCTA-to-DCDA twin group had better pregnancy and neonatal outcomes than the DCTA-to-MCDA twin group. This reduction approach may be beneficial for patients with dichorionic triamniotic triplet pregnancies who have a strong desire to have DCDA twins.
Collapse
Affiliation(s)
- Shuhua Liu
- Department of Obstetrics and Gynecology, Hefei Maternity Child Health Hospital, Hefei, 230000, China.
- Department of Obstetrics and Gynecology, Anhui Women and Children's Medical Center, Hefei, 230000, China.
- Reproductive Medicine Center, Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, 230032, China.
| | - Qianhua Xu
- Reproductive Medicine Center, Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, 230032, China
| | - Dehong Liu
- Department of Obstetrics and Gynecology, Hefei Maternity Child Health Hospital, Hefei, 230000, China
- Department of Obstetrics and Gynecology, Anhui Women and Children's Medical Center, Hefei, 230000, China
| | - Qiuru Li
- Department of Obstetrics and Gynecology, Hefei Maternity Child Health Hospital, Hefei, 230000, China
- Department of Obstetrics and Gynecology, Anhui Women and Children's Medical Center, Hefei, 230000, China
| | - Jingyu Qian
- Department of Obstetrics and Gynecology, Hefei Maternity Child Health Hospital, Hefei, 230000, China
- Department of Obstetrics and Gynecology, Anhui Women and Children's Medical Center, Hefei, 230000, China
| | - Bin Zhang
- Department of Obstetrics and Gynecology, Hefei Maternity Child Health Hospital, Hefei, 230000, China.
- Department of Obstetrics and Gynecology, Anhui Women and Children's Medical Center, Hefei, 230000, China.
| | - Xianxia Chen
- Department of Obstetrics and Gynecology, Hefei Maternity Child Health Hospital, Hefei, 230000, China.
- Department of Obstetrics and Gynecology, Anhui Women and Children's Medical Center, Hefei, 230000, China.
| |
Collapse
|
3
|
Rodo C, Maiz N, Arevalo S, Lewi L, Couck I, Hollwitz B, Kyvernitakis I, Carreras E, Hecher K. 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. Am J Obstet Gynecol 2023:S0002-9378(23)02059-8. [PMID: 38036166 DOI: 10.1016/j.ajog.2023.11.1245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 11/08/2023] [Accepted: 11/12/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Miscarriage and preterm birth are leading causes of loss and disability in monochorionic twins after laser treatment of twin-twin transfusion syndrome. OBJECTIVE This study aimed to investigate the use of cervical pessary to reduce preterm birth before 32 weeks of gestation in monochorionic diamniotic twin pregnancies after fetal surgery for twin-twin transfusion syndrome. STUDY DESIGN In 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 of gestation. The secondary outcomes were birth before 28, 30, 34, or 37 weeks of gestation; preterm premature 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. Moreover, 2 interim analyses were planned. RESULTS The trial was stopped prematurely after the first planned interim analysis for futility. Overall, 137 women were included in the analysis, 67 in the pessary group and 70 in the conservative management group. Preterm birth before 32 weeks of gestation occurred in 27 of 67 women (40.3%) in the pessary group and in 25 of 70 women (35.7%) in the conservative management group (adjusted odds ratio, 1.19; 95% confidence interval, 0.58-2.47; P=.63). No differences between groups was observed in the rate of deliveries before 28, 30, 34, and 37 weeks of gestation. Overall survival to delivery was 91.2% (125/137) for at least 1 twin, and 70.8% (97/137) for both twins, with no difference between groups. Neonatal survival at 30 days was 76.5% (208/272). There was no difference between the groups in maternal or neonatal morbidity. CONCLUSION In monochorionic diamniotic twin pregnancies requiring fetal therapy for twin-twin transfusion syndrome, routine use of cervical pessary did not reduce the rate of preterm birth before 32 weeks of gestation.
Collapse
Affiliation(s)
- Carlota Rodo
- Maternal-Fetal Medicine Unit, Department of Obstetrics, Vall d'Hebron Institut de Recerca, Vall d'Hebron Hospital Universitari, Barcelona, Spain.
| | - Nerea Maiz
- Maternal-Fetal Medicine Unit, Department of Obstetrics, Vall d'Hebron Institut de Recerca, Vall d'Hebron Hospital Universitari, Barcelona, Spain.
| | - Silvia Arevalo
- Maternal-Fetal Medicine Unit, Department of Obstetrics, Vall d'Hebron Institut de Recerca, Vall d'Hebron Hospital Universitari, Barcelona, Spain
| | - Liesbeth Lewi
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, Biomedical Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Isabel Couck
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - Bettina Hollwitz
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ioannis Kyvernitakis
- Department of Obstetrics and Prenatal Medicine, Asklepios Klinik Barmbek, Hamburg, Germany
| | - Elena Carreras
- Maternal-Fetal Medicine Unit, Department of Obstetrics, Vall d'Hebron Institut de Recerca, Vall d'Hebron Hospital Universitari, Barcelona, Spain
| | - Kurt Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
4
|
Chimenea Á, García-Díaz L, Antiñolo G. Two Year Neurodevelopmental Outcome after Fetoscopic Laser Therapy for Twin-Twin Transfusion Syndrome: Comparison with Uncomplicated Monochorionic Diamniotic Twins. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1250. [PMID: 37508747 PMCID: PMC10378473 DOI: 10.3390/children10071250] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/07/2023] [Accepted: 07/19/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND Twin-twin Transfusion Syndrome (TTTS) represents a significant complication in monochorionic twin pregnancies, caused by an unbalanced shunting of blood through intertwin placental vascular anastomoses. Despite advances in fetoscopic laser surgery, TTTS is still associated with a high rate of cerebral injury. However, there are no studies comparing these pregnancies with uncomplicated monochorionic diamniotic (MCDA) twin pregnancies, establishing the baseline risk of neurodevelopmental impairment. The aim of this study is to evaluate the odds of neurodevelopmental impairment in MCDA twins who undergo fetoscopic laser surgery for twin-twin transfusion syndrome, in comparison to a cohort of uncomplicated MCDA twin pregnancies. STUDY DESIGN This is a retrospective cohort study of children born from MCDA twin pregnancies at a single center between 2008 and 2019. A routine, standardized follow-up assessment was conducted at a minimum of 2 years after delivery. The primary outcome of this was a 2 year neurodevelopmental impairment. Neurological, motor, and cognitive development was assessed by using the revised Brunet-Lézine scale. RESULTS 176 children met the enrolment criteria. Of these, 42 (24%; TTTS group) underwent fetoscopic laser surgery for TTTS during pregnancy, and 134 (76%; uncomplicated MCDA group) were uncomplicated MCDA pregnancies. The primary outcome was found in four children (9.52%) in the TTTS group and ten children (7.46%) in the uncomplicated MCDA group (p = 0.67, aOR 2.82, 95% CI 0.49-16.23). Major neurologic impairment was found in 2.38% after fetoscopic laser surgery and 1.49% in uncomplicated MCDA twins (p = 0.70, aOR 0.97, 95% CI 0.22-4.24). The data were adjusted by birth order, birth weight, and gestational age at birth. CONCLUSIONS The outcome in MCDA twins who underwent fetoscopic laser surgery for TTTS is comparable to the outcome in uncomplicated MCDA twins. Our findings emphasize the need for long-term neurodevelopmental follow-ups in all children from monochorionic twin gestations.
Collapse
Affiliation(s)
- Ángel Chimenea
- Department of Materno-Fetal Medicine, Genetics and Reproduction, Institute of Biomedicine of Seville (IBIS), Hospital Universitario Virgen del Rocio, CSIC, University of Seville, ES-41013 Seville, Spain
- Fetal, IVF and Reproduction Simulation Training Centre (FIRST), ES-41010 Seville, Spain
| | - Lutgardo García-Díaz
- Department of Materno-Fetal Medicine, Genetics and Reproduction, Institute of Biomedicine of Seville (IBIS), Hospital Universitario Virgen del Rocio, CSIC, University of Seville, ES-41013 Seville, Spain
| | - Guillermo Antiñolo
- Department of Materno-Fetal Medicine, Genetics and Reproduction, Institute of Biomedicine of Seville (IBIS), Hospital Universitario Virgen del Rocio, CSIC, University of Seville, ES-41013 Seville, Spain
- Fetal, IVF and Reproduction Simulation Training Centre (FIRST), ES-41010 Seville, Spain
- Centre for Biomedical Network Research on Rare Diseases (CIBERER), ES-41013 Seville, Spain
| |
Collapse
|
5
|
Knijnenburg PJ, Slaghekke F, Rahmattulla C, Ge Y, Scholl IM, van Klink JM, Haak MC, Middeldorp JM, Sun L, Lopriore E. Intertwin Membrane Perforation and Umbilical Cord Entanglement after Laser Surgery for Twin-Twin Transfusion Syndrome: Prevalence, Risk Factors, and Outcome. Fetal Diagn Ther 2023; 50:289-298. [PMID: 37285826 PMCID: PMC10614233 DOI: 10.1159/000531450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 06/01/2023] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Perforation of the intertwin membrane can occur as a complication of fetoscopic laser surgery for twin-twin transfusion syndrome (TTTS). Data on the occurrence and the risk of subsequent cord entanglement are limited. The objective of this study was to assess the prevalence, risk factors and outcome of intertwin membrane perforation, and cord entanglement after laser surgery for TTTS. METHODS In this multicenter retrospective study, we included all TTTS pregnancies treated with laser surgery in two fetal therapy centers, Shanghai (China) and Leiden (the Netherlands) between 2002 and 2020. We evaluated the occurrence of intertwin membrane perforation and cord entanglement after laser, based on routine fortnightly ultrasound examination and investigated the risk factors and the association with adverse short- and long-term outcomes. RESULTS Perforation of the intertwin membrane occurred in 118 (16%) of the 761 TTTS pregnancies treated with laser surgery and was followed by cord entanglement in 21% (25/118). Perforation of the intertwin membrane was associated with higher laser power settings, 45.8 Watt versus 42.2 Watt (p = 0.029) and a second fetal surgery procedure 17% versus 6% (p < 0.001). The group with intertwin membrane perforation had a higher rate of caesarean section (77% vs. 31%, p < 0.001) and a lower gestational age at birth (30.7 vs. 33.3 weeks of gestation, p < 0.001) compared to the group with an intact intertwin membrane. Severe cerebral injury occurred more often in the group with intertwin membrane perforation, 9% (17/185) versus 5% (42/930), respectively (p = 0.019). Neurodevelopmental outcome at 2 years of age was similar between the groups with and without perforation of the intertwin membrane and between the subgroups with and without cord entanglement. CONCLUSION Perforation of the intertwin membrane after laser occurred in 16% of TTTS cases treated with laser and led to cord entanglement in at least 1 in 5 cases. Intertwin membrane perforation was associated with a lower gestational age at birth and a higher rate of severe cerebral injury in surviving neonates.
Collapse
Affiliation(s)
- Patricia J.C. Knijnenburg
- Division of Neonatology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Femke Slaghekke
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Chinar Rahmattulla
- Division of Neonatology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Yuchun Ge
- Department of Fetal Medicine and Prenatal Diagnosis Center, Shanghai 1st Maternity and Infant Hospital of Tongji University, Shanghai, China
| | - Irene M. Scholl
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeanine M.M. van Klink
- Division of Child and Adolescent Psychology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Monique C. Haak
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Johanna M. Middeldorp
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Luming Sun
- Department of Fetal Medicine and Prenatal Diagnosis Center, Shanghai 1st Maternity and Infant Hospital of Tongji University, Shanghai, China
| | - Enrico Lopriore
- Division of Neonatology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| |
Collapse
|