1
|
Bartin R, Andrioli Peralta CF, Peneluppi Horak AC, Rodrigues da Costa KJ, Colmant C, Stirnemann J, Ville Y. Management of short cervix in twin-to-twin transfusion syndrome: a role for pessary placement following fetoscopic laser surgery? Am J Obstet Gynecol 2024; 230:91.e1-91.e12. [PMID: 37453653 DOI: 10.1016/j.ajog.2023.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/06/2023] [Accepted: 07/10/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Preterm labor and delivery is a major concern for patients with twin-to-twin transfusion syndrome undergoing fetoscopic laser surgery. A preoperative short cervix is a risk factor for preterm labor. Pessary placement is a short-acting intervention that may be useful to reduce this adverse event. OBJECTIVE This study aimed to investigate the relationship between pessary placement and preterm delivery in monochorionic twin pregnancies with twin-to-twin transfusion syndrome and a short cervix before fetoscopic laser surgery. STUDY DESIGN This was a retrospective study in 2 centers, including all pregnancies affected by twin-to-twin transfusion syndrome that underwent fetoscopic laser surgery with the Solomon technique between 2013 and 2022 (center A) and 2014 and 2022 (center B) with a preoperative cervical length below 25 mm. This study explored the correlation between cervical length and fetoscopic laser surgery-to-delivery interval following active or expectant management and compared perinatal outcomes between patients managed expectantly and patients managed with pessary placement, using multivariate analysis to control for potential confounders. Patients with a cervical length below 5 mm were not included in the comparative analysis. RESULTS Of 685 patients, 134 met the inclusion criteria. Moreover, 21 patients were treated with a cervical cerclage and excluded from the analysis, leaving 113 patients for the final analysis. There was a significant negative correlation between cervical length at fetoscopic laser surgery and the risk of early delivery (adjusted odds ratio, 0.66; 95% confidence interval, 0.49-0.81; P<.001). The use of a pessary correlated with fewer patients delivering before 28 weeks of gestation (adjusted odds ratio, 0.28; 95% confidence interval, 0.09-0.75), fewer double neonatal demise (adjusted odds ratio, 0.2; 95% confidence interval, 0.05-0.75). Posthoc subgroup analysis suggested that these improvements were essentially noticeable for cervical lengths between 5 and 18 mm, where pessary placement was associated with an increased fetoscopic laser surgery-to-delivery interval (+24 days; 95% confidence interval, 0.86-42; P=.042) and later gestational age at delivery (+3.3 weeks; 95% confidence interval, 0.86-42; P=.035). CONCLUSION Patients with a moderately shortened cervix, between 5 and 18 mm, may benefit from pessary placement after fetoscopic surgery for twin-to-twin transfusion syndrome, resulting in a reduction of adverse neonatal outcomes, double neonatal demise, and severe preterm delivery.
Collapse
Affiliation(s)
- Raphael Bartin
- Department of Obstetrics and Fetal Medicine, Necker-Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France; Faculté de Médecine, Université de Paris, Paris, France
| | - Cleisson Fábio Andrioli Peralta
- Gestar Fetal Medicine and Surgery Center, São Paulo, Brazil; Brazilian Ministry of Health, Programa de Desenvolvimento Institucional do Sistema Único de Saúde, São Paulo, Brazil
| | - Anna Clara Peneluppi Horak
- Heart Hospital Research Institute, São Paulo, Brazil; Brazilian Ministry of Health, Programa de Desenvolvimento Institucional do Sistema Único de Saúde, São Paulo, Brazil
| | - Karina Jorge Rodrigues da Costa
- Heart Hospital Research Institute, São Paulo, Brazil; Brazilian Ministry of Health, Programa de Desenvolvimento Institucional do Sistema Único de Saúde, São Paulo, Brazil
| | - Claire Colmant
- Department of Obstetrics and Fetal Medicine, Necker-Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Julien Stirnemann
- Department of Obstetrics and Fetal Medicine, Necker-Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France; Faculté de Médecine, Université de Paris, Paris, France
| | - Yves Ville
- Department of Obstetrics and Fetal Medicine, Necker-Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France; Faculté de Médecine, Université de Paris, Paris, France.
| |
Collapse
|
2
|
Faiola S, Mandalari M, Coco C, Casati D, Laoreti A, Mannarino S, Corti C, Consonni D, Cetin I, Lanna M. Long-Term Postnatal Follow-Up in Monochorionic TTTS Twin Pregnancies Treated with Fetoscopic Laser Surgery and Complicated by Right Ventricular Outflow Tract Anomalies. J Clin Med 2023; 12:4734. [PMID: 37510848 PMCID: PMC10381265 DOI: 10.3390/jcm12144734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 07/14/2023] [Accepted: 07/16/2023] [Indexed: 07/30/2023] Open
Abstract
Right ventricular outflow tract anomalies (RVOTAs), such as pulmonary stenosis (PS), pulmonary atresia (PA), and pulmonary insufficiency (PI), are typical cardiac anomalies in monochorionic twins, and they are complicated by twin-to-twin transfusion syndrome (TTTS). The aim of this study was to conduct a long-term postnatal cardiological evaluation of prenatal RVOTAs in monochorionic diamniotic twin pregnancies complicated by TTTS and treated with fetoscopic laser surgery (FLS) and to analyze possible prenatal predictors of congenital heart disease (CHD). Prenatal RVOTAs were retrospectively retrieved from all TTTS cases treated with FLS in our unit between 2009 and 2019. Twenty-eight prenatal cases of RVOTAs (16 PI, 10 PS, 2 PA) were observed out of 335 cases of TTTS. Four cases did not reach the postnatal period. CHD was present in 17 of the remaining 24 cases (70.8%), with 10 being severe (58.8%; 10/17); nine cases of PS required balloon valvuloplasty, and one case required biventricular non-compaction cardiomyopathy. The risk of major CHD increased with prenatal evidence of PS and decreased with the gestational age at the time of TTTS and with the prenatal normalization of blood flow across the pulmonary valve. Despite treatment with FLS, the majority of monochorionic diamniotic twin pregnancies complicated by TTTS with prenatal RVOTAs had CHD at long-term follow-up.
Collapse
Affiliation(s)
- Stefano Faiola
- Fetal Therapy Unit 'Umberto Nicolini', Buzzi Children's Hospital, 20154 Milan, Italy
- Department of Woman, Mother and Neonate, Buzzi Children's Hospital, 20154 Milan, Italy
| | - Maria Mandalari
- Department of Woman, Mother and Neonate, Buzzi Children's Hospital, 20154 Milan, Italy
| | - Chiara Coco
- Department of Woman, Mother and Neonate, Buzzi Children's Hospital, 20154 Milan, Italy
| | - Daniela Casati
- Fetal Therapy Unit 'Umberto Nicolini', Buzzi Children's Hospital, 20154 Milan, Italy
- Department of Woman, Mother and Neonate, Buzzi Children's Hospital, 20154 Milan, Italy
| | - Arianna Laoreti
- Fetal Therapy Unit 'Umberto Nicolini', Buzzi Children's Hospital, 20154 Milan, Italy
- Department of Woman, Mother and Neonate, Buzzi Children's Hospital, 20154 Milan, Italy
| | - Savina Mannarino
- Pediatric Cardiology Unit, Buzzi Children's Hospital, 20154 Milan, Italy
| | - Carla Corti
- Pediatric Cardiology Unit, Buzzi Children's Hospital, 20154 Milan, Italy
| | - Dario Consonni
- Epidemiology Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Irene Cetin
- Department of Woman, Mother and Neonate, Buzzi Children's Hospital, 20154 Milan, Italy
| | - Mariano Lanna
- Fetal Therapy Unit 'Umberto Nicolini', Buzzi Children's Hospital, 20154 Milan, Italy
- Department of Woman, Mother and Neonate, Buzzi Children's Hospital, 20154 Milan, Italy
| |
Collapse
|
3
|
Saab RH, DeVore GR, Monson M, Masri J, Korst LM, Chmait RH. Correction of fetal umbilical vein flow imbalance following laser surgery for twin-twin transfusion syndrome. Ultrasound Obstet Gynecol 2022; 60:774-779. [PMID: 36454633 PMCID: PMC10107838 DOI: 10.1002/uog.26041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 07/10/2022] [Accepted: 07/18/2022] [Indexed: 05/27/2023]
Abstract
OBJECTIVES 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. METHODS 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. RESULTS 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. CONCLUSION 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.
Collapse
Affiliation(s)
- R. H. Saab
- Division of Maternal–Fetal Medicine, Department of Obstetrics and GynecologyKeck School of Medicine, University of Southern CaliforniaLos AngelesCAUSA
| | - G. R. DeVore
- Fetal Diagnostic CentersPasadenaCAUSA
- Department of Obstetrics and GynecologyDavid Geffen School of Medicine, UCLALos AngelesCAUSA
- Department of Obstetrics and GynecologyWayne State UniversityDetroitMIUSA
| | - M. Monson
- Division of Maternal–Fetal Medicine, Department of Obstetrics and GynecologyKeck School of Medicine, University of Southern CaliforniaLos AngelesCAUSA
| | - J. Masri
- Division of Maternal–Fetal Medicine, Department of Obstetrics and GynecologyKeck School of Medicine, University of Southern CaliforniaLos AngelesCAUSA
| | - L. M. Korst
- Childbirth Research AssociatesNorth HollywoodCAUSA
| | - R. H. Chmait
- Division of Maternal–Fetal Medicine, Department of Obstetrics and GynecologyKeck School of Medicine, University of Southern CaliforniaLos AngelesCAUSA
| |
Collapse
|
4
|
Ogoyama M, Takahashi H, Kagawa K, Shimozawa H, Yada Y, Wada S, Sago H, Fujiwara H. Disseminated intravascular coagulation complicated by amniotic band syndrome associated with deceased fetal umbilical cord following fetoscopic laser surgery. J Obstet Gynaecol Res 2022; 48:1989-1996. [PMID: 35614528 DOI: 10.1111/jog.15281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 02/27/2022] [Accepted: 04/25/2022] [Indexed: 12/15/2022]
Abstract
Fetoscopic laser surgery occasionally causes amniotic band syndrome, in which the disrupted amniotic membrane constricts fetal body parts, leading to functional or morphological loss. We report a case of fetal distress at 31 weeks of gestation in the larger surviving twin after fetoscopic laser surgery for selective intrauterine growth restriction, necessitating emergent cesarean section. Physical examination of the infant showed constriction rings caused by a disrupted amniotic membrane on the digits, and the distal part of the right index finger was necrotic because of tight strangulation by an amniotic band with the umbilical cord of the deceased smaller twin. Laboratory data showed severe coagulopathy, and the infant was diagnosed with disseminated intravascular coagulation (DIC). Immediate treatment improved his condition. DIC may have been associated with the necrotic finger, which was strangulated by the umbilical cord of the deceased fetus, because neither maternal coagulopathy nor an underlying neonatal disorder was detected.
Collapse
Affiliation(s)
- Manabu Ogoyama
- Department of Obstetrics and Gynecology, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Hironori Takahashi
- Department of Obstetrics and Gynecology, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Keiko Kagawa
- Department of Obstetrics and Gynecology, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Hironori Shimozawa
- Department of Pediatrics, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Yukari Yada
- Department of Pediatrics, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Seiji Wada
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Haruhiko Sago
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Hiroyuki Fujiwara
- Department of Obstetrics and Gynecology, Jichi Medical University, Shimotsuke, Tochigi, Japan
| |
Collapse
|
5
|
Duy Anh N, Duy An N, Huyen Thuong PT, Thu Ha NT, Sim NT, Sy Hung H, Manh Tri N, Duc Lam N, Tuan Dat D, Ville Y, Manh Ha N, Minh Duc N. The Efficacy of Fetoscopic Laser Surgery in Twin-Twin Transfusion Syndrome: A Preliminary Vietnamese Study. Clin Ter 2022; 173:265-273. [PMID: 35612342 DOI: 10.7417/ct.2022.2430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.
Collapse
Affiliation(s)
- N Duy Anh
- Department of Fetal Intervention, Hanoi Obstetrics and Gynecology Hospital, Hanoi, Vietnam
| | - N Duy An
- Department of Obstetrics and Gynecology, Hanoi Medical University, Hanoi, Vietnam
| | - P T Huyen Thuong
- Department of Fetal Intervention, Hanoi Obstetrics and Gynecology Hospital, Hanoi, Vietnam
| | - N T Thu Ha
- Department of Assisted Reproduction, Hanoi Obstetrics and Gynecology Hospital, Hanoi, Vietnam
| | - N T Sim
- Department of Fetal Intervention, Hanoi Obstetrics and Gynecology Hospital, Hanoi, Vietnam
| | - H Sy Hung
- Department of Obstetrics and Gynecology, Hanoi Medical University, Hanoi, Vietnam
| | - N Manh Tri
- Department of Prenatal diagnostic and Newborn screening, Hanoi Obstetrics and Gynecology Hospital, Hanoi, Vietnam
| | - N Duc Lam
- Department of Obstetrics and Gynecology, Hanoi Medical University, Hanoi, Vietnam
| | - D Tuan Dat
- Department of Obstetrics and Gynecology, Hanoi Medical University, Hanoi, Vietnam
| | - Y Ville
- Department of Obstetrics and Fetal Medicine at Necker-Enfants-Malades Hospital at the Paris Descartes Universi-ty, Paris, French
| | - N Manh Ha
- Department of Histology and Embryology, Hanoi Medical University, Hanoi, Vietnam
| | - N Minh Duc
- Department of Radiology, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
| |
Collapse
|
6
|
Buskmiller C, Bergh EP, Brock C, Miller J, Baschat A, Galan H, Behrendt N, Habli M, Peiro JL, Snowise S, Fisher J, Macpherson C, Thom E, Pedroza C, Johnson A, Blackwell S, Papanna R. Interventions to prevent preterm delivery in women with short cervix before fetoscopic laser surgery for twin-twin transfusion syndrome. Ultrasound Obstet Gynecol 2022; 59:169-176. [PMID: 34129709 DOI: 10.1002/uog.23708] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 06/03/2021] [Accepted: 06/04/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Preoperative short cervical length (CL) remains a major risk factor for preterm birth after laser surgery for twin-twin transfusion syndrome (TTTS), but the optimal intervention to prolong pregnancy remains elusive. The objective of this study was to compare secondary methods for the prevention of preterm birth in twin pregnancies with TTTS undergoing fetoscopic laser photocoagulation (FLP), in the setting of a short cervix at the time of FLP, in five North American Fetal Treatment Network (NAFTNet) centers. METHODS This was a secondary analysis of data collected prospectively at five NAFTNet centers, conducted from January 2013 to March 2020. Inclusion criteria were a monochorionic diamniotic twin pregnancy complicated by TTTS, undergoing FLP, with preoperative CL < 30 mm. Management options for a short cervix included expectant management, vaginal progesterone, pessary (Arabin, incontinence or Bioteque cup), cervical cerclage or a combination of two or more treatments. Patients were not included if the intervention was initiated solely on the basis of having a twin gestation rather than at the diagnosis of a short cervix. Demographics, ultrasound characteristics, operative data and outcomes were compared. The primary outcome was FLP-to-delivery interval. Propensity-score matching was performed, with each treatment group matched (1:1) to the expectant-management group for CL, in order to estimate the effect of each treatment on the FLP-to-delivery interval. RESULTS A total of 255 women with a twin pregnancy complicated by TTTS and a short cervix undergoing FLP were included in the study. Of these, 151 (59%) were managed expectantly, 32 (13%) had vaginal progesterone only, 21 (8%) had pessary only, 21 (8%) had cervical cerclage only and 30 (12%) had a combination of treatments. A greater proportion of patients in the combined-treatment group had had a prior preterm birth compared with those in the expectant-management group (33% vs 9%; P = 0.01). Mean preoperative CL was shorter in the pessary, cervical-cerclage and combined-treatment groups (14-16 mm) than in the expectant-management and vaginal-progesterone groups (22 mm for both) (P < 0.001). There was no significant difference in FLP-to-delivery interval between the groups, nor in gestational age at delivery or the rate of live birth or neonatal survival. Vaginal progesterone was associated with a decrease in the risk of delivery before 28 weeks' gestation compared with cervical cerclage and combined treatment (P = 0.03). Using propensity-score matching for CL, cervical cerclage was associated with a reduction in FLP-to-delivery interval of 13 days, as compared with expectant management. CONCLUSIONS A large proportion of pregnancies with TTTS and a short maternal cervix undergoing FLP were managed expectantly for a short cervix, establishing a high (62%) risk of delivery before 32 weeks in this condition. No treatment that significantly improved outcome was identified; however, there were significant differences in potential confounders and there were also likely to be unmeasured confounders. Cervical cerclage should not be offered as a secondary prevention for preterm birth in twin pregnancies with TTTS and a short cervix undergoing FLP. A large randomized controlled trial is urgently needed to determine the effects of treatments for the prevention of preterm birth in these pregnancies. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
Collapse
Affiliation(s)
- C Buskmiller
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, UTHealth The University of Texas McGovern Medical School and the Fetal Center at Children's Memorial Hermann Hospital, Houston, TX, USA
| | - E P Bergh
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, UTHealth The University of Texas McGovern Medical School and the Fetal Center at Children's Memorial Hermann Hospital, Houston, TX, USA
| | - C Brock
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, UTHealth The University of Texas McGovern Medical School and the Fetal Center at Children's Memorial Hermann Hospital, Houston, TX, USA
| | - J Miller
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - A Baschat
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - H Galan
- Department of Obstetrics and Gynecology, University of Colorado Denver, Colorado Fetal Care Center, Children's Hospital of Colorado, Denver, CO, USA
| | - N Behrendt
- Department of Obstetrics and Gynecology, University of Colorado Denver, Colorado Fetal Care Center, Children's Hospital of Colorado, Denver, CO, USA
| | - M Habli
- Cincinnati Children's Fetal Care Center, Cincinnati, OH, USA
| | - J L Peiro
- Cincinnati Children's Fetal Care Center, Cincinnati, OH, USA
| | - S Snowise
- Midwest Fetal Care Center, Children's Minnesota, Minneapolis, MN, USA
| | - J Fisher
- Midwest Fetal Care Center, Children's Minnesota, Minneapolis, MN, USA
| | - C Macpherson
- The Biostatistics Center, George Washington University, Rockville, MD, USA
| | - E Thom
- The Biostatistics Center, George Washington University, Rockville, MD, USA
| | - C Pedroza
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, UTHealth The University of Texas McGovern Medical School and the Fetal Center at Children's Memorial Hermann Hospital, Houston, TX, USA
| | - A Johnson
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, UTHealth The University of Texas McGovern Medical School and the Fetal Center at Children's Memorial Hermann Hospital, Houston, TX, USA
| | - S Blackwell
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, UTHealth The University of Texas McGovern Medical School and the Fetal Center at Children's Memorial Hermann Hospital, Houston, TX, USA
| | - R Papanna
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, UTHealth The University of Texas McGovern Medical School and the Fetal Center at Children's Memorial Hermann Hospital, Houston, TX, USA
| |
Collapse
|
7
|
Knijnenburg PJC, Spruijt MS, Jansen L, Rijken M, Tan RNGB, Slaghekke F, Middeldorp JM, Lopriore E, van Klink JMM. Neurodevelopmental Trajectories of Preterm Born Survivors of Twin-Twin Transfusion Syndrome: From Birth to 5 Years of Age. J Pediatr 2022; 240:51-57.e1. [PMID: 34506853 DOI: 10.1016/j.jpeds.2021.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 08/21/2021] [Accepted: 09/01/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To investigate the neurodevelopmental outcome at age 2 and 5 years in survivors of twin-twin transfusion syndrome (TTTS) treated with fetoscopic laser surgery and born premature and/or small for gestational age. STUDY DESIGN At 2 and 5 years of age, standardized neurologic, motor, and cognitive assessments were performed by a neonatologist, a pediatric physical therapist, and a psychologist. Behavior was assessed using a validated questionnaire completed by parents. RESULTS Neurodevelopmental assessment at both time points was available for 73 survivors of TTTS. Mild to moderate neurodevelopmental impairment (NDI) was detected in 34% of survivors (25 of 73) at 5 years, compared with 25% (18 of 73) at 2 years (P = .178). Severe NDI was observed in 12% (9 of 73) at 5 years and in 3% (2 of 73) at 2 years (P = .035). Mean cognitive score was lower at the 5-year follow-up (90.7 ± 12.3 vs 95.6 ± 13.1 at 2 years; P = .001), and more children were diagnosed with mild cognitive impairment at 5 years (29% vs 11% at 2 years; P = .007). When comparing individual outcomes at both time points, 35% (25 of 71) moved from a normal outcome or mild to moderate impairment at 2 years toward more severe impairment at 5 years. CONCLUSIONS A high rate of mild to moderate cognitive impairment and severe NDI at age 5 years was not identified at age 2 years. Our data highlight the importance of longitudinal follow-up of survivors of TTTS beyond age 2 years and emphasize the precautions that should be taken when diagnosing an absence of impairment before school age.
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
| | - Marjolijn S Spruijt
- Division of Neonatology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Lisette Jansen
- Division of Child and Adolescent Psychology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Monique Rijken
- Division of Neonatology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Ratna N G B Tan
- Division of Neonatology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Femke Slaghekke
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Johanna M Middeldorp
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Enrico Lopriore
- Division of Neonatology, Department of Pediatrics, Willem-Alexander Children's Hospital, 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.
| |
Collapse
|
8
|
Donepudi R, Krispin E, Mustafa H, Espinoza J, Nassr AA, Belfort MA, Sanz Cortes M, Mostafaei S, Harman C, Turan O, Shamshirsaz AA. Twin twin transfusion syndrome with and without selective fetal growth restriction: Predictors of donor demise. Prenat Diagn 2021; 41:1524-1530. [PMID: 34570378 DOI: 10.1002/pd.6049] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 08/17/2021] [Accepted: 09/11/2021] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Evaluate survival in twin twin transfusion syndrome (TTTS) with and without selective fetal growth restriction (sFGR) after fetoscopic laser surgery (FLS). METHODS Retrospective study of monochorionic diamniotic twins undergoing FLS. The cohort was classified as TTTS and TTTS with sFGR. Baseline, intra-operative and postoperative variables were analyzed. Mann-Whitney U, Pearson chi-square, Fisher's exact, t-test and receiver operating characteristic (ROC) curve analysis were performed. RESULTS Four hundred and ninety-two pregnancies were included, 304 (61.78%) TTTS and 188 (38.22%) TTTS with sFGR. No difference in donor outcomes. TTTS group had higher donor estimated fetal weight (EFW%) percentile (19.7 ± 18.8 vs. 2.2 ± 2.1, p < 0.001). Significant predictors for demise at 30 days were 37% intertwin weight discordance (IWD) with donor EFW% < first (area under ROC curve [AUC] = 0.85, p = 0.001) or IWD >25% and intertwin umbilical artery pulsatility index discordance (DUAPI) ≥0.4 (AUC = 0.71, p = 0.001). CONCLUSION Combination of IWD of 37% and donor EFW% <first was most predictive for demise 30 days after birth. DUAPI ≥0.4 was also associated with increased risk for demise.
Collapse
Affiliation(s)
- Roopali Donepudi
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, USA
| | - Eyal Krispin
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, USA
| | - Hiba Mustafa
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jimmy Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, USA
| | - Ahmed A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, USA
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, USA
| | - Magdalena Sanz Cortes
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, USA
| | - Shayan Mostafaei
- Department of Biostatistics, Faculty of Health, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Christopher Harman
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ozhan Turan
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Alireza A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, USA
| |
Collapse
|
9
|
Takano M, Nakata M, Ishii K, Wada S, Sumie M, Yamamoto R, Ozawa K, Sakuma J, Nagasaki S, Sago H. Outcomes of fetoscopic laser surgery for twin-to-twin transfusion syndrome between 26 and 27 weeks of gestation in Japan. J Obstet Gynaecol Res 2021; 47:3821-3827. [PMID: 34227180 DOI: 10.1111/jog.14922] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 06/09/2021] [Accepted: 06/26/2021] [Indexed: 12/31/2022]
Abstract
AIM The purpose of this study was to investigate the outcomes of fetoscopic laser photocoagulation (FLP) for twin-to-twin transfusion syndrome (TTTS) in Japan. METHODS The retrospective cohort study (2012-2018) was conducted in monochorionic twin pregnancies that underwent FLP for TTTS between 26 and 27 weeks from 2012 to 2018. The perioperative data, maternal complications, gestational age (GA) at delivery, neonatal complications, and survival of infants at 28 days of age were analyzed. At term-equivalent age, severe neurological complications were identified by imaging study. RESULTS Of 644 patients, 28 (4.3%) underwent FLP between 26 and 27 weeks, and 26 were analyzed. FLP procedures were technically successful in all cases. There were no cases of major maternal complications after surgery. Preterm rupture of membranes occurred in 34.6% of cases, and the mean GA at delivery was 33.2 ± 3.1 weeks. The survival of both twins was found in 23 (88.4%) cases, and the perinatal survival rate of at least one twin at 28 days of age was 100%. Severe neurological complications were found in six (12.2%) cases out of 49. CONCLUSIONS FLP for TTTS between 26 and 27 weeks provided a good prognosis and caused no major maternal complications. However, severe neurological findings were found in 12% of infants.
Collapse
Affiliation(s)
- Mayumi Takano
- Department of Obstetrics and Gynecology, Toho University Faculty of Medicine, Tokyo, Japan.,Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - Masahiko Nakata
- Department of Obstetrics and Gynecology, Toho University Faculty of Medicine, Tokyo, Japan.,Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - Keisuke Ishii
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Seiji Wada
- Division of Fetal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Masahiro Sumie
- Department of Obstetrics, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Ryo Yamamoto
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Katsusuke Ozawa
- Division of Fetal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Junya Sakuma
- Department of Obstetrics and Gynecology, Toho University Faculty of Medicine, Tokyo, Japan.,Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - Sumito Nagasaki
- Department of Obstetrics and Gynecology, Toho University Faculty of Medicine, Tokyo, Japan.,Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - Haruhiko Sago
- Division of Fetal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| |
Collapse
|
10
|
Kanazawa S, Ozawa K, Muromoto J, Sugibayashi R, Wada Y, Wada S, Ito Y, Sago H. Risk Profiling of the Solomon Technique versus Selective Technique of Fetoscopic Laser Surgery for Twin-Twin Transfusion Syndrome. Twin Res Hum Genet 2021; 24:42-8. [PMID: 33900164 DOI: 10.1017/thg.2020.94] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
We evaluated the outcomes and adverse events after fetoscopic laser surgery (FLS) for twin-twin transfusion syndrome (TTTS) using the Solomon technique in comparison to the selective technique. A retrospective analysis of a single-center consecutive cohort of FLS-treated TTTS using the selective (January 2010 to July 2014) and Solomon (August 2014 to December 2017) techniques was performed. Among 395 cases, 227 underwent selective coagulation and 168 underwent the Solomon technique. The incidence rates of recurrent TTTS (Solomon vs. selective: 0% vs. .9%, p = .510) and twin anemia-polycythemia sequence (.6% vs. .4%, p = .670) were very low in both groups. The incidence rates of placental abruption (Solomon vs. selective: 10.7% vs. 3.5%, p = .007) and preterm premature rupture of the membranes (pPROM) with subsequent delivery before 32 weeks (20.2% vs. 7.1%, p < .001) were higher in the Solomon group. The median birth recipient weight was significantly smaller in the Solomon group (1790 g vs. 1933 g, p = .049). The rate of survival of at least one twin was significantly higher in the Solomon group (98.2% vs. 93.8%, p = .046). The Solomon technique and total laser energy were significant risk factors for pPROM (odds ratio: 2.64, 1.07, 95% CI [1.32, 5.28], [1.01, 1.13], p = .006, p = .014, respectively). These findings suggest that the Solomon technique led to superior survival outcomes but increased risks of placental abruption, pPROM and fetal growth impairment. Total laser energy was associated with the occurrence of pPROM. Close attention to adverse events is required for perinatal management after FLS to treat TTTS using the Solomon technique.
Collapse
|
11
|
Knijnenburg PJC, Slaghekke F, Tollenaar LSA, Gijtenbeek M, Haak MC, Middeldorp JM, Klumper FJCM, van Klink JMM, Oepkes D, Lopriore E. Prevalence, risk factors, and outcome of postprocedural amniotic band disruption sequence after fetoscopic laser surgery in twin-twin transfusion syndrome: a large single-center case series. Am J Obstet Gynecol 2020; 223:576.e1-576.e8. [PMID: 32335054 DOI: 10.1016/j.ajog.2020.04.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 04/04/2020] [Accepted: 04/18/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Postprocedural amniotic band disruption sequence is a condition that is associated with intrauterine interventions, and it is characterized by a constriction of the limbs or umbilical cord by fibrous strands, leading to edema, amputation, and/or fetal demise. OBJECTIVE To evaluate the prevalence of, risk factors for, and the outcome of postprocedural amniotic band disruption sequence after fetoscopic laser surgery in twin-twin transfusion syndrome cases. STUDY DESIGN All consecutive cases of twin-twin transfusion syndrome treated with fetoscopic laser coagulation of the vascular anastomoses at our center between January 2002 and March 2019 were included in the study. The occurrence of postprocedural amniotic band disruption sequence in these cases was recorded, and the potential risk factors were analyzed. RESULTS Postprocedural amniotic band disruption sequence was detected, at birth, in 2.2% (15/672) of twin-twin transfusion syndrome cases treated with fetoscopic laser surgery, in both the recipients (10/15, 67%) and the donors (5/15, 33%). Postprocedural amniotic band disruption sequence primarily affected the lower extremities (11/15, 73%) and, less frequently, the upper extremities (2/15, 13%), both the upper and lower extremities (1/15, 7%), or the umbilical cord (1/15, 7%). Postprocedural amniotic band disruption sequence led to the amputation of toes in 5 of 15 cases (33%) and resulted in fetal demise because of constriction of the umbilical cord in 1 case (7%). The independent risk factors identified for postprocedural amniotic band disruption sequence were lower gestational age at laser surgery (odds ratio per week, 1.43; 95% confidence interval, 1.12-1.79; P=.003) and the presence of postprocedural chorioamniotic membrane separation on antenatal ultrasound examination (odds ratio, 41.66; 95% confidence interval, 5.44-319.25; P<.001). CONCLUSION The prevalence of postprocedural amniotic band disruption sequence is low, but, when present, it may lead to severe consequences, with amputation of extremities or fetal demise occurring in more than one-third of the cases. Lower gestational age at the time of laser therapy and chorioamniotic membrane separation are independent risk factors for the postprocedural amniotic band disruption sequence.
Collapse
Affiliation(s)
- Patricia J C Knijnenburg
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands.
| | - Femke Slaghekke
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Lisanne S A Tollenaar
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Manon Gijtenbeek
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Monique C Haak
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Johanna M Middeldorp
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Frans J C M Klumper
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Jeanine M M van Klink
- Division of Child and Adolescent Psychology, Department of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Dick Oepkes
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Enrico Lopriore
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands
| |
Collapse
|
12
|
Spruijt MS, Lopriore E, Tan RNGB, Slaghekke F, Klumper FJCM, Middeldorp JM, Haak MC, Oepkes D, Rijken M, van Klink JMM. Long-Term Neurodevelopmental Outcome in Twin-to-Twin Transfusion Syndrome: Is there still Room for Improvement? J Clin Med 2019; 8:jcm8081226. [PMID: 31443258 PMCID: PMC6723379 DOI: 10.3390/jcm8081226] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 08/02/2019] [Accepted: 08/12/2019] [Indexed: 12/23/2022] Open
Abstract
Despite many developments in its management, twin-to-twin transfusion syndrome (TTTS) remains an important risk factor for long-term neurodevelopmental impairment (NDI). Our objective was to compare the incidence of severe NDI in a recent cohort of TTTS survivors, treated with laser surgery from 2011 to 2014, with a previous cohort treated from 2008 to 2010. Neurological, cognitive, and motor development were assessed at two years of age. We determined risk factors associated with Bayley-III scores. Severe NDI occurred in 7/241 (3%) survivors in the new cohort compared to 10/169 (6%) in the previous cohort (p = 0.189). Disease-free survival (survival without severe impairment) did not significantly differ. Low birth weight and being small for gestational age (SGA) were independently associated with lower cognitive scores (both p < 0.01). Severe cerebral injury was related to decreased motor scores (B = −14.10; 95% CI −3.16, −25.04; p = 0.012). Children with severe NDI were born ≥32 weeks’ gestation in 53% of cases and had no evidence of cerebral injury on cranial ultrasound in 59% of cases. Our results suggest that improvement in outcome of TTTS has reached a plateau. Low birth weight, SGA, and cerebral injury are risk factors for poor neurodevelopmental outcome. Neither gestational age above 32 weeks nor the absence of cerebral injury preclude severe NDI.
Collapse
Affiliation(s)
- Marjolijn S Spruijt
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, J7-48, Albinusdreef 2, 2333 ZA Leiden, The Netherlands.
| | - Enrico Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, J7-48, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Ratna N G B Tan
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, J7-48, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Femke Slaghekke
- Department of Obstetrics, Division of Fetal Therapy, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Frans J C M Klumper
- Department of Obstetrics, Division of Fetal Therapy, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Johanna M Middeldorp
- Department of Obstetrics, Division of Fetal Therapy, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Monique C Haak
- Department of Obstetrics, Division of Fetal Therapy, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Dick Oepkes
- Department of Obstetrics, Division of Fetal Therapy, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Monique Rijken
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, J7-48, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Jeanine M M van Klink
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, J7-48, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| |
Collapse
|
13
|
Takano M, Nakata M, Rikitake T, Nagasaki S, Hayata E, Morita M. Successful use of fetoscopic laser surgery as treatment for a monochorionic-triamniotic triplet pregnancy complicated by twin-reversed arterial perfusion sequence and severe selective fetal growth restriction: A case report. J Obstet Gynaecol Res 2019; 45:1584-1587. [PMID: 31064035 DOI: 10.1111/jog.13994] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 04/11/2019] [Indexed: 11/26/2022]
Abstract
Monochorionic triplet pregnancy is a rare condition, and twin-reversed arterial perfusion (TRAP) sequence and severe selective fetal growth restriction (FGR) are associated with high perinatal morbidity and mortality rates. We report a case of TRAP sequence and selective FGR typeIIconcurrently complicating a monochorionic triplet pregnancy. Fetoscopic laser surgery (FLS) was performed at 16 + 1 weeks of gestation and was technically successful. Inter-fetus placental anastomoses were coagulated. The pregnancy continued until 28 + 4 weeks of gestation, when the patient presented with preterm rupture of membranes and preterm labor. Two live female newborns were delivered by a cesarean section, and their postnatal course of the neonates was uneventful and in accordance with their gestational age at birth. To our knowledge, this is the first case report of FLS resulting in favorable outcomes for a monochorionic triplet pregnancy concurrently complicated with TRAP sequence and selective FGR type II.
Collapse
Affiliation(s)
- Mayumi Takano
- Department of Obstetrics and Gynecology, Toho University Graduate School of Medicine, Tokyo, Japan.,Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - Masahiko Nakata
- Department of Obstetrics and Gynecology, Toho University Graduate School of Medicine, Tokyo, Japan.,Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - Takayuki Rikitake
- Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - Sumito Nagasaki
- Department of Obstetrics and Gynecology, Toho University Graduate School of Medicine, Tokyo, Japan.,Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - Eijiro Hayata
- Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - Mineto Morita
- Department of Obstetrics and Gynecology, Toho University Graduate School of Medicine, Tokyo, Japan.,Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| |
Collapse
|
14
|
Abstract
Monochorionic twin pregnancies can be complicated by twin-to-twin transfusion syndrome (TTTS). The best treatment option for TTTS is fetoscopic laser coagulation of the vascular anastomoses between donor and recipient. After laser therapy, up to 33% residual anastomoses were seen. These residual anastomoses can cause twin anemia polycythemia sequence (TAPS) and recurrent TTTS. In order to reduce the number of residual anastomoses and their complications, a new technique, the Solomon technique, where the whole vascular equator will be coagulated, was introduced. The Solomon technique showed a reduction of recurrent TTS compared to the selective technique. The incidence of recurrent TTTS after the Solomon technique ranged from 0% to 3.9% compared to 5.3-8.5% after the selective technique. The incidence of TAPS after the Solomon technique ranged from 0% to 2.9% compared to 4.2-15.6% after the selective technique. The Solomon technique may improve dual survival rates ranging from 64% to 85% compared to 46-76% for the selective technique. There was no difference reported in procedure-related complications such as intrauterine infection and preterm premature rupture of membranes. The Solomon technique significantly reduced the incidence of TAPS and recurrent TTTS and may improve survival and neonatal outcome, without identifiable adverse outcome or complications; therefore, the Solomon technique is recommended for the treatment of TTTS.
Collapse
|
15
|
Malshe A, Snowise S, Mann LK, Boring N, Johnson A, Bebbington MW, Moise KJ, Papanna R. Preterm delivery after fetoscopic laser surgery for twin-twin transfusion syndrome: etiology and risk factors. Ultrasound Obstet Gynecol 2017; 49:612-616. [PMID: 27222097 DOI: 10.1002/uog.15972] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 04/23/2016] [Accepted: 05/16/2016] [Indexed: 06/05/2023]
Abstract
OBJECTIVE Preterm delivery after fetoscopic laser surgery (FLS) for twin-twin transfusion syndrome (TTTS) is a major complication. The causative factors leading to preterm delivery continue to be elusive and a better understanding of the risk factors could reduce complications. The objective of this study was to determine the etiology of preterm delivery after FLS for TTTS and its associated risk factors. METHODS This was a secondary analysis of a prospective study of 203 patients with TTTS who underwent FLS at a single center between September 2011 and December 2014. Preoperative, operative, postoperative, delivery and neonatal data were reviewed. Preterm delivery was categorized according to etiology into three groups: spontaneous (SPT), indicated (IND) and elective (ELC). Comparisons between groups were performed by ANOVA. Kaplan-Meier survival analysis was performed to compare the procedure-to-delivery interval between groups. To identify risk factors for preterm delivery, logistic regression, with calculation of relative risks (RR), was performed, with P < 0.05 considered statistically significant. RESULTS Mean gestational age at time of FLS was 20.6 ± 2.4 weeks and mean gestational age at delivery was 30.9 ± 4.7 weeks. Iatrogenic preterm prelabor rupture of membranes (iPPROM) occurred in 39% of cases. SPT preterm delivery occurred in 97 (48%) patients, IND preterm delivery in 65 (32%) and ELC preterm delivery in 41 (20%). In the IND group, 30 (46%) patients delivered for fetal indications, 31 (48%) for maternal indications and four (6%) for combined fetal and maternal indications. The overall chorioamnionitis rate was 6.4%; of these, nine (9%) were in the SPT group and four (6%) were in the IND group, with no case occurring in the ELC group. There was a significant difference in procedure-to-delivery interval between groups (P < 0.0001). Using variables from the ELC group as a baseline, significant risk factors for SPT preterm delivery were iPPROM (RR, 16.2 (95% CI, 4.5-57.7)), preoperative cervical length (RR, 0.96 (95% CI, 0.92-0.998)) and number of anastomoses (RR, 1.14 (95% CI, 1.02-1.27)). Significant risk factors for IND preterm delivery were iPPROM (RR, 9.6 (95% CI, 2.6-35.0)) and number of ablated anastomoses (RR, 1.13 (95% CI, 1.02-1.30)). CONCLUSION iPPROM and an increased number of ablated placental anastomoses were associated independently with SPT and IND preterm deliveries. A shorter preoperative cervical length was associated with SPT preterm delivery. Strategies to prevent iPPROM and for management of cervical length shortening are needed urgently in these pregnancies. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
Collapse
Affiliation(s)
- A Malshe
- Department of Obstetrics, Gynecology and Reproductive Sciences, UTHealth Medical School, Houston, TX, USA
| | - S Snowise
- Department of Obstetrics, Gynecology and Reproductive Sciences, UTHealth Medical School, Houston, TX, USA
- The Fetal Center, Children's Memorial Hermann Hospital, Houston, TX, USA
| | - L K Mann
- Department of Obstetrics, Gynecology and Reproductive Sciences, UTHealth Medical School, Houston, TX, USA
- The Fetal Center, Children's Memorial Hermann Hospital, Houston, TX, USA
| | - N Boring
- The Fetal Center, Children's Memorial Hermann Hospital, Houston, TX, USA
| | - A Johnson
- Department of Obstetrics, Gynecology and Reproductive Sciences, UTHealth Medical School, Houston, TX, USA
- The Fetal Center, Children's Memorial Hermann Hospital, Houston, TX, USA
| | - M W Bebbington
- Department of Obstetrics, Gynecology and Reproductive Sciences, UTHealth Medical School, Houston, TX, USA
- The Fetal Center, Children's Memorial Hermann Hospital, Houston, TX, USA
| | - K J Moise
- Department of Obstetrics, Gynecology and Reproductive Sciences, UTHealth Medical School, Houston, TX, USA
- The Fetal Center, Children's Memorial Hermann Hospital, Houston, TX, USA
| | - R Papanna
- Department of Obstetrics, Gynecology and Reproductive Sciences, UTHealth Medical School, Houston, TX, USA
- The Fetal Center, Children's Memorial Hermann Hospital, Houston, TX, USA
| |
Collapse
|
16
|
Slaghekke F, Zhao DP, Middeldorp JM, Klumper FJ, Haak MC, Oepkes D, Lopriore E. Antenatal management of twin-twin transfusion syndrome and twin anemia-polycythemia sequence. Expert Rev Hematol 2016; 9:815-20. [PMID: 27322562 DOI: 10.1080/17474086.2016.1200968] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Twin-twin transfusion syndrome (TTTS) and twin anemia polycythemia sequence (TAPS) are severe complications in monochorionic twin pregnancies associated with high mortality and morbidity risk if left untreated. Both diseases result from imbalanced inter-twin blood transfusion through placental vascular anastomoses. AREAS COVERED This review focuses on the differences in antenatal management between TTTS and TAPS. Expert commentary: The optimal management for TTTS is fetoscopic laser coagulation of the vascular anastomoses, preferably using the Solomon technique in which the whole vascular equator is coagulated. The Solomon technique is associated with a reduction of residual anastomosis and a reduction in post-operative complications. The optimal management for TAPS is not clear and includes expectant management, intra-uterine transfusion with or without partial exchange transfusion and fetoscopic laser surgery.
Collapse
Affiliation(s)
- Femke Slaghekke
- a Division of Fetal Medicine, Department of Obstetrics , Leiden University Medical Centre , Leiden , The Netherlands
| | - Depeng P Zhao
- b Division of Neonatology, Department of Pediatrics , Leiden University Medical Centre , Leiden , The Netherlands
| | - Johanna M Middeldorp
- a Division of Fetal Medicine, Department of Obstetrics , Leiden University Medical Centre , Leiden , The Netherlands
| | - Frans J Klumper
- a Division of Fetal Medicine, Department of Obstetrics , Leiden University Medical Centre , Leiden , The Netherlands
| | - Monique C Haak
- a Division of Fetal Medicine, Department of Obstetrics , Leiden University Medical Centre , Leiden , The Netherlands
| | - Dick Oepkes
- a Division of Fetal Medicine, Department of Obstetrics , Leiden University Medical Centre , Leiden , The Netherlands
| | - Enrico Lopriore
- b Division of Neonatology, Department of Pediatrics , Leiden University Medical Centre , Leiden , The Netherlands
| |
Collapse
|
17
|
Papanna R, Mann LK, Moise KY, Johnson A, Moise KJ. Absorbable gelatin plug does not prevent iatrogenic preterm premature rupture of membranes after fetoscopic laser surgery for twin-twin transfusion syndrome. Ultrasound Obstet Gynecol 2013; 42:456-460. [PMID: 23606579 DOI: 10.1002/uog.12487] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Revised: 04/07/2013] [Accepted: 04/10/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVE Despite fetoscopic laser ablation (FLA) having emerged as an effective treatment for twin-twin transfusion syndrome (TTTS), major postintervention challenges, such as iatrogenic preterm premature rupture of membranes (iPPROM), remain. A chorioamniotic plug (CAP) made of absorbable gelatin sponge has been used to seal the trocar entry site in the chorioamniotic layers to promote healing and prevent iPPROM, yet the results have been equivocal. Our objective was to test the hypothesis that, following FLA for TTTS, iPPROM may be prevented by placement of an absorbable gelatin CAP. METHODS A retrospective cohort study was performed on prospectively collected data from 134 consecutive patients who underwent FLA for TTTS. The decision for CAP placement was at the discretion of the physician. Preoperative, operative and postoperative variables were collected and analyzed. The primary outcome was the incidence of iPPROM, and the secondary outcomes were procedure-to-delivery interval and gestational age at delivery. Comparative statistical analysis was performed as appropriate. RESULTS A CAP was placed in 72 (54%) of 134 patients. Factors significantly associated with CAP placement were higher gravidity (P = 0.03), anterior placentation (P = 0.04), general endotracheal intubation (P = 0.02) and a cannula diameter of 12-Fr (P = 0.003). There were no differences between CAP and no-CAP groups in the rate of iPPROM (39% vs 34%, respectively; P = 0.42) or in the procedure-to-delivery interval (65.3 ± 34.7 days vs 58.2 ± 30.8 days, respectively; P = 0.21). The gestational age at delivery was later in the CAP group compared with the no-CAP group (30.7 ± 4.5 weeks vs 28.9 ± 3.9 weeks, respectively; P = 0.02). CONCLUSIONS CAP did not reduce the overall risk for iPPROM and did not increase the procedure-to-delivery interval. Further research is needed to identify other methods to prevent iPPROM and prolong pregnancy after laser therapy.
Collapse
Affiliation(s)
- R Papanna
- Section of Maternal-Fetal Medicine, Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and the Texas Children's Fetal Center, Houston, TX, USA
| | | | | | | | | |
Collapse
|