160: Chromosomal microarray for patient choice disadvantage may outweigh benefit (original) (raw)
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Acta Obstetricia et Gynecologica Scandinavica, 2021
Introduction: Untreated Twin-to-twin transfusion syndrome (TTTS) is associated with a high risk of perinatal mortality and morbidity. Laser surgery is recommended before 26 weeks' gestation. However, the optimal management in case of late (occurring >26 weeks) TTTS is yet to be established. Material and methods: We conducted a systematic review and meta-analysis to evaluate the outcomes of monochorionic diamniotic twin pregnancies complicated by late TTTS according to different management options (expectant, laser therapy, amnioreduction or delivery). The primary outcome was mortality, including single and double intrauterine, neonatal and perinatal death. Secondary outcomes were composite morbidity, neuromorbidity, respiratory distress syndrome, admission to neonatal intensive care unit, intact survival (i.e. free from neurological complications) and preterm birth <32 weeks' gestation. Outcomes were reviewed according to the management and reported for the overall population of twins and disease status (i.e. donor and recipient separately). Random-effect meta-analyses of proportions were used to analyse the data. Results: Nine studies including 796 twin pregnancies affected by TTTS were included. No randomized-controlled trials were available for inclusion. TTTS occurred at ≥26 weeks of gestation in 8.7% (95% CI 6.9-10.9; 67/769) of cases reporting TTTS at all gestation. Intrauterine death occurred in 17.7% (95% CI 4.9-36.2) pregnancies managed expectantly, 5.3% (95% CI 0.9-12.9) pregnancies treated with laser and 0% (95% CI 0-9) after amnioreduction. Neonatal death occurred in 42.5% (95% CI 17.5-69.7) pregnancies managed expectantly, in 2.8% (95% CI 0.3-7.7) cases treated with laser and in 20.2% (95% CI 6-40) after amnioreduction. Only one study (ten cases) reported data on immediate delivery after diagnosis with no perinatal deaths. Perinatal death incidence was 55.7% (95% CI 31.4-78.6) in twin pregnancies managed expectantly, 5.6% (95% CI 0.5-15.3) in those treated with laser and 20.2% (95% CI 6-40) in those after amnioreduction. Intact survival was reported in 44.4%, 96.4% and 78% fetuses managed expectantly, with laser or amnioreduction, respectively. Conclusions: Evidence regarding perinatal mortality and morbidity in twin pregnancies complicated by late TTTS according to the different managements are of very low quality. Therefore further high-quality research in this field is needed to elucidate the optimal management of these pregnancies.
Acta Obstetricia et Gynecologica Scandinavica, 2020
Introduction: Twin-to-twin transfusion syndrome (TTTS) is associated with a high risk of perinatal mortality and morbidity if not treated. However, the optimal timing and management in case of early (occurring <18 weeks) TTTS has not been established yet. Material and Methods: This is a systematic review and meta-analysis aiming at evaluating the outcomes of monochorionic diamniotic (MCDA) twin pregnancies complicated by early (i.e. before 18 weeks) TTTS according to different management options (expectant, laser therapy, amnioreduction or cord occlusion). The primary outcome was mortality, including single and double intra-uterine, neonatal and perinatal death. Secondary outcomes were: composite morbidity, neuromorbidity, respiratory distress syndrome, admission to neonatal intensive care unit, intact survival (defined as survival free from neurological complications) and preterm birth <32 weeks' gestation. All outcomes were reviewed according to the different management options (expectant, laser therapy, amnioreduction or cord occlusion) and reported in the overall population of twins, and in the donor and recipient separately. Subgroup analysis for TTTS occurring before 16 weeks of gestation was performed. Random-effect meta-analyses of proportions were used to analyze the data. Results: Thirteen studies were included. Early TTTS occurred in 14.3% (95% CI 11.9-17.0) of cases. Mortality: The incidence of intra-uterine death was 19.0% (95% CI 2.6-45.5) in twins managed expectantly, 32.4% (95% CI 16.5-50.7) in those who received laser treatment and 12.5% (95% CI 4.8-23.0) in those treated with amnioreduction. The incidence of neonatal death was 22.6% (95% CI 4.2-49.8) in twins managed expectantly, 24.7% (95% CI 0.5-80.3) in those who received laser and 20.2 (95% CI 5.8-43.4) in those who had amnioreduction, while it was not possible to compute the incidence of these outcomes in twins undergoing cord occlusion because of insufficient sample and lack of reporting of most of the observed outcomes. Overall, the incidence of perinatal death was 43.9% (95% CI 5.9-87.7) in twins managed expectantly, 47.3% (95% CI 21.4-70.) in those treated with laser and 28.5% in those who had amnioreduction. Conclusions: Twin pregnancies affected by early TTTS are at substantial risk of perinatal mortality and morbidity; however data comes from very small studies with high risk of selection bias.
American Journal of Obstetrics and Gynecology, 2015
Background: Endoscopic laser coagulation of placental anastomoses is the first-line treatment for severe twin-to-twin transfusion syndrome (TTTS). A recent randomized controlled trial reported that laser coagulation along the entire vascular equator was associated with a similar dual survival and survival of at least one twin compared to the group treated with the selective technique. In addition, there was a significantly lower incidence of postoperative recurrence of TTTS and development of twin anemia-polycytemia sequence (TAPS) in the equatorial group. Objective: To report on neonatal survival in TTTS pregnancies treated with endoscopic laser using the equatorial technique and to examine the relationship between preoperative factors and twin loss. Study design: Endoscopic equatorial laser was carried out as the primary treatment for TTTS in all consecutive monochorionic diamniotic twin pregnancies referred at a single fetal surgery Centre over a 4 years' period. All visible placental anastomoses were coagulated and additional laser ablation of the placental tissue between the coagulated vessels was carried out. Pre-laser ultrasound data, peri-procedural complications, pregnancy outcome and postnatal survival at hospital discharge were recorded and analysed. Results: A total of 106 pregnancies were treated during the study period. Median gestational age at laser was 19.7 (range 15.1-27.6) weeks. There was postoperative recurrence of TTTS or development of TAPS in 2 (1.9%) and 2 (1.9%) cases, respectively. The survival rates of both and at least one twin were 56.6% and 83.0%, respectively. Donor survival was significantly lower compared to the recipient co-twin (64.2% vs 75.5%, respectively; p<0.05). The rate of fetal death, which was the most common cause of twin loss, was significantly higher in donors compared to recipient 4 fetuses (23.6% vs 10.4%, respectively; p<0.05). In cases with absent or reversed end-diastolic velocity in the donor umbilical artery, dual and donor survival rates were significantly lower compared to the remaining TTTS pregnancies (40.0% vs 64.8% and 40.0% vs 76.1%, respectively; p<0.05). There were no significant differences between the two groups in the survival of at least one twin and in the recipient survival. Conclusions: Endoscopic equatorial laser was associated with a survival of both and at least one twin of about 55% and 83%, respectively, and with a low rate of recurrent TTTS and TAPS. In addition, the preoperative finding of abnormal donor umbilical artery Doppler identified a subgroup of TTTS pregnancies with a lower dual survival rate due to increased intrauterine mortality of donor twins.
Ultrasound in obstetrics & gynecology : the official journal of the International Society of Ultrasound in Obstetrics and Gynecology, 2013
To document perinatal outcomes following use of the 'Solomon technique' in the selective photocoagulation of placental anastomoses for severe twin-twin transfusion syndrome (TTTS). Between January 2010 and July 2012, data were collected from 102 consecutive monochorionic twin pregnancies complicated by severe TTTS that underwent fetoscopic laser ablation at four different centers. We compared outcomes between subjects that underwent selective laser coagulation using the Solomon technique (cases) and those that underwent selective laser coagulation without this procedure (controls). Of the 102 pregnancies examined, 26 (25.5%) underwent the Solomon technique and 76 (74.5%) did not. Of the 204 fetuses, 139 (68.1%) survived up to 30 days of age. At least one twin survived in 82 (80.4%) pregnancies and both twins survived in 57 (55.9%) pregnancies. When compared with the control group, the Solomon-technique group had a significantly higher survival rate for both twins (84.6 vs 46...
Fetal diagnosis and therapy, 2014
Background and Objective: To investigate the efficacy of sequential laser coagulation in the treatment of twin-to-twin transfusion syndrome (TTTS). Data Sources: MEDLINE, EMBASE and the Cochrane Library were systematically searched for comparative studies on the efficacy of sequential versus standard selective laser coagulation for TTTS. The primary outcome measure in these studies was survival of at least one twin, both twins and fetal demise. Results: Three cohort studies comparing the selective laser treatment technique (n = 120) versus the sequential technique (n = 224) in 344 monochorionic twin pregnancies were included. Mean survival of at least one twin was 88% in the selective group versus 92% (p = 0.22) in the sequential group. Mean survival of both twins was lower in the selective group (52%) than in the sequential group (75%) (p = 0.002). Donor fetal demise decreased from 34% in the selective to 10% in the sequential group (p < 0.01), and recipient fetal demise decreas...