Is the Sequential Laser Technique for Twin-to-Twin Transfusion Syndrome Truly Superior to the Standard Selective Technique? A Meta-Analysis (original) (raw)
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A worldwide survey of laser surgery for twin-twin transfusion syndrome
Ultrasound in obstetrics & gynecology : the official journal of the International Society of Ultrasound in Obstetrics and Gynecology, 2015
To evaluate differences between international fetal centers in their treatment of twin-twin transfusion syndrome (TTTS) by fetoscopic placental laser coagulation. Fetal therapy centers worldwide were sent a web-based questionnaire. Participants were identified through networks and through scientific presentations and papers. Questions included physician and center demographics, treatment criteria, operative technique and instrumentation. Laser treatment was compared between low-volume (< 20 procedures/year) and high-volume (≥ 20 procedures/year) centers. Data were analyzed using descriptive statistics. Of 106 fetal therapy specialists approached, 76 (72%) from 64 centers in 25 countries responded. Of these, 48% (31/64) of centers and 63% (48/76) of operators performed fewer than 20 laser procedures annually. Comparison of low- and high-volume centers showed differences in technique, gestational age limits for treatment and geography. High-volume centers more often used the Solomo...
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.
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.
Laser for the treatment of twin to twin transfusion syndrome
Acta Cirurgica Brasileira, 2005
PURPOSE: To report the initial experience in our country with a new technique for twin to twin transfusion syndrome (TTTS) treatment, using laser to coagulate the placental vessels responsible for the twin transfusion during gestation. METHODS: Prospective study of eight cases diagnosed with TTTS evaluated in our service from january 2001 to june 2005. Through percutaneous introduction of a 2,0mm diameter fetoscope in the uterine cavity, placental surface vessels where directly visualized. Those identified as responsible for the transfusion were laser coagulated. The procedure combines ultrasonography and fetoscopy, in a so-called sonoendoscopic technique (FETENDO). RESULTS: Among the eight pregnancies evaluated, five cases were submitted to the procedure (10 fetuses). All fetuses survived for at least five weeks after surgery. A total of eight fetuses were born alive and five survived the neonatal period. In a 18 months follow-up after birth, all five are still alive and well and their mean age is now 10,6 months. The total survival rate was 50% and in three pregnancies, at least one fetus survived. CONCLUSIONS: Laser fetoscopy is actually the "gold-standard" treatment of TTTS. Nevertheless is a sophisticated technique that epends of proper training. Our service is the first in our country to offer this therapeutic technique. Our success rate is comparable with the international literature.
BJSTR, 2021
To examine the outcome of laser coagulation therapy in 61 pregnancies having twin-twin transfusion syndrome and other related factors in Viet Nam during 2018-2019. Methods: In this prospective study, we included 61 pregnancies between 15 and 26 weeks of gestation having twin-twin transfusion syndrome (TTTS). All pregnancies were categorized with TTTS stage II or higher (Quintero classification) by ultrasound. Laser coagulation was performed by fetoscopic surgery. The last follow-up of the outcome of positive results was for 7 days after delivery. T-test and odds ratio and 95% confidence was estimated. Results: All 61 pregnant women were healthy by the last follow-up time and 37 of them (60.7%) having live births, of which six cases gave the single birth of the donor fetus, eleven cases gave the single birth of the recipient fetus, and 20 cases had successful birth of both twins. Newborn survived for 7 days was 57 (46.7% of 122 gestation). There were not significant differences in birth weight between 6 single donor babies and 11 single recipient babies (mean 1,858.3g versus mean 1,954.5g, respectively), but significant differences in birth weight between blood donor and receiver in 20 cases of survived twins (mean 1,410.0g versus mean 1,782.5g, respectively). Conclusion: The present findings suggest that other unknown factors might be responsible to a significant imbalance of birth weight among 20 of survived twins that warrant further significant investigation.
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.