NIH sponsored prospective randomized clinical trial of amnioreduction vs selective fetoscopic laser photocoagulation for twin-twin transfusion syndrome (original) (raw)
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Obstetrics & gynecology science, 2018
To evaluate the initial maternal and perinatal outcomes of fetoscopic laser photocoagulation for the treatment of twin-to-twin transfusion syndrome (TTTS) in a referral center in Brazil. This prospective observational study analyzed 24 fetoscopic laser photocoagulation procedures at 18-26 weeks of gestation. TTTS severity was determined using the Quintero classification. Blood vessels that crossed the interamniotic membrane were nonselectively photocoagulated. The χ test and Mann-Whitney test were used for the statistical analysis. The mean (±standard deviation) age of pregnant women, gestational age at surgery, surgical time, gestational age at birth, and newborn weight were 32.2±4.1 years, 20.7±2.9 weeks, 51.8±16.7 minutes, 30.5±4.1 weeks, and 1,531.0±773.1 g, respectively. Using the Quintero classification, there was a higher percentage of cases in stage III (54.2%), followed by stages IV (20.8%), II (16.7%), and I (8.3%). Ten (41.7%) donor fetuses died and 14 (58.3%) donor fetus...
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.
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...
Journal of Obstetrics and Gynaecology Research, 2009
Twin-twin transfusion syndrome (TTTS) complicated with absent or reversed end-diastolic flow in the umbilical artery (UA-AREDF) of the donor has a high perinatal mortality rate. To improve the prenatal outcome, we introduced and modified the technique of sequential selective laser photocoagulation of communicating vessels (SQLPCV), and assessed the clinical efficacy. Methods: The modified SQLPCV was designed with the following order of coagulation: (i) artery-to-artery (AA) anastomoses; (ii) venous-to-venous anastomoses; (iii) artery-to-venous anastomoses from donor to recipient; and (iv) artery-to-venous anastomoses from recipient to donor. TTTS patients with UA-AREDF of donors were recruited, and the perinatal outcome and its association with the types of anastomoses were compared in patients who underwent the standard selective laser method (SLPCV). Results: Twenty-three patients underwent modified SQLPCV and 29 underwent SLPCV. Total intrauterine fetal death (IUFD) was significantly lower in modified SQLPCV than in SLPCV (9% vs 38%; P < 0.001). Donor IUFD was significantly lower in modified SQLPCV than in SLPCV (13% vs 52%; P = 0.007); however, no significant effect was noted in the recipient IUFD cases. When AA anastomoses were present, donor IUFD was significantly lower in modified SQLPCV than it was in SLPCV (18% vs 71%; P = 0.018); however, the difference was not significant when AA anastomoses were not present (8% vs 25%; P = 0.59). Logistic regression analysis revealed that modified SQLPCV served as the protective factor against the donor's IUFD (odds ratio = 0.015; 95% confidence interval [0.0001-0.775]; P = 0.037). Conclusion: The modified SQLPCV was useful for the prevention of the donor's IUFD in cases of TTTS with UA-AREDF.
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.