Postnatal survival after endoscopic equatorial laser for the treatment of twin-to-twin transfusion syndrome (original) (raw)
2015, American Journal of Obstetrics and Gynecology
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.
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