Perinatal outcomes of twin pregnancies complicated by late twin‐twin transfusion syndrome: A systematic review and meta‐analysis (original) (raw)

2021, Acta Obstetricia et Gynecologica Scandinavica

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.

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