Incidence and impact of perioperative complications in 175 fetoscopy-guided laser coagulations of chorionic plate anastomoses in fetofetal transfusion syndrome before 26 weeks of gestation

Recent findings on laser treatment of twin-to-twin transfusion syndrome

PURPOSE OF REVIEW

Despite the recent demonstration of the benefit of the primary laser over amnioreduction, overall survival is far from optimal (70-80%), and therefore diagnosis and management of early and late complications following placental surgery became of great importance.

RECENT FINDINGS

Laser therapy has proven to be better than amnioreduction in treating twin-to-twin transfusion syndrome. Miscarriage, preterm premature rupture of the membranes and preterm delivery account for more than 20% of perinatal mortality after treatment. In those who die despite treatment, recurrence of twin-to-twin transfusion syndrome, placental insufficiency or feto-fetal hemorrhage with anemia/polycythemia are complications that have to be managed with different secondary therapeutic options, such as amnioreduction, cord coagulation, intrauterine transfusion or repeat fetoscopy-guided laser. Ex-vivo placental angiography has confirmed that these complications occur when anastomoses are missed. Early predictors of laser efficacy in twin-to-twin transfusion syndrome treatment, such as improvement in the umbilical vein flow imbalance and urine production, are being evaluated, because they are earlier predictors of outcome than amniotic fluid discordance.

SUMMARY

Optimization of laser treatment of twin-to-twin transfusion syndrome and new insight into the follow-up are likely to become the key to a better prognosis, and they are therefore important issues that have to be addressed in forthcoming studies.

Fetal medicine: Intrauterine fetal demise following laser treatment in twin-to-twin transfusion syndrome

OBJECTIVE

To evaluate the incidence, risk factors and consequences of intrauterine fetal demise (IUFD) of at least one twin in twin-to-twin transfusion syndrome (TTTS) treated by laser.

DESIGN

Retrospective analysis.

SETTING

Experience of a single centre between 1999 and 2004.

POPULATION

A subgroup of 45 cases with fetal demise of one or both twins from a series of 120 cases of TTTS treated by laser.

METHODS

All cases were entered prospectively into a dedicated database and the results were analysed retrospectively.

MAIN OUTCOME MEASURES

Fetal demise prognostic factors, survival, fetal anaemia, brain lesions, neonatal death and intact survival.

RESULTS

IUFD of one twin occurred in 40 of 120 cases (19 donors and 21 recipients). IUFD of both twins occurred in another five cases. From these 40 cases, miscarriage occurred in two and pregnancy termination was requested in another two cases because of antenatal brain lesions. Two neonates died and two presented severe morbidity, survivors were therefore neurologically normal at 6-44 months of life in 89% (32/36) of the cases. Univariate analysis showed that preoperative abnormal umbilical artery Doppler in the donor before laser treatment and in the recipient following laser treatment was associated with their demise. Incomplete coagulation was suspected in cases where anaemia or cerebral lesions developed following the death of the first twin (10).

CONCLUSIONS

IUFD of one or both twins occurred in 45 of 120 (38%) cases of severe TTTS treated by laser. In these, separation of the placental circulations was incomplete in at least 22% (10/45) of the cases. Umbilical artery Doppler abnormalities before laser were found to be risk factors for the donors' demise following the procedure.