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Prasad S, Beg S, Badran D, Masciullo L, Huddy C, Khalil A. Neurodevelopmental outcome in complicated twin pregnancy: prospective observational study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:189-197. [PMID: 37550962 DOI: 10.1002/uog.27448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 07/08/2023] [Accepted: 07/21/2023] [Indexed: 08/09/2023]
Abstract
OBJECTIVE Twin pregnancy is associated with increased perinatal mortality and morbidity, but long-term neurodevelopmental outcome remains underinvestigated. The primary objective of this study was to investigate the incidence of adverse neurodevelopment after 1 year of age in complicated monochorionic diamniotic (MCDA) twin pregnancies compared with uncomplicated twin pregnancies. METHODS This was a prospective cohort study conducted at St George's University Hospital NHS Foundation Trust, London, UK. Women with a twin pregnancy culminating in at least one surviving child, aged between 12 and 60 months (corrected for prematurity) at the time of assessment, were invited to complete the relevant Ages and Stages Questionnaire® version 3 (ASQ-3) test. The two study groups were: (1) complicated MCDA twin pregnancies, including those with twin-twin transfusion syndrome, twin anemia-polycythemia sequence, selective fetal growth restriction, twin reversed arterial perfusion sequence and/or single intrauterine demise; and (2) uncomplicated MCDA and dichorionic diamniotic twin pregnancies. The primary outcome measure was an abnormal ASQ-3 score, defined as a score of more than 2 SD below the mean in any one of the five domains. Mixed-effects multivariable logistic regression analysis was performed to determine whether a complicated MCDA twin pregnancy was associated independently with an abnormal ASQ-3 score. RESULTS The study included 174 parents who completed the questionnaire for one or both twins; therefore, 327 ASQ-3 questionnaires were available for analysis. Of those, 117 (35.8%) were complicated MCDA twin pregnancies and 210 (64.2%) were controls. The overall rate of an abnormal ASQ-3 score in children born of a complicated MCDA twin pregnancy was nearly double that of those from uncomplicated twin pregnancies (14.5% vs 7.6%; P = 0.056). Children born of a complicated MCDA twin pregnancy had a significantly higher rate of impairment in the gross-motor domain compared with the control group (8.5% vs 2.9%; P = 0.031). Complicated MCDA twin pregnancies that underwent prenatal intervention had a significantly higher rate of abnormal ASQ-3 score compared with those that did not undergo prenatal intervention (28.1% vs 1.7%; P < 0.001). On multilevel logistic regression analysis, complicated MCDA twin pregnancy was an independent predictor of abnormal ASQ-3 score (adjusted odds ratio, 3.28 (95% CI, 3.27-3.29); P < 0.001). CONCLUSIONS This study demonstrates that survivors of complicated MCDA twin pregnancies have a higher rate of adverse neurodevelopmental outcome, independently of prematurity. Long-term neurodevelopmental follow-up in these pregnancies can ensure timely and optimal management of those affected. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- S Prasad
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - S Beg
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - D Badran
- NHS Greater Glasgow and Clyde, Glasgow, UK
| | - L Masciullo
- Department of Obstetrics and Gynecology, Cristo Re Hospital, Rome, Italy
| | - C Huddy
- Department of Neonatology, St George's University Hospital, London, UK
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Twins and Multiples Centre for Research and Clinical Excellence, London, UK
- Fetal Medicine Unit, Liverpool Women's Hospital, University of Liverpool, Liverpool, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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Chimenea Á, García-Díaz L, Antiñolo G. Two Year Neurodevelopmental Outcome after Fetoscopic Laser Therapy for Twin-Twin Transfusion Syndrome: Comparison with Uncomplicated Monochorionic Diamniotic Twins. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1250. [PMID: 37508747 PMCID: PMC10378473 DOI: 10.3390/children10071250] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/07/2023] [Accepted: 07/19/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND Twin-twin Transfusion Syndrome (TTTS) represents a significant complication in monochorionic twin pregnancies, caused by an unbalanced shunting of blood through intertwin placental vascular anastomoses. Despite advances in fetoscopic laser surgery, TTTS is still associated with a high rate of cerebral injury. However, there are no studies comparing these pregnancies with uncomplicated monochorionic diamniotic (MCDA) twin pregnancies, establishing the baseline risk of neurodevelopmental impairment. The aim of this study is to evaluate the odds of neurodevelopmental impairment in MCDA twins who undergo fetoscopic laser surgery for twin-twin transfusion syndrome, in comparison to a cohort of uncomplicated MCDA twin pregnancies. STUDY DESIGN This is a retrospective cohort study of children born from MCDA twin pregnancies at a single center between 2008 and 2019. A routine, standardized follow-up assessment was conducted at a minimum of 2 years after delivery. The primary outcome of this was a 2 year neurodevelopmental impairment. Neurological, motor, and cognitive development was assessed by using the revised Brunet-Lézine scale. RESULTS 176 children met the enrolment criteria. Of these, 42 (24%; TTTS group) underwent fetoscopic laser surgery for TTTS during pregnancy, and 134 (76%; uncomplicated MCDA group) were uncomplicated MCDA pregnancies. The primary outcome was found in four children (9.52%) in the TTTS group and ten children (7.46%) in the uncomplicated MCDA group (p = 0.67, aOR 2.82, 95% CI 0.49-16.23). Major neurologic impairment was found in 2.38% after fetoscopic laser surgery and 1.49% in uncomplicated MCDA twins (p = 0.70, aOR 0.97, 95% CI 0.22-4.24). The data were adjusted by birth order, birth weight, and gestational age at birth. CONCLUSIONS The outcome in MCDA twins who underwent fetoscopic laser surgery for TTTS is comparable to the outcome in uncomplicated MCDA twins. Our findings emphasize the need for long-term neurodevelopmental follow-ups in all children from monochorionic twin gestations.
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Affiliation(s)
- Ángel Chimenea
- Department of Materno-Fetal Medicine, Genetics and Reproduction, Institute of Biomedicine of Seville (IBIS), Hospital Universitario Virgen del Rocio, CSIC, University of Seville, ES-41013 Seville, Spain
- Fetal, IVF and Reproduction Simulation Training Centre (FIRST), ES-41010 Seville, Spain
| | - Lutgardo García-Díaz
- Department of Materno-Fetal Medicine, Genetics and Reproduction, Institute of Biomedicine of Seville (IBIS), Hospital Universitario Virgen del Rocio, CSIC, University of Seville, ES-41013 Seville, Spain
| | - Guillermo Antiñolo
- Department of Materno-Fetal Medicine, Genetics and Reproduction, Institute of Biomedicine of Seville (IBIS), Hospital Universitario Virgen del Rocio, CSIC, University of Seville, ES-41013 Seville, Spain
- Fetal, IVF and Reproduction Simulation Training Centre (FIRST), ES-41010 Seville, Spain
- Centre for Biomedical Network Research on Rare Diseases (CIBERER), ES-41013 Seville, Spain
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Shamshirsaz AA, Chmait RH, Stirnemann J, Habli MA, Johnson A, Hessami K, Mostafaei S, Nassr AA, Donepudi RV, Sanz Cortes M, Espinoza J, Krispin E, Belfort MA. Solomon versus selective fetoscopic laser photocoagulation for twin-twin transfusion syndrome: A systematic review and meta-analysis. Prenat Diagn 2023; 43:72-83. [PMID: 36184777 DOI: 10.1002/pd.6246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 09/07/2022] [Accepted: 09/28/2022] [Indexed: 01/27/2023]
Abstract
This meta-analysis aims to compare the perinatal outcome of twin-twin transfusion syndrome (TTTS) pregnancies undergoing selective versus vascular equator (Solomon) fetoscopic laser photocoagulation (FLP). We performed a systematic search in PubMed and Web of Science from inception up to 25 July 2021. Studies comparing the Solomon and selective techniques of FLP for treatment of TTTS pregnancies were eligible. Random-effects or fixed-effect models were used to pool standardized mean differences (SMD) and log odds ratio. Seven studies with a total of 1664 TTTS pregnancies (n = 671 undergoing Solomon and n = 993 selective techniques) were included. As compared to the selective FLP, Solomon was associated with a lower risk of recurrent TTTS compared to the selective technique (Log odds ratio [OR]: -1.167; 95% credible interval [CrI]: -2.01, -0.33; p = 0.021; I2 : 67%). In addition, Solomon was significantly associated with a higher risk of placental abruption than the selective technique (Log [OR]: 1.44; 95% CrI: 0.45, 2.47; p = 0.012; I2 : 0.0%). Furthermore, a trend for the higher risk of preterm premature rupture of membranes was observed among those undergoing Solomon (Log [OR]: 0.581; 95% CrI: -0.43, 1.49; p = 0.131; I2 : 17%). As compared to selective FLP, the Solomon technique for TTTS pregnancies is associated with a significantly lower recurrence of TTTS; however, it significantly increases the risk of placental abruption.
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Affiliation(s)
- Alireza A Shamshirsaz
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ramen H Chmait
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Julien Stirnemann
- Department of Obstetrics and Maternal-Fetal Medicine, Hôpital Necker-Enfants Malades, Université de Paris, Paris, France
| | - Mounira A Habli
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Good Samaritan Hospital, Cincinnati, Ohio, USA
| | - Anthony Johnson
- Department of Obstetrics and Gynecology, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Kamran Hessami
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Shayan Mostafaei
- Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinksa Institutet, Stockholm, Sweden
| | - Ahmed A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Roopali V Donepudi
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Magdalena Sanz Cortes
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Jimmy Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Eyal Krispin
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
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Long-term follow-up of complicated monochorionic twin pregnancies: Focus on neurodevelopment. Best Pract Res Clin Obstet Gynaecol 2022; 84:166-178. [PMID: 35491308 DOI: 10.1016/j.bpobgyn.2022.03.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/13/2022] [Indexed: 11/23/2022]
Abstract
Monochorionic twin pregnancies have an increased risk of morbidity and mortality. Due to the advancements in screening and treatment strategies, mortality rates have decreased. Improving survival rates demands a shift in scope toward long-term outcomes. In this review, we focus on neurodevelopmental outcome in survivors from complicated monochorionic twin pregnancies, including twin-twin transfusion syndrome (TTTS), twin anemia-polycythemia sequence (TAPS), acute peripartum TTTS, acute perimortem TTTS, selective fetal growth restriction (sFGR) and monoamnionicity. Our aim is to provide an overview of the current knowledge on the long-term outcome in survivors, including psychomotor development and quality of life, and provide recommendations for future research and follow-up programs.
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Gomez NG, Monson MA, Chon AH, Korst LM, Llanes A, Chmait RH. Outcomes of laser surgery for stage I twin-twin transfusion syndrome. Prenat Diagn 2022; 42:172-179. [PMID: 35032038 DOI: 10.1002/pd.6094] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 11/29/2021] [Accepted: 01/08/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVE A recent randomized controlled trial (RCT) demonstrated no difference in 6 month survival in expectantly managed stage I twin-twin transfusion syndrome (TTTS) patients and those undergoing immediate laser surgery. We aimed to describe outcomes following immediate laser surgery at a single fetal surgery center. METHODS A retrospective study of monochorionic diamniotic twins diagnosed with stage I TTTS who underwent laser surgery between 16 and 26 gestational weeks from 2006 to 2019. The primary outcome was 6 month survivorship. Intact survival was also assessed. Secondarily, outcomes were compared to the RCT expectant management group. RESULTS Of 126 consecutive stage I TTTS patients, 114 (90.5%) met inclusion criteria. Median (range) gestational age at delivery was 34.1 (20.6-39.4) weeks. At 6 months, the proportion of patients with at-least-one survivor in the single-center-laser cohort was 97.4%, with 88.6% dual survivorship. Neurological morbidity outcomes were available in 110 pregnancies (220 fetuses). Severe neurological morbidity occurred in 2.7% (6/220), and 6 month survival without severe neurological morbidity was 90.0%. Outcomes compared favorably with the RCT expectant management group. CONCLUSIONS Given favorable survival and neurological outcomes, laser surgery is a reasonable treatment option for stage I TTTS at experienced fetal surgery centers. Further study is warranted to optimize treatment strategies.
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Affiliation(s)
- Nicole G Gomez
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Martha A Monson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Andrew H Chon
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Lisa M Korst
- Childbirth Research Associates, North Hollywood, California, USA
| | - Arlyn Llanes
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Ramen H Chmait
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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Knijnenburg PJC, Spruijt MS, Jansen L, Rijken M, Tan RNGB, Slaghekke F, Middeldorp JM, Lopriore E, van Klink JMM. Neurodevelopmental Trajectories of Preterm Born Survivors of Twin-Twin Transfusion Syndrome: From Birth to 5 Years of Age. J Pediatr 2022; 240:51-57.e1. [PMID: 34506853 DOI: 10.1016/j.jpeds.2021.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 08/21/2021] [Accepted: 09/01/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To investigate the neurodevelopmental outcome at age 2 and 5 years in survivors of twin-twin transfusion syndrome (TTTS) treated with fetoscopic laser surgery and born premature and/or small for gestational age. STUDY DESIGN At 2 and 5 years of age, standardized neurologic, motor, and cognitive assessments were performed by a neonatologist, a pediatric physical therapist, and a psychologist. Behavior was assessed using a validated questionnaire completed by parents. RESULTS Neurodevelopmental assessment at both time points was available for 73 survivors of TTTS. Mild to moderate neurodevelopmental impairment (NDI) was detected in 34% of survivors (25 of 73) at 5 years, compared with 25% (18 of 73) at 2 years (P = .178). Severe NDI was observed in 12% (9 of 73) at 5 years and in 3% (2 of 73) at 2 years (P = .035). Mean cognitive score was lower at the 5-year follow-up (90.7 ± 12.3 vs 95.6 ± 13.1 at 2 years; P = .001), and more children were diagnosed with mild cognitive impairment at 5 years (29% vs 11% at 2 years; P = .007). When comparing individual outcomes at both time points, 35% (25 of 71) moved from a normal outcome or mild to moderate impairment at 2 years toward more severe impairment at 5 years. CONCLUSIONS A high rate of mild to moderate cognitive impairment and severe NDI at age 5 years was not identified at age 2 years. Our data highlight the importance of longitudinal follow-up of survivors of TTTS beyond age 2 years and emphasize the precautions that should be taken when diagnosing an absence of impairment before school age.
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Affiliation(s)
- Patricia J C Knijnenburg
- Division of Neonatology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Marjolijn S Spruijt
- Division of Neonatology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Lisette Jansen
- Division of Child and Adolescent Psychology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Monique Rijken
- Division of Neonatology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Ratna N G B Tan
- Division of Neonatology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Femke Slaghekke
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Johanna M Middeldorp
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Enrico Lopriore
- Division of Neonatology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeanine M M van Klink
- Division of Child and Adolescent Psychology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands.
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The Role of Fetal Brain Magnetic Resonance Imaging in Current Fetal Medicine. J Belg Soc Radiol 2022; 106:130. [PMID: 36569393 PMCID: PMC9756908 DOI: 10.5334/jbsr.3000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 11/16/2022] [Indexed: 12/15/2022] Open
Abstract
In open spina bifida we studied the use of MRI for the assessment of the posterior fossa and prevalence of supratentorial anomalies before and after in utero repair. New postprocessing techniques were applied to evaluate fetal brain development in this population compared to controls. In fetuses with congenital diaphragmatic hernia, we evaluated the brain development in comparison to controls. Diffusion weighted imaging was applied to study difference between fetuses with proven first trimester cytomegalovirus infection and controls. Finally, we investigated the value of third trimester fetal brain MRI after treatment for complicated monochorionic diamniotic pregnancies.
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Hessami K, Nassr AA, Sananès N, Castillo J, Castillo HA, Sanz Cortes M, Espinoza J, Donepudi RV, Sun RC, Krispin E, Belfort MA, Shamshirsaz AA. Perinatal risk factors of neurodevelopmental impairment after fetoscopic laser photocoagulation for twin-twin transfusion syndrome: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:658-668. [PMID: 34097320 DOI: 10.1002/uog.23706] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/19/2021] [Accepted: 05/27/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Monochorionic twins with twin-twin transfusion syndrome (TTTS) treated with fetoscopic laser photocoagulation (FLP) are at increased risk of neurodevelopmental impairment (NDI). This meta-analysis aimed to identify the prevalence of and perinatal risk factors for NDI in TTTS survivors treated with FLP. METHODS We performed a search in PubMed, EMBASE, Scopus and Web of Science, from inception to 13 February 2021, for studies evaluating perinatal risk factors for NDI in children diagnosed prenatally with TTTS managed by FLP. Data on severity of TTTS at the time of diagnosis, defined according to the Quintero staging system, FLP-related complications and perinatal outcomes were compared between children with a history of TTTS treated with FLP with and those without NDI, which was defined as performance on a cognitive or developmental assessment tool ≥ 2 SD below the mean or a defined motor or sensory disability. A random-effects model was used to pool the mean differences or odds ratios (OR) with the corresponding 95% CIs. Heterogeneity was assessed using the I2 statistic. RESULTS Nine studies with a total of 1499 TTTS survivors were included. The overall incidence of NDI was 14.0% (95% CI, 9.0-18.0%). The occurrence of NDI in TTTS survivors was associated with later gestational age (GA) at FLP (mean difference, 0.94 weeks (95% CI, 0.50-1.38 weeks); P < 0.0001, I2 = 0%), earlier GA at delivery (mean difference, -1.44 weeks (95% CI, -2.28 to -0.61 weeks); P = 0.0007, I2 = 49%) and lower birth weight (mean difference, -343.26 g (95% CI, -470.59 to -215.92 g); P < 0.00001, I2 = 27%). Evaluation of different GA cut-offs showed that preterm birth before 32 weeks was associated with higher risk for NDI later in childhood (OR, 2.25 (95% CI, 1.02-4.94); P = 0.04, I2 = 35%). No statistically significant difference was found between cases with and those without NDI with respect to Quintero stage of TTTS, recipient or donor status, development of postlaser twin anemia-polycythemia sequence, recurrence of TTTS and incidence of small- for-gestational age or cotwin fetal demise. CONCLUSIONS TTTS survivors with later GA at the time of FLP, earlier GA at delivery and lower birth weight are at higher risk of developing NDI. No significant association was found between Quintero stage of TTTS and risk of NDI. Our findings may be helpful for parental counseling and highlight the need for future studies to understand better the risk factors for NDI in TTTS survivors. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- K Hessami
- Maternal-Fetal Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Department of Obstetrics and Gynecology, Baylor College of Medicine & Texas Children's Fetal Center, Houston, TX, USA
| | - A A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine & Texas Children's Fetal Center, Houston, TX, USA
| | - N Sananès
- Department of Maternal-Fetal Medicine, Strasbourg University Hospital, Strasbourg, France
| | - J Castillo
- Department of Pediatrics, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - H A Castillo
- Department of Pediatrics, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - M Sanz Cortes
- Department of Obstetrics and Gynecology, Baylor College of Medicine & Texas Children's Fetal Center, Houston, TX, USA
| | - J Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine & Texas Children's Fetal Center, Houston, TX, USA
| | - R V Donepudi
- Department of Obstetrics and Gynecology, Baylor College of Medicine & Texas Children's Fetal Center, Houston, TX, USA
| | - R C Sun
- Doernbecher Children's Hospital, Oregon Health & Science University, Division of Pediatric Surgery, Portland, OR, USA
- Division of Pediatric Surgery, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - E Krispin
- Department of Obstetrics and Gynecology, Baylor College of Medicine & Texas Children's Fetal Center, Houston, TX, USA
| | - M A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine & Texas Children's Fetal Center, Houston, TX, USA
| | - A A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine & Texas Children's Fetal Center, Houston, TX, USA
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The prevalence of brain lesions after in utero surgery for twin-to-twin transfusion syndrome on third-trimester MRI: a retrospective cohort study. Eur Radiol 2020; 31:4097-4103. [PMID: 33210202 DOI: 10.1007/s00330-020-07452-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 08/22/2020] [Accepted: 11/02/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Due to the increased risk of antenatal brain lesions, we offer a third-trimester magnetic resonance imaging (MRI) scan to all patients who underwent an in utero intervention for twin-twin transfusion syndrome (TTTS). However, the usefulness of such a policy has not been demonstrated yet. Therefore, we determined the prevalence of antenatal brain lesions detected on third-trimester MRI and the proportion of lesions detected exclusively on MRI. MATERIALS AND METHODS We conducted a retrospective cohort study of monochorionic diamniotic twin pregnancies complicated by TTTS that underwent laser coagulation of the vascular anastomoses or fetal reduction by umbilical cord occlusion between 2010 and 2017. We reviewed the third-trimester MRI findings and compared those with the prenatal ultrasonography. RESULTS Of the 141 patients treated with laser coagulation and 17 managed by cord occlusion, 112/141 (79%) and 15/17 (88%) patients reached 28 weeks. Of those, 69/112 (62%) and 11/15 (73%) underwent an MRI between 28 and 32 weeks. After laser coagulation, MRI detected an antenatal brain lesion in 6 of 69 pregnancies (9%) or in 6 of 125 fetuses (5%). In 4 cases (67%), the lesion was detected only on MRI. In the 11 patients treated with cord occlusion, no brain lesions were diagnosed. CONCLUSION The prevalence of brain lesions detected by third-trimester MRI is higher compared to prenatal ultrasonography alone, making MRI a useful adjunct to detect antenatal brain lesions in twin pregnancies after in utero treatment for TTTS. KEY POINTS • In utero interventions for twin-to-twin transfusion syndrome (TTTS) do not prevent the occurrence of antenatal brain lesions. • Fetal magnetic resonance imaging (MRI) has high accuracy in detecting anomalies of cortical development and can be a useful adjunct to ultrasonography in diagnosing certain brain abnormalities. • After laser coagulation of the anastomoses for TTTS, third-trimester MRI diagnosed a brain lesion that was not detected earlier on ultrasound scan in 6% of pregnancies.
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Neurodevelopmental Outcome After Fetoscopic Laser Surgery for Twin-twin Transfusion Syndrome: A Systematic Review of Follow-up Studies from the Last Decade. MATERNAL-FETAL MEDICINE 2020. [DOI: 10.1097/fm9.0000000000000033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Matsushima S, Ozawa K, Sugibayashi R, Ogawa K, Tsukamoto K, Miyazaki O, Wada S, Ito Y, Sago H. Neurodevelopmental impairment at 3 years of age after fetoscopic laser surgery for twin-to-twin transfusion syndrome. Prenat Diagn 2020; 40:1013-1019. [PMID: 32362029 DOI: 10.1002/pd.5726] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 12/14/2019] [Accepted: 04/25/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND Data on neurodevelopmental outcomes of children surviving after fetoscopic laser surgery (FLS) for twin-to-twin transfusion syndrome (TTTS) are scarce. METHODS We retrospectively investigated children surviving after FLS for TTTS at 16 to 26 weeks' gestation between 2003 and 2014. Children were evaluated by standardized neurologic examinations using the Kyoto Scale 2001 at a corrected age of 3 years ± 6 months. Neurodevelopmental impairment (NDI) was defined as cerebral palsy (CP), bilateral blindness, bilateral deafness or a developmental quotient (DQ) < 70 points. Brain magnetic resonance imaging (MRI) was performed at term-equivalent age. RESULTS A total of 188 children from 110 twin pregnancies were evaluated. NDI was detected in 16/188 (8.5%) children, including six cases of CP (3.2%). No children had bilateral blindness or deafness. An earlier gestational age at delivery was associated with a higher incidence of NDI (P < .001). Abnormal brain MRI findings were detected in 9/16 (56%) of children with NDI, including 6/6 (100%) with CP. CONCLUSION The incidence of NDI in children following FLS at 3 years old was 8.5%. Prematurity is a strong risk factor for NDI. Brain MRI may predict the development of CP.
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Affiliation(s)
- Sachio Matsushima
- Division of Fetal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Katsusuke Ozawa
- Division of Fetal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Rika Sugibayashi
- Division of Fetal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Kohei Ogawa
- Division of Obstetrics, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Keiko Tsukamoto
- Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Osamu Miyazaki
- Department of Radiology, National Center for Child Health and Development, Tokyo, Japan
| | - Seiji Wada
- Division of Fetal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Yushi Ito
- Division of Obstetrics, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Haruhiko Sago
- Division of Fetal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan.,Division of Obstetrics, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan.,Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
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12
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Spruijt MS, Lopriore E, J Steggerda S, Slaghekke F, Van Klink JMM. Twin-twin transfusion syndrome in the era of fetoscopic laser surgery: antenatal management, neonatal outcome and beyond. Expert Rev Hematol 2020; 13:259-267. [PMID: 31971028 DOI: 10.1080/17474086.2020.1720643] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Introduction: Twin-twin transfusion syndrome (TTTS) is a devastating complication of monochorionic twin pregnancy and remains a major challenge for worldwide fetal medicine specialists. In TTTS, intertwin transfusion through vascular anastomoses in the shared placenta leads to severe hemodynamic imbalance. This review summarizes the current knowledge of TTTS.Areas covered: The most recent insights concerning the management of TTTS, as well as fetal and neonatal complications are described. Relevant articles were selected based on a Pubmed search using the keywords below. Understanding of the underlying pathophysiology has improved greatly as a result of placental injection studies. Advancements in antenatal management have led to increased perinatal survival and a decreased incidence of neonatal complications, including brain injury and neurodevelopmental impairment.Expert opinion: Further opportunities for improvement comprise technological innovations in laser procedures and the prevention of preterm rupture of membranes with subsequent prematurity. A noninvasive treatment such as high-intensity focused ultrasound (HIFU) seems to hold promise for the future treatment of TTTS. Fetal MRI studies are important to improve our understanding of fetal brain injury and should relate their findings to long-term neurodevelopment. International collaboration and centralization of care are of paramount importance to ensure the best care for our patients.
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Affiliation(s)
- Marjolijn S Spruijt
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Enrico Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Sylke J Steggerda
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Femke Slaghekke
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeanine M M Van Klink
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
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13
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Miralles-Gutiérrez A, Narbona-Arias I, González-Mesa E. Neurological complications after therapy for fetal-fetal transfusion syndrome: a systematic review of the outcomes at 24 months. J Perinat Med 2018; 46:991-997. [PMID: 28961141 DOI: 10.1515/jpm-2017-0217] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 08/31/2017] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The main objective of this study was to review the available scientific evidence about mid-term neurological outcomes in twins after laser therapy for twin-to-twin transfusion syndrome (TTTS). METHODS A systematic review of studies on neurodevelopmental outcomes (cognition, motor development, communication skills and cerebral palsy) of twins after laser therapy for TTTS was conducted. Outcomes at 24 months of age and the use of validated scales for assessment were the selected criteria. Electronic and manual research identified 25 studies, and nine of them were eligible for the review. RESULTS The global mean rate of neurological injury in twins treated with laser was 14.07%. The mean rate of cognitive impairment was 8.41%, 11.14% for motor delay, 16.5% for communication delay and 5.73% for cerebral palsy. These rates were higher than the results found in dichorionic twins, but lower than the results found in twins treated with amnio-reductions or conservative management. CONCLUSION Laser therapy is associated with a lower rate of neurological injury at 24 months of age compared to other therapeutic techniques. This tendency was also observed with specific incidences regarding cognition, motor skills and cerebral palsy.
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Affiliation(s)
- Ana Miralles-Gutiérrez
- Department of Obstetrics and Gynecology, School of Medicine, Málaga University, Málaga, Spain
| | - Isidoro Narbona-Arias
- Department of Obstetrics and Gynecology, Regional University Hospital, Málaga, Spain
| | - Ernesto González-Mesa
- Department of Obstetrics and Gyncecology, School of Medicine, Regional University Hospital, Málaga University, 32, Boulevard Louis Pasteur, 29010, Málaga, Spain
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14
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Hecher K, Gardiner HM, Diemert A, Bartmann P. Long-term outcomes for monochorionic twins after laser therapy in twin-to-twin transfusion syndrome. THE LANCET CHILD & ADOLESCENT HEALTH 2018; 2:525-535. [PMID: 30169324 DOI: 10.1016/s2352-4642(18)30127-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 03/09/2018] [Accepted: 04/03/2018] [Indexed: 12/28/2022]
Abstract
Twin-to-twin transfusion syndrome typically occurs in the second trimester in 10-15% of monochorionic twin pregnancies. Vascular anastomoses of monochorionic placentae are the underlying cause of the development of the syndrome. If a blood flow imbalance occurs, one fetus becomes the so-called donor twin and the other the recipient. If untreated, perinatal mortality is 80-90%. Fetoscopic laser coagulation of the vascular anastomoses destroys the cause of the syndrome and leads to dual twin survival rates of around 70% and more than 90% of pregnancies with at least one survivor. However, unequal placental sharing, intrauterine death, and severe prematurity are still limiting factors for further improvement of survival rates and decreases in long-term morbidity. Prematurity and neurodevelopmental impairment affect the donor and recipient twins, whereas cardiovascular failure and obstruction of the right ventricular outflow tract are typical complications of recipients, which can lead to long-term morbidity. In this Review, we summarise the literature on follow-up data for survivors of twin-to-twin-transfusion syndrome after laser therapy, including neurodevelopmental outcomes, cardiovascular outcomes, growth, renal function, and ischaemic events, as well as the potential effects of intrauterine programming on later life.
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Affiliation(s)
- Kurt Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Helena M Gardiner
- Fetal Center at Children's Memorial Herman Hospital, McGovern Medical School at UTHealth, University of Texas Health Sciences Center, Houston, TX, USA
| | - Anke Diemert
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Bartmann
- Children's Hospital, University Hospital Bonn, Bonn, Germany
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15
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Le Lous M, Mediouni I, Chalouhi G, Salomon LJ, Bussières L, Carrier A, Bernard JP, Ville Y. Impact of laser therapy for twin-to-twin transfusion syndrome on subsequent pregnancy. Prenat Diagn 2018; 38:293-297. [PMID: 29417606 DOI: 10.1002/pd.5227] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 01/19/2018] [Accepted: 01/20/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The objective of our study was to determine the impact of laser therapy for twin-to-twin transfusion syndrome (TTTs) on subsequent pregnancies. METHODS This was a monocentric retrospective observational study. Women treated by laser fetoscopy for TTTs were asked to answer a postal questionnaire about subsequent pregnancies. The primary outcome was fecundity (number of pregnancies and time to pregnancy). We also assessed pregnancy complications, birth weight, and gestational age at delivery. Pregnancy complications included the following: threatened preterm labor, preeclampsia, placenta accreta, postpartum hemorrhage, and psychological disorders. Our study population was compared with an external control group made up of mothers of monochorionic twins without TTTs. RESULTS We included 122 cases managed at the Necker Hospital between 2008 and 2012 and 39 controls. The median conception time was longer in the TTTs group (6.4 ± 11.1 versus 2 ± 1.6 months, P = .03). The numbers of live childbirths at the end of those pregnancies were equivalent (77.6% versus 66.7%, P = .56). Birth weight (3317 ± 726 versus 3240 ± 382 g, P = .81) and gestational age at delivery (38.2 ± 6.8 WG versus 39.5 ± 1.2 WG, P = .64) were similar, with no increase of obstetrical complications compared with the control group. DISCUSSION Twin-to-twin transfusion syndrome and its treatment do not seem to impact subsequent pregnancies.
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Affiliation(s)
- Maela Le Lous
- Department of Obstetrics and Gynecology, University Hospital of Rennes, Rennes, France
| | - Imen Mediouni
- Department of Obstetrics and Fetal Therapy, AP-HP, Necker-Enfants Malades Hospital, Paris, France
| | - Gihad Chalouhi
- Department of Obstetrics and Fetal Therapy, AP-HP, Necker-Enfants Malades Hospital, Paris, France.,Sorbonne Paris-Cité, Paris Descartes University, Paris, France
| | - Laurent J Salomon
- Department of Obstetrics and Fetal Therapy, AP-HP, Necker-Enfants Malades Hospital, Paris, France.,Sorbonne Paris-Cité, Paris Descartes University, Paris, France
| | - Laurence Bussières
- Department of Obstetrics and Fetal Therapy, AP-HP, Necker-Enfants Malades Hospital, Paris, France
| | - Aude Carrier
- Department of Obstetrics and Fetal Therapy, AP-HP, Necker-Enfants Malades Hospital, Paris, France
| | - Jean-Pierre Bernard
- Department of Obstetrics and Fetal Therapy, AP-HP, Necker-Enfants Malades Hospital, Paris, France
| | - Yves Ville
- Department of Obstetrics and Fetal Therapy, AP-HP, Necker-Enfants Malades Hospital, Paris, France.,Sorbonne Paris-Cité, Paris Descartes University, Paris, France
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16
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Sago H, Ishii K, Sugibayashi R, Ozawa K, Sumie M, Wada S. Fetoscopic laser photocoagulation for twin-twin transfusion syndrome. J Obstet Gynaecol Res 2018; 44:831-839. [PMID: 29436080 PMCID: PMC5969296 DOI: 10.1111/jog.13600] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 12/31/2017] [Indexed: 12/27/2022]
Abstract
The aim of this study was to review fetoscopic laser photocoagulation (FLP), which ablates placental vascular anastomoses to treat twin–twin transfusion syndrome (TTTS). A review of studies reporting on the procedures, outcomes, complications and nonconventional applications of FLP for TTTS was conducted. FLP has been established as the primary treatment for monochorionic twin pregnancy associated with TTTS at 16–26 weeks. FLP is the only therapy that directly addresses the underlying pathophysiology. The recent technique modification of FLP, referred to as the ‘Solomon technique’, induces selective coagulation to connect the anastomoses ablation sites and has been introduced to reduce residual anastomoses. The perinatal survival following FLP improved significantly with advances in the technique after its introduction. The recent survival rates of both twins and at least one twin are 70% and more than 90%, respectively. However, there is still an 11–14% risk of long‐term neurodevelopment impairment. The premature rupture of membranes that leads to preterm labor is a common complication after FLP. FLP is a valuable treatment option for feto‐fetal transfusion syndrome in triplets and for TTTS after 26 weeks. FLP for selective intrauterine growth restriction may be potentially beneficial when accompanied by abnormal Doppler findings and oligohydramnios. FLP is the optimal treatment option for TTTS at 16–26 weeks of gestation. FLP appears to be applicable in triplets, TTTS after 26 weeks and cases of selective intrauterine growth restriction with abnormal Doppler findings and oligohydramnios. FLP is the most common and successful fetal intervention. Improvement in the neurodevelopmental outcomes after FLP is a future focus.
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Affiliation(s)
- Haruhiko Sago
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Keisuke Ishii
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Rika Sugibayashi
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Katsusuke Ozawa
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Masahiro Sumie
- Department of Obstetrics, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Seiji Wada
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
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