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Bartin R, Andrioli Peralta CF, Peneluppi Horak AC, Rodrigues da Costa KJ, Colmant C, Stirnemann J, Ville Y. Management of short cervix in twin-to-twin transfusion syndrome: a role for pessary placement following fetoscopic laser surgery? Am J Obstet Gynecol 2024; 230:91.e1-91.e12. [PMID: 37453653 DOI: 10.1016/j.ajog.2023.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/06/2023] [Accepted: 07/10/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Preterm labor and delivery is a major concern for patients with twin-to-twin transfusion syndrome undergoing fetoscopic laser surgery. A preoperative short cervix is a risk factor for preterm labor. Pessary placement is a short-acting intervention that may be useful to reduce this adverse event. OBJECTIVE This study aimed to investigate the relationship between pessary placement and preterm delivery in monochorionic twin pregnancies with twin-to-twin transfusion syndrome and a short cervix before fetoscopic laser surgery. STUDY DESIGN This was a retrospective study in 2 centers, including all pregnancies affected by twin-to-twin transfusion syndrome that underwent fetoscopic laser surgery with the Solomon technique between 2013 and 2022 (center A) and 2014 and 2022 (center B) with a preoperative cervical length below 25 mm. This study explored the correlation between cervical length and fetoscopic laser surgery-to-delivery interval following active or expectant management and compared perinatal outcomes between patients managed expectantly and patients managed with pessary placement, using multivariate analysis to control for potential confounders. Patients with a cervical length below 5 mm were not included in the comparative analysis. RESULTS Of 685 patients, 134 met the inclusion criteria. Moreover, 21 patients were treated with a cervical cerclage and excluded from the analysis, leaving 113 patients for the final analysis. There was a significant negative correlation between cervical length at fetoscopic laser surgery and the risk of early delivery (adjusted odds ratio, 0.66; 95% confidence interval, 0.49-0.81; P<.001). The use of a pessary correlated with fewer patients delivering before 28 weeks of gestation (adjusted odds ratio, 0.28; 95% confidence interval, 0.09-0.75), fewer double neonatal demise (adjusted odds ratio, 0.2; 95% confidence interval, 0.05-0.75). Posthoc subgroup analysis suggested that these improvements were essentially noticeable for cervical lengths between 5 and 18 mm, where pessary placement was associated with an increased fetoscopic laser surgery-to-delivery interval (+24 days; 95% confidence interval, 0.86-42; P=.042) and later gestational age at delivery (+3.3 weeks; 95% confidence interval, 0.86-42; P=.035). CONCLUSION Patients with a moderately shortened cervix, between 5 and 18 mm, may benefit from pessary placement after fetoscopic surgery for twin-to-twin transfusion syndrome, resulting in a reduction of adverse neonatal outcomes, double neonatal demise, and severe preterm delivery.
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Affiliation(s)
- Raphael Bartin
- Department of Obstetrics and Fetal Medicine, Necker-Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France; Faculté de Médecine, Université de Paris, Paris, France
| | - Cleisson Fábio Andrioli Peralta
- Gestar Fetal Medicine and Surgery Center, São Paulo, Brazil; Brazilian Ministry of Health, Programa de Desenvolvimento Institucional do Sistema Único de Saúde, São Paulo, Brazil
| | - Anna Clara Peneluppi Horak
- Heart Hospital Research Institute, São Paulo, Brazil; Brazilian Ministry of Health, Programa de Desenvolvimento Institucional do Sistema Único de Saúde, São Paulo, Brazil
| | - Karina Jorge Rodrigues da Costa
- Heart Hospital Research Institute, São Paulo, Brazil; Brazilian Ministry of Health, Programa de Desenvolvimento Institucional do Sistema Único de Saúde, São Paulo, Brazil
| | - Claire Colmant
- Department of Obstetrics and Fetal Medicine, Necker-Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Julien Stirnemann
- Department of Obstetrics and Fetal Medicine, Necker-Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France; Faculté de Médecine, Université de Paris, Paris, France
| | - Yves Ville
- Department of Obstetrics and Fetal Medicine, Necker-Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France; Faculté de Médecine, Université de Paris, Paris, France.
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Knijnenburg PJ, Slaghekke F, Rahmattulla C, Ge Y, Scholl IM, van Klink JM, Haak MC, Middeldorp JM, Sun L, Lopriore E. Intertwin Membrane Perforation and Umbilical Cord Entanglement after Laser Surgery for Twin-Twin Transfusion Syndrome: Prevalence, Risk Factors, and Outcome. Fetal Diagn Ther 2023; 50:289-298. [PMID: 37285826 PMCID: PMC10614233 DOI: 10.1159/000531450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 06/01/2023] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Perforation of the intertwin membrane can occur as a complication of fetoscopic laser surgery for twin-twin transfusion syndrome (TTTS). Data on the occurrence and the risk of subsequent cord entanglement are limited. The objective of this study was to assess the prevalence, risk factors and outcome of intertwin membrane perforation, and cord entanglement after laser surgery for TTTS. METHODS In this multicenter retrospective study, we included all TTTS pregnancies treated with laser surgery in two fetal therapy centers, Shanghai (China) and Leiden (the Netherlands) between 2002 and 2020. We evaluated the occurrence of intertwin membrane perforation and cord entanglement after laser, based on routine fortnightly ultrasound examination and investigated the risk factors and the association with adverse short- and long-term outcomes. RESULTS Perforation of the intertwin membrane occurred in 118 (16%) of the 761 TTTS pregnancies treated with laser surgery and was followed by cord entanglement in 21% (25/118). Perforation of the intertwin membrane was associated with higher laser power settings, 45.8 Watt versus 42.2 Watt (p = 0.029) and a second fetal surgery procedure 17% versus 6% (p < 0.001). The group with intertwin membrane perforation had a higher rate of caesarean section (77% vs. 31%, p < 0.001) and a lower gestational age at birth (30.7 vs. 33.3 weeks of gestation, p < 0.001) compared to the group with an intact intertwin membrane. Severe cerebral injury occurred more often in the group with intertwin membrane perforation, 9% (17/185) versus 5% (42/930), respectively (p = 0.019). Neurodevelopmental outcome at 2 years of age was similar between the groups with and without perforation of the intertwin membrane and between the subgroups with and without cord entanglement. CONCLUSION Perforation of the intertwin membrane after laser occurred in 16% of TTTS cases treated with laser and led to cord entanglement in at least 1 in 5 cases. Intertwin membrane perforation was associated with a lower gestational age at birth and a higher rate of severe cerebral injury in surviving neonates.
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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
| | - Femke Slaghekke
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Chinar Rahmattulla
- Division of Neonatology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Yuchun Ge
- Department of Fetal Medicine and Prenatal Diagnosis Center, Shanghai 1st Maternity and Infant Hospital of Tongji University, Shanghai, China
| | - Irene M. Scholl
- Department of Obstetrics, Division of Fetal Medicine, 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
| | - Monique C. Haak
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Johanna M. Middeldorp
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Luming Sun
- Department of Fetal Medicine and Prenatal Diagnosis Center, Shanghai 1st Maternity and Infant Hospital of Tongji University, Shanghai, China
| | - Enrico Lopriore
- Division of Neonatology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
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Yamamoto R, Yamada T, Yamamoto R, Wagata M, Hayashi S, Ishii K. Perioperative risk factors of preterm delivery after fetoscopic laser photocoagulation for twin-twin transfusion syndrome. Prenat Diagn 2023; 43:393-399. [PMID: 36726286 DOI: 10.1002/pd.6325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 01/25/2023] [Accepted: 01/30/2023] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To identify risk factors for preterm delivery (PTD) in patients who received fetoscopic laser photocoagulation (FLP) of placental anastomoses for twin-twin transfusion syndrome (TTTS). METHODS This retrospective cohort study prospectively analyzed and recorded perioperative data in a cohort of patients who had FLP for TTTS, identifying perioperative risk factors for PTD using a Cox proportional hazard regression model. RESULTS Of 304 patients included, 26 (8.6%) delivered within 4 weeks of FLP. Independent predictors of delivery within 4 weeks of FLP were a history of PTD (hazard ratio [HR]: 5.91, 95% confidence interval [CI]:1.21-28.82, p = 0.03), vaginal bleeding in the second trimester (HR: 6.62, 95% CI: 1.76-24.90, p < 0.01), and amnioreduction ≥1715 mL (HR: 3.16, 95% CI: 1.11-9.05, p < 0.03). CONCLUSION Patients with a history of PTD, preoperative vaginal bleeding, and amnioreduction ≥1715 mL were more likely to deliver prematurely.
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Affiliation(s)
- Rumiko Yamamoto
- Department of Fetal Maternal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Takuma Yamada
- Department of Fetal Maternal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Ryo Yamamoto
- Department of Fetal Maternal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Maiko Wagata
- Department of Fetal Maternal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Shusaku Hayashi
- Department of Fetal Maternal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Keisuke Ishii
- Department of Fetal Maternal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
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Subchorionic Hemorrhage in the Second and Third Trimesters of Pregnancy: A Review. Obstet Gynecol Surv 2022; 77:745-752. [PMID: 36477386 DOI: 10.1097/ogx.0000000000001082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Importance Subchorionic hemorrhage (SCH) in the second and third trimesters of pregnancy can be associated with maternal morbidity and fetal morbidity/mortality. Management of SCH in the second or third trimesters can be complicated, especially in the setting of a large SCH that requires hospitalization and blood transfusion. Objective The aim of this review is to describe SCH in second and third trimesters, risk factors, diagnosis, maternal and fetal outcomes, and management of this uncommon pregnancy complication. Evidence Acquisition A PubMed, Web of Science, and CINAHL search was undertaken with no limitations on the number of years searched. Results There were 123 abstracts and/or articles reviewed, with 48 articles being the basis of review. The only known risk factors for SCH are maternal factor deficiency and anticoagulation therapy. The diagnosis is usually made by ultrasound imaging. Subchorionic hemorrhage in second and third trimesters has been associated with several adverse fetal outcomes including preterm birth, preterm prelabor rupture of membranes, fetal growth restriction, fetal demise, and neonatal pulmonary morbidity. There is no proven treatment for SCH, although there are several investigational therapies reported. Conclusions Subchorionic hemorrhage can be complex and difficult to manage in the second and third trimesters. There are no recommendations or guidelines for management; however, serial growth ultrasounds, umbilical artery Doppler studies, and antenatal fetal testing should be considered particularly if the SCH is large or treatment requires a maternal blood transfusion. Relevance Subchorionic hemorrhage in the second and third trimester is associated with poor fetal outcomes and maternal morbidity, especially if the SCH is significant.
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Krispin E, Mustafa HJ, Sun RC, Donepudi R, Espinoza J, Nassr AA, Belfort MA, Sanz Cortes M, Mostafaei S, Harman C, Turan O, Shamshirsaz AA. Iatrogenic chorioamniotic separation and septostomy following fetoscopic laser photocoagulation for twin-twin transfusion syndrome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 59:506-512. [PMID: 34182599 DOI: 10.1002/uog.23723] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 06/04/2021] [Accepted: 06/17/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To compare the perinatal outcomes of pregnancies complicated by chorioamniotic separation (CAS) vs septostomy following fetoscopic laser photocoagulation (FLP) for twin-twin transfusion syndrome (TTTS). METHODS This was a retrospective cohort analysis of monochorionic diamniotic twin pregnancies with TTTS that underwent FLP at one of two university-affiliated tertiary medical centers between January 2012 and December 2020. CAS and septostomy were diagnosed either during the procedure or by ultrasonography within 24-48 h after FLP. Data on procedure and postprocedure parameters, pregnancy outcomes and survival were collected from the patients' electronic medical records. Pregnancies were stratified according to the presence of CAS, septostomy or neither. Patients diagnosed with both CAS and septostomy were analyzed separately. RESULTS Of the 522 women included in the cohort, 38 (7.3%) were diagnosed with CAS, 68 (13.0%) with septostomy and 23 (4.4%) with both CAS and septostomy. The remaining 393 (75.3%) women comprised the control group. Groups did not differ in demographic characteristics. The septostomy group had a lower rate of selective fetal growth restriction than did the CAS and control groups (24.2% vs 36.8% vs 42.7%, respectively; P = 0.017). Moreover, intertwin size discordance was lower in the septostomy group (15.1% vs 23.4% in the CAS group and 25.5% in the control group; P = 0.001). Median gestational age at FLP was significantly lower in the CAS group (19.3 weeks vs 20.4 weeks in controls and 20.9 weeks in the septostomy group; P = 0.049). The rate of delivery prior to 34 weeks was significantly higher in the CAS group (89.2%), followed by the septostomy group (80.9%), compared with the control group (69.0%) (P = 0.006). A secondary analysis demonstrated that patients with both CAS and septostomy presented the highest rates of delivery prior to 34 weeks (100%) and 32 weeks (68.2%). CONCLUSIONS CAS and septostomy following laser surgery for TTTS are independently associated with higher rates of preterm delivery. The presence of these two findings in the same patient enhances the risk of prematurity. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- E Krispin
- Department of Obstetrics and Gynecology, Division of Fetal Therapy and Surgery, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - H J Mustafa
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - R C Sun
- Department of Obstetrics and Gynecology, Division of Fetal Therapy and Surgery, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - R Donepudi
- Department of Obstetrics and Gynecology, Division of Fetal Therapy and Surgery, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - J Espinoza
- Department of Obstetrics and Gynecology, Division of Fetal Therapy and Surgery, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - A A Nassr
- Department of Obstetrics and Gynecology, Division of Fetal Therapy and Surgery, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - M A Belfort
- Department of Obstetrics and Gynecology, Division of Fetal Therapy and Surgery, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - M Sanz Cortes
- Department of Obstetrics and Gynecology, Division of Fetal Therapy and Surgery, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - S Mostafaei
- Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - C Harman
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - O Turan
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - A A Shamshirsaz
- Department of Obstetrics and Gynecology, Division of Fetal Therapy and Surgery, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
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Twin-to-twin transfusion syndrome: Controversies in the diagnosis and management. Best Pract Res Clin Obstet Gynaecol 2022; 84:143-154. [PMID: 35589537 DOI: 10.1016/j.bpobgyn.2022.03.013] [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: 01/25/2022] [Accepted: 03/12/2022] [Indexed: 11/21/2022]
Abstract
In twin-to-twin transfusion syndrome (TTTS) communicating placental vessels on the chorionic plate between the donor and recipient twins are responsible for the chronic imbalance of blood flow. Evidence demonstrates that fetoscopic laser ablation is superior to serial amnioreductions in terms of survival and neurological outcome for stages II-IV TTTS. However, the optimal management of stage I TTTS remains poorly understood. It is well established that all chorionic plate anastomoses should be closed by laser ablation. Compared to the selective laser method, the Solomon technique yields a significant reduction of recurrent TTTS and post-laser twin anemia polycythemia sequence (TAPS). Over the past 25 years, survival rates after fetoscopic laser surgery have significantly increased. High volume centers report up to 70% double survival and at least one survivor in >90% cases. In this review, we discuss the controversies in the diagnosis and management of TTTS, especially, the optimal management in stage I cases, very early or late diagnosis, and the optimal laser technique. Furthermore, we will discuss a stage-related outcome after laser surgery and examine whether it is necessary at all to distinguish between stages I and II. Finally, the optimal timing as well as mode of delivery after TTTS laser treatment will be discussed.
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Youssefzadeh AC, Glassen GL, Chon AH, Korst LM, Esakoff TF, Afshar Y, Gheorghe CP, Llanes A, Chmait RH. Dual demise following laser surgery for twin-twin transfusion syndrome: Analysis of 52 cases at a single fetal surgery center. Prenat Diagn 2021; 41:1548-1559. [PMID: 34669208 DOI: 10.1002/pd.6058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 09/06/2021] [Accepted: 10/07/2021] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To evaluate all individual cases of dual twin demise following laser surgery for twin-twin transfusion syndrome (TTTS). METHOD This is an analysis of all monochorionic diamniotic twin gestations with TTTS complicated by dual demise following laser surgery from 2006 to 2019. Cases were reviewed by (1) a fetal surgeon researcher and (2) a panel of independent experienced maternal-fetal medicine specialists to code an etiology of demise for the donor and recipient, and to assess for possible preventability. RESULTS Of 753 twins that underwent laser surgery for TTTS, 52 (6.9%) had postoperative dual demise. In this subgroup, gestational age at surgery was 19.5 (16.1-24.9) weeks, and 36 (69.2%) patients were Quintero stage III and IV. The most common etiology was the spectrum of disorders leading to preterm delivery, which included cervical insufficiency, preterm premature rupture of membranes, and preterm labor (44.2% and 48.1%, donor and recipient, respectively). Some degree of preventability was estimated for 23.1% of dual demises. CONCLUSIONS The most common cause of dual demise post laser surgery for TTTS was preterm birth, reinforcing the need for studies regarding the etiology and prevention of post-fetoscopy prematurity. Nearly one-quarter of dual demise cases were deemed potentially preventable.
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Affiliation(s)
- Ariane C Youssefzadeh
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Gabrielle L Glassen
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Andrew H Chon
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Lisa M Korst
- Childbirth Research Associates, LLC, North Hollywood, California, USA
| | - Tania F Esakoff
- Department of Obstetrics and Gynecology, Division of Maternal Fetal-Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Yalda Afshar
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Ciprian P Gheorghe
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Loma Linda University, Loma Linda, California, USA
| | - Arlyn Llanes
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Ramen H Chmait
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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Abstract
Twin to twin transfusion syndrome (TTTS) is a common complication that typically presents in the second trimester of pregnancy in 10-15% of monochorionic twins due to net transfer of volume and hormonal substances from one twin to the other across vascular anastomoses on the placenta. Without recognition and treatment, TTTS is the greatest contributor to fetal loss prior to viability in 90-100% of advanced cases. Ultrasound diagnosis of monochorionicity is most reliable in the first trimester and sets the monitoring strategy for this type of twins. The diagnosis of TTTS is made by ultrasound with the findings of polyhydramnios due to volume overload and polyuria in one twin and oligohydramnios due to oliguria of the co-twin. Assessment of bladder filling as well as arterial and venous Doppler patterns are required for staging disease severity. Assessment of fetal cardiac function also provides additional insight into the fetal cardiovascular impacts of the disease as well as help identify fetuses that may require postnatal follow up. Fetoscopic laser ablation of the communicating vascular anastomoses between the twins is the standard treatment for TTTS. It aims to cure the condition by interrupting the link between their circulations and making them independent of one another. Contemporary outcome data after laser surgery suggests survival for both fetuses can be anticipated in up to 65% of cases and survival of a single fetus in up to 88% of cases. However, preterm birth remains a significant contributor to postnatal morbidity and mortality. Long term outcomes of TTTS survivors indicate that up to 11% of children may show signs of neurologic impairment. Strategies to minimize preterm birth after treatment and standardized reporting by laser centers are important considerations to improve overall outcomes and understand the long-term impacts of TTTS.
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Affiliation(s)
- Jena L Miller
- The Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, MD, USA
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Yamamoto R, Nakanishi K, Kawaguchi H, Hayashi S, Ishii K. Prevalence of Extraplacental Anastomoses in Monochorionic Twin Pregnancies. Fetal Diagn Ther 2020; 48:24-27. [PMID: 33059349 DOI: 10.1159/000510636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 08/03/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To evaluate the prevalence of extraplacental anastomoses (EPA) and the factors associated. METHODS A retrospective study including 144 placentas from monochorionic diamniotic (MCDA) twins delivering at one institution was performed. EPA were defined as any intertwin anastomosis located outside the chorionic plate on macroscopic inspection. The association with perinatal factors and with umbilical cord insertion site was analyzed. RESULTS The prevalence of EPA was 4.9% (7/144). Velamentous cord insertion of both twins was significantly associated with the presence of EPA in the multivariate logistic regression model (p = 0.045). DISCUSSION EPA was found in ≈5% of MCDA twin pregnancies.
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Affiliation(s)
- Ryo Yamamoto
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan,
| | - Kentaro Nakanishi
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Haruna Kawaguchi
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Shusaku Hayashi
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Keisuke Ishii
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
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Valenzuela I, van der Merwe J, De Catte L, Devlieger R, Deprest J, Lewi L. Foetal therapies and their influence on preterm birth. Semin Immunopathol 2020; 42:501-514. [PMID: 32785752 DOI: 10.1007/s00281-020-00811-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/26/2020] [Indexed: 12/12/2022]
Abstract
Foetal therapy aims to improve perinatal survival or to prevent severe long-term handicap. Foetal medicine opens a new territory by treating the foetus as a patient. The mother has nothing to gain in terms of health benefits, yet she is inherently also undergoing treatment. In utero foetal interventions can be divided into ultrasound-guided minimally invasive procedures, fetoscopic procedures and open hysterotomy procedures, which carry an inherent risk of ruptured membranes and preterm birth. In this review, we summarise the conditions that may benefit from foetal therapy and review the current therapies on offer, each with their associated risk of ruptured membrane and preterm birth. We also look into some risk limiting and preventative strategies to mitigate these complications.
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Affiliation(s)
- Ignacio Valenzuela
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium
| | - Johannes van der Merwe
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium
| | - Luc De Catte
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium
| | - Roland Devlieger
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium
| | - Jan Deprest
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium.,Institute for Women's Health, University College London, London, United Kingdom
| | - Liesbeth Lewi
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium. .,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium.
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11
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Fetal surgery and neonatal ICU admissions. Curr Opin Pediatr 2020; 32:619-624. [PMID: 32692057 DOI: 10.1097/mop.0000000000000900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Fetal intervention is a dynamic field with wide-reaching implications on neonatal ICU admissions and the care of neonates with congenital anomalies. The aim of this review is to summarize recent advancements in fetal surgery and provide a broad understanding of how these topics interrelate. RECENT FINDINGS Advancements in prenatal imaging and diagnosis have dramatically expanded the indications for fetal intervention. Most recently, there has been a large focus on evaluating minimally invasive strategies of fetal intervention, notably fetoscopic surgery, and the use of stem cells for fetal treatment of myelomeningocele. With the advances in fetal intervention, neonatal care has adapted to the needs of these various patients to help improve the outcomes of this unique population. SUMMARY Fetal intevention relies on a multidisciplinary team from prenatal imaging and maternal fetal medicine to fetal surgery and postnatal subspecialty care, particuarly neonatology. Fetal intervention uniquely involves two patients, both mother and fetus, and therefore, has unique risks and considerations, particularly in the advancement of the field. As the number of conditions suited to fetal intervention grows, awareness and advancement of the postnatal intensive care necessary for these patients are essential.
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Chmait RH, Catanzarite V, Chon AH, Korst LM, Llanes A, Ouzounian JG. Fetoscopic Laser Ablation Therapy for Type II Vasa Previa. Fetal Diagn Ther 2020; 47:682-688. [PMID: 32629451 DOI: 10.1159/000508044] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 04/20/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND In type II vasa previa, fetoscopic laser ablation has the potential to avoid prolonged hospitalization, elective prematurity, and cesarean delivery associated with traditional conservative management. OBJECTIVE To assess the feasibility and to report perinatal outcomes of type II vasa previa patients treated via fetoscopic laser ablation. STUDY DESIGN This is a retrospective descriptive study of all women with vasa previa treated with laser at our center between 2006 and 2019. After 2010, laser ablation of vasa previa was only offered after 31 gestational weeks. Continuous variables are expressed as means ± SD. RESULTS 33 patients were evaluated for laser ablation of suspected vasa previa. Fifteen were not candidates (7 had type I vasa previa and 8 had no vasa previa), and the 18 remaining had type II vasa previa. Ten (56%) elected to undergo in utero laser ablation of the vasa previa vessel(s), which was successful in all patients. The mean gestational age (GA) at the time of the procedure was 28.8 ± 5.4 weeks, and the total operative time was 48.1 ± 21.3 min; there were no perioperative complications. The number of vessels lasered were distributed as follows: 1 (2 cases), 2 (5 cases), and 3 (3 cases). All patients except for 1 were subsequently managed as outpatients. The mean GA at delivery was 35.5 ± 3.2 weeks, and vaginal delivery occurred in 5 cases. The 5 patients with singletons who underwent laser ablation for primary diagnosis of type II vasa previa after the protocol change in 2010 had the following outcomes: mean GA of surgery was 32.5 ± 0.8 weeks, mean GA at delivery was 38.1 ± 1.4 weeks, vaginal delivery occurred in all cases, mean birth weight was 2,965 ± 596 g, and none were admitted to the neonatal intensive care unit. CONCLUSION This cohort represents the largest number of vasa previa cases treated via in utero laser reported to date. Laser occlusion of type II vasa previa was technically achievable in all cases and resulted in favorable outcomes.
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Affiliation(s)
- 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,
| | - Valerian Catanzarite
- San Diego Perinatal Center, Rady Children's Specialists of San Diego, San Diego, 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, Los Angeles, 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
| | - Joseph G Ouzounian
- 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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De Zoysa MY, Chon AH, Korst LM, Llanes A, Chmait RH. Membrane Separation and Perinatal Outcomes after Laser Treatment for Twin-Twin Transfusion Syndrome. Fetal Diagn Ther 2019; 47:307-314. [PMID: 31822010 DOI: 10.1159/000504361] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 10/23/2019] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Postoperative membrane separation is a complication of selective laser photocoagulation of communicating vessels (SLPCV) for the treatment of twin-twin transfusion syndrome (TTTS). OBJECTIVE The aim of this work was to determine whether a quantitative grading system of membrane separation following SLPCV was associated with preterm premature rupture of membranes (PPROM) and preterm delivery (PTD). METHODS Patients with membrane separation after SLPCV on postoperative day 1 were stratified into greatest width of separation <1 cm (Group A) or ≥1 cm (Group B) and compared to patients without separation by the following outcomes: PPROM ≤21 postoperative days, PTD <28 gestational weeks, and PTD <32 gestational weeks. RESULTS Of 654 patients, 123 (18.8%) had membrane separation. Of these, 120 patients were eligible for study and divided into Groups A (n = 91) and B (n = 29). Multiple logistic regression analysis yielded associations with PPROM ≤21 days for Groups B (OR 8.60, 95% CI 3.38-21.90, p < 0.0001) and A (OR 2.39, 95% CI 1.05-5.40, p = 0.0369) compared to those without membrane separation. In similar models, Group B was associated with PTD <32 weeks (OR 2.41, 95% CI 1.10-5.28, p = 0.0274). CONCLUSION Postoperative membrane separation was associated with an increased risk of PPROM ≤21 days. Membrane separation ≥1 cm had a higher risk of PTD <32 weeks.
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Affiliation(s)
- Madushka Y De Zoysa
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Pasadena, California, USA
| | - Andrew H Chon
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Pasadena, California, USA
| | - Lisa M Korst
- Childbirth Research Associates, North Hollywood, California, USA
| | - Arlyn Llanes
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Pasadena, California, USA
| | - Ramen H Chmait
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Pasadena, California, USA,
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Li WF, Chao AS, Chang SD, Cheng PJ, Yang LY, Chang YL. Effects and outcomes of septostomy in twin-to-twin transfusion syndrome after fetoscopic laser therapy. BMC Pregnancy Childbirth 2019; 19:397. [PMID: 31675920 PMCID: PMC6824012 DOI: 10.1186/s12884-019-2555-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 10/10/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND To evaluate the incidence and outcomes of septostomy in twin-to-twin transfusion syndrome (TTTS) after fetoscopic laser therapy. METHODS A retrospective analysis of TTTS postlaser septostomy between 2005 and 2018 was performed. Postlaser septostomy was diagnosed using both (1) a free-floating intertwin membrane flap visible on ultrasound examination and (2) the rapid equalization of amniotic fluid maximum vertical pocket in the donor and recipient amniotic sacs observed after laser therapy. Perinatal survival, neonatal brain image anomaly, gestational age at operation and birth, incidence of premature rupture of membranes (PROM) within 3 weeks after operation, pseudoamniotic band syndrome, and cord entanglement were evaluated. RESULTS In the 159 TTTS cases included, 12 had postlaser septostomy. Relative to the group without septostomy, the septostomy group had a lower total fetal survival rate (54.2% vs 73.6%, p = 0.041), an earlier mean gestational age at delivery (27.8 vs 34.4 weeks, p = 0.009), a higher risk of PROMs within 3 weeks after operation (33.3% vs 5.4%, p = 0.004), a higher cord entanglement rate (16.7% vs 0%, p = 0.005), and a higher brain image anomaly rate (23.0% [3/13] vs 5.0% [11/218], p = 0.035). After considering the severe Quintero stages (stage III and IV), postlaser septostomy was the only variable [p = 0.003, odds ratio = 5.1] to predict neonatal brain image anomaly. Postlaser septostomy combined with severe Quintero stages could predict PROMs within 3 weeks after laser therapy [p = 0.001, odds ratio = 14.1 and p = 0.03, odds ratio = 5.4, respectively] and delivery before the gestational age of 28 weeks [p = 0.017, odds ratio = 4.5 and p = 0.034, odds ratio = 2.3, respectively]. The risk of pseudoamniotic band syndrome was not increased by postlaser septostomy in this case series. CONCLUSIONS Postlaser septostomy in TTTS was associated with poorer fetal survival and more adverse perinatal outcomes even after considering severe Quintero stages before laser therapy. Efforts should be made to prevent septostomy during laser therapy, and septostomy as the primary method to treat TTTS is not advisable.
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Affiliation(s)
- Wen-Fang Li
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Tao-Yuan, Taiwan
| | - An-Shine Chao
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Tao-Yuan, Taiwan
| | - Shuenn-Dyh Chang
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Tao-Yuan, Taiwan
| | - Po-Jen Cheng
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Tao-Yuan, Taiwan
| | - Lan-Yan Yang
- Biostatistics Unit of Clinical Trial Center, Chang Gung Memorial Hospital, Taoyuan, 333, Taiwan
| | - Yao-Lung Chang
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Tao-Yuan, Taiwan.
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou Medical Center, 5, Fu-Shin Street, Kweishan, Taoyuan, 333, Taiwan, Republic of China.
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North American Fetal Therapy Network: Timing of and indications for delivery following laser ablation for twin-twin transfusion syndrome. Am J Obstet Gynecol MFM 2019; 1:74-81. [PMID: 32832884 DOI: 10.1016/j.ajogmf.2019.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background Despite improvements in fetal survival for pregnancies affected by twin-twin transfusion syndrome since the introduction of laser photocoagulation, prematurity remains a major source of neonatal morbidity and mortality. Objective To investigate the indications and factors influencing the timing of delivery following laser treatment, we collected delivery information regarding twin-twin transfusion syndrome cases in a large multicenter cohort. Study Design Eleven North American Fetal Therapy Network (NAFTNet) centers conducted a retrospective review of twin-twin transfusion syndrome patients who underwent laser photocoagulation. Clinical, demographic and ultrasound variables including twin-twin transfusion syndrome stage, and gestational age at treatment and delivery were recorded. Primary and secondary maternal and fetal indications for delivery were identified. Univariate analysis was used to select candidate variables with significant correlation with latency and GA at delivery. Multivariable Cox regression with competing risk analysis was utilized to determine the independent associations. Results A total of 847 pregnancies were analyzed. After laser, the average latency to delivery was 10.11 ± 4.8 weeks and the mean gestational age at delivery was 30.7 ± 4.5 weeks. Primary maternal indications for delivery comprised 79% of cases. The leading indications included spontaneous labor (46.8%), premature rupture of membranes (17.1%), and placental abruption (8.4%). Primary fetal indications accounted for 21% of cases and the most frequent indications included donor non-reassuring status (20.5%), abnormal donor Dopplers (15.1%), and donor growth restriction (14.5%). The most common secondary indications for delivery were premature rupture of membranes, spontaneous labor and donor growth restriction. Multivariate modeling found gestational age at diagnosis, stage, history of prior amnioreduction, cerclage, interwin membrane disruption, procedure complications and chorioamniotic membrane separation as predictors for both gestational age at delivery and latency. Conclusion Premature delivery after laser therapy for twin-twin transfusion syndrome is primarily due to spontaneous labor, preterm premature rupture of membranes and non-reassuring status of the donor fetus. Placental abruption was found to be a frequent complication resulting in early delivery. Future research should be directed toward the goal of prolonging gestation after laser photocoagulation to further reduce morbidity and mortality associated with twin-twin transfusion syndrome.
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Chon AH, Chan Y, Korst LM, Llanes A, Abdel-Sattar M, Chmait RH. Quantitative fetal fibronectin to predict spontaneous preterm delivery after laser surgery for twin-twin transfusion syndrome. Sci Rep 2019; 9:4438. [PMID: 30872799 PMCID: PMC6418228 DOI: 10.1038/s41598-019-41163-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 03/01/2019] [Indexed: 11/09/2022] Open
Abstract
Our goal was to assess whether quantitative fetal fibronectin (qfFN) is associated with spontaneous preterm birth (sPTB) after laser surgery for twin-twin transfusion syndrome (TTTS). qfFN was collected within 24 hours before and after laser surgery. Aims were: (1) To determine if qfFN changed with operative fetoscopy; and (2) To estimate the number of patients needed to study the predictive value of qfFN for sPTB <28 and <32 weeks. Results are reported as median (range). Among 49 patients, there was no net difference in qfFN levels after laser surgery [0.0 ng/mL (-37 to +400), p = 0.6041]. However, patients with a qfFN increase >10 ng/mL were 19 times more likely to undergo sPTB at <28 weeks (OR = 19.5). We determined that 383 and 160 patients would be needed to achieve adequate statistical power for qfFN to be predictive of sPTB at a GA <28 weeks and <32 weeks, respectively. In conclusion, laser surgery did not alter the qfFN level within the entire cohort, but qfFN may be useful in identifying a subset of patients at increased risk of preterm delivery.
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MESH Headings
- Female
- Fetofetal Transfusion/surgery
- Fibronectins/metabolism
- Gestational Age
- Humans
- Infant, Newborn
- Infant, Newborn, Diseases/diagnosis
- Infant, Newborn, Diseases/etiology
- Infant, Newborn, Diseases/metabolism
- Infant, Newborn, Diseases/pathology
- Laser Therapy/adverse effects
- Pregnancy
- Pregnancy, Twin
- Premature Birth/diagnosis
- Premature Birth/etiology
- Premature Birth/metabolism
- Premature Birth/pathology
- Prospective Studies
- Twin Studies as Topic
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Affiliation(s)
- 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
| | - Yen Chan
- 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, Los Angeles, 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
| | - Mira Abdel-Sattar
- 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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Sacco A, Van der Veeken L, Bagshaw E, Ferguson C, Van Mieghem T, David AL, Deprest J. Maternal complications following open and fetoscopic fetal surgery: A systematic review and meta-analysis. Prenat Diagn 2019; 39:251-268. [PMID: 30703262 PMCID: PMC6492015 DOI: 10.1002/pd.5421] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 01/16/2019] [Accepted: 01/20/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To establish maternal complication rates for fetoscopic or open fetal surgery. METHODS We conducted a systematic literature review for studies of fetoscopic or open fetal surgery performed since 1990, recording maternal complications during fetal surgery, the remainder of pregnancy, delivery, and after the index pregnancy. RESULTS One hundred sixty-six studies were included, reporting outcomes for open fetal (n = 1193 patients) and fetoscopic surgery (n = 9403 patients). No maternal deaths were reported. The risk of any maternal complication in the index pregnancy was 20.9% (95%CI, 15.22-27.13) for open fetal and 6.2% (95%CI, 4.93-7.49) for fetoscopic surgery. For severe maternal complications (grades III to V Clavien-Dindo classification of surgical complications), the risk was 4.5% (95% CI 3.24-5.98) for open fetal and 1.7% (95% CI, 1.19-2.20) for fetoscopic surgery. In subsequent pregnancies, open fetal surgery increased the risk of preterm birth but not uterine dehiscence or rupture. Nearly one quarter of reviewed studies (n = 175, 23.3%) was excluded for failing to report the presence or absence of maternal complications. CONCLUSIONS Maternal complications occur in 6.2% fetoscopic and 20.9% open fetal surgeries, with serious maternal complications in 1.7% fetoscopic and 4.5% open procedures. Reporting of maternal complications is variable. To properly quantify maternal risks, outcomes should be reported consistently across all fetal surgery studies.
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Affiliation(s)
- Adalina Sacco
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Lennart Van der Veeken
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
| | - Emma Bagshaw
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Catherine Ferguson
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Tim Van Mieghem
- Department of Obstetrics and GynaecologyMount Sinai Hospital and University of TorontoTorontoOntarioCanada
| | - Anna L. David
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
- National Institute for Health ResearchUniversity College London Hospitals Biomedical Research CentreLondonUK
| | - Jan Deprest
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
- Clinical Department Obstetrics and GynaecologyUniversity Hospitals LeuvenLeuvenBelgium
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Gordon B, Chon A, Korst L, Llanes A, Miller D, Chmait R. Incidental Septostomy after Laser Surgery for Twin-Twin Transfusion Syndrome: Perinatal Outcomes and Antenatal Management. Fetal Diagn Ther 2017; 44:285-290. [DOI: 10.1159/000485034] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 11/04/2017] [Indexed: 01/15/2023]
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Chon AH, Korst LM, Grubbs BH, Kontopoulos EV, Quintero RA, Chmait RH. Risk factors for fetomaternal bleeding after laser therapy for twin-twin transfusion syndrome. Prenat Diagn 2017; 37:1232-1237. [PMID: 29071724 DOI: 10.1002/pd.5173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 10/03/2017] [Accepted: 10/18/2017] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To quantify and assess potential risk factors for transplacental passage of fetal red blood cells (RBCs) into the maternal circulation (fetomaternal bleeding, FMB) after laser surgery for twin-twin transfusion syndrome (TTTS). STUDY DESIGN A retrospective study of Rhesus-D negative patients that underwent laser surgery for TTTS. Patients with and without postoperative detectable fetal RBCs on Kleihauer-Betke (KB) testing were compared to determine risk factors for FMB. Patients were further sub-classified into those with a FMB < 20% and ≥20% of estimated fetoplacental blood volume. RESULTS Of 60 studied patients, 26/60 (43%) had a positive postoperative KB test. The median fetal:adult RBC ratio was 0.00125, estimated to be a FMB volume of 6.25 mL. There were 17/26 (65%) of patients with FMB < 20% and 9/26 (35%) patients with ≥20% of the fetoplacental blood volume. Stage III-Recipient and III-Recipient/Donor patients were more likely to have a positive KB test (14/21 [66.7%] vs 12/39 [30.8%], OR = 4.50 [1.27-16.54], P = 0.0162). No other risk factors for FMB were apparent. CONCLUSIONS Fetomaternal bleed appears to be a common finding after laser surgery for TTTS. TTTS Stage, particularly stage III-Recipient and III-Recipient/Donor, appears to be a risk factor for FMB.
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Affiliation(s)
- Andrew H Chon
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Lisa M Korst
- Childbirth Research Associates, North Hollywood, CA, USA
| | - Brendan H Grubbs
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | - Rubén A Quintero
- Wertheim School of Medicine, Florida International University, Miami, FL, USA
| | - Ramen H Chmait
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Malshe A, Snowise S, Mann LK, Boring N, Johnson A, Bebbington MW, Moise KJ, Papanna R. Preterm delivery after fetoscopic laser surgery for twin-twin transfusion syndrome: etiology and risk factors. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 49:612-616. [PMID: 27222097 DOI: 10.1002/uog.15972] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 04/23/2016] [Accepted: 05/16/2016] [Indexed: 06/05/2023]
Abstract
OBJECTIVE Preterm delivery after fetoscopic laser surgery (FLS) for twin-twin transfusion syndrome (TTTS) is a major complication. The causative factors leading to preterm delivery continue to be elusive and a better understanding of the risk factors could reduce complications. The objective of this study was to determine the etiology of preterm delivery after FLS for TTTS and its associated risk factors. METHODS This was a secondary analysis of a prospective study of 203 patients with TTTS who underwent FLS at a single center between September 2011 and December 2014. Preoperative, operative, postoperative, delivery and neonatal data were reviewed. Preterm delivery was categorized according to etiology into three groups: spontaneous (SPT), indicated (IND) and elective (ELC). Comparisons between groups were performed by ANOVA. Kaplan-Meier survival analysis was performed to compare the procedure-to-delivery interval between groups. To identify risk factors for preterm delivery, logistic regression, with calculation of relative risks (RR), was performed, with P < 0.05 considered statistically significant. RESULTS Mean gestational age at time of FLS was 20.6 ± 2.4 weeks and mean gestational age at delivery was 30.9 ± 4.7 weeks. Iatrogenic preterm prelabor rupture of membranes (iPPROM) occurred in 39% of cases. SPT preterm delivery occurred in 97 (48%) patients, IND preterm delivery in 65 (32%) and ELC preterm delivery in 41 (20%). In the IND group, 30 (46%) patients delivered for fetal indications, 31 (48%) for maternal indications and four (6%) for combined fetal and maternal indications. The overall chorioamnionitis rate was 6.4%; of these, nine (9%) were in the SPT group and four (6%) were in the IND group, with no case occurring in the ELC group. There was a significant difference in procedure-to-delivery interval between groups (P < 0.0001). Using variables from the ELC group as a baseline, significant risk factors for SPT preterm delivery were iPPROM (RR, 16.2 (95% CI, 4.5-57.7)), preoperative cervical length (RR, 0.96 (95% CI, 0.92-0.998)) and number of anastomoses (RR, 1.14 (95% CI, 1.02-1.27)). Significant risk factors for IND preterm delivery were iPPROM (RR, 9.6 (95% CI, 2.6-35.0)) and number of ablated anastomoses (RR, 1.13 (95% CI, 1.02-1.30)). CONCLUSION iPPROM and an increased number of ablated placental anastomoses were associated independently with SPT and IND preterm deliveries. A shorter preoperative cervical length was associated with SPT preterm delivery. Strategies to prevent iPPROM and for management of cervical length shortening are needed urgently in these pregnancies. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- A Malshe
- Department of Obstetrics, Gynecology and Reproductive Sciences, UTHealth Medical School, Houston, TX, USA
| | - S Snowise
- Department of Obstetrics, Gynecology and Reproductive Sciences, UTHealth Medical School, Houston, TX, USA
- The Fetal Center, Children's Memorial Hermann Hospital, Houston, TX, USA
| | - L K Mann
- Department of Obstetrics, Gynecology and Reproductive Sciences, UTHealth Medical School, Houston, TX, USA
- The Fetal Center, Children's Memorial Hermann Hospital, Houston, TX, USA
| | - N Boring
- The Fetal Center, Children's Memorial Hermann Hospital, Houston, TX, USA
| | - A Johnson
- Department of Obstetrics, Gynecology and Reproductive Sciences, UTHealth Medical School, Houston, TX, USA
- The Fetal Center, Children's Memorial Hermann Hospital, Houston, TX, USA
| | - M W Bebbington
- Department of Obstetrics, Gynecology and Reproductive Sciences, UTHealth Medical School, Houston, TX, USA
- The Fetal Center, Children's Memorial Hermann Hospital, Houston, TX, USA
| | - K J Moise
- Department of Obstetrics, Gynecology and Reproductive Sciences, UTHealth Medical School, Houston, TX, USA
- The Fetal Center, Children's Memorial Hermann Hospital, Houston, TX, USA
| | - R Papanna
- Department of Obstetrics, Gynecology and Reproductive Sciences, UTHealth Medical School, Houston, TX, USA
- The Fetal Center, Children's Memorial Hermann Hospital, Houston, TX, USA
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21
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Yamamoto R, Ishii K, Mabuchi A, Oota S, Haino K, Hayashi S, Kanagawa T, Mitsusda N. Prior uterine bleeding is associated with low visibility due to discolored amniotic fluid on fetoscopic laser photocoagulation. J Obstet Gynaecol Res 2016; 42:1652-1656. [PMID: 27647818 DOI: 10.1111/jog.13133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 07/08/2016] [Accepted: 07/18/2016] [Indexed: 11/30/2022]
Abstract
AIM To investigate the association between uterine bleeding preceding fetoscopic laser photocoagulation (FLP) and the presence of discolored amniotic fluid that impedes FLP. METHODS A retrospective review of all multiple gestations requiring FLP at the present institution was conducted. The rate of low visibility because of discolored amniotic fluid at the beginning of FLP was compared between patients with and without a history of uterine bleeding, defined as either genital bleeding or ultrasonographically detected subchorionic hematoma. RESULTS The prevalence of low visibility because of discolored amniotic fluid was 4.5% (seven in 156 patients). Two of the seven cases of low visibility resulted in double fetal death. The incidence of low visibility was significantly higher in the group with uterine bleeding before surgery compared with that without bleeding (28.6% vs 0.74%, P < 0.001). CONCLUSIONS Patients with a history of uterine bleeding prior to FLP may encounter more technical difficulties owing to discolored amniotic fluid during FLP.
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Affiliation(s)
- Ryo Yamamoto
- Department of Obstetrics, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Keisuke Ishii
- Department of Obstetrics, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Aki Mabuchi
- Department of Obstetrics, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Shiyo Oota
- Department of Obstetrics, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Kazufumi Haino
- Department of Obstetrics, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Shusaku Hayashi
- Department of Obstetrics, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Takeshi Kanagawa
- Department of Obstetrics, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Nobuaki Mitsusda
- Department of Obstetrics, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
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Papanna R, Mann LK, Snowise S, Morales Y, Prabhu SP, Tseng SCG, Grill R, Fletcher S, Moise KJ. Neurological Outcomes after Human Umbilical Cord Patch for In Utero Spina Bifida Repair in a Sheep Model. AJP Rep 2016; 6:e309-17. [PMID: 27621952 PMCID: PMC5017885 DOI: 10.1055/s-0036-1592316] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES The objective of our study was to test the hypothesis that in utero repair of surgically created spina bifida in a sheep model using cryopreserved human umbilical cord (HUC) patch improves neurological outcome. METHODS Spina bifida with myelotomy was surgically created in timed pregnant ewes at gestational day (GD) 75. The fetuses were randomly assigned to unrepaired versus HUC and treated at GD 95 and then delivered at GD 140. Neurological evaluation was performed using the Texas Spinal Cord Injury Scale (TSCIS), bladder control using ultrasound, and the hindbrain herniation. RESULTS Three lambs without the spina bifida creation served as controls. There were four lambs with spina bifida: two were unrepaired and two underwent HUC repair. The control lambs had normal function. Both unrepaired lambs had nonhealed skin lesions with leakage of cerebrospinal fluid, a 0/20 TSCIS score, no bladder control, and the hindbrain herniation. In contrast, both HUC lambs had a completely healed skin defect and survived to day 2 of life, a 3/20 and 4/20 TSCIS score (nociception), partial bladder control, and normal hindbrain anatomy. CONCLUSIONS Cryopreserved HUC patch appears to improve survival and neurological outcome in this severe form of the ovine model of spina bifida.
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Affiliation(s)
- Ramesha Papanna
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Medicine, UTHealth, The University of Texas Health Science at Houston, McGovern Medical School and the Fetal Center at Children's Memorial Hermann Hospital, Houston, Texas
| | - Lovepreet K Mann
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Medicine, UTHealth, The University of Texas Health Science at Houston, McGovern Medical School and the Fetal Center at Children's Memorial Hermann Hospital, Houston, Texas
| | - Saul Snowise
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Medicine, UTHealth, The University of Texas Health Science at Houston, McGovern Medical School and the Fetal Center at Children's Memorial Hermann Hospital, Houston, Texas
| | - Yisel Morales
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Medicine, UTHealth, The University of Texas Health Science at Houston, McGovern Medical School and the Fetal Center at Children's Memorial Hermann Hospital, Houston, Texas
| | - Sanjay P Prabhu
- Department of Radiology, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Scheffer C G Tseng
- The Ocular Surface Center, Miami, Florida; TissueTech, Inc., Miami, Florida
| | - Raymond Grill
- Department of Neurobiology and Anatomical Sciences, University of Mississippi Medical Center, Jackson, Mississippi
| | - Stephen Fletcher
- Division of Pediatric Neurosurgery, The Department of Pediatrics, UTHealth, The University of Texas Health Science at Houston, McGovern Medical School, Houston, Texas; Department of Pediatric Surgery, UTHealth, The University of Texas Health Science at Houston, McGovern Medical School, Houston, Texas
| | - Kenneth J Moise
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Medicine, UTHealth, The University of Texas Health Science at Houston, McGovern Medical School and the Fetal Center at Children's Memorial Hermann Hospital, Houston, Texas
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23
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Twin-to-Twin Transfusion Syndrome: Definition, Staging, and Ultrasound Assessment. Twin Res Hum Genet 2016; 19:175-83. [DOI: 10.1017/thg.2016.34] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Objective: The purpose of this article is to review the definition of twin-to-twin transfusion syndrome (TTTS) and the sonographic diagnostic assessment of these cases prior to therapy.Materials and Methods: The article addresses the terminology used to refer to the condition and describes the systematic ultrasound assessment of the condition, including the ultrasound diagnosis, the staging of the disease, cervical assessment and pre-operative mapping.Results: From an etymologic and medical point of view, the term ‘fetofetal transfusion’ is more appropriate than ‘TTTS’. However, as the latter, and its attendant acronym TTTS, have been widely adopted in the English language, it is impractical to change at this point. TTTS is defined sonographically in the combined presence of a maximum vertical pocket (MVP) of 8 cm or greater in one sac and 2 cm or less in the other sac, regardless of the gestational age at diagnosis. Staging of the condition using the Quintero staging system is practical, reproducible, and accepted. Transvaginal cervical length assessment should be an integral part of the ultrasound evaluation. Pre-operative mapping to anticipate the location of the placental vascular anastomoses and avoid injuring the dividing membrane is also discussed.Conclusions: The term ‘TTTS’ can continue to be used in the English medical literature. The condition can be diagnosed and assessed following a systematic ultrasound methodology. The use of such ultrasound methodology breaks the examination into a distinct set of components, assuring a comprehensive examination and proper communication among caregivers.
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Finneran M, Temming L, Templin M, Stephenson C. Effect of Cervical Length Recovery after Laser Surgery for Twin-Twin Transfusion Syndrome. AJP Rep 2016; 6:e137-41. [PMID: 26989569 PMCID: PMC4794440 DOI: 10.1055/s-0036-1579654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Objective To evaluate the impact of polyhydramnios on preoperative cervical length and whether cervical length recovery after amnioreduction during selective fetoscopic laser photocoagulation (SFLP) is associated with a greater gestational age at delivery in pregnancies complicated by twin-twin transfusion syndrome (TTTS). Methods Retrospective study of 50 pregnancies complicated by TTTS treated with SFLP between March 2010 and July 2014 at a single center. Preoperative maximum vertical pocket (MVP) was measured along with pre- and postoperative cervical length. A cervical length difference was calculated, with a difference of ± 3 mm considered no change. Results Only 12 (34%) patients showed an increased cervical length after amnioreduction during laser surgery. There was no statistical difference between either negative or positive change in cervical length groups and mean gestational age at delivery (p = 0.82). There also was no correlation between preoperative MVP and preoperative cervical length (p = 0.36) or gestational age at delivery (p = 0.77). However, there was a statistically shorter mean preoperative cervical length in patients who delivered <32 weeks of gestation (3.62 ± 0.66 vs. 4.20 ± 0.85 cm; p = 0.03). Conclusion Severity of polyhydramnios does not correlate with preoperative cervical length, and variability of the cervix postoperatively does not appear to affect gestational age at delivery.
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Affiliation(s)
- Matthew Finneran
- Department of Obstetrics and Gynecology, Charlotte Fetal Care Center, Charlotte, North Carolina
| | - Lorene Temming
- Department of Obstetrics and Gynecology, Washington University, St. Louis, Missouri
| | - Megan Templin
- Dickson Advanced Analytics, Carolinas Medical Center, Charlotte, North Carolina
| | - Courtney Stephenson
- Department of Obstetrics and Gynecology, Charlotte Fetal Care Center, Charlotte, North Carolina
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Pruetz JD, Schrager SM, Wang TV, Llanes A, Chmait RH, Vanderbilt DL. Blood pressure evaluation in children treated with laser surgery for twin-twin transfusion syndrome at 2-year follow-up. Am J Obstet Gynecol 2015; 213:417.e1-7. [PMID: 26003061 DOI: 10.1016/j.ajog.2015.05.031] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Revised: 03/06/2015] [Accepted: 05/14/2015] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Twin survivors of twin-twin transfusion syndrome (TTTS) may be at risk for early onset of cardiovascular disease. The aim of this study was to determine prevalence and risk factors for elevated blood pressure (BP) among children treated with selective laser photocoagulation of communicating vessels. STUDY DESIGN Data were prospectively collected from surviving children treated for TTTS with laser surgery from 2008 through 2010. Systolic BP (SBP) and diastolic BP (DBP) were obtained from 91 child survivors at age 24 months (±6 weeks) and evaluated based on age, sex, and height percentile. BP percentiles were calculated for each patient and categorized as normal (<95%) or abnormal (>95%). Clinical variables were evaluated using multilevel regression models to evaluate risk factors for elevated BP. RESULTS BP was categorized as normal in 38% and abnormal in 62% of twin survivors based on percentile for sex, age, and height; a comparable distribution was found for DBP elevation. There were no differences between donor and recipient twins for absolute SBP and DBP or BP classification. In a multivariate analysis, significant risk factors for higher SBP included prematurity (β -0.54; 95% confidence interval [CI], -0.99 to -0.09; P = .02), higher weight percentile (β 0.24; 95% CI, 0.05-0.42; P = .01), and presence of cardiac disease (β 0.50; 95% CI, 0.10-0.89; P = .01). Prematurity was also a significant risk for abnormal DBP (odds ratio, 0.89; 95% CI, 0.80-1.00; P = .05). CONCLUSION Child survivors of TTTS had elevated SBP and DBP measurements at 2 years of age, with no differences seen between former donor and recipient twins. Prematurity may be a risk factor for elevated BP measurements in this population. Future studies are warranted to ascertain whether these cardiovascular findings persist over time.
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26
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Long-term neurologic outcomes after common fetal interventions. Am J Obstet Gynecol 2015; 212:527.e1-9. [PMID: 25448510 DOI: 10.1016/j.ajog.2014.10.1092] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Revised: 10/06/2014] [Accepted: 10/28/2014] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Fetal interventions have clearly decreased mortality, but the neurological outcomes of survivors are of critical concern. Here we consolidated available data on long-term neurological outcomes after common fetal interventions to guide counseling, management, and future research. STUDY DESIGN Published studies assessing long-term neurological outcomes after common fetal interventions from 1990 through 2014 were collected. We included all studies with a cohort of more than 5 patients and with follow-up of 1 year or longer. We divided procedures into those performed for singletons and for multiples. Singleton procedures included amnioinfusion for preterm premature rupture of membranes, intrauterine transfusion for red cell alloimmunization-associated anemia, intrauterine transfusion for parvovirus-associated anemia, vesicoamniotic shunts, thoracoamniotic shunts, ventriculoamniotic shunts, fetal endoscopic tracheal occlusion for congenital diaphragmatic hernia, and open fetal cases by myelomeningocele and others. Multiple procedures included those done for monochorionic twins including serial amnioreduction, selective fetoscopic laser photocoagulation, and selective termination. RESULTS Of 1341 studies identified, 28 met the inclusion criteria. We combined available literature for all procedures. Studies varied in their length of follow-up and method of assessing neurological status. Neurological outcome after intervention varied by procedure but was normal in 40-93%, mildly impaired in 3-33%, and severely impaired in 1-40%. Follow-up to school age was rare with the exception of procedures for monochorionic twins. CONCLUSION Fetal treatments have been successful in achieving survival in previously hopeless cases, but success should also be determined by the outcomes of survivors. Except for monochorionic twins, there is a dearth of reported long-term outcomes. Standardized reporting of long-term neurological sequelae is imperative so that meaningful analysis and study comparisons can be made.
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27
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Papanna R, Mann LK, Baschat AA, Bebbington MW, Khalek N, Johnson A, Snowise S, Moise KJ. Cervical length in prediction of preterm birth after laser surgery for twin-twin transfusion syndrome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 45:175-182. [PMID: 25319967 DOI: 10.1002/uog.14696] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 09/21/2014] [Accepted: 10/04/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To determine the risk factors for spontaneous preterm delivery (PTD) or preterm prelabor rupture of membranes (PPROM) at < 34 weeks' gestation after fetoscopic laser surgery for twin-twin transfusion syndrome and to identify the optimal threshold for preoperative cervical length (CL) that indicates a high risk for spontaneous PTD. METHODS This was a secondary analysis of data prospectively collected from 449 patients at three fetal centers. CL measurements were obtained by preoperative transvaginal ultrasound, at a gestational age of 16-26 weeks. The risk factors associated with spontaneous PTD before 34 weeks' gestation were determined using multivariable logistic regression analysis. We excluded patients with dual fetal demise and those with maternal or fetal indications for delivery without PPROM (n = 63). The optimal threshold for cervical length to predict spontaneous PTD before 34 weeks was determined using a receiver-operating characteristics (ROC) curve and Youden index. Additionally, the CL threshold for spontaneous PTD at 2-week intervals between 24 and 34 weeks was determined. RESULTS Spontaneous PTD before 34 weeks occurred in 206 (53.4%) of the included patients. Only the preoperative CL was significantly associated with spontaneous PTD. The preoperative CL was normally distributed with a mean of 37.6 ± 10.3 mm (range, 5-66 mm). Maternal age and parity were positively associated, and gestational age at procedure and anterior placenta were negatively associated, with CL on multivariable linear regression analysis. The area under the ROC curve for predicting spontaneous PTD with CL measurements was 0.61 (P = 0.02) and the optimal threshold was 28 mm with a Youden index of 0.19 (sensitivity and specificity of 92% and 27%, respectively). A CL measurement of < 28 mm increased the risk of spontaneous PTD for all gestational age thresholds. CONCLUSIONS Spontaneous PTD at < 34 weeks' gestation is associated with a preoperative CL of < 28 mm. Preventive strategies should focus on this high-risk group.
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Affiliation(s)
- R Papanna
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, The Fetal Center at Children's Memorial Hermann Hospital, UT Health - The University of Texas Medical School at Houston, TX, USA
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28
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Peeters SHP, Stolk TT, Slaghekke F, Middeldorp JM, Klumper FJ, Lopriore E, Oepkes D. Iatrogenic perforation of intertwin membrane after laser surgery for twin-to-twin transfusion syndrome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 44:550-556. [PMID: 24961923 DOI: 10.1002/uog.13445] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 06/02/2014] [Accepted: 06/09/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To evaluate management and outcome of iatrogenic monoamniotic twins (iMAT) compared with twins with intact intertwin dividing membranes after laser surgery for twin-to-twin transfusion syndrome (TTTS). METHODS This was a retrospective analysis of twins with and without iatrogenic rupture of the intertwin membranes that had been treated for TTTS with laser surgery at our center between 2004 and 2012. Primary outcomes were perinatal survival and severe neonatal morbidity. Secondary outcomes were mode of delivery, gestational age at birth and cord entanglement. RESULTS In total, 338 pregnancies were included. In 67/338 (20%) pregnancies, iMAT was suspected antenatally. In 47 of these 67 (70%), a preterm Cesarean section was performed for monoamnionicity. Perinatal survival was 108/134 (81%) vs 396/542 (73%) in twins with intact intertwin membranes (P = 0.13). Mean gestational age at birth in iMAT was 31 completed weeks, compared to 33 weeks in twins with intact membranes (P < 0.01). At birth, cord entanglement was present in 8/67 (12%) iMAT pregnancies. Severe neonatal morbidity was assessed in 106/110 (96%) in iMAT cases and 392/416 (94%) in controls. The incidence of severe neonatal morbidity was 28/106 (26%) in iMAT vs 72/392 (18%) in controls (P = 0.25). Severe cerebral injury was significantly increased in the iMAT group as compared with controls, at 16/106 (15%) vs 18/392 (5%) (P < 0.01). CONCLUSIONS Iatrogenic rupture of intertwin membranes was suspected in 20% of pregnancies treated with laser therapy for TTTS and was associated with a lower gestational age at birth and increased neonatal morbidity.
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Affiliation(s)
- S H P Peeters
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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29
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Vanderbilt DL, Schrager SM, Llanes A, Hamilton A, Seri I, Chmait RH. Predictors of 2-year cognitive performance after laser surgery for twin-twin transfusion syndrome. Am J Obstet Gynecol 2014; 211:388.e1-7. [PMID: 24681290 DOI: 10.1016/j.ajog.2014.03.050] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Revised: 02/20/2014] [Accepted: 03/21/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The purpose of this study was to determine risk factors for poor cognitive performance among children who are treated with in utero selective laser photocoagulation of communicating vessels for twin-twin transfusion syndrome. STUDY DESIGN This was a prospectively enrolled cohort study. Cognitive performance at age 2 years (±6 weeks) was assessed with the Battelle Developmental Inventory 2nd Edition (BDI-2). Multilevel regression models evaluated risk factors for poor cognitive performance at shared (pregnancy) and individual (child) levels. In addition to development, blindness, deafness, and cerebral palsy were assessed based on physical examination. A priori power analysis determined that a sample of ≥100 children was required for adequate statistical power (0.80). RESULTS One hundred children (57 families) were evaluated. Total BDI-2 score was within normal range (mean, 101.3 ± [SD]12.2); 1 child had a BDI-2 score of <70. Individual child-level risk factors for lower BDI-2 included male sex (β = -0.37; P < .01), lower head circumference (β = 0.28; P < .01), and higher diastolic blood pressure (β = -0.29; P < .01). At the pregnancy level, lower maternal education (β = 0.60; P < .001), higher Quintero stage (β = -0.36; P < .01), and lower gestational age at birth (β = 0.30; P < .01) were associated with worse cognitive outcomes. Donor/recipient status, gestational age at surgery, fetal growth restriction, and co-twin fetal death were not risk factors. The rate of neurodevelopmental impairment (blindness, deafness, cerebral palsy, and/or a BDI-2 score <70) was 4%. CONCLUSION Overall cognitive performance quotients were in the normal range, with risk factors for poor outcomes seen at the pregnancy and child levels. Clinical and socioeconomic characteristics can identify at-risk children who need additional interventions.
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Polley N, Singh S, Giri A, Pal SK. Evanescent field: a potential light-tool for theranostics application. THE REVIEW OF SCIENTIFIC INSTRUMENTS 2014; 85:033108. [PMID: 24689565 DOI: 10.1063/1.4868589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
A noninvasive or minimally invasive optical approach for theranostics, which would reinforce diagnosis, treatment, and preferably guidance simultaneously, is considered to be major challenge in biomedical instrument design. In the present work, we have developed an evanescent field-based fiber optic strategy for the potential theranostics application in hyperbilirubinemia, an increased concentration of bilirubin in the blood and is a potential cause of permanent brain damage or even death in newborn babies. Potential problem of bilirubin deposition on the hydroxylated fiber surface at physiological pH (7.4), that masks the sensing efficacy and extraction of information of the pigment level, has also been addressed. Removal of bilirubin in a blood-phantom (hemoglobin and human serum albumin) solution from an enhanced level of 77 μM/l (human jaundice >50 μM/l) to ~30 μM/l (normal level ~25 μM/l in human) using our strategy has been successfully demonstrated. In a model experiment using chromatography paper as a mimic of biological membrane, we have shown efficient degradation of the bilirubin under continuous monitoring for guidance of immediate/future course of action.
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Affiliation(s)
- Nabarun Polley
- Department of Chemical, Biological and Macromolecular Sciences, S. N. Bose National Centre for Basic Sciences, Block JD, Sector III, Salt Lake, Kolkata 700 098, India
| | - Soumendra Singh
- Department of Chemical, Biological and Macromolecular Sciences, S. N. Bose National Centre for Basic Sciences, Block JD, Sector III, Salt Lake, Kolkata 700 098, India
| | - Anupam Giri
- Department of Chemical, Biological and Macromolecular Sciences, S. N. Bose National Centre for Basic Sciences, Block JD, Sector III, Salt Lake, Kolkata 700 098, India
| | - Samir Kumar Pal
- Department of Chemical, Biological and Macromolecular Sciences, S. N. Bose National Centre for Basic Sciences, Block JD, Sector III, Salt Lake, Kolkata 700 098, India
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