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Molecular Mechanisms Underlying Twin-to-Twin Transfusion Syndrome. Cells 2022; 11:cells11203268. [PMID: 36291133 PMCID: PMC9600593 DOI: 10.3390/cells11203268] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 10/14/2022] [Accepted: 10/15/2022] [Indexed: 11/17/2022] Open
Abstract
Twin-to-twin transfusion syndrome is a unique disease and a serious complication occurring in 10–15% of monochorionic multiple pregnancies with various placental complications, including hypoxia, anemia, increased oxidative stress, and ischemia-reperfusion injury. Fetoscopic laser photocoagulation, a minimally invasive surgical procedure, seals the placental vascular anastomoses between twins and dramatically improves the survival rates in twin-to-twin transfusion syndrome. However, fetal demise still occurs, suggesting the presence of causes other than placental vascular anastomoses. Placental insufficiency is considered as the main cause of fetal demise in such cases; however, little is known about its underlying molecular mechanisms. Indeed, the further association of the pathogenic mechanisms involved in twin-to-twin transfusion syndrome placenta with several molecules and pathways, such as vascular endothelial growth factor and the renin–angiotensin system, makes it difficult to understand the underlying pathological conditions. Currently, there are no effective strategies focusing on these mechanisms in clinical practice. Certain types of cell death due to oxidative stress might be occurring in the placenta, and elucidation of the molecular mechanism underlying this cell death can help manage and prevent it. This review reports on the molecular mechanisms underlying the development of twin-to-twin transfusion syndrome for effective management and prevention of fetal demise after fetoscopic laser photocoagulation.
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Gibbone E, Campos RV, Calero AJ, Lucena PC, Sonia Molina Garcia F. Perinatal and Long-Term Outcome of Endoscopic Laser Surgery for Twin-Twin Transfusion Syndrome with and without Selective Fetal Growth Restriction: A retrospective cohort study. Prenat Diagn 2022; 42:1438-1447. [PMID: 36050925 DOI: 10.1002/pd.6231] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 08/23/2022] [Accepted: 08/27/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Report survival rates, neonatal mortality and morbidity and long-term outcomes of monochorionic(MC) twin pregnancies complicated by twin-to-twin transfusion syndrome(TTTS)or TTTS plus selective fetal growth restriction(sFGR)treated by endoscopic laser surgery. METHODS Retrospective cohort study including 149 MC twin pregnancies complicated by TTTS or TTTS plus sFGR.Medical records were reviewed for survival rates,neonatal mortality, neonatal morbidity and long-term outcomes at 2 and 6 years of age. RESULTS Survival of both babies was higher in the TTTS group than in the TTTS plus sFGR group(72.9%vs.54.8%);survival of at least one baby was similar in the two groups (90.7% and 88.1%).The incidence of severe neurological disability was not significantly different between TTTS and TTTS plus FGR group at both stages,1.9% vs 2.3% (p-value = 1) and 3.4%vs6.1%(p-value=0.31).Multivariable analysis demonstrated that intact neurological outcome at 2 years of age was related with gestational age at birth and z score birthweight, and at 6 years of age with gestational age at birth,z score birthweight and TTTS stage4.sFGR or abnormal brain findings at neonatal ultrasound were not related with impaired neurological outcome at 2 or 6 years of age. CONCLUSIONS In pregnancies with TTTS and TTTS plus sFGR survival of at least one baby and long-term neurological outcome are comparable between both groups. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Elena Gibbone
- Fetal Medicine Unit, San Cecilio University Hospital, Granada, Spain.,Harris Birthright Research Centre for Fetal Medicine, King's College, London, UK
| | - Rosa Vallenas Campos
- Fetal Medicine Unit, San Cecilio University Hospital, Granada, Spain.,Harris Birthright Research Centre for Fetal Medicine, King's College, London, UK
| | - Antonio Jerez Calero
- Neonatal Unit. Department of Pediatrics, San Cecilio University Hospital, Granada, Spain
| | - Pilar Carretero Lucena
- Fetal Medicine Unit, San Cecilio University Hospital, Granada, Spain.,Instituto de Investigación Biosanitaria Ibs.GRANADA, Granada, Spain
| | - Francisca Sonia Molina Garcia
- Fetal Medicine Unit, San Cecilio University Hospital, Granada, Spain.,Instituto de Investigación Biosanitaria Ibs.GRANADA, Granada, Spain
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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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Espinoza J, Belfort MA, Shamshirsaz AA, Nassr AA, Sanz Cortes M, Donepudi R, Espinoza AF, Ostovar-Kermani TG, Johnson RM, Harman C, Ozdemir H, Turan O. Intertwin differences in umbilical artery pulsatility index are associated with infant survival in twin-to-twin transfusion syndrome. J Perinat Med 2021; 49:1122-1128. [PMID: 34118799 DOI: 10.1515/jpm-2021-0060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/27/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To evaluate the association of intertwin differences in umbilical artery pulsatility index (DUAPI) and infant survival in twin-to-twin transfusion syndrome (TTTS). METHODS Absolute DUAPI was calculated prior to laser surgery. Receiver-operating characteristics (ROC) curve analysis provided an intertwin DUAPI cutoff of 0.4 for the prediction of double twin survival to 30 days of life. Infant survival was compared between women with an intertwin DUAPI <0.4 and ≥0.4 in the whole cohort, in TTTS cases with Quintero stages I/II and in those with Quintero stages III/IV. Regression analyses were performed to evaluate the association of intertwin DUAPI <0.4 and infant survival adjusted for confounders. RESULTS In total, 349 TTTS cases were included. Double twin survival to 30 days was observed in 67% (234/349) of cases. Significant differences in double twin survival was seen between intertwin DUAPI groups in the whole cohort (76.8 vs. 52.2%; p<0.001), in women with TTTS Quintero stage I or II (77.8 vs. 58.5%; p=0.015) as well as in women with TTTS Quintero stage III or IV (75 vs. 49.5%; p=0.001). Intertwin DUAPI <0.4 conferred a threefold increased chance for double twin survival. CONCLUSIONS Small intertwin DUAPI is associated with increased double infant survival in early and advanced TTTS stages.
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Affiliation(s)
- Jimmy Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
- Texas Children's Hospital-Pavilion for Women, Houston, TX, USA
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
- Texas Children's Hospital-Pavilion for Women, Houston, TX, USA
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Alireza A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
- Texas Children's Hospital-Pavilion for Women, Houston, TX, USA
| | - Ahmed A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
- Texas Children's Hospital-Pavilion for Women, Houston, TX, USA
| | - Magdalena Sanz Cortes
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
- Texas Children's Hospital-Pavilion for Women, Houston, TX, USA
| | - Roopali Donepudi
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
- Texas Children's Hospital-Pavilion for Women, Houston, TX, USA
| | - Andres F Espinoza
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | | | - Rebecca M Johnson
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
- Texas Children's Hospital-Pavilion for Women, Houston, TX, USA
| | - Christopher Harman
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Halis Ozdemir
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ozhan Turan
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
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5
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Hochberg A, Silber R, Avnet H, Rosen H, Katorza E, Hoffmann C, Mazkereth R, Lipitz S, Weisz B, Yinon Y. Fetal and neonatal brain lesions following laser ablation for twin-to-twin-transfusion-syndrome as detected by pre- and post-natal brain imaging. Prenat Diagn 2021; 41:1531-1540. [PMID: 34671994 DOI: 10.1002/pd.6061] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 09/25/2021] [Accepted: 10/15/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To determine the rate of and risk factors for fetal and neonatal brain lesions following laser ablation for twin-to-twin transfusion syndrome (TTTS). METHODS A retrospective cohort study of 83 women with monochorionic twin pregnancies who underwent ablation for TTTS at a single tertiary hospital. Post-laser survivors were followed-up with fetal neurosonogram every 2 weeks and fetal brain MRI at 28-32 weeks of gestation; post-natal brain imaging included neurosonogram. Cases with pre- and post-natal brain lesions were compared to those without. RESULTS 153 fetuses survived the immediate post-laser period and underwent brain imaging. Of these, 17 (11.11%) exhibited brain lesions on prenatal imaging studies, and 36 (32.4%) on post-natal ultrasound. Later gestational age (GA) at the time of ablation (23.0 vs. 21.4 weeks, p = 0.0244), post-laser twin-anemia-polycythemia-sequence (TAPS) (29.41% vs. 9.56%, p = 0.035) and birthweight discordancy (30% vs. 9%, p = 0.0025) were associated with prenatal brain lesions. Earlier GA at delivery (31.0 weeks vs. 32.2, p = 0.0002) and post-laser TAPS (25% vs. 9.33%, p = 0.038) were associated with post-natal brain lesions. CONCLUSIONS Survivors of ablation for TTTS are at risk for brain lesions, which can be detected prenatally. Incorporation of neurosonogram and fetal brain MRI into the routine surveillance of such pregnancies should be considered.
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Affiliation(s)
- Alyssa Hochberg
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ronit Silber
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hagai Avnet
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hadar Rosen
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eldad Katorza
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Gertner Institute of Epidemiology & Health Policy Research, Sheba Medical Center, Tel-Hashomer, Israel
| | - Chen Hoffmann
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Radiology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Ram Mazkereth
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Neonatology, Edmond and Lily Safra Children Hospital, Sheba Medical Center, Tel-Hashomer, Israel
| | - Shlomo Lipitz
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Boaz Weisz
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yoav Yinon
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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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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7
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Risk Profiling of the Solomon Technique versus Selective Technique of Fetoscopic Laser Surgery for Twin-Twin Transfusion Syndrome. Twin Res Hum Genet 2021; 24:42-48. [PMID: 33900164 DOI: 10.1017/thg.2020.94] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
We evaluated the outcomes and adverse events after fetoscopic laser surgery (FLS) for twin-twin transfusion syndrome (TTTS) using the Solomon technique in comparison to the selective technique. A retrospective analysis of a single-center consecutive cohort of FLS-treated TTTS using the selective (January 2010 to July 2014) and Solomon (August 2014 to December 2017) techniques was performed. Among 395 cases, 227 underwent selective coagulation and 168 underwent the Solomon technique. The incidence rates of recurrent TTTS (Solomon vs. selective: 0% vs. .9%, p = .510) and twin anemia-polycythemia sequence (.6% vs. .4%, p = .670) were very low in both groups. The incidence rates of placental abruption (Solomon vs. selective: 10.7% vs. 3.5%, p = .007) and preterm premature rupture of the membranes (pPROM) with subsequent delivery before 32 weeks (20.2% vs. 7.1%, p < .001) were higher in the Solomon group. The median birth recipient weight was significantly smaller in the Solomon group (1790 g vs. 1933 g, p = .049). The rate of survival of at least one twin was significantly higher in the Solomon group (98.2% vs. 93.8%, p = .046). The Solomon technique and total laser energy were significant risk factors for pPROM (odds ratio: 2.64, 1.07, 95% CI [1.32, 5.28], [1.01, 1.13], p = .006, p = .014, respectively). These findings suggest that the Solomon technique led to superior survival outcomes but increased risks of placental abruption, pPROM and fetal growth impairment. Total laser energy was associated with the occurrence of pPROM. Close attention to adverse events is required for perinatal management after FLS to treat TTTS using the Solomon technique.
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8
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Child Temperament Outcomes After Laser Surgery for Twin-Twin Transfusion Syndrome. J Dev Behav Pediatr 2021; 42:41-45. [PMID: 32858578 DOI: 10.1097/dbp.0000000000000851] [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] [Received: 11/05/2019] [Accepted: 06/15/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Twin-twin transfusion syndrome (TTTS) is a severe pregnancy complication of monochorionic (identical) twins that results in markedly discordant in utero environments for each twin. The aim of this study was to test for differences in temperament between former donor (hypovolemic, smaller) and recipient (hypervolemic, larger) twins with TTTS. METHODS Parents of dual survivors aged 3 to 7 years who underwent in utero laser surgery for TTTS were surveyed using the Children's Behavior Questionnaire-Very Short Form (CBQ-VSF). The CBQ-VSF assessed 3 traits: Surgency, Negative Affect, and Effortful Control. Differences in traits between donor and recipients were assessed using a paired t test. RESULTS We studied 85 twin pairs treated in utero for TTTS. There were no statistically significant differences in Surgency, Negative Affect, or Effortful Control between recipients and donors, although score differences for each trait varied widely among sibling pairs. CONCLUSION Despite varied in utero environments, no temperament differences between donor and recipient monozygotic twins were found for the population as a whole. This finding may be of some reassurance to parents whose pregnancies are complicated by TTTS.
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Sutton D, Miller R. Neurologic Outcomes After Prenatal Treatment of Twin-Twin Transfusion Syndrome. Clin Perinatol 2020; 47:719-731. [PMID: 33153657 DOI: 10.1016/j.clp.2020.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Monochorionic twin gestations possess disproportionately higher risk for perinatal morbidity and mortality when compared with dichorionic twin pregnancies due to their potential to develop specific complications attributable to a shared placenta and intertwin placental circulation. Since the advent of fetoscopic laser surgery, outcomes of pregnancies affected by twin-twin transfusion syndrome (TTTS) have improved, with reduced rates of mortality and morbidity when compared with amnioreduction or expectant management. The focus of this article is to review the literature regarding neurologic outcomes among pediatric survivors of fetal intervention for TTTS.
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Affiliation(s)
- Desmond Sutton
- Division of Maternal-Fetal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, 622 West 168th Street, PH16-66, New York, NY 10032, USA
| | - Russell Miller
- Division of Maternal-Fetal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, 622 West 168th Street, PH16-66, New York, NY 10032, USA.
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Di Mascio D, Khalil A, D'Amico A, Buca D, Benedetti Panici P, Flacco ME, Manzoli L, Liberati M, Nappi L, Berghella V, D'Antonio F. Outcome of twin-twin transfusion syndrome according to Quintero stage of disease: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:811-820. [PMID: 32330342 DOI: 10.1002/uog.22054] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 03/29/2020] [Accepted: 04/12/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES To report the outcome of pregnancies complicated by twin-twin transfusion syndrome (TTTS) according to Quintero stage. METHODS MEDLINE, EMBASE and CINAHL databases were searched for studies reporting the outcome of pregnancies complicated by TTTS stratified according to Quintero stage (I-V). The primary outcome was fetal survival rate according to Quintero stage. Secondary outcomes were gestational age at birth, preterm birth (PTB) before 34, 32 and 28 weeks' gestation and neonatal morbidity. Outcomes are reported according to the different management options (expectant management, laser therapy or amnioreduction) for pregnancies with Stage-I TTTS. Only cases treated with laser therapy were considered for those with Stages-II-IV TTTS and only cases managed expectantly were considered for those with Stage-V TTTS. Random-effects head-to-head meta-analysis was used to analyze the extracted data. RESULTS Twenty-six studies (2699 twin pregnancies) were included. Overall, 610 (22.6%) pregnancies were diagnosed with Quintero stage-I TTTS, 692 (25.6%) were Stage II, 1146 (42.5%) were Stage III, 247 (9.2%) were Stage IV and four (0.1%) were Stage V. Survival of at least one twin occurred in 86.9% (95% CI, 84.0-89.7%) (456/552) of pregnancies with Stage-I, in 85% (95% CI, 79.1-90.1%) (514/590) of those with Stage-II, in 81.5% (95% CI, 76.6-86.0%) (875/1040) of those with Stage-III, in 82.8% (95% CI, 73.6-90.4%) (172/205) of those with Stage-IV and in 54.6% (95% CI, 24.8-82.6%) (5/9) of those with Stage-V TTTS. The rate of a pregnancy with no survivor was 11.8% (95% CI, 8.4-15.8%) (69/564) in those with Stage-I, 15.0% (95% CI, 9.9-20.9%) (76/590) in those with Stage-II, 18.6% (95% CI, 14.2-23.4%) (165/1040) in those with Stage-III, 17.2% (95% CI, 9.6-26.4%) (33/205) in those with Stage-IV and in 45.4% (95% CI, 17.4-75.2%) (4/9) in those with Stage-V TTTS. Gestational age at birth was similar in pregnancies with Stages-I-III TTTS, and gradually decreased in those with Stages-IV and -V TTTS. Overall, the incidence of PTB and neonatal morbidity increased as the severity of TTTS increased, but data on these two outcomes were limited by the small sample size of the included studies. When stratifying the analysis of pregnancies with Stage-I TTTS according to the type of intervention, the rate of fetal survival of at least one twin was 84.9% (95% CI, 70.4-95.1%) (94/112) in cases managed expectantly, 86.7% (95% CI, 82.6-90.4%) (249/285) in those undergoing laser therapy and 92.2% (95% CI, 84.2-97.6%) (56/60) in those after amnioreduction, while the rate of double survival was 67.9% (95% CI, 57.0-77.9%) (73/108), 69.7% (95% CI, 61.6-77.1%) (203/285) and 80.8% (95% CI, 62.0-94.2%) (49/60), respectively. CONCLUSIONS Overall survival in monochorionic diamniotic pregnancies affected by TTTS is higher for earlier Quintero stages (I and II), but fetal survival rates are moderately high even in those with Stage-III or -IV TTTS when treated with laser therapy. Gestational age at birth was similar in pregnancies with Stages-I-III TTTS, and gradually decreased in those with Stages-IV and -V TTTS treated with laser and expectant management, respectively. In pregnancies affected by Stage-I TTTS, amnioreduction was associated with slightly higher survival compared with laser therapy and expectant management, although these findings may be confirmed only by future head-to-head randomized trials. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- D Di Mascio
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - A D'Amico
- Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - D Buca
- Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - P Benedetti Panici
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - M E Flacco
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - L Manzoli
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - M Liberati
- Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - L Nappi
- Fetal Medicine and Cardiology Unit, Department of Obstetrics and Gynecology, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - V Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - F D'Antonio
- Fetal Medicine and Cardiology Unit, Department of Obstetrics and Gynecology, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
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11
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Rajagopalan V, Ashouri K, Llanes A, Vanderbilt DL, Lepore N, Bluml S, Lai HA, Wisnowski J, Chon AH, Chmait RH. Fetal neurodevelopmental recovery in donors after laser surgery for twin-twin transfusion syndrome. Prenat Diagn 2020; 41:190-199. [PMID: 33191511 DOI: 10.1002/pd.5866] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 07/21/2020] [Accepted: 10/23/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Fetal magnetic resonance imaging (MRI) and spectroscopy (MRS) provide a unique opportunity to non-invasively measure markers of neurodevelopment in survivors of twin-twin transfusion syndrome (TTTS). OBJECTIVE To characterize fetal brain maturation after laser surgery for TTTS by measuring brain volumes and cerebral metabolite concentrations using fetal MRI + MRS. STUDY DESIGN Prospective study of dual surviving fetuses treated with laser surgery for TTTS. At 4-5 postoperative weeks, fetal MRI was used together with novel image analysis to automatically extract major brain tissue volumes. Fetal MRS was used to measure major metabolite concentrations in the fetal brain. RESULTS Twenty-one twin pairs were studied. The average (±SD) gestational age at MRI was 25.89 (±2.37) weeks. Total brain volume (TBV) was lower in the donors, although cerebral volumes were not different between twin pairs. Recipients showed lower proportions of cortical and cerebellar volumes, normalized to TBV and cerebral volumes. MRS data showed that biochemical differences between twin brains were related to discrepancy in their brain volumes. CONCLUSION Although donors have a smaller TBV compared to recipients, proportionality of brain tissue volumes are preserved in donors. MRS maturational markers of fetal brain development show that recovery in donors persists 4 weeks after surgery.
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Affiliation(s)
- Vidya Rajagopalan
- Department of Radiology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Karam Ashouri
- Department of Radiology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, 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
| | - Douglas L Vanderbilt
- Department of Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Natasha Lepore
- Department of Radiology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Stefan Bluml
- Department of Radiology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Hollie A Lai
- Children's Hospital of Orange County, Orange, California, USA
| | - Jessica Wisnowski
- Department of Radiology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.,Department of Pediatrics, Children's Hospital Los Angeles, 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
| | - 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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Complications of Monochorionic Diamniotic Twins: Stepwise Approach for Early Identification, Differential Diagnosis, and Clinical Management. MATERNAL-FETAL MEDICINE 2020. [DOI: 10.1097/fm9.0000000000000076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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13
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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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14
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Kocaoglu M, Kline-Fath BM, Calvo-Garcia MA, Zhang B, Nagaraj UD. Magnetic resonance imaging of the fetal brain in monochorionic diamniotic twin gestation: correlation of cerebral injury with ultrasound staging and survival outcomes. Pediatr Radiol 2020; 50:1131-1138. [PMID: 32358676 DOI: 10.1007/s00247-020-04661-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 02/17/2020] [Accepted: 03/12/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND The current staging system of twin-twin transfusion syndrome (TTTS) is based on the ultrasound criteria and does not consider the cerebral injury. OBJECTIVE To assess the incidence of cerebral damage on fetal MRI and correlate abnormal cerebral diffusion-weighted imaging (DWI) findings with survival outcome and the ultrasound staging of TTTS. MATERIALS AND METHODS We conducted a retrospective review of MRI/DWI of fetal brains and the electronic medical records in monochorionic diamniotic twin gestations. Axial DWI of each fetal brain was performed on 1.5-tesla (T) clinical magnet with b values of 0 s/mm2 and 700 s/mm2. We correlated MRI/DWI abnormalities with the Quintero staging system and survival outcomes of the fetuses. RESULTS Thirty-four pregnancies (68 fetuses) with 42 fetal cerebral abnormalities were identified by MRI/DWI alone. Of these 42 fetal cerebral abnormalities, 33 fetal brain lesions were visible only on DWI (n=25 donor, n=8 recipients; n=30 unilateral, n=3 bilateral; n=26 diffuse, n=7 focal). Quintero staging in these 34 pregnancies was as follows: 9 Stage I, 7 Stage II, 13 Stage III, 4 Stage IV, 1 Stage V. There was no significant correlation between the presence of cerebral infarction or hemorrhage using MRI/DWI and ultrasound staging (P=0.138). The overall survival rate was 63.2% (43/68). There was a significant correlation between the presence of cerebral infarction or hemorrhage on MRI/DWI and delivery status (P=0.009). CONCLUSION Abnormal cerebral imaging findings on MRI/DWI from hypoxic-ischemic injury or hemorrhage can be seen at the beginning of the second trimester and do not correlate with the current ultrasound staging system; however, they do correlate with decreased survival. Fetal cerebral abnormalities could be incorporated into the TTTS staging system as an independent risk factor.
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Affiliation(s)
- Murat Kocaoglu
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH, 45229, USA.
| | - Beth M Kline-Fath
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH, 45229, USA
| | - Maria A Calvo-Garcia
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH, 45229, USA
| | - Bin Zhang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Usha D Nagaraj
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH, 45229, USA
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Dempsey E, Homfray T, Simpson JM, Jeffery S, Mansour S, Ostergaard P. Fetal hydrops – a review and a clinical approach to identifying the cause. Expert Opin Orphan Drugs 2020. [DOI: 10.1080/21678707.2020.1719827] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Esther Dempsey
- Molecular and Clinical Sciences, St George’s University of London, London, UK
| | - Tessa Homfray
- SW Thames Regional Genetics Department, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - John M Simpson
- Department of Congenital Heart Disease, Evelina London Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Steve Jeffery
- Molecular and Clinical Sciences, St George’s University of London, London, UK
| | - Sahar Mansour
- Molecular and Clinical Sciences, St George’s University of London, London, UK
- SW Thames Regional Genetics Department, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Pia Ostergaard
- Molecular and Clinical Sciences, St George’s University of London, London, UK
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16
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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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17
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Bergh EP, Mann LK, Jain RR, Donepudi R, Moise KJ, Johnson A, Papanna R. Effect of intra-amniotic fluid pressure from polyhydramnios on cervical length in patients with twin-twin transfusion syndrome undergoing fetoscopic laser surgery. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 54:774-779. [PMID: 30693576 DOI: 10.1002/uog.20228] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 01/18/2019] [Accepted: 01/24/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To determine the relationship between intra-amniotic pressure and cervical length (CL) in patients with twin-twin transfusion syndrome (TTTS) undergoing fetoscopic laser photocoagulation (FLP), and to identify pre- or intraoperative factors associated with increased intra-amniotic pressure in this population. METHODS This was a prospective cohort study of patients undergoing FLP for TTTS. Exclusion criteria were triplet or higher-order gestation and prior cervical cerclage, amnioreduction or FLP procedure. CL was assessed using preprocedure transvaginal ultrasound. Intra-amniotic pressure measurements were obtained on initial placement of the trocar into the amniotic cavity, using a direct hydrostatic pressure gauge. The relationship between intra-amniotic pressure and CL was assessed using multivariate linear regression analysis, including relevant preoperative and intraoperative variables. RESULTS In total, 283 pregnancies met the inclusion criteria. Quintero stage of TTTS was I in 33 pregnancies, II in 88, III in 150 and IV in 12. Mean gestational age (GA) at FLP was 20.7 ± 3 weeks. Mean intra-amniotic pressure was 23.1 ± 9 mmHg. On unadjusted linear regression analysis, there was no significant association between intra-amniotic pressure and preoperative CL (P = 0.24) or GA at delivery (P = 0.22). On multivariate analysis, the factors associated significantly with intra-amniotic pressure were: number of prior term deliveries (P = 0.03), recipient maximum vertical pocket (P < 0.0001), Quintero stage IV (P = 0.01) and type of anesthesia (sedation vs general anesthesia; P = 0.01). CONCLUSION In pregnancies with TTTS, intra-amniotic pressure is not associated with CL or GA at delivery. This novel finding suggests that cervical shortening in this population is not mechanically driven. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- E P Bergh
- The Texas Fetal Center, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas Health Medical School, Houston, TX, USA
| | - L K Mann
- The Texas Fetal Center, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas Health Medical School, Houston, TX, USA
| | - R R Jain
- Department of Anesthesiology, McGovern Medical School, Houston, TX, USA
| | - R Donepudi
- The Texas Fetal Center, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas Health Medical School, Houston, TX, USA
| | - K J Moise
- The Texas Fetal Center, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas Health Medical School, Houston, TX, USA
| | - A Johnson
- The Texas Fetal Center, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas Health Medical School, Houston, TX, USA
| | - R Papanna
- The Texas Fetal Center, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas Health Medical School, Houston, TX, USA
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18
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Loh M, Bhatia A, Tan KL, Thia E, Yeo GSH. Outcomes following selective fetoscopic laser ablation for twin-to-twin transfusion syndrome: a single-centre experience. Singapore Med J 2019; 61:523-531. [PMID: 31489429 DOI: 10.11622/smedj.2019107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Fetoscopic laser photocoagulation (FLP), a treatment option for twin-to-twin transfusion syndrome (TTTS) in monochorionic twin pregnancies, is currently the treatment of choice at our centre. We previously reported on our experience of FLP from June 2011 to March 2014. This paper audits our fetal surgery performance since then. METHODS 15 consecutive patients who underwent FLP for Stage II-III TTTS before 26 weeks of gestation from June 2011 to January 2017 were retrospectively reviewed, consisting of five cases from our initial experience and ten subsequent cases. Perioperative, perinatal and neonatal outcomes were analysed. RESULTS Of 15 pregnancies, 10 (66.7%) and 5 (33.3%) were for Stage II and III TTTS respectively, with FLP performed at an earlier Quintero stage in the later cohort. Overall mean gestational ages at presentation, laser and delivery were comparable between the cohorts at 19.7 (15.4-24.3) weeks, 20.3 (16.3-25.0) weeks and 31.2 (27.6-37.0) weeks, respectively. 2 (13.3%) cases had intra-amniotic bleeding and 1 (6.7%) had iatrogenic septostomy. 1 (6.7%) case had persistent TTTS requiring repeat FLP, and another (6.7%) had preterm premature rupture of membranes at seven weeks post procedure. The overall perinatal survival rate was 21 (75.0%) out of 28 infants. One mother underwent termination of pregnancy for social reasons at 1.4 weeks post procedure. Double survival occurred in 8 (57.1%) out of 14 pregnancies, while 13 (92.9%) had at least one survivor. CONCLUSION FLP requires a highly specialised team and tertiary neonatal facility. Continual training improves maternal and perinatal outcomes, ensuring comparable standards with international centres.
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Affiliation(s)
- Michelle Loh
- Department of Obstetrics and Gynaecology, KK Women's and Children's Hospital, Singapore
| | - Anju Bhatia
- Department of Maternal Fetal Medicine, KK Women's and Children's Hospital, Singapore
| | - Kai Lit Tan
- Department of Maternal Fetal Medicine, KK Women's and Children's Hospital, Singapore
| | - Edwin Thia
- Department of Maternal Fetal Medicine, KK Women's and Children's Hospital, Singapore
| | - George Seow Heong Yeo
- Department of Maternal Fetal Medicine, KK Women's and Children's Hospital, Singapore
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19
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Spruijt MS, Lopriore E, Tan RNGB, Slaghekke F, Klumper FJCM, Middeldorp JM, Haak MC, Oepkes D, Rijken M, van Klink JMM. Long-Term Neurodevelopmental Outcome in Twin-to-Twin Transfusion Syndrome: Is there still Room for Improvement? J Clin Med 2019; 8:jcm8081226. [PMID: 31443258 PMCID: PMC6723379 DOI: 10.3390/jcm8081226] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 08/02/2019] [Accepted: 08/12/2019] [Indexed: 12/23/2022] Open
Abstract
Despite many developments in its management, twin-to-twin transfusion syndrome (TTTS) remains an important risk factor for long-term neurodevelopmental impairment (NDI). Our objective was to compare the incidence of severe NDI in a recent cohort of TTTS survivors, treated with laser surgery from 2011 to 2014, with a previous cohort treated from 2008 to 2010. Neurological, cognitive, and motor development were assessed at two years of age. We determined risk factors associated with Bayley-III scores. Severe NDI occurred in 7/241 (3%) survivors in the new cohort compared to 10/169 (6%) in the previous cohort (p = 0.189). Disease-free survival (survival without severe impairment) did not significantly differ. Low birth weight and being small for gestational age (SGA) were independently associated with lower cognitive scores (both p < 0.01). Severe cerebral injury was related to decreased motor scores (B = −14.10; 95% CI −3.16, −25.04; p = 0.012). Children with severe NDI were born ≥32 weeks’ gestation in 53% of cases and had no evidence of cerebral injury on cranial ultrasound in 59% of cases. Our results suggest that improvement in outcome of TTTS has reached a plateau. Low birth weight, SGA, and cerebral injury are risk factors for poor neurodevelopmental outcome. Neither gestational age above 32 weeks nor the absence of cerebral injury preclude severe NDI.
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Affiliation(s)
- Marjolijn S Spruijt
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, J7-48, Albinusdreef 2, 2333 ZA Leiden, The Netherlands.
| | - Enrico Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, J7-48, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Ratna N G B Tan
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, J7-48, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Femke Slaghekke
- Department of Obstetrics, Division of Fetal Therapy, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Frans J C M Klumper
- Department of Obstetrics, Division of Fetal Therapy, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Johanna M Middeldorp
- Department of Obstetrics, Division of Fetal Therapy, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Monique C Haak
- Department of Obstetrics, Division of Fetal Therapy, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Dick Oepkes
- Department of Obstetrics, Division of Fetal Therapy, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Monique Rijken
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, J7-48, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Jeanine M M van Klink
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, J7-48, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
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20
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Korsakissok M, Groussolles M, Dicky O, Alberge C, Casper C, Azogui-Assouline C. Mortality, morbidity and 2-years neurodevelopmental prognosis of twin to twin transfusion syndrome after fetoscopic laser therapy: a prospective, 58 patients cohort study. J Gynecol Obstet Hum Reprod 2018; 47:555-560. [PMID: 29698746 DOI: 10.1016/j.jogoh.2018.04.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 04/10/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To describe the morbidity and mortality and long-term neurodevelopmental outcomes in children born from a Twin-to-Twin Transfusion Syndrome (TTTS) pregnancy treated using laser fetoscopy in Toulouse. POPULATION AND METHOD All pregnancies with TTTS treated by laser fetoscopy in our centre were included. Antenatal and postnatal morbidity and neonatal morbidity were identified in the medical records retrospectively. The neurodevelopmental outcome was studied using Ages and Stages Questionnaires (ASQ) sent to the parents, an oral interview with the parents and with the child's doctor (last objective neurological examination, rehabilitation needs, learning disabilities). RESULTS Seventy-one pregnancies, or 144 foetuses, were included from 2008 to 2014, overall survival at 2 years was 72.9% and the survival of at least one child at 2 years was 91.5%, severe neonatal morbidity was 11.2% of the children, severe brain damage accounted for 3.6% of children admitted to the hospital unit. It was possible to study the neurodevelopmental outcome for 58 children (55.3%), with a corrected age from 24 to 95 months. Five children (8.6%) had severe neurological abnormalities and 17 (29.3%) had moderate neurological abnormalities. DISCUSSION The mortality, neonatal morbidity and long-term neurological morbidity of our cohort are higher than those of premature infants (EPIPAGE-2 French cohort), which confirms the severity of this syndrome, and are comparable to those of the TTTS cohorts described in the literature.
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Affiliation(s)
- Mélanie Korsakissok
- Children Hospital, University Hospital, Paul Sabatier University, 31000 Toulouse, France.
| | - Marion Groussolles
- Maternal Fetal Medicine Department, Paule-de-Viguier Hospital, University Hospital, UMR 1027, INSERM, Paul Sabatier University, 31000 Toulouse, France
| | - Odile Dicky
- Department of Neonatology, Children Hospital, University Hospital, UMR 1027, INSERM, Paul Sabatier University, 31000 Toulouse, France
| | - Corinne Alberge
- Department of Neonatology, Children Hospital, University Hospital, 31000 Toulouse, France
| | - Charlotte Casper
- Department of Neonatology, Children Hospital, University Hospital, UMR 1027, INSERM, Paul Sabatier University, 31000 Toulouse, France
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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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Chon AH, Mamey MR, Schrager SM, Vanderbilt DL, Chmait RH. The relationship between preoperative fetal head circumference and 2-year cognitive performance after laser surgery for twin-twin transfusion syndrome. Prenat Diagn 2018; 38:173-178. [PMID: 29314091 DOI: 10.1002/pd.5204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 12/18/2017] [Accepted: 12/25/2017] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To determine the relationship between preoperative fetal head circumference (HC) and cognitive performance among children treated with laser surgery for twin-twin transfusion syndrome (TTTS). METHODS Donor and recipient twin HCs were measured preoperatively (16-26 weeks' gestation) and at 2 years corrected age. Multilevel multivariate regression models were used to test pregnancy and child-level risk factors for lower Battelle Developmental Inventory Second Edition (BDI-2) scores. A repeated-measures ANOVA was used to examine HC growth among recipients and donors between preoperative and 2 years. RESULTS Ninety-nine children were evaluated. The average BDI-2 score for the cohort was 101.4 (SD = 12.2). After controlling for covariates, larger preoperative HC percentiles were significantly associated with an increase in total BDI-2 scores (β = 0.29; P < 0.001), where a 12.5% increase in preoperative HC percentile was associated with 1-point increase in total BDI-2 score. The mean recipient and donor twin HC percentiles preoperatively and at age 2 years were 51st percentile vs 20th percentile (P = .050) and 60th percentile vs 49th percentile (P = .676), respectively. CONCLUSION Smaller preoperative HC percentiles identified children at risk of lower, but still within normal range, total BDI-2 scores. The discordance in HC percentiles between the donor and recipient twin decreased after laser surgery.
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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
| | - Mary Rose Mamey
- Department of Pediatrics, Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Sheree M Schrager
- Department of Pediatrics, Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Douglas L Vanderbilt
- Department of Pediatrics, Division of General Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, 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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Djaafri F, Stirnemann J, Mediouni I, Colmant C, Ville Y. Twin-twin transfusion syndrome - What we have learned from clinical trials. Semin Fetal Neonatal Med 2017; 22:367-375. [PMID: 29122542 DOI: 10.1016/j.siny.2017.08.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Monochorionic twin pregnancies are at increased risk for adverse outcome compared to dichorionic twin pregnancies and singletons. Monochorionic-specific complications include twin-twin transfusion syndrome (TTTS), twin anemia-polycythemia sequence, single intrauterine fetal demise and its consequences on the co-twin, and selective intrauterine growth restriction. Whereas the natural history of monochorionic-specific complications carries a high risk of fetal death or severe neurologic disability, a framework now exists, based on well-designed clinical trials, for optimal treatment of these entities. Fetoscopic selective laser coagulation of anastomotic vessels on the chorionic plate has been clearly demonstrated to improve survival and neurologic outcomes for Quintero stage ≥2 TTTS. However, many challenges remain unsolved, the most important of which is preterm premature rupture of membranes. Further improvement in the outcomes of monochorionic pregnancies will require improvements in the rate of premature delivery, and improved diagnosis and treatment strategies for early and late onset TTTS.
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Affiliation(s)
- Fatiha Djaafri
- Obstetrics and Maternal-Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France
| | - Julien Stirnemann
- Obstetrics and Maternal-Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France; EA7328, Faculté de Medicine Paris Descartes, Paris, France
| | - Imen Mediouni
- Obstetrics and Maternal-Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France
| | - Claire Colmant
- Obstetrics and Maternal-Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France
| | - Yves Ville
- Obstetrics and Maternal-Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France; EA7328, Faculté de Medicine Paris Descartes, Paris, France.
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Solomon Technique Versus Selective Coagulation for Twin-Twin Transfusion Syndrome. Twin Res Hum Genet 2017; 19:217-21. [PMID: 27203607 DOI: 10.1017/thg.2016.25] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Monochorionic twin pregnancies can be complicated by twin-to-twin transfusion syndrome (TTTS). The best treatment option for TTTS is fetoscopic laser coagulation of the vascular anastomoses between donor and recipient. After laser therapy, up to 33% residual anastomoses were seen. These residual anastomoses can cause twin anemia polycythemia sequence (TAPS) and recurrent TTTS. In order to reduce the number of residual anastomoses and their complications, a new technique, the Solomon technique, where the whole vascular equator will be coagulated, was introduced. The Solomon technique showed a reduction of recurrent TTS compared to the selective technique. The incidence of recurrent TTTS after the Solomon technique ranged from 0% to 3.9% compared to 5.3-8.5% after the selective technique. The incidence of TAPS after the Solomon technique ranged from 0% to 2.9% compared to 4.2-15.6% after the selective technique. The Solomon technique may improve dual survival rates ranging from 64% to 85% compared to 46-76% for the selective technique. There was no difference reported in procedure-related complications such as intrauterine infection and preterm premature rupture of membranes. The Solomon technique significantly reduced the incidence of TAPS and recurrent TTTS and may improve survival and neonatal outcome, without identifiable adverse outcome or complications; therefore, the Solomon technique is recommended for the treatment of TTTS.
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Chmait RH, Chon AH, Schrager SM, Llanes A, Hamilton AH, Vanderbilt DL. Neonatal cerebral lesions predict 2-year neurodevelopmental impairment in children treated with laser surgery for twin-twin transfusion syndrome. J Matern Fetal Neonatal Med 2017; 32:80-84. [PMID: 28835143 DOI: 10.1080/14767058.2017.1371694] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The objective of this study is to assess whether postnatally detected cerebral abnormalities are predictive of neurodevelopmental impairment (NDI) in survivors of twin-twin transfusion syndrome (TTTS) that underwent laser surgery. MATERIALS AND METHODS Ninety-nine children treated for TTTS had neurodevelopmental assessment at age 2-years (±6 weeks). 'High-risk survivors' had cerebral imaging in the neonatal period. 'High-risk survivors' were defined as (1) delivered at <32 weeks; or (2) cerebral imaging clinically indicated. NDI was a composite outcome of: Battelle Developmental Inventory 2nd edition (BDI-2) score <70, cerebral palsy, blindness, and/or deafness. Multilevel logistic regression with robust standard errors was used to evaluate associations between cerebral lesions and NDI. RESULTS Fifty-six children were 'high-risk survivors' and had neonatal cerebral imaging. Ten twins (18%) had at least one cerebral lesion, including grade 1-2 intraventricular hemorrhage (8), cystic periventricular leukomalacia (2), ventriculomegaly (1), and bilateral subependymal cyst (1). The risk of NDI in the 'high-risk survivors' was 7% (4/56) compared with 0% (0/43) in the remaining group. Among 'high-risk survivors', cerebral lesions were a significant risk factor for NDI (OR = 19.28, p < .001). CONCLUSIONS Among 'high-risk survivors' of TTTS treated with laser surgery, cerebral lesions identified on neonatal imaging were associated with NDI at 2-years.
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Affiliation(s)
- Ramen H Chmait
- a Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology , Keck School of Medicine, University of Southern California , Los Angeles , CA , USA
| | - Andrew H Chon
- a Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology , Keck School of Medicine, University of Southern California , Los Angeles , CA , USA
| | - Sheree M Schrager
- b Division of Hospital Medicine, Department of Pediatrics , Children's Hospital Los Angeles , Los Angeles , CA , USA
| | - Arlyn Llanes
- a Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology , Keck School of Medicine, University of Southern California , Los Angeles , CA , USA
| | - Anita H Hamilton
- c Division of Neurology, Department of Surgery , Keck School of Medicine, University of Southern California , Los Angeles , CA , USA
| | - Douglas L Vanderbilt
- d Division of General Pediatrics, Department of Pediatrics , 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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Akkermans J, de Vries SM, Zhao D, Peeters SH, Klumper FJ, Middeldorp JM, Oepkes D, Slaghekke F, Lopriore E. What is the impact of placental tissue damage after laser surgery for twin-twin transfusion syndrome? A secondary analysis of the Solomon trial. Placenta 2017; 52:71-76. [DOI: 10.1016/j.placenta.2017.02.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 02/23/2017] [Accepted: 02/24/2017] [Indexed: 10/20/2022]
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Spruijt MS, Tameeris E, Zhao DP, Middeldorp JM, Haak MC, Oepkes D, Lopriore E. Incidence and Causes of Intentional Fetal or Neonatal Demise in Twin-Twin Transfusion Syndrome. Fetal Diagn Ther 2017; 43:19-25. [PMID: 28285310 DOI: 10.1159/000461580] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 02/08/2017] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The aim of this study is to evaluate the incidence and causes of intentional fetal and neonatal demise in twin-twin transfusion syndrome (TTTS). MATERIAL AND METHODS All TTTS pregnancies managed at our centre between 2000 and 2014 were included. We evaluated incidence and causes of intentional fetal/neonatal demise, defined as termination of pregnancy, selective fetal reduction, or withdrawal of neonatal intensive care. RESULTS Intentional fetal/neonatal demise occurred in 9.8% (110/1,122) of fetuses and was due to termination of pregnancy (2.2%), selective fetal reduction (4.2%), or withdrawal of neonatal intensive care (3.4%). Reasons for termination of pregnancy included complications of laser treatment (72.0%), severe fetal anomaly (20.0%), and unwanted pregnancy (8.0%). Reasons for selective fetal reduction were technical difficulties to perform laser surgery (51.1%), fetal complications (38.3%), and parental preference for fetal reduction rather than laser treatment (10.6%). Reasons for withdrawal of neonatal intensive care treatment were severe cerebral injury (47.4%), severe pulmonary complications (15.8%), birth asphyxia (5.3%), multiple complications of TTTS and/or prematurity combined (21.1%), or other (10.5%). CONCLUSIONS Intentional fetal or neonatal demise in TTTS occurs frequently and is often due to complications after laser surgery and/or severe (cerebral) injury in affected fetuses or neonates.
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Affiliation(s)
- Marjolijn S Spruijt
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Centre, Leiden, The Netherlands
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Lecointre L, Sananès N, Weingertner AS, Gaudineau A, Akladios C, Cavillon V, Langer B, Favre R. [Fetoscopic laser coagulation in 200 consecutive monochorionic pregnancies with twin-twin transfusion syndrome]. J Gynecol Obstet Hum Reprod 2017; 46:175-181. [PMID: 28403975 DOI: 10.1016/j.jogoh.2016.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Revised: 10/09/2016] [Accepted: 10/10/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To report preoperative data, surgical characteristics, complications and perinatal outcome of twin-twin transfusion syndrome (TTTS) managed with laser ablation surgery, to analyze predictors of neonatal survival and to compare the 100 most recent cases with the older 100. MATERIALS AND METHODS Observational cohort moncentric study of 200 cases of TTTS consecutively treated with fetoscopic laser coagulation between January 2004 and December 2014. RESULTS There were 49 stage I, 88 stage II, 55 stage III and eight stage IV. Median gestation at time of laser was 20.1±3.0 weeks' gestation (WG) whereas median gestation at delivery was 31.6±5.4 WG. Overall perinatal survival rate was 68.0% and 84.0% have one or more surviving twins. Preterm premature rupture of membranes occurred in 39 cases with and the median gestational age for this complication was 28.8±4.6 SA. Predictive factors to have at least one living birth were Quintero stage and gestational age at delivery. In the most recent period, there were significantly more TTTS Quintero stage I treated with laser, more coagulation by the Solomon technique and a larger number of coagulated vessels. CONCLUSION The neonatal survival of TTTS is improved by fetoscopic laser coagulation, preferely by using Solomon tecnhique. The use of active management of stage I is currently on research.
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Affiliation(s)
- L Lecointre
- Pôle de gynécologie-obstétrique, département d'échographie et de médecine fœtale, CMCO-HUS, 19, rue Louis-Pasteur, 67300 Schiltigheim/Strasbourg, France; Pôle de gynécologie-obstétrique, département d'obstétrique, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France.
| | - N Sananès
- Pôle de gynécologie-obstétrique, département d'échographie et de médecine fœtale, CMCO-HUS, 19, rue Louis-Pasteur, 67300 Schiltigheim/Strasbourg, France; Pôle de gynécologie-obstétrique, département d'obstétrique, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France; Inserm, UMR-S 1121, « Biomatériaux et Bioingénierie », 11, rue Humann, 67085 Strasbourg cedex, France
| | - A S Weingertner
- Pôle de gynécologie-obstétrique, département d'échographie et de médecine fœtale, CMCO-HUS, 19, rue Louis-Pasteur, 67300 Schiltigheim/Strasbourg, France
| | - A Gaudineau
- Pôle de gynécologie-obstétrique, département d'échographie et de médecine fœtale, CMCO-HUS, 19, rue Louis-Pasteur, 67300 Schiltigheim/Strasbourg, France; Pôle de gynécologie-obstétrique, département d'obstétrique, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France
| | - C Akladios
- Pôle de gynécologie-obstétrique, département d'obstétrique, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France
| | - V Cavillon
- Pôle de gynécologie-obstétrique, département d'échographie et de médecine fœtale, CMCO-HUS, 19, rue Louis-Pasteur, 67300 Schiltigheim/Strasbourg, France
| | - B Langer
- Pôle de gynécologie-obstétrique, département d'obstétrique, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France
| | - R Favre
- Pôle de gynécologie-obstétrique, département d'échographie et de médecine fœtale, CMCO-HUS, 19, rue Louis-Pasteur, 67300 Schiltigheim/Strasbourg, France
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Sierakowski A, Eapen V, Črnčec R, Smoleniec J. Developmental and behavioral outcomes of uncomplicated monochorionic diamniotic twins born in the third trimester. Neuropsychiatr Dis Treat 2017; 13:1373-1384. [PMID: 28579783 PMCID: PMC5449110 DOI: 10.2147/ndt.s122739] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Relatively little is known about the neurodevelopmental and behavioral outcomes of monochorionic diamniotic (MCDA) twin pregnancies where there are no antenatal complications peculiar to monochorionicity or prematurity. METHODS Twenty-two MCDA twins (44 children) with an average age of 4.3 years, and with no antenatal complications detected by 28 weeks of gestation, were recruited from a feto-maternal unit database. Parents completed a battery of neurodevelopmental and behavioral assessment questionnaires. RESULTS Eighteen children (41%) were identified as having developmental or behavioral concerns, predominantly of mild severity, which in turn were associated with a lower birth weight of medium effect size (Cohen's d=0.59). CONCLUSION MCDA twins delivered in the third trimester with no antenatal monochorionic complications in the first two trimesters appear to be at risk for subtle neurodevelopmental difficulties, associated with a lower birth weight. Ongoing developmental surveillance of these children during preschool-age is indicated for early identification and intervention.
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Affiliation(s)
| | - Valsamma Eapen
- School of Psychiatry, University of New South Wales.,Academic Unit of Infant, Child and Adolescent Psychiatry, Ingham Institute, Liverpool Hospital, South Western Sydney Local Health District
| | - Rudi Črnčec
- School of Psychiatry, University of New South Wales.,Academic Unit of Infant, Child and Adolescent Psychiatry, Ingham Institute, Liverpool Hospital, South Western Sydney Local Health District
| | - John Smoleniec
- Division of Women's and Children's Health, University of New South Wales, Sydney.,Department of Maternal-Fetal Medicine, Liverpool Hospital, Liverpool, NSW, Australia
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Abstract
PURPOSE OF REVIEW Twin-to-twin transfusion syndrome (TTTS) is an uncommon, but dangerous, complication of monochorionic diamniotic twin gestations. The purpose of this review is to provide an update on the evolving treatments in TTTS as it pertains primarily to laser photocoagulation, as well as to provide recently published information on outcomes. RECENT FINDINGS The Solomon laser technique, in which selective fetoscopic laser photocoagulation is first performed and then followed by laser of the vascular equator from one side of the placenta to the other, reduces TTTS complications of twin anemia-polycythemia syndrome and recurrent TTTS. The addition of fetal echocardiography to the historical staging of TTTS adds important information that may guide future therapies. The postlaser ablation rate of neurodevelopmental delay in TTTS has recently been reported to be 14%. Cotwin demise is a significant complication of untreated TTTS and survival carries a 25% risk of cystic periventricular leukomalacia, middle cerebral artery infarction, and injury to other central nervous system structures as noted by neuroimaging. SUMMARY Laser therapy for TTTS is clearly the only therapy that halts the disease process, allows both fetuses an opportunity to survive and protects a surviving cotwin in the event of the demise of one twin. Laser techniques have evolved greatly over the last 25 years and recent reports with the addition of the Solomon technique appearing to reduce some postlaser complications (twin anemia-polycythemia sequence and recurrent TTTS). Future focus of TTTS therapy should be centered on understanding the pathophysiology of the disease better with improvement in staging of the disease and on comparison of different laser techniques with the overall goal of not only increasing twin survival rates but also reducing long term neurodevelopmental morbidity.
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Sananès N, Gabriele V, Weingertner AS, Ruano R, Sanz-Cortes M, Gaudineau A, Langer B, Nisand I, Akladios CY, Favre R. Evaluation of long-term neurodevelopment in twin-twin transfusion syndrome after laser therapy. Prenat Diagn 2016; 36:1139-1145. [DOI: 10.1002/pd.4950] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 10/10/2016] [Accepted: 10/18/2016] [Indexed: 12/13/2022]
Affiliation(s)
- Nicolas Sananès
- Department of Obstetrics and Gynecology; Strasbourg University Hospital; Strasbourg France
- INSERM, UMR-S 1121, ‘Biomatériaux et Bioingénierie’; Strasbourg France
| | - Victor Gabriele
- Department of Obstetrics and Gynecology; Strasbourg University Hospital; Strasbourg France
| | | | - Rodrigo Ruano
- Texas Children's Fetal Center and Baylor College of Medicine; Houston TX USA
| | | | - Adrien Gaudineau
- Department of Obstetrics and Gynecology; Strasbourg University Hospital; Strasbourg France
| | - Bruno Langer
- Department of Obstetrics and Gynecology; Strasbourg University Hospital; Strasbourg France
| | - Israël Nisand
- Department of Obstetrics and Gynecology; Strasbourg University Hospital; Strasbourg France
| | | | - Romain Favre
- Department of Obstetrics and Gynecology; Strasbourg University Hospital; Strasbourg France
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Shaw CJ, Civale J, Botting KJ, Niu Y, Ter Haar G, Rivens I, Giussani DA, Lees CC. Noninvasive high-intensity focused ultrasound treatment of twin-twin transfusion syndrome: A preliminary in vivo study. Sci Transl Med 2016; 8:347ra95. [PMID: 27412787 DOI: 10.1126/scitranslmed.aaf2135] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 06/13/2016] [Indexed: 02/11/2024]
Abstract
We investigated the efficacy, maternofetal responses, and safety of using high-intensity focused ultrasound (HIFU) for noninvasive occlusion of placental vasculature compared to sham treatment in anesthetized pregnant sheep. This technique for noninvasive occlusion of placental vasculature may be translatable to the treatment of conditions arising from abnormal placental vasculature, such as twin-twin transfusion syndrome (TTTS). Eleven pregnant sheep were instrumented with maternal and fetal arterial catheters and time-transit flow probes to monitor cardiovascular, acid-base, and metabolic status, and then exposed to HIFU (n = 5) or sham (n = 6) ablation of placental vasculature through the exposed uterine surface. Placental vascular flow was occluded in 28 of 30 targets, and histological examination confirmed occlusion in 24 of 30 targets. In both HIFU and sham exposures, uterine contact reduced maternal uterine artery flow, but delivery of oxygen and glucose to the fetal brain remained normal. HIFU can consistently occlude in vivo placental vessels and ablate blood flow in a pregnant sheep model. Cardiovascular and metabolic fetal responses suggest that the technique is safe in the short term and potentially translatable to human pregnancy.
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Affiliation(s)
- Caroline J Shaw
- Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge CB2 3EG, UK. Institute of Reproductive and Developmental Biology, Imperial College London, London W12 0HS, UK
| | - John Civale
- Joint Department of Physics, Institute of Cancer Research, Sutton, London SM2 5NG, UK
| | - Kimberley J Botting
- Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge CB2 3EG, UK
| | - Youguo Niu
- Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge CB2 3EG, UK
| | - Gail Ter Haar
- Joint Department of Physics, Institute of Cancer Research, Sutton, London SM2 5NG, UK
| | - Ian Rivens
- Joint Department of Physics, Institute of Cancer Research, Sutton, London SM2 5NG, UK
| | - Dino A Giussani
- Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge CB2 3EG, UK
| | - Christoph C Lees
- Institute of Reproductive and Developmental Biology, Imperial College London, London W12 0HS, UK. Department of Obstetrics and Gynaecology, University Hospitals Leuven, 3000 Leuven, Belgium.
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Abstract
Historical suggestions of twin-to-twin transfusion syndrome (TTTS) date back to the early 17th century. Placental anastomoses were first reported in 1687; however, it was Schatz who first identified their importance in 1875. He recognized ‘the area of transfusion’ within the ‘villous district’ of the placenta, which he named the ‘third circulation’. This article describes how the management of TTTS has evolved as we have gained a more sophisticated understanding and appreciation of the complex vascular anastomoses that exist in monochorionic twin placentae. Currently, fetosopic laser occlusion is the preferred treatment option for TTTS.
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Fetal Brain Injury in Survivors of Twin Pregnancies Complicated by Demise of One Twin: A Review. Twin Res Hum Genet 2016; 19:262-7. [DOI: 10.1017/thg.2016.39] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Perinatal mortality is increased considerably in multiple pregnancies compared to singleton pregnancies, with single intrauterine fetal demise (sIUFD) presenting a rare but unique perinatal problem. Monochorionic pregnancies are at particular risk of sIUFD due to bidirectional inter-twin placental vascular anastomoses. The resulting inter-twin blood flow can become unbalanced, causing acute and chronic inter-twin transfusion and profound anemia secondary to fetal exsanguination into the low-pressure circulation of the dead fetus. If the sIUFD occurs after 14 weeks’ gestation it is believed to have the most significant effect on the continuing pregnancy as the co-twin is at increased risk of preterm delivery, long-term neurological complications, and death. This article will focus on fetal brain injury in the surviving co-twin in the case of sIUFD, as it is the most common kind of injury in sIUFD, and one which concerns parents and may be the basis for terminating the pregnancy. We will outline how these brain injuries are thought to occur and describe potential pathophysiological mechanisms. We will discuss risk factors for brain injury in cases of sIUFD, including: chorionicity, cause of the sIUFD (spontaneous or secondary to an underlying pathological process such as twin-to-twin transfusion syndrome), gestation of delivery and how to prevent brain injury in the co-twin. We also review modes of imaging, discuss the difficulties in predicting the long-term outcome for co-twin survivors, and highlight the dearth of research in this area.
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Histologic changes of the fetal membranes after fetoscopic laser surgery for twin-twin transfusion syndrome. Pediatr Res 2015; 78:247-55. [PMID: 26020146 DOI: 10.1038/pr.2015.105] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 02/27/2015] [Indexed: 11/08/2022]
Abstract
BACKGROUND Preterm premature rupture of membranes remains a major complication after fetoscopic laser surgery (FLS) for twin-twin transfusion syndrome (TTTS). We studied the histologic changes of fetal membranes post-FLS and investigated a possible impact of amniotic fluid (AF) dilution. METHODS Fetal membranes of 31 pregnancies that underwent FLS for TTTS were investigated histologically at delivery at different sites: trocar site of recipient sac and at distance, donor sac, and inter-twin membrane. RESULTS The trocar insertion site on the recipient sac showed no signs of histologic hallmarks of healing. Wide-spread alteration in collagen organization and higher apoptotic index in the amnion of the recipient sac which were absent in donor's and reference membranes. To explain the mechanisms, we analyzed the AF composition of recipient sacs from TTTS pregnancies vs. GA-matched healthy singleton controls and found glucose, protein and lactate dehydrogenase activity were all significantly lower in TTTS sacs consistent with over-dilution of recipient's AF (~2-fold). In-vitro exposure of healthy amniochorion to analogous dilutional stress conditions recapitulated the histologic changes and induced apoptosis and autophagy. CONCLUSION Alteration in structural integrity of the recipient's amniochorion, possibly in response to dilution stress, along with ineffective repair mechanisms may explain the increased incidence of preterm birth post-FLS.
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Arias AV, Campos D, Campos-Zanelli TM, Souza DSD, Peralta CFA, Guerreiro MM. Twin-twin transfusion syndrome: neurodevelopmental screening test. ARQUIVOS DE NEURO-PSIQUIATRIA 2015; 73:194-9. [PMID: 25807123 DOI: 10.1590/0004-282x20140237] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2014] [Accepted: 12/08/2014] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To assess the neurodevelopmental functions (cognition, language and motor function) of survivors of twin-twin transfusion syndrome (TTTS). METHOD Observational cross-sectional study of a total of 67 monochorionic diamniotic twins who underwent fetoscopic laser coagulation (FLC) for treatment of TTTS. The study was conducted at the Center for Investigation in Pediatrics (CIPED), Universidade Estadual de Campinas. Ages ranged from one month and four days to two years four months. Bayley Scales of Infant and Toddler Development Screening Test-III, were used for evaluation. RESULTS Most children reached the competent category and were classified as having appropriate performance. The preterm children scored worse than term infants for gross motor subtest (p = 0.036). CONCLUSION The majority of children reached the expected development according to their age. Despite the good neurodevelopment, children classified at risk should be monitored for development throughout childhood.
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Affiliation(s)
- Amabile Vessoni Arias
- Departamento de Neurologia, Centro de Investigação em Pediatria, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | - Denise Campos
- Departamento de Neurologia, Centro de Investigação em Pediatria, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | - Thatiane Moura Campos-Zanelli
- Departamento de Neurologia, Centro de Investigação em Pediatria, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | - Daniela Silva de Souza
- Departamento de Neurologia, Centro de Investigação em Pediatria, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | - Cleisson Fabio Andrioli Peralta
- Hospital da Mulher Prof. Dr. José Aristodemo Pinotti, Departamento de Obstetrícia e Ginecologia, Universidade Estadual de Campinas, Sao Paulo, SP, Brazil
| | - Marilisa Mantovani Guerreiro
- Departamento de Neurologia, Centro de Investigação em Pediatria, Universidade Estadual de Campinas, Campinas, SP, Brazil
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Chmait RH, Kontopoulos EV, Jackson M, Horenstein J, Timor-Tritsch I, Quintero RA. Selective Reduction Using Intravascular Potassium Chloride Injection after Laser Surgery for Twin-Twin Transfusion Syndrome. Fetal Diagn Ther 2015; 39:306-10. [PMID: 26067899 DOI: 10.1159/000431255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Accepted: 05/05/2015] [Indexed: 11/19/2022]
Abstract
Selective reduction (SR) via intravascular potassium chloride (KCl) injection is contraindicated in monochorionic twins due to the presence of placental vascular communications, which may serve as a conduit for inter-twin passage of KCl or allow exsanguination of the living twin into the demised twin. After successful selective laser photocoagulation of communicating vessels (SLPCV) for twin-twin transfusion syndrome (TTTS), the twins' circulatory systems are rendered independent. Theoretically, intravascular KCl injection into one twin after successful SLPCV should not result in passage of the feticidal agent nor cause hemodynamic alterations in the co-twin. We describe 3 cases of 1,069 patients (0.3%) that underwent SLPCV for TTTS between 2003 and 2013 and subsequent SR. SLPCV was successfully completed at 180, 226, and 230 weeks' gestational age for Quintero stages III, IV, and III TTTS, respectively. SR via intravascular KCl injection was later performed at maternal request due to the risk of neurological compromise in one twin at 226, 254, and 236 weeks' gestational age. All co-twins survived after SR, and no neurological sequelae were suspected after birth. Further study is necessary before SR can be routinely considered after laser surgery for TTTS.
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Affiliation(s)
- Ramen H Chmait
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, Calif., USA
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Abstract
In utero fetal surgery interventions are currently considered in selected cases of congenital diaphragmatic hernia, cystic pulmonary abnormalities, amniotic band sequence, selected congenital heart abnormalities, myelomeningocele, sacrococcygeal teratoma, obstructive uropathy, and complications of twin pregnancy. Randomized controlled trials have demonstrated an advantage for open fetal surgery of myelomeningocele and for fetoscopic selective laser coagulation of placental vessels in twin-to-twin transfusion syndrome. The evidence for other fetal surgery interventions, such as tracheal occlusion in congenital diaphragmatic hernia, excision of lung lesions, fetal balloon cardiac valvuloplasty, and vesicoamniotic shunting for obstructive uropathy, is more limited. Conditions amenable to intrauterine surgical treatment are rare; the mother may consider termination of pregnancy as an option for many of them; treatment can be lifesaving but in itself carries risks to both the infant (preterm premature rupture of the membranes, preterm delivery) and the mother. This makes conducting prospective or randomized trials difficult and explains the relative lack of good-quality evidence in this field. Moreover, there is scanty information on long-term outcomes. It is recommended that fetal surgery procedures be performed in centers with extensive facilities and expertise. The aims of this review were to describe the main fetal surgery procedures and their evidence-based results and to provide generalist obstetricians with an overview of current indications for fetal surgery.
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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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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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Slaghekke F, van Klink JMM, Koopman HM, Middeldorp JM, Oepkes D, Lopriore E. Neurodevelopmental outcome in twin anemia-polycythemia sequence 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 2014; 44:316-321. [PMID: 24753027 DOI: 10.1002/uog.13387] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Revised: 04/10/2014] [Accepted: 04/11/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To evaluate the long-term neurodevelopmental outcome in children who developed twin anemia-polycythemia sequence (TAPS) after fetoscopic laser surgery for twin-twin transfusion syndrome (TTTS). METHODS Neurological, motor and cognitive development was assessed in a consecutive cohort of TTTS survivors treated with laser surgery between 2004 and 2011 and complicated by post-laser TAPS. Primary outcome was neurodevelopmental impairment, a composite outcome including any of the following: cerebral palsy, bilateral deafness, blindness, severe motor and/or cognitive developmental delay (>2 SD below the mean). A risk analysis on cognitive outcome was performed. RESULTS During the study period, 33/306 (11%) monochorionic twin pairs developed TAPS after laser surgery for TTTS. Survival was 53/66 (80%). Long-term outcome was assessed in 47/53 (89%) children. The incidence of neurodevelopmental impairment was 4/47 (9%), occurring in one donor (1/20; 5%) and three recipients (3/27; 11%) (P=0.63). Mild-to-moderate cognitive delay, i.e. scores below 85, was detected in 8/47 (17%) children. Risk factors for low cognitive scores were low gestational age at birth (P=0.02) and low birth weight (P<0.01). The lowest cognitive scores were detected in the subgroup of TAPS survivors treated with intrauterine transfusion (median score, 82.5). CONCLUSIONS Neurodevelopmental impairment and cognitive delay were found in almost one in five children surviving post-laser TAPS. Better treatment and, ideally, prevention of this complication after laser treatment for TTTS is urgently needed.
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Affiliation(s)
- F Slaghekke
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden University, Leiden, The Netherlands
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Akkermans J, Peeters SH, Klumper FJ, Middeldorp JM, Lopriore E, Oepkes D. Is the Sequential Laser Technique for Twin-to-Twin Transfusion Syndrome Truly Superior to the Standard Selective Technique? A Meta-Analysis. Fetal Diagn Ther 2014; 37:251-8. [DOI: 10.1159/000365212] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 06/12/2014] [Indexed: 11/19/2022]
Abstract
Background and Objective: To investigate the efficacy of sequential laser coagulation in the treatment of twin-to-twin transfusion syndrome (TTTS). Data Sources: MEDLINE, EMBASE and the Cochrane Library were systematically searched for comparative studies on the efficacy of sequential versus standard selective laser coagulation for TTTS. The primary outcome measure in these studies was survival of at least one twin, both twins and fetal demise. Results: Three cohort studies comparing the selective laser treatment technique (n = 120) versus the sequential technique (n = 224) in 344 monochorionic twin pregnancies were included. Mean survival of at least one twin was 88% in the selective group versus 92% (p = 0.22) in the sequential group. Mean survival of both twins was lower in the selective group (52%) than in the sequential group (75%) (p = 0.002). Donor fetal demise decreased from 34% in the selective to 10% in the sequential group (p < 0.01), and recipient fetal demise decreased from 16 to 7% (p = 0.02). Conclusion: Limited evidence suggests improved double neonatal survival as well as decreased donor and recipient fetal demise with the use of the sequential technique. However, these results are based on small non-randomized studies with evident forms of bias and methodological limitations. A randomized controlled trial to assess the efficacy of sequential laser technique is therefore required.
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Slaghekke F, Lopriore E, Lewi L, Middeldorp JM, van Zwet EW, Weingertner AS, Klumper FJ, DeKoninck P, Devlieger R, Kilby MD, Rustico MA, Deprest J, Favre R, Oepkes D. Fetoscopic laser coagulation of the vascular equator versus selective coagulation for twin-to-twin transfusion syndrome: an open-label randomised controlled trial. Lancet 2014; 383:2144-51. [PMID: 24613024 DOI: 10.1016/s0140-6736(13)62419-8] [Citation(s) in RCA: 202] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Monochorionic twin pregnancies complicated by twin-to-twin transfusion syndrome are typically treated with fetoscopic laser coagulation. Postoperative complications can occur due to residual vascular anastomoses on the placenta. We aimed to assess the efficacy and safety of a novel surgery technique that uses laser coagulation of the entire vascular equator (Solomon technique). METHODS We undertook an open-label, international, multicentre, randomised controlled trial at five European tertiary referral centres. Women with twin-to-twin transfusion syndrome were randomly assigned by online randomisation (1:1) with permuted blocks to the Solomon technique or standard laser coagulation. The primary outcome was a composite of incidence of twin anaemia polycythaemia sequence, recurrence of twin-to-twin transfusion syndrome, perinatal mortality, or severe neonatal morbidity. Analyses were by intention to treat, with results expressed as odds ratios (ORs) and 95% CIs. This trial is registered with the Dutch Trial Registry, number NTR1245. FINDINGS Between March 11, 2008, and July 12, 2012, 274 women were randomly assigned to either the Solomon group (n=139) or the standard treatment group (n=135). The primary outcome occurred in 94 (34%) of 274 fetuses in the Solomon group versus 133 (49%) of 270 in the standard treatment group (OR 0·54; 95% CI 0·35-0·82). The Solomon technique was associated with a reduction in twin anaemia polycythaemia sequence (3% vs 16% for the standard treatment; OR 0·16, 95% CI 0·05-0·49) and recurrence of twin-to-twin transfusion syndrome (1% vs 7%; 0·21, 0·04-0·98). Perinatal mortality and severe neonatal morbidity did not differ significantly between the two groups. Outside of the common and well-known complications of twin-to-twin transfusion syndrome and its treatment, no serious adverse events occurred. INTERPRETATION Fetoscopic laser coagulation of the entire vascular equator reduces postoperative fetal morbidity in severe twin-to-twin transfusion syndrome. We recommend that fetoscopic surgeons consider adopting this strategy for treatment of women with twin-to-twin transfusion syndrome. FUNDING Netherlands Organization for the Health Research and Development (ZonMw 92003545).
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Affiliation(s)
- Femke Slaghekke
- Department of Obstetrics, Leiden University Medical Centre, Leiden, Netherlands
| | - Enrico Lopriore
- Department of Pediatrics, Leiden University Medical Centre, Leiden, Netherlands
| | - Liesbeth Lewi
- Department of Obstetrics, University Hospitals KU Leuven, Leuven, Belgium
| | | | - Erik W van Zwet
- Department of Medical Statistics, Leiden University Medical Centre, Leiden, Netherlands
| | | | - Frans J Klumper
- Department of Obstetrics, Leiden University Medical Centre, Leiden, Netherlands
| | - Philip DeKoninck
- Department of Obstetrics, University Hospitals KU Leuven, Leuven, Belgium
| | - Roland Devlieger
- Department of Obstetrics, University Hospitals KU Leuven, Leuven, Belgium
| | - Mark D Kilby
- Fetal Medical Centre, Birmingham Women's Foundation Trust and University of Birmingham, Edgbaston, Birmingham, UK
| | - Maria Angela Rustico
- Department of Obstetrics, Fetal Therapy Unit, Children's Hospital Vittore Buzzi, Milan, Italy
| | - Jan Deprest
- Department of Obstetrics, University Hospitals KU Leuven, Leuven, Belgium
| | - Romain Favre
- Department of Obstetrics, University Hospital of Strasbourg, Strasbourg, France
| | - Dick Oepkes
- Department of Obstetrics, Leiden University Medical Centre, Leiden, Netherlands.
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Shaw CJ, ter Haar GR, Rivens IH, Giussani DA, Lees CC. Pathophysiological mechanisms of high-intensity focused ultrasound-mediated vascular occlusion and relevance to non-invasive fetal surgery. J R Soc Interface 2014; 11:20140029. [PMID: 24671935 PMCID: PMC4006242 DOI: 10.1098/rsif.2014.0029] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Accepted: 03/06/2014] [Indexed: 12/27/2022] Open
Abstract
High-intensity focused ultrasound (HIFU) is a non-invasive technology, which can be used occlude blood vessels in the body. Both the theory underlying and practical process of blood vessel occlusion are still under development and relatively sparse in vivo experimental and therapeutic data exist. HIFU would however provide an alternative to surgery, particularly in circumstances where serious complications inherent to surgery outweigh the potential benefits. Accordingly, the HIFU technique would be of particular utility for fetal and placental interventions, where open or endoscopic surgery is fraught with difficulty and likelihood of complications including premature delivery. This assumes that HIFU could be shown to safely and effectively occlude blood vessels in utero. To understand these mechanisms more fully, we present a review of relevant cross-specialty literature on the topic of vascular HIFU and suggest an integrative mechanism taking into account clinical, physical and engineering considerations through which HIFU may produce vascular occlusion. This model may aid in the design of HIFU protocols to further develop this area, and might be adapted to provide a non-invasive therapy for conditions in fetal medicine where vascular occlusion is beneficial.
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Affiliation(s)
- C. J. Shaw
- Imperial College London, Hammersmith Campus, Du Cane Road, London W12 0HS, UK
- Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge CB2 3EG, UK
| | - G. R. ter Haar
- Joint Department of Physics, Institute of Cancer Research: Royal Marsden NHSF Trust, Downs Road, Sutton, Surrey SM2 5PT, UK
| | - I. H. Rivens
- Joint Department of Physics, Institute of Cancer Research: Royal Marsden NHSF Trust, Downs Road, Sutton, Surrey SM2 5PT, UK
| | - D. A. Giussani
- Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge CB2 3EG, UK
| | - C. C. Lees
- Imperial College London, Hammersmith Campus, Du Cane Road, London W12 0HS, UK
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Campus Gasthuisberg, KU Leuven, Belgium
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van Klink JM, Koopman HM, van Zwet EW, Middeldorp JM, Walther FJ, Oepkes D, Lopriore E. Improvement in neurodevelopmental outcome in survivors of twin-twin transfusion syndrome treated with laser surgery. Am J Obstet Gynecol 2014; 210:540.e1-7. [PMID: 24412743 DOI: 10.1016/j.ajog.2014.01.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 11/04/2013] [Accepted: 01/02/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To compare the incidence of neurodevelopmental impairment in surviving children from pregnancies with twin-twin transfusion syndrome (TTTS) treated with laser surgery between 2 time periods. STUDY DESIGN We compared the neurodevelopmental outcome between the first consecutive cohort of TTTS pregnancies treated with laser surgery from 2000 to 2005, with a cohort treated between 2008 and 2010. Neurologic, cognitive, and motor development was evaluated using Bayley scales at 2 years of age corrected for prematurity. RESULTS A total of 229 twin pregnancies were treated with laser surgery, 113 in the first cohort and 106 in the recent cohort. Overall survival increased from 70% (158/226) to 80% (170/212) (P = .014). The incidence of neurodevelopmental impairment decreased from 18% (28/152) to 6% (10/155) (P < .01). In multivariate analysis, severe cerebral injury at birth was independently associated with neurodevelopmental impairment (odds ratio, 34.86; 95% confidence interval, 11.83-102.75; P < .01). CONCLUSION Overall survival in TTTS has improved over time, with a concomitant reduction in the incidence of neurodevelopmental impairment. Research focused on prevention of cerebral injury is needed to further improve outcomes of these complicated twin pregnancies.
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Shek NWM, Hillman SC, Kilby MD. Single-twin demise: Pregnancy outcome. Best Pract Res Clin Obstet Gynaecol 2014; 28:249-63. [DOI: 10.1016/j.bpobgyn.2013.11.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Revised: 10/24/2013] [Accepted: 11/21/2013] [Indexed: 12/01/2022]
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Tosello B, Blanc J, Haumonté JB, D'Ercole C, Gire C. Short and medium-term outcomes of live-born twins after fetoscopic laser therapy for twin-twin transfusion syndrome. J Perinat Med 2014; 42:99-105. [PMID: 24006317 DOI: 10.1515/jpm-2013-0119] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Accepted: 08/14/2013] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To evaluate short and medium term outcomes of children born of monochorionic pregnancies complicated by twin-twin transfusion syndrome treated by fetoscopic laser surgery. METHODS This was a retrospective observational study performed between May 2007 and 2012. Neonatal data was from 45 patients under 5 years of age. The prospective observational study was of the neurologic outcome of these children using the Ages and Stages Questionnaire (ASQ), 2nd edition, French version, at up to 5 years of age. RESULTS Neurologic assessment at discharge from maternity unit was normal for 41 infants (93.2%). Logistic regression suggested that the risk of neurosensory sequelae was significantly related to the status of donor [odds ratio=4.62 (1.18; 18.0)] and significantly preterm birth <32 weeks of gestation [odds ratio=5.50 (1.38; 21.9)]. Eleven questionnaires were considered abnormal (31.1%). Two children presented a severe neurologic abnormality (5.7%). There was no significant correlation between any area of the questionnaire and status at birth (donor or recipient). CONCLUSIONS The data from our cohort, particularly as regards neurologic outcome, were satisfactory and concordant with previously published results. The use of the ASQ as a screening tool for neurologic outcome in children is original, which allowed in our cohort to highlight early neurological disorders.
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Papanna R, Block-Abraham D, Mann LK, Buhimschi IA, Bebbington M, Garcia E, Kahlek N, Harman C, Johnson A, Baschat A, Moise KJ. Risk factors associated with preterm delivery after fetoscopic laser ablation for twin-twin transfusion syndrome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 43:48-53. [PMID: 24013922 PMCID: PMC4142227 DOI: 10.1002/uog.13206] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/02/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVE Despite improved perinatal survival following fetoscopic laser ablation (FLA) for twin-twin transfusion syndrome (TTTS), prematurity remains an important contributor to perinatal mortality and morbidity. The objective of the study was to identify risk factors for complicated preterm delivery after FLA. METHODS Retrospective cohort study of prospectively collected data on maternal/fetal demographics and pre-operative, operative and postoperative variables of 459 patients treated with FLA in three USA fetal centers. Multivariate linear regression was performed to identify significant risk factors associated with preterm delivery, which were cross-validated using the k-fold method. Multivariate logistic regression was performed to identify risk factors for early compared with late preterm delivery based on median gestational age at delivery of 32 weeks. RESULTS There were significant differences in case selection and outcomes between the centers. After controlling for the center of surgery, multivariate analysis indicated that a lower maternal age at procedure, a history of previous prematurity, shortened cervical length, use of amnioinfusion, a cannula diameter of 12 French (Fr), lack of a collagen plug placement and iatrogenic preterm premature rupture of membranes (iPPROM) were significantly associated with a lower gestational age at delivery. CONCLUSIONS Specific fetal/maternal and operative variables are associated with preterm delivery after FLA for the treatment of TTTS. Further studies to modify some of these variables may decrease the perinatal morbidity after laser therapy.
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Affiliation(s)
- R Papanna
- Section of Maternal-Fetal Medicine, Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA; Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
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Abstract
Congenital birth defects and early/premature birth are common complex conditions affecting populations throughout the world, the interaction of which accounts for a significant proportion of neonatal morbidity and mortality. The relationship between these two conditions is not well understood. Several congenital birth defects can directly lead to early delivery. In addition, certain fetal conditions may necessitate early or premature delivery, several of which are also associated with maternal conditions necessitating early birth. Further understanding of both the incidences and causes of congenital birth defects and of early and premature birth will facilitate establishment of strategies to improve neonatal mortality and morbidity.
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Affiliation(s)
- Jonathan R Swanson
- Department of Pediatrics, University of Virginia Children's Hospital, University of Virginia, Box 800386, Charlottesville, VA 22908, USA
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