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Tchirikov M, Zühlke A, Schlabritz-Lutsevich N, Entezami M, Seliger G, Bergner M, Li W, Köninger A, Wienke A, Yusupbaev R, Ebert AD. Fetoscopic laser coagulation for twin-to-twin transfusion syndrome: a comparison of flexible 1.0/1.2 mm fetoscopes with curved sheaths of 2.7/3.3 mm 2 vs. 2 mm fetoscopic lens technique with sheaths of 6.6/11.3 mm 2. J Perinat Med 2024; 52:530-537. [PMID: 38536953 DOI: 10.1515/jpm-2023-0328] [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: 08/08/2023] [Accepted: 02/19/2024] [Indexed: 06/02/2024]
Abstract
OBJECTIVES Fetoscopic laser coagulation of placental anastomoses is usually performed for a treatment of twin-to-twin transfusion syndrome (TTTS). A common complication of fetoscopic laser coagulation for TTTS is preterm preliminary rupture of fetal membranes (PPROM) aggravating the neonatal outcome significantly. However, use of an flexible 1 mm fetoscope with an curved sheath could reduce iatrogenic damage of the amniotic membrane and improve neonatal outcomes after laser treatment. The aim of this study was to compare neonatal outcomes using this flexible fetoscope with curved sheath vs. use of a standard lens technique. METHODS Outcomes were retrospective analyzed after use of a standard lens fetoscope of 2 mm (sheath 6.63 mm2 or 11.27 mm2 for anterior placenta) and a flexible fetoscope of 1 mm or 1.2 mm (sheath 2.65 mm2 or 3.34 mm2) in two German centers of fetal surgery, performed during 2006-2019. RESULTS Neonatal outcome of 247 TTTS patients were analyzed including the rates of double and single fetal survival. The survival of at least one fetus was 97.2 % in the group with the ultrathin technique (n=154) compared to 88.3 % (n=93) in the group with the standard lens fetoscope (p=0.008). Survival of both fetuses was not different between groups (81.0 vs. 75.3 %). The procedure to delivery interval was significantly increased using the ultrathin fetoscope (89.1±35.0 d vs. 71.4±35.4 d, p=0.001) resulting in an increased gestational age at delivery by 11 days on average (231.9±28.1 d vs. 221.1±32.7 d, p=0.012). CONCLUSIONS Fetal survival can be significantly increased following TTTS using flexible fetoscope of 1 mm or 1.2 mm (sheath 2.65 mm2 or 3.34 mm2).
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Affiliation(s)
| | - Anja Zühlke
- Clinic of Anesthesiology, Martha-Maria Clinic, Halle-Dölau, Germany
| | - Natalia Schlabritz-Lutsevich
- School of Medicine at the Permian Basin, Texas Tech University, Health Sciences Center (TTUHSC), Odessa, TX, USA
| | - Michael Entezami
- Center of Prenatal Diagnostic and Human Genetic Kudamm-199, Berlin, Germany
| | - Gregor Seliger
- Martin-Luther University Halle-Wittenberg, Halle, Germany
| | | | - Weijing Li
- EWK, Clinic of Obstetrics and Gynecology, Berlin, Germany
| | - Angela Köninger
- University Clinic of Obstetrics and Gynecology, St. Hedwig, Barmherzige Brüder, Regensburg, Germany
| | - Andreas Wienke
- Institute of Medical Epidemiology, Biostatistics and Informatics, Martin-Luther University Halle-Wittenberg, Halle, Germany
| | - Rustem Yusupbaev
- Republican Scientific and Practical Medical Center for Obstetrics and Gynecology, Tashkent, Uzbekistan
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Tchirikov M, Haiduk C, Tchirikov M, Riemer M, Bergner M, Li W, Henschen S, Entezami M, Wienke A, Seliger G. Treatment of Classic Mid-Trimester Preterm Premature Rupture of Membranes (PPROM) with Oligo/Anhydramnion between 22 and 26 Weeks of Gestation by Means of Continuous Amnioinfusion: Protocol of a Randomized Multicentric Prospective Controlled TRIAL and Review of the Literature. Life (Basel) 2022; 12:life12091351. [PMID: 36143388 PMCID: PMC9500795 DOI: 10.3390/life12091351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 08/23/2022] [Accepted: 08/25/2022] [Indexed: 11/27/2022] Open
Abstract
Background: The classic mid-trimester preterm premature rupture of membranes (PPROM) is defined as a rupture of the fetal membranes prior to 28 weeks of gestation (WG) with oligo/anhydramnion; it complicates approximately 0.4–0.7% of all pregnancies and is associated with very high neonatal mortality and morbidity. Antibiotics have limited success to prevent bacterial growth, chorioamnionitis and fetal inflammation. The repetitive amnioinfusion does not work because fluid is lost immediately after the intervention. The continuous amnioinfusion through the transabdominal port system or catheter in patients with classic PPROM shows promise by flushing out the bacteria and inflammatory components from the amniotic cavity, replacing amniotic fluid and thus prolonging the PPROM-to-delivery interval. Objective: This multicenter trial aims to test the effect of continuous amnioinfusion on the neonatal survival without the typical major morbidities, such as severe bronchopulmonary dysplasia, intraventricular hemorrhage, cystic periventricular leukomalacia and necrotizing enterocolitis one year after the delivery. Study Design: We plan to conduct a randomized multicenter trial with a two-arm parallel design. Randomization will be between 22/0 and 26/0 SSW. The control group: PPROM patients between 20/0 and 26/0 WG who will be treated with antibiotics and corticosteroids (from 22/0 SSW) in accordance with the guidelines of German Society of Obstetrics and Gynecology (standard PPROM therapy). In the interventional group, the standard PPROM therapy will be complemented with the Amnion Flush Method, with the amnioinfusion of Amnion Flush Solution through the intra-amnial catheter (up to 100 mL/h, 2400 mL/day). Subjects: The study will include 68 patients with classic PPROM between 20/0 and 26/0 WG. TRIAL-registration: ClinicalTrials.gov ID: NCT04696003. German Clinical Trials Register: DRKS00024503, January 2021.
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Affiliation(s)
- Michael Tchirikov
- Clinic of Obstetrics and Prenatal Medicine, Center of Fetal Surgery, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, 06120 Halle (Saale), Germany
- Correspondence: ; Tel.: +49-345-557-3250; Fax: +49-345-557-3251
| | - Christian Haiduk
- Center of Clinical Studies, Martin Luther University Halle-Wittenberg, 06108 Halle (Saale), Germany
| | - Miriam Tchirikov
- Clinic of Obstetrics and Prenatal Medicine, Center of Fetal Surgery, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, 06120 Halle (Saale), Germany
| | - Marcus Riemer
- Clinic of Obstetrics and Prenatal Medicine, Center of Fetal Surgery, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, 06120 Halle (Saale), Germany
| | - Michael Bergner
- Clinic of Obstetrics and Prenatal Medicine, Center of Fetal Surgery, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, 06120 Halle (Saale), Germany
| | - Weijing Li
- Clinic of Obstetrics and Gynecology, St. Joseph Krankenhaus Berlin Tempelhof, 12101 Berlin, Germany
| | - Stephan Henschen
- Clinic of Obstetrics and Gynecology, Hamburg Medical School, Helios Clinics GmbH, 19049 Schwerin, Germany
| | - Michael Entezami
- Center of Prenatal Diagnostic and Human Genetic, 10719 Berlin, Germany
| | - Andreas Wienke
- Institute of Medical Epidemiology, Biostatistics and Informatics, Martin-Luther-University Halle-Wittenberg, 06120 Halle (Saale), Germany
| | - Gregor Seliger
- Clinic of Obstetrics and Prenatal Medicine, Center of Fetal Surgery, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, 06120 Halle (Saale), Germany
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Sacco A, Van der Veeken L, Bagshaw E, Ferguson C, Van Mieghem T, David AL, Deprest J. Maternal complications following open and fetoscopic fetal surgery: A systematic review and meta-analysis. Prenat Diagn 2019; 39:251-268. [PMID: 30703262 PMCID: PMC6492015 DOI: 10.1002/pd.5421] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 01/16/2019] [Accepted: 01/20/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To establish maternal complication rates for fetoscopic or open fetal surgery. METHODS We conducted a systematic literature review for studies of fetoscopic or open fetal surgery performed since 1990, recording maternal complications during fetal surgery, the remainder of pregnancy, delivery, and after the index pregnancy. RESULTS One hundred sixty-six studies were included, reporting outcomes for open fetal (n = 1193 patients) and fetoscopic surgery (n = 9403 patients). No maternal deaths were reported. The risk of any maternal complication in the index pregnancy was 20.9% (95%CI, 15.22-27.13) for open fetal and 6.2% (95%CI, 4.93-7.49) for fetoscopic surgery. For severe maternal complications (grades III to V Clavien-Dindo classification of surgical complications), the risk was 4.5% (95% CI 3.24-5.98) for open fetal and 1.7% (95% CI, 1.19-2.20) for fetoscopic surgery. In subsequent pregnancies, open fetal surgery increased the risk of preterm birth but not uterine dehiscence or rupture. Nearly one quarter of reviewed studies (n = 175, 23.3%) was excluded for failing to report the presence or absence of maternal complications. CONCLUSIONS Maternal complications occur in 6.2% fetoscopic and 20.9% open fetal surgeries, with serious maternal complications in 1.7% fetoscopic and 4.5% open procedures. Reporting of maternal complications is variable. To properly quantify maternal risks, outcomes should be reported consistently across all fetal surgery studies.
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Affiliation(s)
- Adalina Sacco
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Lennart Van der Veeken
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
| | - Emma Bagshaw
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Catherine Ferguson
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Tim Van Mieghem
- Department of Obstetrics and GynaecologyMount Sinai Hospital and University of TorontoTorontoOntarioCanada
| | - Anna L. David
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
- National Institute for Health ResearchUniversity College London Hospitals Biomedical Research CentreLondonUK
| | - Jan Deprest
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
- Clinical Department Obstetrics and GynaecologyUniversity Hospitals LeuvenLeuvenBelgium
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Tchirikov M, Springer C, Seeger S, Behrmann C, Bergner M, Haase R. Long tail balloon as a new approach for fetoscopic tracheal occlusion for a treatment of severe congenital diaphragmatic hernia. J Obstet Gynaecol Res 2019; 45:719-723. [PMID: 30656800 PMCID: PMC6590211 DOI: 10.1111/jog.13895] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 11/30/2018] [Indexed: 12/03/2022]
Abstract
Severe congenital diaphragmatic hernia (CDH) remains a significant challenge for neonatal specialists. In order to reduce complications during extraction of the surgical balloon after fetoscopic tracheal occlusion (FETO) CDH, we have developed a FETO with a ‘long tail balloon’ of 2.5 mL volume. Here we describe two successful uses of the device with observed/expected total fetal lung volume (o/e TFLV) of 15% and with o/e TFLV of 24% and ‘liver up’. The o/e TFLV increased to 134% in first case and to 47% in second fetus. The balloon was successfully extracted at 34 weeks' gestation by pulling the long tail suture during second fetoscopy. In the second case the fetus pulled out the balloon from trachea itself by traction onto the balloon's long tail. Both neonates were operated on for their CDH with a good outcome. This work showed the feasibility of this long tail balloon for FETO to reduce the technical difficulty of the balloon extraction and the possibility that fetuses are able to extract the balloon by itself by pulling the balloons' long tail. Further development of long tail balloon for FETO could facilitate its extraction thereby reducing neonatal complications.
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Affiliation(s)
- Michael Tchirikov
- University Clinic of Obstetrics and Prenatal Medicine, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Carsten Springer
- Department of Obstetrics, St. Elisabeth Hospital, Leipzig, Germany
| | - Sven Seeger
- Department of Obstetrics, St. Elisabeth Hospital, Halle, Germany
| | - Curd Behrmann
- University Clinic of Radiology, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Michael Bergner
- University Clinic of Obstetrics and Prenatal Medicine, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Roland Haase
- University Clinic of Pediatrics, Martin Luther University Halle-Wittenberg, Halle, Germany
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Sadda P, Imamoglu M, Dombrowski M, Papademetris X, Bahtiyar MO, Onofrey J. Deep-learned placental vessel segmentation for intraoperative video enhancement in fetoscopic surgery. Int J Comput Assist Radiol Surg 2018; 14:227-235. [PMID: 30484115 DOI: 10.1007/s11548-018-1886-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 11/06/2018] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Twin-to-twin transfusion syndrome (TTTS) is a potentially lethal condition that affects pregnancies in which twins share a single placenta. The definitive treatment for TTTS is fetoscopic laser photocoagulation, a procedure in which placental blood vessels are selectively cauterized. Challenges in this procedure include difficulty in quickly identifying placental blood vessels due to the many artifacts in the endoscopic video that the surgeon uses for navigation. We propose using deep-learned segmentations of blood vessels to create masks that can be recombined with the original fetoscopic video frame in such a way that the location of placental blood vessels is discernable at a glance. METHODS In a process approved by an institutional review board, intraoperative videos were acquired from ten fetoscopic laser photocoagulation surgeries performed at Yale New Haven Hospital. A total of 345 video frames were selected from these videos at regularly spaced time intervals. The video frames were segmented once by an expert human rater (a clinician) and once by a novice, but trained human rater (an undergraduate student). The segmentations were used to train a fully convolutional neural network of 25 layers. RESULTS The neural network was able to produce segmentations with a high similarity to ground truth segmentations produced by an expert human rater (sensitivity = 92.15% ± 10.69%) and produced segmentations that were significantly more accurate than those produced by a novice human rater (sensitivity = 56.87% ± 21.64%; p < 0.01). CONCLUSION A convolutional neural network can be trained to segment placental blood vessels with near-human accuracy and can exceed the accuracy of novice human raters. Recombining these segmentations with the original fetoscopic video frames can produced enhanced frames in which blood vessels are easily detectable. This has significant implications for aiding fetoscopic surgeons-especially trainees who are not yet at an expert level.
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Affiliation(s)
| | - Metehan Imamoglu
- Yale University School of Medicine, New Haven, USA.,Department of Obstetrics and Gynecology, Yale University School of Medicine, New Haven, USA.,Yale Fetal Care Center, New Haven, USA
| | - Michael Dombrowski
- Yale University School of Medicine, New Haven, USA.,Department of Obstetrics and Gynecology, Yale University School of Medicine, New Haven, USA.,Yale Fetal Care Center, New Haven, USA
| | - Xenophon Papademetris
- Yale University School of Medicine, New Haven, USA.,Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, USA.,Department of Biomedical Engineering, Yale University School of Medicine, New Haven, USA
| | - Mert O Bahtiyar
- Yale University School of Medicine, New Haven, USA.,Department of Obstetrics and Gynecology, Yale University School of Medicine, New Haven, USA.,Yale Fetal Care Center, New Haven, USA
| | - John Onofrey
- Yale University School of Medicine, New Haven, USA.,Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, USA
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Tchirikov M, Schlabritz-Loutsevitch N, Maher J, Buchmann J, Naberezhnev Y, Winarno AS, Seliger G. Mid-trimester preterm premature rupture of membranes (PPROM): etiology, diagnosis, classification, international recommendations of treatment options and outcome. J Perinat Med 2018; 46:465-488. [PMID: 28710882 DOI: 10.1515/jpm-2017-0027] [Citation(s) in RCA: 124] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 05/19/2017] [Indexed: 12/12/2022]
Abstract
Mid-trimester preterm premature rupture of membranes (PPROM), defined as rupture of fetal membranes prior to 28 weeks of gestation, complicates approximately 0.4%-0.7% of all pregnancies. This condition is associated with a very high neonatal mortality rate as well as an increased risk of long- and short-term severe neonatal morbidity. The causes of the mid-trimester PPROM are multifactorial. Altered membrane morphology including marked swelling and disruption of the collagen network which is seen with PPROM can be triggered by bacterial products or/and pro-inflammatory cytokines. Activation of matrix metalloproteinases (MMP) have been implicated in the mechanism of PPROM. The propagation of bacteria is an important contributing factor not only in PPROM, but also in adverse neonatal and maternal outcomes after PPROM. Inflammatory mediators likely play a causative role in both disruption of fetal membrane integrity and activation of uterine contraction. The "classic PPROM" with oligo/an-hydramnion is associated with a short latency period and worse neonatal outcome compared to similar gestational aged neonates delivered without antecedent PPROM. The "high PPROM" syndrome is defined as a defect of the chorio-amniotic membranes, which is not located over the internal cervical os. It may be associated with either a normal or reduced amount of amniotic fluid. It may explain why sensitive biochemical tests such as the Amniosure (PAMG-1) or IGFBP-1/alpha fetoprotein test can have a positive result without other signs of overt ROM such as fluid leakage with Valsalva. The membrane defect following fetoscopy also fulfils the criteria for "high PPROM" syndrome. In some cases, the rupture of only one membrane - either the chorionic or amniotic membrane, resulting in "pre-PPROM" could precede "classic PPROM" or "high PPROM". The diagnosis of PPROM is classically established by identification of nitrazine positive, fern positive watery leakage from the cervical canal observed during in specula investigation. Other more recent diagnostic tests include the vaginal swab assay for placental alpha macroglobulin-1 test or AFP and IGFBP1. In some rare cases amniocentesis and infusion of indigo carmine has been used to confirm the diagnosis of PPROM. The management of the PPROM requires balancing the potential neonatal benefits from prolongation of the pregnancy with the risk of intra-amniotic infection and its consequences for the mother and infant. Close monitoring for signs of chorioamnionitis (e.g. body temperature, CTG, CRP, leucocytes, IL-6, procalcitonine, amniotic fluid examinations) is necessary to minimize the risk of neonatal and maternal complications. In addition to delayed delivery, broad spectrum antibiotics of penicillin or cephalosporin group and/or macrolide and corticosteroids have been show to improve neonatal outcome [reducing risk of chorioamnionitis (average risk ratio (RR)=0.66), neonatal infections (RR=0.67) and abnormal ultrasound scan of neonatal brain (RR=0.67)]. The positive effect of continuous amnioinfusion through the subcutaneously implanted perinatal port system with amniotic fluid like hypo-osmotic solution in "classic PPROM" less than 28/0 weeks' gestation shows promise but must be proved in future prospective randomized studies. Systemic antibiotics administration in "pre-PPROM" without infection and hospitalization are also of questionable benefit and needs to be further evaluated in well-designed randomized prospective studies to evaluate if it is associated with any neonatal benefit as well as the relationship to possible adverse effect of antibiotics on to fetal development and neurological outcome.
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Affiliation(s)
- Michael Tchirikov
- Department of Obstetrics and Prenatal Medicine, Center of Fetal Surgery, Martin Luther University of Halle-Wittenberg, Halle, Germany
| | - Natalia Schlabritz-Loutsevitch
- Department of Obstetrics and Gynecology, Texas Tech University Health Sciences Center (TTUHSC), School of Medicine at the Permian Basin, Odessa, TX, USA
| | - James Maher
- Department of Obstetrics and Gynecology, Texas Tech University Health Sciences Center (TTUHSC), School of Medicine at the Permian Basin, Odessa, TX, USA
| | - Jörg Buchmann
- Department of Pathology, Martha-Maria Hospital, Halle-Dölau, Halle, Germany
| | - Yuri Naberezhnev
- Department of Obstetrics and Prenatal Medicine, Center of Fetal Surgery, Martin Luther University of Halle-Wittenberg, Halle, Germany
| | - Andreas S Winarno
- Department of Obstetrics and Prenatal Medicine, Center of Fetal Surgery, Martin Luther University of Halle-Wittenberg, Halle, Germany
| | - Gregor Seliger
- Department of Obstetrics and Prenatal Medicine, Center of Fetal Surgery, Martin Luther University of Halle-Wittenberg, Halle, Germany
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Akkermans J, Peeters SH, Klumper FJ, Lopriore E, Middeldorp JM, Oepkes D. Twenty-Five Years of Fetoscopic Laser Coagulation in Twin-Twin Transfusion Syndrome: A Systematic Review. Fetal Diagn Ther 2015; 38:241-53. [DOI: 10.1159/000437053] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 06/17/2015] [Indexed: 11/19/2022]
Abstract
Objective: The aim of this study was to assess the perinatal outcome of pregnancies with twin-twin transfusion syndrome (TTTS) treated with laser therapy over the past 25 years, and in relation to different techniques used in this time period. Methods: A systematic review of studies reporting on perinatal outcome according to the Meta-Analysis of Observational Studies in Epidemiology (MOOSE) guidelines was conducted. The MEDLINE, Embase and Cochrane Library databases were systematically searched. Comparisons were made in respect to time period and laser technique and Quintero stages. Results: In total, 34 studies reporting on 3,868 monochorionic twin pregnancies were included. The mean survival of both twins increased from 35 to 65% (p = 0.012) and for at least one twin from 70 to 88% (p = 0.009) over the past 25 years. Mean gestational age at birth remained stable over the years at 32 weeks gestation. Also, we showed a significantly improved perinatal survival with the evolution of the laser technique from non-selective to selective, selective sequential and the Solomon technique (p = 0.010). Discussion: Since the introduction of laser therapy for TTTS more than two decades ago, perinatal survival improved significantly. Improved outcome is probably associated with several factors, including evolution of the laser technique, learning curve effect, better referral and improved early neonatal care.
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