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van der Schot AM, van Steenis JL, Sikkel E, Spaanderman MEA, van Drongelen J. Impact of cannula diameter on pregnancy outcomes after minimally invasive fetal laser surgery in the treatment of twin-to-twin transfusion syndrome: A systematic review and meta-analysis. Acta Obstet Gynecol Scand 2024; 103:1242-1253. [PMID: 38400574 PMCID: PMC11168272 DOI: 10.1111/aogs.14761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 10/27/2023] [Accepted: 11/27/2023] [Indexed: 02/25/2024]
Abstract
INTRODUCTION Preterm prelabor rupture of membranes (PPROM) remains a major complication of fetal laser surgery in the treatment of twin-to-twin transfusion syndrome (TTTS). The aim of the study was to determine the impact of cannula size on pregnancy outcomes, with a particular focus on PPROM. MATERIAL AND METHODS The protocol was developed and registered in the PROSPERO database under registration number CRD42022333630. The PubMed, Web of Science, and EMBASE databases were searched electronically on May 18, 2022, and updated on March 2, 2023, utilizing a combination of the relevant MeSH terms, keywords, and word variants for "TTTS" and "laser". Randomized controlled trials, prospective and retrospective cohorts, case-control studies, and case reports/series with more than five participants were considered eligible for inclusion. Studies reporting the cannula diameter and PPROM rate after laser surgery in the treatment of monochorionic pregnancies affected by TTTS between 16- and 26 weeks' gestation were included. Data was extracted independently, and when appropriate, a random-effects meta-analysis was undertaken to calculate pooled estimates and their confidence intervals. Heterogeneity in the effect estimates of the individual studies was calculated using the I2 statistic. The primary outcome was PPROM rate. Secondary outcomes were survival rate, preterm birth, and incomplete surgery. The quality of the included studies was assessed using a modified quality in prognosis study tool. RESULTS We included a total of 22 studies, consisting of 3426 patients. Only one study was scored as low quality, seven as moderate quality, and the remaining 14 as high quality. The mean PPROM rate after laser surgery treating TTTS was 22.9%, ranging from 11.6% for 9 French (Fr) to 54.0% for 12 Fr. Subsequent meta-regression for the clinically relevant PPROM rate before 34 weeks of gestation, showed increased PPROM rates for increased cannula size (p-value 0.01). CONCLUSIONS This systematic review confirmed PPROM as a frequent complication of fetal laser surgery, with a mean PPROM rate of 22.9%. A larger cannula diameter relates to a significant higher PPROM risk for PPROM before 34 weeks gestation. Hence, the ideal balance between optimal visualization requiring larger port diameters and shorter operation time and more complete procedures that benefit from larger diameters is crucial to reduce iatrogenic PPROM rates.
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Affiliation(s)
- Anouk M. van der Schot
- Department of Obstetrics & GynecologyRadboud University Medical CenterNijmegenThe Netherlands
| | - Josee L. van Steenis
- Department of Obstetrics & GynecologyRadboud University Medical CenterNijmegenThe Netherlands
- Technical Medicine, Science and TechnologyUniversity of TwenteEnschedeThe Netherlands
| | - Esther Sikkel
- Department of Obstetrics & GynecologyRadboud University Medical CenterNijmegenThe Netherlands
| | - Marc E. A. Spaanderman
- Department of Obstetrics & GynecologyRadboud University Medical CenterNijmegenThe Netherlands
- Department of Obstetrics & GynecologyMaastricht University Medical Center+MaastrichtThe Netherlands
- GROW School for Oncology and Reproduction Maastricht UniversityMaastrichtThe Netherlands
| | - Joris van Drongelen
- Department of Obstetrics & GynecologyRadboud University Medical CenterNijmegenThe Netherlands
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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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Mustafa HJ, Javinani A, Krispin E, Tadbiri H, Espinoza J, Shamshirsaz AA, Nassr AA, Donepudi R, Belfort MA, Cortes MS, Harman C, Turan OM. Fetoscopic laser surgery for twin-to-twin transfusion syndrome in DCTA triplets compared to MCDA twins: collaborative study and literature review. J Matern Fetal Neonatal Med 2022; 35:10348-10354. [PMID: 36529927 DOI: 10.1080/14767058.2022.2128649] [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: 12/23/2022]
Abstract
OBJECTIVE To compare the outcomes of dichorionic triamniotic (DCTA) triplets with that of monochorionic diamniotic (MCDA) twin gestations undergoing fetoscopic laser surgery (FLS) for treatment of twin-to-twin transfusion syndrome (TTTS). METHODS Retrospective cohort study of prospectively collected data of consecutive DCTA triplet and MCDA twin pregnancies with TTTS that underwent FLS at two fetal treatment centers between 2012 and 2020. Preoperative, operative and, postoperative variables were collected. Perinatal outcomes were investigated. Primary outcome was survival to birth and to neonatal period. Secondary outcomes were gestational age (GA) at birth and procedure-to-delivery interval. Literature review was conducted in which PubMed, Web of Science, and Scopus were searched from inception to September, 2020. RESULTS Twenty four sets of DCTA triplets were compared to MCDA twins during the study period. There were no significant differences in survival (no survivor, single, or double survivors) to birth and to the neonatal period of the MC twin pairs of the DCTA triplets vs MCDA twins. Median GA at delivery was approximately three weeks earlier in DCTA triplets compared to MCDA twins (28.4 weeks vs 31.4 weeks, p = .035, respectively). Rates of preterm birth (PTB) less than 32 and less than 28 weeks were significantly higher in DCTA triplets compared to twins (<32 weeks: 70.8% vs 51.1%, p = .037, respectively, and <28 weeks: 37.5% vs 20.8%, p = .033, respectively). CONCLUSION Perinatal survival including fetal and neonatal are comparable between DCTA triplets and MCDA twins. However, this might have resulted from the small sample size of the DCTA triplets. GA at delivery is earlier in triplets, which could be due to the nature of triplet gestation rather than to the laser procedure itself.
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Affiliation(s)
- Hiba J Mustafa
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ali Javinani
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, USA
| | - Eyal Krispin
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, USA
| | - Hooman Tadbiri
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jimmy Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, USA
| | - Alireza A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, USA
| | - Ahmed A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, USA
| | - Roopali Donepudi
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, USA
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, USA
| | - Magdalena Sanz Cortes
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, USA
| | - Christopher Harman
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ozhan M Turan
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, 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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Sacco A, Van der Veeken L, Bagshaw E, Ferguson C, Van Mieghem T, David AL, Deprest J. Maternal complications following open and fetoscopic fetal surgery: A systematic review and meta-analysis. Prenat Diagn 2019; 39:251-268. [PMID: 30703262 PMCID: PMC6492015 DOI: 10.1002/pd.5421] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 01/16/2019] [Accepted: 01/20/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To establish maternal complication rates for fetoscopic or open fetal surgery. METHODS We conducted a systematic literature review for studies of fetoscopic or open fetal surgery performed since 1990, recording maternal complications during fetal surgery, the remainder of pregnancy, delivery, and after the index pregnancy. RESULTS One hundred sixty-six studies were included, reporting outcomes for open fetal (n = 1193 patients) and fetoscopic surgery (n = 9403 patients). No maternal deaths were reported. The risk of any maternal complication in the index pregnancy was 20.9% (95%CI, 15.22-27.13) for open fetal and 6.2% (95%CI, 4.93-7.49) for fetoscopic surgery. For severe maternal complications (grades III to V Clavien-Dindo classification of surgical complications), the risk was 4.5% (95% CI 3.24-5.98) for open fetal and 1.7% (95% CI, 1.19-2.20) for fetoscopic surgery. In subsequent pregnancies, open fetal surgery increased the risk of preterm birth but not uterine dehiscence or rupture. Nearly one quarter of reviewed studies (n = 175, 23.3%) was excluded for failing to report the presence or absence of maternal complications. CONCLUSIONS Maternal complications occur in 6.2% fetoscopic and 20.9% open fetal surgeries, with serious maternal complications in 1.7% fetoscopic and 4.5% open procedures. Reporting of maternal complications is variable. To properly quantify maternal risks, outcomes should be reported consistently across all fetal surgery studies.
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Affiliation(s)
- Adalina Sacco
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Lennart Van der Veeken
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
| | - Emma Bagshaw
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Catherine Ferguson
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Tim Van Mieghem
- Department of Obstetrics and GynaecologyMount Sinai Hospital and University of TorontoTorontoOntarioCanada
| | - Anna L. David
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
- National Institute for Health ResearchUniversity College London Hospitals Biomedical Research CentreLondonUK
| | - Jan Deprest
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
- Clinical Department Obstetrics and GynaecologyUniversity Hospitals LeuvenLeuvenBelgium
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Ota S, Ishii K, Kawamura H, Mabuchi A, Yamamoto R, Hayashi S, Kanagawa T, Mitsuda N. Transient amniotic fluid leakage after fetoscopic laser photocoagulation for twin-twin transfusion syndrome. J Obstet Gynaecol Res 2017; 44:223-227. [PMID: 29027307 DOI: 10.1111/jog.13494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 08/04/2017] [Indexed: 11/28/2022]
Abstract
AIM Iatrogenic premature rupture of membrane (PROM) is one of the major complications related to fetoscopic laser photocoagulation (FLP) for twin-twin transfusion syndrome (TTTS). However, amniotic fluid leakage (AFL) sometimes spontaneously disappears. This study evaluated the incidence and clinical characteristics of transient AFL after FLP. METHODS We retrospectively reviewed pregnancies that underwent FLP for TTTS at a single center. Patients with apparent AFL within 2 weeks after FLP were divided into two groups: transient AFL, defined by the disappearance of fluid leakage within a week; and PROM, if AFL persisted continuously for more than a week or premature birth occurred, including miscarriage, within a week of the first symptom of AFL. RESULTS Among 201 monochorionic twin pregnancies that underwent FLP during the study period, nine patients (4.5%) were diagnosed with AFL within a week after FLP. Four patients (2.0%) were classified as transient AFL and five as PROM. Median gestational age at FLP was not significantly different between the groups; operative time in the PROM group was significantly longer (P = 0.01). The surgery to delivery interval and median gestational age at delivery were greater in the transient AFL group (87.8 vs 17.6 days, P = 0.01; 32.5 vs 23.6 weeks, P = 0.01, respectively). CONCLUSIONS The incidence of transient AFL after FLP was 2%. Perinatal outcomes of transient AFL might be better than that of PROM.
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Affiliation(s)
- Shiyo Ota
- Department of Maternal Fetal Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Keisuke Ishii
- Department of Maternal Fetal Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Hiroshi Kawamura
- Department of Maternal Fetal Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Aki Mabuchi
- Department of Maternal Fetal Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Ryo Yamamoto
- Department of Maternal Fetal Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Shusaku Hayashi
- Department of Maternal Fetal Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Takeshi Kanagawa
- Department of Maternal Fetal Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Nobuaki Mitsuda
- Department of Maternal Fetal Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
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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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Yang L, Wang J, Ando T, Kubota A, Yamashita H, Sakuma I, Chiba T, Kobayashi E. Towards scene adaptive image correspondence for placental vasculature mosaic in computer assisted fetoscopic procedures. Int J Med Robot 2015; 12:375-86. [PMID: 26443691 DOI: 10.1002/rcs.1700] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2015] [Indexed: 11/11/2022]
Abstract
BACKGROUND Visualization of the vast placental vasculature is crucial in fetoscopic laser photocoagulation for twin-to-twin transfusion syndrome treatment. However, vasculature mosaic is challenging due to the fluctuating imaging conditions during fetoscopic surgery. METHOD A scene adaptive feature-based approach for image correspondence in free-hand endoscopic placental video is proposed. It contributes towards existing techniques by introducing a failure detection method based on statistical attributes of the feature distribution, and an updating mechanism that self-tunes parameters to recover from registration failures. RESULTS Validations on endoscopic image sequences of a phantom and a monkey placenta are carried out to demonstrate mismatch recovery. In two 100-frame sequences, automatic self-tuned results improved by 8% compared with manual experience-based tuning and a slight 2.5% deterioration against exhaustive tuning (gold standard). CONCLUSION This scene-adaptive image correspondence approach, which is not restricted to a set of generalized parameters, is suitable for applications associated with dynamically changing imaging conditions. Copyright © 2015 John Wiley & Sons, Ltd.
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Affiliation(s)
- Liangjing Yang
- Graduate School of Engineering, The University of Tokyo, Tokyo, Japan
| | - Junchen Wang
- Graduate School of Engineering, The University of Tokyo, Tokyo, Japan
| | - Takehiro Ando
- Graduate School of Engineering, The University of Tokyo, Tokyo, Japan
| | - Akihiro Kubota
- Graduate School of Engineering, The University of Tokyo, Tokyo, Japan
| | - Hiromasa Yamashita
- Clinical Research Center, National Center for Child Health and Development, Tokyo, Japan
| | - Ichiro Sakuma
- Graduate School of Engineering, The University of Tokyo, Tokyo, Japan
| | - Toshio Chiba
- Clinical Research Center, National Center for Child Health and Development, Tokyo, Japan
| | - Etsuko Kobayashi
- Graduate School of Engineering, The University of Tokyo, Tokyo, Japan
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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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Argoti PS, Papanna R, Bebbington MW, Kahlek N, Baschat A, Johnson A, Moise KJ. Outcome of fetoscopic laser ablation for twin-to-twin transfusion syndrome in dichorionic-triamniotic triplets compared with monochorionic-diamniotic twins. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 44:545-549. [PMID: 24659447 DOI: 10.1002/uog.13369] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Revised: 12/23/2013] [Accepted: 01/10/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To compare outcome of dichorionic-triamniotic (DCTA) triplet gestations with that of a paired cohort of monochorionic-diamniotic (MCDA) twin gestations undergoing laser therapy for treatment of twin-to-twin transfusion syndrome (TTTS). METHODS All DCTA triplets treated at four referral centers between specified dates were included. A matched cohort group of MCDA twin gestations affected by TTTS was used for comparison. RESULTS Sixteen sets of DCTA triplets treated with laser photocoagulation of placental anastomoses were compared with 32 matched sets of MCDA twins. All of the 'singleton' fetuses in the triplet gestations survived to birth and to the end of the neonatal period. There were no differences in single or double survival or the rate of non-survivors to birth and at age 28 days. A mean 3-week difference was found in the procedure-to-delivery interval in DCTA triplets vs MCDA twins (60 ± 35.8 days vs 83.6 ± 33.2 days; P = 0.029). A mean difference of 3 weeks was also found in the gestational age at delivery in DCTA triplets vs MCDA twins (28.5 ± 3.5 weeks vs 31.9 ± 5 weeks; P = 0.024). A similar post-laser fetal growth pattern in donors and recipients of both groups was noted. CONCLUSIONS DCTA triplet gestations with TTTS have a similar rate of post-laser survival but deliver earlier than can be expected for twins treated with laser. These findings have potential implications for the risk of prematurity and long-term outcomes.
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Affiliation(s)
- P S Argoti
- Department of Obstetrics, Gynecology and Reproductive Medicine, Division of Maternal-Fetal Medicine, UT Health - School of Medicine at Houston, The Texas Fetal Center, Children's Memorial Hermann Hospital, Houston, TX, USA
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Has R, Kalelioglu I, Corbacioglu Esmer A, Ermis H, Dural O, Dogan Y, Yasa C, Yumru H, Demir O, Yuksel A, Ibrahimoglu L, Yildirim A. Stage-related outcome after fetoscopic laser ablation in twin-to-twin transfusion syndrome. Fetal Diagn Ther 2014; 36:287-92. [PMID: 25096484 DOI: 10.1159/000362385] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2013] [Accepted: 03/14/2014] [Indexed: 11/19/2022]
Abstract
AIM To review the perinatal outcome of twin-to-twin transfusion syndrome (TTTS) treated with fetoscopic laser coagulation in a developing country with detailed analysis according to the stage of the syndrome. METHODS This was a retrospective study of 85 TTTS cases treated with fetoscopic laser coagulation at the Fetal Diagnosis and Treatment Unit of Istanbul Faculty of Medicine between January 2006 and March 2013. RESULTS The surgical failure rate was 5.8% (5/85). Among all the cases of the total cohort, only 1 fetus survived in 27 pregnancies (31.8%), and both fetuses survived in 22 pregnancies (25.9%). In 49 pregnancies (57.6%) at least one fetus survived at the end of the neonatal period. The overall survival and live birth rates were 41.8% (71/170) and 56.4% (96/170), respectively, and they significantly decreased as the stage of disease increased. Delivery occurred before 32 weeks of gestation in 54 (63.5%) pregnancies. Logistic regression analysis showed that gestational age at delivery was the only independent factor, and the risk of nonsurvival significantly decreased with increasing age. CONCLUSION Based on our experience, the outcome of fetoscopic laser coagulation of the placental anastomoses for TTTS became worse as the Quintero stage of the disease advanced.
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Affiliation(s)
- Recep Has
- Department of Obstetrics and Gynecology, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey
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12
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Walsh CA, McAuliffe FM. Recurrent twin-twin transfusion syndrome after selective fetoscopic laser photocoagulation: a systematic review of the literature. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2012; 40:506-512. [PMID: 22378622 DOI: 10.1002/uog.11105] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/03/2012] [Indexed: 05/31/2023]
Abstract
OBJECTIVES Selective fetoscopic laser photocoagulation (SFLP) is now the treatment of choice for twin-twin transfusion syndrome (TTTS). The incidence of recurrent TTTS following SFLP has been inconsistently reported across different studies. We performed a systematic review of TTTS recurrence following SFLP. METHODS PubMed and MEDLINE online databases were searched for articles published between 2000 and August 2011, using combinations of the terms 'twin-twin transfusion', 'TTTS', 'laser', 'recur' and 'outcome'. Citations identified in the primary search were screened for eligibility. Studies reporting outcomes from selective SFLP for TTTS in twin pregnancies, which addressed specifically the issue of TTTS recurrence, were included. The primary outcome was rate of TTTS recurrence. Secondary outcomes were therapeutic preference and fetal outcomes in cases of recurrent TTTS. RESULTS The primary search identified 22 eligible studies that are included in this review (n = 2447 twin pregnancies). Two studies included a minority of non-selective procedures. The published incidence of recurrent TTTS ranged from 0 to 16%. Clinical management was reported in 65.7% (71/108) cases, with repeat SFLP the most commonly performed secondary intervention. Only three studies provided comprehensive outcome data for cases of recurrent TTTS. The overall rate of neurologically-intact survival was 44% (23/52). The data were inadequate to determine the effects of secondary therapeutic approach, placental location or gestational age on perinatal outcome in cases of recurrent TTTS. CONCLUSIONS The published rate of TTTS recurrence following SFLP in monochorionic twin pregnancies ranges from 0 to 16%. Although limited follow-up data suggest that recurrence is associated with significant perinatal mortality and morbidity, further study is needed. Currently, there are insufficient data available to guide recommendations for clinical management of TTTS recurrence. Future studies on SFLP for TTTS must include details on recurrence rates and provide outcome data specific to the recurrent subset.
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Affiliation(s)
- C A Walsh
- Department of Fetal Medicine, National Maternity Hospital, Dublin, Ireland
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Tchirikov M, Oshovskyy V, Steetskamp J, Falkert A, Huber G, Entezami M. Neonatal outcome using ultrathin fetoscope for laser coagulation in twin-to-twin-transfusion syndrome. J Perinat Med 2011; 39:725-30. [PMID: 21867454 DOI: 10.1515/jpm.2011.091] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To improve neonatal outcome using ultrathin fetoscope for laser treatment of twin-to-twin transfusion syndrome. METHODS Retrospective cohort study of a series of 80 cases of twin-to-twin-transfusion syndrome prior to 26-weeks' gestation subjected to laser coagulation by means of a 1.0/1.2 mm fiber fetoscope with a sheath sectional area 2.65 mm(2)/3.34 mm(2) (n=27) and a 2.0 mm classic lens fetoscope with a sheath sectional area: 6.63 mm(2)/11.27 mm(2) (n=53). RESULTS The survival rates of at least one twin in the compared groups were 94.4% (classic optic) and 100% (ultrathin optic), for both twins: 75.5% and 83.3%, respectively. By decreasing sheath diameter a pregnancy was prolonged by an average of 21.3 days (P=0.0045), with a resulting increase in the recipient's weight of 389 g (P=0.0049) and an increase in the donor's Apgar score. However, the intervention with ultrathin optic took 11 min longer (P=0.031). CONCLUSION The reduction of the iatrogenic damage of the amniotic membrane using ultrathin fetoscope with a small sheath, significantly improves the neonatal outcome after laser treatment of twin-to-twin-transfusion syndrome. The operator should only commence working with the 1 mm fetoscope after the learning curve has been accomplished.
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Affiliation(s)
- Michael Tchirikov
- University Clinic of Obstetrics and Fetal Medicine, University Medical Center Halle (Saale) of Martin Luther University of Halle-Wittenberg, Germany.
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Patel KK, Caramelli B, Silva MRE. Original research articles on the cardiopulmonary system recently appeared in Brazilian clinical and surgical journals. Rev Assoc Med Bras (1992) 2011. [DOI: 10.1590/s0104-42302011000600022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Original research articles on the cardiopulmonary system recently appeared in Brazilian clinical and surgical journals. Rev Assoc Med Bras (1992) 2011. [DOI: 10.1016/s0104-4230(11)70140-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Neurodevelopmental Outcomes After Laser Therapy for Twin–Twin Transfusion Syndrome. Obstet Gynecol 2011; 118:1145-1150. [DOI: 10.1097/aog.0b013e318231827f] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Tchirikov M. Monochorionic twin pregnancy: screening, pathogenesis of complications and management in the era of microinvasive fetal surgery. J Perinat Med 2010; 38:451-9. [PMID: 20629496 DOI: 10.1515/jpm.2010.069] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The management of monochorionic (MC) twin pregnancies varies in different medical centers. This paper compares screening methods to predict the complications of the MC twin pregnancy and different treatment methods. METHODS We performed a literature search without language restriction in Cochrane library and PubMed (1970-2009). Case series and cohort screening studies, pathogenesis and management of complications of MC pregnancy were included. RESULTS Elevated risk for intrauterine fetal death (IUFD) and twin-to-twin transfusion syndrome (TTTS) can be detected sonographically. Monitoring of MC pregnancies at increased risk and regular training sessions for the operating team combined with reduced fetoscopic amniotic membrane damage increase fetal survival rate from laser coagulation to nearly 100% for at least one fetus and to 90% for both. CONCLUSION Monitoring of MC pregnancies at increased risk and laser treatment of TTTS in medical centers with sufficient experience might improve neonatal outcome.
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Affiliation(s)
- Michael Tchirikov
- Department of Obstetrics and Fetal Medicine, Clinic of Obstetrics and Gynecology, University Medical Center of Johannes Gutenberg University Mainz, Mainz, Germany.
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Investigation of the factors affecting the perinatal outcome of monochorionic diamniotic twins. Arch Gynecol Obstet 2010; 283:1239-43. [DOI: 10.1007/s00404-010-1549-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2010] [Accepted: 06/01/2010] [Indexed: 11/24/2022]
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