Most reproductive endocrinologists reported concern over the rising risk of high-order multiple gestations resulting from therapies such as superovulation with intrauterine insemination or in vitro fertilization. However, the ways in which patients are counseled regarding such events, their sequelae, and methods to avoid them greatly differ among respondents. Given the inconsistent practice patterns, a multifaceted educational approach may provide an opportunity to reduce the incidence of high-order multiple gestations and their sequelae.
Detachment of membranes is an unavoidable complication of therapeutic amniocentesis for twin-twin transfusion syndrome (TTTS). Subsequent amniocenteses or endoscopic fetal therapy may be hindered or made altogether impossible by this complication. The purpose of this study was to describe our experience in the assessment and management of TTTS patients with iatrogenic preoperative detached membranes (IPDM). Materials and methods: Patients with IPDM referred for fetal surgery for TTTS were considered ineligible for standard surgery and were offered different alternatives, including expectant management, serial amniocentesis, or an attempt at surgery with or without prior amniopatch. Pregnancy outcomes were compared between surgical and non-surgical patients. Results: Nine hundred and forty-four patients with a diagnosis of TTTS were referred between July 1997 and December 2004, of which 322 (34.1%) had a prior therapeutic amniocentesis. Twentysix patients (8%) were complicated by IPDM. Ten patients opted to be managed with subsequent amniocenteses, two of which had an amniopatch. One patient had voluntary interruption of pregnancy. Fifteen patients underwent surgery, 10 of which underwent an amniopatch. Resealing of membranes occurred in 8/12 (66%) of patients. Perinatal outcome was superior in patients treated surgically with or without an amniopatch (12/15, 80% vs. 4/11, 36%, p = 0.04). Conclusion: Membrane detachment is an important complication of therapeutic amniocentesis for the treatment of TTTS. Although successful treatment of IPDM can be achieved with an interim amniopatch in 66% of patients, this alternative is not without risks. Therapeutic amniocenteses should be discouraged in patients considering endoscopic fetal surgery for TTTS.
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