Amniotic Septostomy for the Treatment of Twin Oligohydramnios-Polyhydramnios Sequence

Abstract

Objective: To report our experience with intentional puncture of the intervening membrane (‘septostomy’) for the treatment of the twin oligohydramnios-polyhydramnios sequence (TOPS). Methods: 12 patients were diagnosed with TOPS based on ultrasonographic findings. A 20- to 22-gauge spinal needle was used to puncture the membrane between the twins without any attempt at amnioreduction in 9 patients, while the procedure was combined with amnioreductions in 3 patients. Results: Gestational age was 23.1 ± 3.3 weeks at the time of septostomy and 31.1 ± 4.4 weeks at delivery. Rapid accumulation of fluid around the ‘stuck’ fetus occurred in all cases following a single procedure. Three of the 24 fetuses died in utero and 1 died on the fifth day of life, for a combined survival of 83.3%. In the survivors, the septostomy to delivery interval ranged between 0.6 and 13 weeks (mean ± SD 8.3 ± 4.8). Conclusion: Amniotic septostomy is a promising new method for the management of TOPS and is associated with survival rates that are better than, or comparable to, more invasive modalities. A multicenter trial comparing septostomy to other modalities is warranted.

A prospective, randomized, multicenter trial of amnioreduction vs selective fetoscopic laser photocoagulation for the treatment of severe twin-twin transfusion syndrome

“…The survival with AR is significantly better in the NIH trial (60%) than in the Eurofoetus trial (41%) and consistent with single institution series [6][7][8][9][10][11][12] , a prospective randomized trial 15,16 , and registries (60-65%) 34,35 . This may be due to the standardized aggressive protocol used for serial AR in the NIH trial.…”

“…This inadvertent septostomy has been suggested to account for the "single amnioreduction paradox" in which TTTS appears to stop in up to 20% of patients after only a single AR 36 . Consistent with this view, a prospective randomized trial comparing AR to septostomy found the same 65% survival in each arm of the study 16 . The problem with septostomy has been the risk of creating a mono-amniotic gestation and the attendant risk of cord entanglement with double fetal demise 37 .…”

“…Numerous treatment options for TTTS have been reported, including amnioreduction (AR) [6][7][8][9][10][11][12] , intertwin septostomy [13][14][15][16] , non-selective fetoscopic laser [17][18][19][20] selective fetoscopic laser photocoagulation (SFLP) [21][22][23][24][25][26][27][28] , and cord coagulation [29][30][31][32] , all of which have improved survival rates compared to the untreated natural history of TTTS. It has been controversial which of these treatment options would provide the best outcome in specific cases of TTTS.…”

Amniotic band syndrome following septostomy in management of twin–twin transfusion syndrome: a case report

“…Septostomy using the intentional perforation of the interamniotic membrane to equalize the volume of amniotic fluid in cases of severe TTTS was first introduced by Saade et al 8 Septostomy interrupts the polyhydramnios-oligohydramnios mechanism and induces an amniotic fluid volume increase in the gestational sac of the 'donor' twin, which has been associated with an increase in the circulatory volume, as well as renal perfusion and urinary output. Similarly, septostomy also may benefit the 'recipient' fetus, because when the volume of amniotic fluid and hydrostatic pressure between the gestational sacs are normalized, the inflow of water from the maternal compartment is prevented.…”

“…7 Septostomy, a rupture of the diamniotic membrane separating monozygotic twins essentially creating a monoamniotic gestation, has also been reported as a potential therapeutic modality for TTTS. 3,8 Some complications of septostomy have been reported, including cord entanglement and complete rupture of membranes of both twins, but amniotic band syndrome (ABS) associated with septostomy has never been reported. We report a case of severe ABS with limb amputation after septostomy.…”