An Experience of Laser Surgery for Feto-Fetal Transfusion Syndrome Complicated with Unexpected Feto-Fetal Hemorrhage in a Case of Monochorionic Triamniotic Triplets

Abstract

Feto-fetal transfusion syndrome (FFTS) in monochorionic triplets is a rare clinical entity which may share the principal adverse perinatal outcomes of twin-twin transfusion syndrome. Recently, favorable prognoses regarding morbidity and mortality in twins after selective laser photocoagulation of placental communicating vessels (SLPCV) have been described. But descriptions of this procedure in monochorionic triplet cases are limited. This is the case report of an experience of SLPCV applied to monochorionic triamniotic triplets with FFTS. Triplet A had polyhydramnios, while absent end-diastolic flow in the umbilical artery of triplet B, the triplet with anhydramnios, was persistent. Triplet C looked normal, vertical amniotic pocket and Doppler studies yielding normal results. At the beginning of the SLPCV procedure, feto-fetal hemorrhage, subsequent to the fetal death of the donor triplet, occurred. Both surviving cofetuses showed persistent bradycardia; and 1 fetus died while the other recovered from the fetal bradycardia. All vascular anastomoses between the 3 triplets could be identified and obliterated, requiring two trocars. Our fetoscopic observation revealed feto-fetal hemorrhage after demise of monochorionic triplet, which led to injury of other fetuses due to hypovolemia in an instant. In conclusion, SLPCV might be a valid option for FFTS in triplet cases, while further experience is required in order to evaluate the risks and benefits of this procedure in triplet cases.

Monochorionic Triplets Complicated by Fetofetal Transfusion Syndrome: A Case Series and Review of the Literature

“…Although based on small numbers, these results strongly suggest that laser coagulation is preferable to expectant management or amniodrainage [17]. Five successful cases of MC triplet gestations (with 3 survivors) treated with laser coagulation were reported (including the cases in our study) [2,7,8,9,10,21], but 11 other cases were not successful.…”

“…From 1990 to 2010, 22 articles met the inclusion criteria and we identified 25 MC and 97 DC triplet pregnancies with TTTS [2,3,6,7,8,9,10,11,12,13,14,15,16,17,18,19,21,22,23,24,25]. Quintero stage, in the reported cases including the cases in this study, was stage I in 7% (2/27) stage II in 15% (4/27), stage III in 45% (12/27) and stage IV in 33% (9/27) of the MC triplets.…”

Twin–Twin Transfusion Syndrome and Twin Anemia–Polycythemia Sequence in a Monochorionic Triamniotic Pregnancy

“…The invasive management of TTTS in monochorionic triplet pregnancies with laser photocoagulation bears the risk of intra-uterine death (Chmait et al, 2009;Diemert et al, 2010;Ishii et al, 2006;Sepulveda et al, 2005;Van Shoubroeck et al, 2004) and TAPS (Lopriore et al, 2007;Robyr et al, 2006). Laser photocoagulation is technically challenging in these pregnancies (Chmait et al, 2009;Diemert et al, 2010;Sepulveda et al, 2005;Van Shoubroeck et al, 2004) and is best performed by teams with extensive experience in the treatment of TTTS in monochorionic twin pregnancies.…”

“…In this report, the overall survival was 61% following laser photocoagulation, which was not different from the survival after amnioreduction (Chmait et al, 2009). Poor outcomes from laser photocoagulation reported in other studies (Ishii et al, 2006;Sepulveda et al, 2005) may be attributed to the technical difficulty and complexity of laser photocoagulation in monochorionic triplet pregnancies (Chmait et al, 2009;Diemert et al, 2010;Sepulveda et al, 2005;Van Shoubroeck et al, 2004).…”

Triplets with feto-fetal transfusion syndrome treated with laser ablation: The USFetus experience

“…Data regarding treatment of FFTS in triplets are scant. Reports of amnioreduction [2,[5][6][7][8][9], umbilical cord occlusion [10][11][12][13][14][15], and fetoscopic laser ablation of vascular communications [13,16,17] have involved relatively few patients. The largest case series of fetoscopic laser surgery in triplets with FFTS is from a single institution which reported 10 cases over a 6-year period [16].…”