Fetal and Maternal Complications after Selective Fetoscopic Laser Surgery for Twin-to-Twin Transfusion Syndrome: A Single-Center Experience

Abstract

Objective: To report the incidence of fetal and maternal complications after selective fetoscopic laser surgery for twin-to-twin transfusion syndrome (TTTS). Methods: A total of 150 cases of TTTS were treated from January 2004 to June 2009 (period 1, 2004–2006, 62 cases; period 2, 2007 to June 2009, 88 cases). Fetal complications (double and single intrauterine fetal death, recurrence of TTTS, twin anemia-polycythemia sequence (TAPS), reversal of TTTS, cerebral lesions in one twin) and maternal complications were recorded, and retrospectively analyzed. Results: Nineteen (12.6%), 58 (38.7%), 61 (40.7%) and 12 cases (8.0%) were classified preoperatively as Quintero stage I, II, III and IV, respectively. The anterior placenta was described in 73 cases (48.6%). Double and single fetal death occurred overall in 7.3 and 36.0% of cases, respectively. The rate of recurrence was 11.3%, of TAPS 3.3%, and of reversal of TTTS 1.3%. Cerebral lesions were diagnosed in 3 donors (2.0%). Eighteen cases (12.0%) of fetal complications had a second procedure (6 repeat laser, 4 serial amnioreduction, 8 bipolar cord coagulation). Pregnancies undergoing a second procedure delivered at a median gestational age of 30.2 weeks compared to 32.1 weeks for those not repeating (p = 0.04). Perinatal survival of at least one twin improved from 66.1 to 79.5% (p = 0.06) in the two consecutive periods. For every 10 laser surgeries performed, there was an average improvement of 1.5% in the predicted percentage of survival of at least one twin (OR 1.09, 95% CI 1.00–1.19). Major maternal complications occurred in 9 cases (6.0%), 3 of which required admission to intensive care unit. Conclusions: Fetal complications are common after fetoscopic laser surgery. In this experience, an increasing number of procedures improved the performance of a new fetoscopic laser center.

Twenty-Five Years of Fetoscopic Laser Coagulation in Twin-Twin Transfusion Syndrome: A Systematic Review

“…After full-text analysis a total of 34 studies were included in the time-based analysis [10,12,13,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48]. Twelve studies [5,49,50,51,52,53,54,55,56,57,58,59] presented data overlapping other series, of which one presented data relevant for the technique-based analysis [58].…”

“…One of the studies enrolled was a randomized controlled trial [13]; there were 13 prospective single-center cohort studies [10,12,18,19,20,22,23,24,25,26,28,30,32], 18 retrospective single-center cohort studies [27,29,31,33,34,35,36,37,38,39,40,41,42,43,44,46,47,59], 2 prospective multicenter cohort studies [21,58] and 3 retrospective multicenter cohort studies [45,48,55]. …”

“…Three authors described their series in two separate cohorts in order to display their learning curve [20,39,42]. Eight studies compared different (adaptations of) laser techniques [12,13,20,21,30,46,48,58].…”

“…These groups were analyzed separately, resulting in 41 subgroups describing survival results for different laser techniques. The non-selective laser technique was used in five series [10,18,19,20,21], 28 series used the selective laser technique [12,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,42,43,45,46,47,48,58], the selective sequential technique was used in five series [12,13,30,41,44], and three series used the Solomon technique [13,46,48]. …”

“…Only 12 (33%) of the included studies reported data on PPROM. Definitions ranged from ‘<37 weeks gestation' to ‘within 7 days after fetoscopy', making comparison of these results impossible [13,27,29,31,32,35,36,38,39,42,46,47]. …”