Fetoscopic laser photocoagulation for twin–twin transfusion syndrome

Abstract

The aim of this study was to review fetoscopic laser photocoagulation (FLP), which ablates placental vascular anastomoses to treat twin–twin transfusion syndrome (TTTS). A review of studies reporting on the procedures, outcomes, complications and nonconventional applications of FLP for TTTS was conducted. FLP has been established as the primary treatment for monochorionic twin pregnancy associated with TTTS at 16–26 weeks. FLP is the only therapy that directly addresses the underlying pathophysiology. The recent technique modification of FLP, referred to as the ‘Solomon technique’, induces selective coagulation to connect the anastomoses ablation sites and has been introduced to reduce residual anastomoses. The perinatal survival following FLP improved significantly with advances in the technique after its introduction. The recent survival rates of both twins and at least one twin are 70% and more than 90%, respectively. However, there is still an 11–14% risk of long‐term neurodevelopment impairment. The premature rupture of membranes that leads to preterm labor is a common complication after FLP. FLP is a valuable treatment option for feto‐fetal transfusion syndrome in triplets and for TTTS after 26 weeks. FLP for selective intrauterine growth restriction may be potentially beneficial when accompanied by abnormal Doppler findings and oligohydramnios. FLP is the optimal treatment option for TTTS at 16–26 weeks of gestation. FLP appears to be applicable in triplets, TTTS after 26 weeks and cases of selective intrauterine growth restriction with abnormal Doppler findings and oligohydramnios. FLP is the most common and successful fetal intervention. Improvement in the neurodevelopmental outcomes after FLP is a future focus.

Twin-to-twin transfusion syndrome neurodevelopmental follow-up study (neurodevelopmental outcomes for children whose twin-to-twin transfusion syndrome was treated with placental laser photocoagulation)

“…The Victorian Fetal Therapy Service (VFTS) is a three-centre collaboration between Monash Health, Mercy Hospital for Women (MHW) and The Royal Women’s Hospital (RWH), with surgery conducted at Monash Health. Reported outcomes have been consistent with international experience [ 14 , 17 , 20 , 21 ], with 68% overall infant survival, and survival of one or more twin/s in 86% of gestations treated.…”

Monochorionic diamniotic twins without twin–twin transfusion syndrome: Severe brain damage in the larger infant

“…MD twins with AFD who do not meet the TTTS criteria but who have abnormal umbilical Doppler parameters have a high risk for poor outcomes . Moreover, in a systematic review, MD twins with type II selective IUGR (defined as persistently absent/reversed umbilical artery flow pattern in the smaller infant) were found to be at high risk for abnormal postnatal brain imaging (intraventricular hemorrhage or periventricular leukomalacia) compared with those with type I (12% vs 2.5%) . In contrast, both of the present infants did not have umbilical Doppler abnormalities but did have poor prognosis with brain abnormalities in the larger infant; therefore, this is considered a rare case.…”

“…Although not a TTTS criterion, amniotic fluid discordance (AFD) or selective intrauterine growth restriction (IUGR) also contributes to poor prognosis. 1,2 Herein, we report the case of the larger infant in MD twins with AFD and selective IUGR who presented with unique cerebral hemorrhagic infarction.…”

Impact of first trimester determination of abnormal cord insertion on twin‐to‐twin transfusion syndrome and other adverse outcomes in monochorionic diamniotic twins: A retrospective cohort study

“…Adverse outcome was defined as the occurrence of IUFD. The definitions of TTTS, sIUGR, and TAPS are described in the Appendix (Tables ) as per the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) practice guidelines . Discordant ratio of birth weight (DRBW) was defined with two live births, calculated using the following formula: ([larger BW−smaller BW]/larger BW) × 100% as described by Hartley et al The prevalence of DRBW more than 25% (BWD 25%) was confirmed.…”