Neurodevelopmental Outcomes After Laser Therapy for Twin–Twin Transfusion Syndrome

Rossi, A. Cristina; Vanderbilt, Douglas; Chmait, Ramen H.

doi:10.1097/aog.0b013e318231827f

Cited by 82 publications

(78 citation statements)

References 23 publications

(32 reference statements)

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“…The average gestational age at delivery after procedure ranges between 29 to 33 wk (1,5). Aside from the cost of caring for the premature infants, preterm delivery is directly associated with long-term neurological deficits in TTTS (4,6), undermining the complete benefits of such intervention. PPROM which affects 20-32% of cases is the most important risk factor leading to preterm delivery (2,(7)(8)(9)(10).…”

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Histologic changes of the fetal membranes after fetoscopic laser surgery for twin-twin transfusion syndrome

et al. 2015

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Background: Preterm premature rupture of membranes remains a major complication after fetoscopic laser surgery (FLS) for twin-twin transfusion syndrome (TTTS). We studied the histologic changes of fetal membranes post-FLS and investigated a possible impact of amniotic fluid (AF) dilution. Methods: Fetal membranes of 31 pregnancies that underwent FLS for TTTS were investigated histologically at delivery at different sites: trocar site of recipient sac and at distance, donor sac, and inter-twin membrane. results: The trocar insertion site on the recipient sac showed no signs of histologic hallmarks of healing. Wide-spread alteration in collagen organization and higher apoptotic index in the amnion of the recipient sac which were absent in donor's and reference membranes. To explain the mechanisms, we analyzed the AF composition of recipient sacs from TTTS pregnancies vs. GA-matched healthy singleton controls and found glucose, protein and lactate dehydrogenase activity were all significantly lower in TTTS sacs consistent with over-dilution of recipient's AF (~2-fold). In-vitro exposure of healthy amniochorion to analogous dilutional stress conditions recapitulated the histologic changes and induced apoptosis and autophagy. conclusion: Alteration in structural integrity of the recipient's amniochorion, possibly in response to dilution stress, along with ineffective repair mechanisms may explain the increased incidence of preterm birth post-FLS.d espite the success of fetoscopic laser surgery (FLS) for the treatment of severe twin-twin transfusion (TTTS), preterm delivery with or without preterm premature rupture of membranes (PPROM) remains a major complication (1-4). The average gestational age at delivery after procedure ranges between 29 to 33 wk (1,5). Aside from the cost of caring for the premature infants, preterm delivery is directly associated with long-term neurological deficits in TTTS (4,6), undermining the complete benefits of such intervention. PPROM which affects 20-32% of cases is the most important risk factor leading to preterm delivery (2,7-10).Considered a minimally invasive procedure, FLS necessitates the insertion of a trocar into the amniotic cavity of the recipient twin to allow for insertion of the fetoscope (through a cannula which stays in place throughout the procedure) (11). A laser is used to seal the abnormal blood vessel anastomoses between the monochorionic twin placentas. Lastly, the surgeon performs an amnioreduction to relieve the recipient's polyhydramnios by draining the excess amniotic fluid (AF) through the cannula before removing it. During the procedure to allow proper visualization due to the inadvertent loss of amniotic fluid through cannula port or due to cloudy AF, it is customary for the surgeon to remove a volume of AF and replace it via amnioinfusion with a solution of Lactated Ringer's (LR).Fetal membranes are the outermost layer of fetal compartment in apposition to maternal decidua. The amniotic layer of the fetal membranes is made up of a lining of cuboidal epithe...

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Histologic changes of the fetal membranes after fetoscopic laser surgery for twin-twin transfusion syndrome

et al. 2015

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“…In twins treated with laser therapy the incidence of major cerebral injury is approximately 6% without differences between donors and recipients. 21 Cerebral palsy is the most common adverse neurological outcome. 21 In addition, about 11% of twins affected with TTTS treated with intrauterine laser ablation manifest neurological damage during infancy.…”

Section: Postoperative Managementmentioning

confidence: 99%

Diagnosis and Management of Twin-Twin Transfusion Syndrome

Rossi¹,

Addario²

2012

Donald School Journal of Ultrasound in Obstetrics and Gynecology

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Twin-twin transfusion syndrome (TTTS) is a complication unique to monochorionic twin pregnancies, in which the two twins share a common placenta and unequal blood exchange from one twin (donor) to the cotwin occurs through placental arterovenous anastomoses. The diagnosis is posed with the sonographic detection of oligohydramnios in the donor's sac, as a consequence of hypovolemia, and polyhydramnios in the recipient's sac, resulting from hypervolemia. The severity of TTTS is assessed according to Quintero staging system, which is based on five stages that range from visualization of the donor's bladder to intrauterine demise of one or both twins. Because laser therapy has revealed the optimal treatment for TTTS, management of twins affected with TTTS consists in preoperative and postoperative assessment of the twins by ultrasound examination. The aim of this review was to describe the diagnosis and management of TTTS and discuss controversies and limitations of current literature.

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“…Cerebral injury in TTTS treated with laser surgery is not fully prevented. Periventricular hemorrhagic infarction, and ischemic white matter damage have been detected antenatally in fetuses treated with laser therapy for TTTS 6 . The incidence of cerebral damage may be underestimated because neurodevelopmental impairments and intellectual disability may manifest several months or years after birth 6 .…”

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Twin-twin transfusion syndrome: neurodevelopmental screening test

Arias

Campos

Campos-Zanelli

et al. 2015

Arq. Neuro-Psiquiatr.

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Objective: To assess the neurodevelopmental functions (cognition, language and motor function) of survivors of twin-twin transfusion syndrome (TTTS). Method: Observational cross-sectional study of a total of 67 monochorionic diamniotic twins who underwent fetoscopic laser coagulation (FLC) for treatment of TTTS. The study was conducted at the Center for Investigation in Pediatrics (CIPED), Universidade Estadual de Campinas. Ages ranged from one month and four days to two years four months. Bayley Scales of Infant and Toddler Development Screening Test-III, were used for evaluation. Results: Most children reached the competent category and were classified as having appropriate performance. The preterm children scored worse than term infants for gross motor subtest (p = 0.036). Conclusion: The majority of children reached the expected development according to their age. Despite the good neurodevelopment, children classified at risk should be monitored for development throughout childhood.Keywords: child, child development, diseases in twins, fetofetal transfusion. RESUMOObjetivo: Avaliar as funções do desenvolvimento neurológico (cognição, linguagem e motricidade) de sobreviventes da síndrome de transfusão feto-fetal (STFF). Método: Estudo transversal observacional, total de 67 gêmeos diamnióticos monocoriônicos submetidos à coagulação a laser por fetoscopia para o tratamento da STFF. O estudo foi realizado no Centro de Investigação em Pediatria (CIPED), Universidade Estadual de Campinas. A idade variou entre um mês e quatro dias a dois anos e quatro meses. Foram utilizadas as Bayley Scales of Infant and Toddler Development Screening Test-III para avaliação. Resultados: A maioria das crianças atingiu a categoria competente e foi classificada como tendo desempenho adequado. As crianças prematuras obtiveram desempenho inferior quando comparadas às nascidas a termo no subteste motor global (p = 0,036). Conclusão: A maioria das crianças alcançou o desenvolvimento esperado de acordo para idade. Apesar do bom desenvolvimento neurológico, crianças classificadas na categoria de risco devem ser monitoradas para o desenvolvimento, durante a infância.Palavras-chave: criança, desenvolvimento infantil, doenças em gêmeos, transfusão feto-fetal.Twin-twin transfusion syndrome (TTTS) occurs in approximately 10%-15% of all monochorionic diamniotic twin pregnancies, develops typically between 15 and 26 weeks of gestation and is associated with a high perinatal morbidity and mortality 1,2,3 . The pathophysiology of TTTS is an unbalanced transfusion of blood across placental vascular anastomoses from one twin (donor) to the other (recipient). Twin-twin transfusion syndrome results in a volume-depleted donor twin with signs of oliguria and oligo/anhydramnios and a volumeoverloaded recipient twin with polyuria and polyhydramnios, which may lead to impairment of various organ systems in both affected twins 4 . Serial amnioreduction and fetoscopic laser coagulation (FLC) of placental anastomoses are the two main treatment options...

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Neurodevelopmental Outcomes After Laser Therapy for Twin–Twin Transfusion Syndrome

Abstract: A small number (11.1%) of cases of twin-twin transfusion syndrome treated with laser therapy are affected with neurologic impairment that manifests during infancy. A strict follow-up of apparently healthy neonates is warranted.

Cited by 82 publications

References 23 publications

Histologic changes of the fetal membranes after fetoscopic laser surgery for twin-twin transfusion syndrome

Histologic changes of the fetal membranes after fetoscopic laser surgery for twin-twin transfusion syndrome

Diagnosis and Management of Twin-Twin Transfusion Syndrome

Twin-twin transfusion syndrome: neurodevelopmental screening test

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