Perinatal outcome after fetoscopic laser surgery for twin‐to‐twin transfusion syndrome in triplet pregnancies

Abstract

Objectives The introduction of fetoscopic laser surgery of placental anastomoses has led to a significant improvement of perinatal outcome of twin pregnancies affected by twin-to-twintransfusion syndrome (TTTS). To quantify the perinatal outcome and neurological morbidity in triplet pregnancies complicated by TTTS, which were treated with fetoscopic laser surgery.Search strategy Medline, Embase, Cinahl and Cochrane were searched.Selection criteria The outcomes observed were: fetal and perinatal survival, preterm birth and abnormal neurological outcome.Data collection and analysis Two authors reviewed all abstracts independently. Meta-analyses of proportions were used to combine data.Main results Eight studies (126 triplet pregnancies, 104 dichorionic-triamniotic [DCTA] and 22 monochorionictriamniotic [MCTA]) treated with fetoscopic laser surgery were included in this review. In DCTA and MCTA pregnancies, fetal losses were 18.9% and 28.9%, respectively; perinatal losses were 23.6% and 75.0%; preterm births <28 weeks of gestation were 16.9% and 37.1%; preterm births <32 weeks of gestation were 50.0% and 69.5%; at least one fetus survived in 95.4% and 88.9% of the pregnancies; at least two fetuses survived in 81.8% and 68.3% of the pregnancies; and in 55.9% and 48.4% pregnancies all triplets survived. Finally, the incidence of abnormal neurological outcomes ranged from 0 to 37% in DCTA and from 0 to 50% in MCTA triplets.Conclusions Both DTCA and MCTA triplet pregnancies affected by TTTS are at high risk of adverse perinatal outcome.

Perinatal mortality and morbidity in triplet pregnancy according to chorionicity: systematic review and meta‐analysis

“…In our study, the incidence of TTTS in dichorionic triplets was 12.6%. Fetal and perinatal survival rates are lower in triplets than those reported for twin pregnancies 26 .…”

“…In our study, the incidence of TTTS in dichorionic triplets was 12.6%. Fetal and perinatal survival rates are lower in triplets than those reported for twin pregnancies. Although survival of the unaffected triplet is not usually compromised by the hemodynamic imbalance occurring in the monochorionic pair, the entire pregnancy may be at risk of miscarriage or early preterm labor.…”

Perinatal outcomes of fetoscopic laser surgery for twin–twin transfusion syndrome in triplet pregnancy: cohort study, systematic review and meta‐analysis

“…However, with the accumulation of data and improvement in surgical skills over the years, more recent studies, including our cohort study and systematic review, have demonstrated no difference in survival between DCTA and MCTA triplets. Moreover, compared with a meta‐analysis published in 2016 10 , our systematic review showed a higher rate of fetal survival in MCTA triplet pregnancies, including fetal survival of at least two (90% vs 85%) and three (53% vs 39%) triplets. Although the difference in median FLP‐to‐delivery interval was not significant, it was 38 days longer in MCTA triplets, which might have improved survival outcomes.…”

“…The survival rate of both twins has increased from 35% to 65% with the use of FLP in MC twin pregnancies 8 . In addition, FLP significantly improved the postnatal neurological outcome compared with that of the more conventional treatment approach of amnioreduction 9 , and a promising role of FLP has been reported in numerous studies 10,11 . Management options and survival of triplets with TTTS are frequently discussed in the literature 12–15 .…”

Outcome of monochorionic triamniotic triplet pregnancies: Expectant management versus fetal reduction

“…This seems somewhat lower than the 8%–17.6% and 10%–15% that was previously reported in MCTA triplets and MCDA twins respectively, 11,18,19 which need further large sample and collaborative evaluation in the future. A recent systematic review about the perinatal outcome after fetoscopic laser surgery for TTTS in 22 MCTA triplets revealed that all three fetuses survived in 48.4% of the pregnancies and at least one triplet survived in 88.9% pregnancies, indicating that this technique is feasible for treatment of this condition 20 . Similarly, our MCTA triplet with TTTS was treated successfully with endoscopic laser and continued to delivery with 3 live fetuses.…”