Placental Laser Surgery for Severe Previable Feto-fetal Transfusion Syndrome in Triplet Gestation

Abstract

Information on feto-fetal transfusion syndrome (FFTS) in higher-order multifetal gestation is limited. We report outcomes of 10 triplet pregnancies treated by fetoscopic laser occlusion of the chorioangiopagous vessels (FLOC). The study period was August 1992 to August 2008. Inclusion criteria were gestational age < or =25 weeks and ultrasound confirmation of monochorionicity in at least one twin set and FFTS. Treatment included FLOC, exit amnioreduction, and cerclage when indicated. Hospital records, placental pathology, neonatal course, and long term follow-up of the mother and infants were reviewed. There were eight triamnionic dichorionic and two triamnionic monochorionic triplets. Mean maternal age was 29.8 years, and five conceived following in vitro fertilization. FFTS stage at treatment was > or =II in all cases, at a mean gestational age 20.9 +/- 2.2 weeks. Two patients required immediate rescue cerclage, and all 10 had hypoproteinemia and anemia. Mean age at delivery was 31.2 +/- 3.4 weeks, with a mean birth weight 1568.4 +/- 498 g for the live-born fetuses. Twenty-three (77%) fetuses survived, with at least one fetus surviving in 9 (90%) cases. Cerebral ultrasound imaging and neurological examination were normal in all neonates, and clinical follow-up has remained normal at 67.5 +/- 56 months for the group. FLOC is feasible in dichorionic and monochorionic triplet pregnancy complicated by FFTS. Outcomes are comparable to our experience with twins, namely improved perinatal survival and neonatal morbidity when compared with alternative treatments.

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.…”

“…Management options and survival of triplets with TTTS are frequently discussed in the literature [2,6,7,8,9]. Because an MC twin pair can also be part of any other high-order multiple pregnancy, survival rates of MC triplets are often confused with DC triplets, with one pair of MC twins affected by TTTS and one singleton.…”

Endoscopic Placental Laser Coagulation in Dichorionic and Monochorionic Triplet Pregnancies

“…The literature search identified 5 previous studies reporting data on MCTA pregnancies with FFTS treated by endoscopic laser surgery, and the combined data from these studies with ours are shown in table 3 and figure 2 [10][11][12][13]15] . In a total of 29 such pregnancies, the pooled survival rate of at least one baby was 80.6% (95% CI 64.9-92.4), and the overall survival for all babies was 57.5% (95% CI 36.2-77.4); there was significant heterogeneity between the studies.…”

“…In sFGR with abnormal Doppler findings in the umbilical artery of the affected fetus, there is a high risk of perinatal death and handicap for both twins; the management for affected pregnancies presenting at midgestation includes endoscopic laser coagulation of the inter-twin communicating placental vessels or cord occlusion of the FGR twin [4][5][6][7][8] . Few studies in a small number of patients have reported on endoscopic laser coagulation of communicating placental vessels for the management of FFTS in MC or dichorionic (DC) triamniotic (TA) triplet pregnancies complicated by FFTS [9][10][11][12][13][14][15][16] .…”