Placental surgery: A new frontier

Lia, Julian E. De; Kuhlmann, Randall S.; Cruikshank, D. P.; O'Bee, Lillie R.

doi:10.1016/s0143-4004(05)80201-2

Cited by 36 publications

(13 citation statements)

References 19 publications

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“…In the early days of laser surgery, this was an issue of contention. The original reports suggested that the anastomoses could be identified based on their appearance, that is, based on specific patterns, angles, with drawings intended to aid in this process (identification based on pattern recognition; De Lia et al, 1993). Unfortunately, this was not conducive, given the myriad of patterns that the anastomoses can actually have.…”

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confidence: 99%

Laser Treatment of Twin–to–Twin Transfusion Syndrome

2016

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Objective: Laser ablation of all placental vascular anastomoses is the optimal treatment for twin-twin transfusion syndrome (TTTS). However, two important controversies are apparent in the literature: (a) a gap between concept and performance, and (b) controversy regarding whether all the anastomoses can be identified endoscopically and whether blind lasering of healthy placenta is justified. The purpose of this article is: (a) to address the potential source of the gap between concept and performance by analyzing the fundamental steps needed to successfully accomplish the surgery, and (b) to discuss the resulting competency benchmarks reported with the different surgical techniques. Materials and Methods: Laser surgery for TTTS can be broken down into two fundamental steps: (1) endoscopic identification of the placental vascular anastomoses, (2) laser ablation of the anastomoses. The two steps are not synonymous: (a) regarding the endoscopic identification of the anastomoses, the non-selective technique is based upon lasering all vessels crossing the dividing membrane, whether anastomotic or not. The selective technique identifies and lasers only placental vascular anastomoses. The Solomon technique is based on the theory that not all anastomoses are endoscopically visible and thus involves lasering healthy areas of the placenta between lasered anastomoses, (b) regarding the actual laser ablation of the anastomoses, successful completion of the surgery (i.e., lasering all the anastomoses) can be measured by the rate of persistent or reverse TTTS (PRTTTS) and how often a selective technique can be achieved. Articles representing the different techniques are discussed. Results: The non-selective technique is associated with the lowest double survival rate (35%), compared with 60-75% of the Solomon or the Quintero selective techniques. The Solomon technique is associated with a 20% rate of residual patent placental vascular anastomoses, compared to 3.5-5% for the selective technique (p < .05). Both the Solomon and the selective technique are associated with a 1% risk of PRTTTS. Adequate placental assessment is highest with the selective technique (99%) compared with the Solomon (80%) or the 'standard' (60%) techniques (p < .05). A surgical performance index is proposed. Conclusion: The Quintero selective technique was associated with the highest rate of successful ablation and lowest rate of PRTTTS. The Solomon technique represents a historical backward movement in the identification of placental vascular anastomoses and is associated with higher rate of residual patent vascular communications. The reported outcomes of the Quintero selective technique do not lend support to the existence of invisible anastomoses or justify lasering healthy placental tissue.

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confidence: 99%

Laser Treatment of Twin–to–Twin Transfusion Syndrome

2016

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“…This is true of artery/vein pairs connected to the same cord or to two cords. It means that an a->v an can always be recognized as such at fetoscopy (De Lia et al, 1993;Quintero et al, 1998) or post-partum injection, and this anatomic relationship has also been observed recently by Doppler ultrasound Taylor, Farquharson, et al, 2000).…”

Section: And MC Twin Placentasmentioning

confidence: 59%

Placentation in Multiple Births

Machin¹

2001

Twin res.

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O utcomes of multifetal pregnancy in prenatal life are markedly affected by chorionicity. Several disease processes are found in monochorionic (MC) twins that do not occur in dichorionic (DC) twins. Improvements in prenatal outcomes will depend on reliable first trimester diagnosis of chorionicity, allowing early monitoring for complications of MC placentation. Particular structures and functions of MC twin placentas affect outcomes and can be targeted for specific treatments, especially in twin-twin transfusion. The causes of severe DC twin fetal growth discordance are clarified. In post-natal life, zygosity is a determining effect in genetic predisposition to many chronic diseases, including neoplasia. Few MC twins know that they are monozygotic (MZ). Few twin researchers realize that MZ twins may be genetically discordant. Abandonment of the word "identical" for MZ twins would assist in clarifying these issues of zygosity, concordance and discordance.Chorionicity (C) and zygosity (Z) are closely related. For optimal prenatal care of twins, knowledge of C is paramount. Unfortunately, it is not universally available. In addition, secure knowledge of Z is important in several aspects of life-long health care in twins. Finally, information on C and Z is important to twin researchers, but often is unavailable or incorrect. Matters are not infrequently compounded by the fact that most people (including twin researchers) fail to realize that MZ twins are not necessarily (or possibly ever) genetically identical (Keith & Machin, 1997). Similarly, the fact that they have occupied the same womb does not guarantee that they have experienced the same environmental events (Machin & Keith, 1999). Whereas this paper is primarily about the subject of placentation, the issue of Z must always remain in the background. To the extent that there are any simple rules about Z and C, they are as follows: 1) unlike-sexed twins are usually DZ (exception: 46,XY/45,X MZ twins; Schmid et al., 2000); 2) MC twins are usually MZ (only one known exception; Bieber et al., 1983); 3) Like-sexed (LS) DC twins may be MZ or DZ; 4) Whereas DZ twins are always DC, MZ twins may be DC or MC; however, the majority are MC. MZ twins can have either MC or DC placentation.The first axiom of understanding placentation in twins is the recognition that the MC placenta, whether DA or MA, mimics the structure of a singleton placenta and was designed to function as such. Because it never was 2 placentas that subsequently fused, it is not surprising that most of the adverse outcomes in MC twins result from the structure of their MC placenta per se. Whereas both types of twin pregnancies (MZ and DZ) have risks of "common denominator" disorders such as pre-eclampsia, pre-term labor and PROM, DC twins constitute relatively low-risk pregnancies compared with MC twins. If the diagnosis of MC twins is not made with certainty in the first trimester, most of the special complications of MC placentation will already be at an advanced stage by the time of dating ultrasound ...

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“…Because this syndrome can now be diagnosed prenatally with some degree of certainty (Lachapelle et al, 1997), numerous attempts are made to treat or to eliminate the syndrome before birth. Most successful is the interruption of the offensive anastomoses by laser coagulation in utero (De Lia et al, 1993). This is but one reason why it is essential that the surgeon acquires a good understanding of the placental vascular anatomy.…”

Section: Multiple Pregnancymentioning

confidence: 99%

Remarkable placenta

Benirschke

1998

Clin. Anat.

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Placental surgery: A new frontier

Cited by 36 publications

References 19 publications

Laser Treatment of Twin–to–Twin Transfusion Syndrome

Laser Treatment of Twin–to–Twin Transfusion Syndrome

Placentation in Multiple Births

Remarkable placenta

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