Pregnancy outcomes associated with chorioamnion membrane separation severity following fetoscopic laser surgery for twin‐twin transfusion syndrome

Abstract

ObjectiveWe tested the hypothesis that increasing severity of chorioamnion membrane separation (CAS) after fetoscopic laser surgery (FLS) for twin‐twin transfusion syndrome (TTTS) is associated with worse pregnancy outcomes.MethodsProspective cohort of patients undergoing FLS for TTTS between 2011 and 2018. CAS was defined as separation of fetal membranes from the uterine wall on post‐operative ultrasound. Patient groups were defined: Group 1: No CAS; Group 2: CAS lower than 50th centile; Group 3: CAS upper than 50th centile or complete CAS. Comparative analysis was performed.ResultsOf 387 patients meeting inclusion criteria, 29 (7.5%) had CAS (median 9.8 mm [4.9‐30.8 mm]). Group 1 patients were more likely to undergo FLS at later gestational age, had increased recipient maximum vertical pocket, and higher amnioreduction volume than Group 3. Group 3 had higher rates of preterm premature rupture of membrane, delivered earlier and were more likely to terminate than Group 1. Group 2 had fewer neonatal survivors than Group 1. Survival analysis for gestational age at delivery and Cox proportional hazards model indicated increased risk for early delivery in Groups 2 and 3 compared with Group 1.ConclusionsPatients with CAS ≥9.8 mm or complete CAS after FLS for TTTS had worse obstetric and neonatal outcomes.

Perinatal outcomes of iatrogenic chorioamniotic separation following fetoscopic surgery: systematic review and meta‐analysis

“…With respect to TTTS pregnancies, sensitivity analysis identified no significant change in the findings of this meta-analysis in terms of GA at intervention, interval from intervention to delivery, PPROM < 34 weeks of gestation, preterm delivery < 32 weeks of gestation and neonatal survival. However, after removing the studies by Papanna et al 6 , Ortiz et al 15 and Bergh et al 1 , GA at delivery was not significantly different between TTTS pregnancies and those not complicated by iCAS.…”

“…The pooled results of this systematic review and meta-analysis confirm that earlier GA at the time of intervention is associated with higher odds of iCAS. This finding could be attributed to increased risk of interference Ortiz (2016) 15 Takano (2018) 10 Total (95% CI) Heterogeneity: τ 2 = 0.68; χ 2 = 20.26, df = 4 (P = 0.0004); I 2 = 80% Test for overall effect: Z = 2.53 (P = 0.01) Ortiz (2016) 15 Takano (2018) 10 De Zoysa (2020) 8 Bergh (2020) 1 Total (95% CI) Heterogeneity: τ 2 = 2.46; χ 2 = 29.95, df = 5 (P < 0.0001); I 2 = 83% Test for overall effect: Z = -0.10 (-0.58 to 0.38) De Zoysa (2020) 8 Bergh (2020) 1…”

“…The main limitation of this systematic review is the variation in the timing of follow-up after fetal intervention in the included studies. This is particularly relevant in TTTS cases as some studies reported on development of iCAS in the immediate postoperative period (first 1 or 2 days after the intervention) 1,6 , which could have created selection bias as some of the non-iCAS cases could have developed this complication later on during pregnancy. Another limitation is inability to comment on the degree of severity of iCAS.…”

“…While some studies have suggested an association between iatrogenic CAS (iCAS) following fetal intervention and adverse perinatal outcomes 1,[6][7][8] , others did not support those observations or reported conflicting results about the severity of the outcomes 9,10 . Moreover, there is no consensus on the optimal method for antenatal surveillance and management of pregnancy complicated by iCAS.…”

Risk Factors Associated with Preterm Prelabor Rupture of Membranes after Cord Occlusion in Monochorionic Diamniotic Twins

“…Several studies have tried to identify the risk factors that contribute to the occurrence of PPROM, mainly after the laser coagulation for TTTS, but conclusions remain inconsistent [1, 3, 7, 8, 27]. It has been reported that when the membrane trauma is complicated by chorioamniotic membrane separation [6, 28-31] or septostomy [5, 32, 33], the rates of PPROM are higher. CO shares several technical similarities with fetoscopic laser coagulation for TTTS; however, the risk factors for PPROM after CO have been poorly studied.…”