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

Abstract

<b><i>Introduction:</i></b> Preterm prelabor rupture of membranes (PPROM) is a common complication after fetal surgeries. The aim of this study was to assess risk factors for and outcomes after PPROM following cord occlusion (CO) in monochorionic diamniotic (MCDA) pregnancies. <b><i>Methods:</i></b> This was a retrospective cohort study of 188 consecutive MCDA pregnancies treated by bipolar or laser CO, either primarily because of discordant malformation (dMF) or severe selective fetal growth restriction (sFGR), or secondarily when complete bichorionization was not possible in case of twin-to-twin transfusion syndrome (TTTS) or sFGR. Intentional septostomy was performed when needed. The procedure-related PPROM was defined as rupture of membranes <32 weeks’ gestation (PROM <32 weeks). Selected pre-, intra-, and early postoperative variables were analyzed by univariate and binomial logistic regression to determine they are correlated to PROM <32 weeks after CO. <b><i>Results:</i></b> Between 2006 and 2017, 188 cases underwent CO. Diagnosis was TTTS in 28.2% (<i>n</i> = 53), severe sFGR in 49.5% (<i>n</i> = 93), and dMF in 22.3% (<i>n</i> = 42). PROM <32 weeks occurred in 21.3% (<i>n</i> = 40), resulting in worse perinatal outcomes, as preterm birth <32 weeks occurred in 80.7% (vs. 8.3%, <i>p</i> = 0.000), procedure-to-delivery interval was 47.5 days (vs. 125, <i>p</i> = 0.000), gestational age (GA) at birth 30.0 weeks (vs. 37.7 weeks, <i>p</i> = 0.000), and survival 65.0% (vs. 91.1%, <i>p</i> = 0.000). In univariate analysis, indication, anterior placenta, cervical length, GA at surgery, operation time, amniodistention and drainage fluid volumes, chorioamniotic membrane separation, and septostomy were selected as relevant factors to be included in the regression model. In a multivariate analysis, TTTS was the only factor associated to PROM <32 weeks (OR 3.5 CI 95% 1.5–7.9). <b><i>Conclusions:</i></b> PROM <32 weeks after CO increases the risk of preterm delivery. In this cohort, the membrane rupture was more likely when CO was done in the context of TTTS.

A Case Report on Monochorionic Diamniotic Twin Gestation with Rh Negative Pregnancy

“…Although the cause of PPROM is still unknown, environmental, fetal, and maternal variables are believed to play a role in its development (5). About 30% of pregnancies treated with minimally invasive surgery experience preterm prelabor rupture of membranes (PPROM), which raises the risk of prematurity and its related problems [6].…”

Is Spontaneous Preterm Prelabor of Membrane Rupture Irreversible? A Review of Potentially Curative Approaches

“…Iatrogenic mechanical PPROM performed by minimally invasive fetal surgery for severe complications occurs in 27.4% of cases after fetoscopic laser ablation for twin-totwin transfusion syndrome [31], in 28% of cases of umbilical cord ligation and tracheal occlusion [32], and in 50% of cord occlusion in monochorionic diamniotic twins [33]. Fetoscopic surgery, intrauterine fetal shunting for lower urinary tract obstructions (LUTO), and pleural effusions are associated with mechanical PPROM in variable proportions, between 0 and 100%, depending on the complexity of the procedure.…”