Treatment and outcome of 370 cases with spontaneous or post‐laser twin anemia–polycythemia sequence managed in 17 fetal therapy centers

Tollenaar, Lisanne S.A.; Slaghekke, Femke; Lewi, Liesbeth; Ville, Y.; Lanna, M.; Weingertner, Anne Sophie; Ryan, Greg; Arévalo, Sílvia; Khalil, Asma; Brock, Clifton O.; Klaritsch, Philipp; Hecher, Kurt; Gardener, Glenn; Bevilacqua, Elisa; Kostyukov, Kostyukov K.V.; Bahtiyar, Mert O.; Kilby, Mark; Tiblad, Eleonor; Oepkes, Dick; Lopriore, Enrico; Middeldorp, Johanna M.; Haak, Monique; Klumper, Frans; Akkermans, Joost; Delagrange, Hannelore; Pandya, Viral M.; Faiola, S.; Favre, R.; Hobson, Sebastian; Rodó, Carlota; Thilaganathan, B.; Papanna, Ramesha; Greimel, Patrick; Sousa, M Tavares de; Carlin, Andrew; Гладкова, К.А.; Copel, Joshua A.

doi:10.1002/uog.22042

Cited by 38 publications

(38 citation statements)

References 23 publications

(37 reference statements)

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“…Illustratively, we found a high rate (40%) of residual anastomoses in twins treated with laser reintervention. A detailed evaluation of differences in perinatal outcome between the various management strategies will be presented in a separate study [26].…”

Section: Discussionmentioning

confidence: 99%

Post-Laser Twin Anemia Polycythemia Sequence: Diagnosis, Management, and Outcome in an International Cohort of 164 Cases

Tollenaar

Lopriore

Faiola

et al. 2020

JCM

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The aim of this study was to investigate the management and outcome in the post-laser twin anemia polycythemia sequence (TAPS). Data of the international TAPS Registry, collected between 2014 and 2019, were used for this study. The primary outcomes were perinatal mortality and severe neonatal morbidity. Secondary outcomes included a risk factor analysis for perinatal mortality and severe neonatal morbidity. A total of 164 post-laser TAPS pregnancies were included, of which 92% (151/164) were diagnosed antenatally and 8% (13/164) postnatally. The median number of days between laser for TTTS and detection of TAPS was 14 (IQR: 7–28, range: 1–119). Antenatal management included expectant management in 43% (62/151), intrauterine transfusion with or without partial exchange transfusion in 29% (44/151), repeated laser surgery in 15% (24/151), selective feticide in 7% (11/151), delivery in 6% (9/151), and termination of pregnancy in 1% (1/151). The median gestational age (GA) at birth was 31.7 weeks (IQR: 28.6–33.7; range: 19.0–41.3). The perinatal mortality rate was 25% (83/327) for the total group, 37% (61/164) for donors, and 14% (22/163) for recipients (p < 0.001). Severe neonatal morbidity was detected in 40% (105/263) of the cohort and was similar for donors (43%; 51/118) and recipients (37%; 54/145), p = 0.568. Independent risk factors for spontaneous perinatal mortality were antenatal TAPS Stage 4 (OR = 3.4, 95%CI 1.4-26.0, p = 0.015), TAPS donor status (OR = 4.2, 95%CI 2.1–8.3, p < 0.001), and GA at birth (OR = 0.8, 95%CI 0.7–0.9, p = 0.001). Severe neonatal morbidity was significantly associated with GA at birth (OR = 1.5, 95%CI 1.3–1.7, p < 0.001). In conclusion, post-laser TAPS most often occurs within one month after laser for TTTS, but may develop up to 17 weeks after initial surgery. Management is mostly expectant, but varies greatly, highlighting the lack of consensus on the optimal treatment and heterogeneity of the condition. Perinatal outcome is poor, particularly due to the high rate of perinatal mortality in donor twins.

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Section: Discussionmentioning

confidence: 99%

Post-Laser Twin Anemia Polycythemia Sequence: Diagnosis, Management, and Outcome in an International Cohort of 164 Cases

Tollenaar

Lopriore

Faiola

et al. 2020

JCM

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“…The indications for RFA included TRAPS, TTTS, TAPS, sFGR, discordant fetal anomalies and MFPR for triplets and quadruplets with a MC component. Chorioamnionicity, complications and indications for intervention were determined as reported in our previous publications 1–4,16,17 . In particular, regarding the timing of intervention, cases of TRAPS with evidence of a compromised pump twin were indicated for early therapeutic intervention, before 16 weeks, while parents in cases without a compromised pump twin were counseled about the risk of spontaneous loss of 33% 5 and offered the option of early prophylactic intervention.…”

Section: Methodsmentioning

confidence: 99%

Outcome of radiofrequency ablation for selective fetal reduction before vs at or after 16 gestational weeks in complicated monochorionic pregnancy

Ting

Poon

Tse

et al. 2021

Ultrasound in Obstet & Gyne

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Objective To investigate whether gestational age at intervention (< or ≥ 16 weeks) and other factors affect the risk of loss of the cotwin after selective fetal reduction using radiofrequency ablation (RFA) in monochorionic (MC) pregnancy. Methods This was a single‐center retrospective analysis of 63 consecutive RFA procedures performed at our institution from January 2011 to October 2019 for selective fetal reduction in complicated MC pregnancies. Indications for RFA were twin reversed arterial perfusion sequence (13 cases), twin‐to‐twin transfusion syndrome (12 cases), twin anemia–polycythemia sequence (two cases), selective fetal growth restriction (10 cases), discordant anomalies (17 cases) and multifetal pregnancy reduction in triplets or quadruplets with a MC pair (nine cases). Twenty‐six (41.3%) of these procedures were performed before and 37 (58.7%) after 16 weeks. Potential factors that could affect the risk of loss of the cotwin, including gestational age at RFA, order of multiple pregnancy, amnionicity, indication for RFA and number of ablation cycles, were assessed first by univariate analysis and then by multivariate analysis. Results There were 17 (27.0%) cotwin losses. Ablation cycles numbering four or more was the only factor among those investigated to be associated with loss of the cotwin after RFA (P = 0.035; odds ratio, 5.21), while the indication for RFA, order of multiple pregnancy, amnionicity and gestational age at RFA had no effect. Comparing RFA performed at < 16 vs ≥ 16 weeks, there was no difference in the rate of cotwin loss (23.1% vs 29.7%; P = 0.558) or preterm prelabor rupture of the membranes before 34 weeks (7.7% vs 5.4%; P = 0.853), or in the median gestational age at delivery (36.2 vs 37.3 weeks; P = 0.706). Conclusions RFA is a promising tool for early selective fetal reduction in MC pregnancy before 16 weeks. Four or more ablation cycles is a major risk factor for cotwin loss. Careful assessment pre‐ and post‐RFA, together with proficient operative skills to minimize the number of ablation cycles, are the mainstay to ensure that this procedure is effective and safe. © 2020 International Society of Ultrasound in Obstetrics and Gynecology

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“…However, evidence concerning the effectiveness of IUT for complicated MCDA twin pregnancy is lacking. According to a recent, large‐scale, retrospective review of TAPS cases, the perinatal mortality rate in the IUT group was equal to that in the expectant management group, while the neonatal morbidity rate was higher in the IUT group than in the expectant management group 19 . Regarding acute feto‐fetal transfusion after the co‐twin's demise, although no reports have compared IUT with expectant management, the neurological morbidity rate of surviving twins after IUT was reported to be around 20%, 20 which was not markedly different from that of the natural course.…”

Section: Discussionmentioning

confidence: 99%

Nationwide survey of intrauterine blood transfusion for fetal anemia in Japan

Mizuuchi

Murotsuki

Ishii

et al. 2021

J of Obstet and Gynaecol

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Aim The present study investigated the current situation regarding intrauterine blood transfusion (IUT) for fetal anemia in Japan. Methods We conducted a nationwide, multicenter, retrospective cohort questionnaire survey for cases that underwent IUT from 2011 to 2015. The questionnaire required perioperative information, indications, details of the procedure, procedure‐related complications, and neonatal morbidity. Results A total of 100 IUT procedures were performed in 66 cases at 19 institutions during the study period. The most frequent indication of IUT was complicated monochorionic diamniotic (MCDA) twins in 28 (42.4%) cases, followed by 16 (24.2%) cases of red‐cell alloimmunization, and 10 (15.2%) cases of parvovirus B19 infection. IUT was performed through the umbilical cord in the vast of majority cases (92%). Bleeding from the IUT site was the most common adverse event (40%). Two cases (2%) underwent emergency cesarean section after the procedure. There were no cases of rupture of membrane or intrauterine infection after IUT. The neonatal survival rate was 77.3% in the 66 total cases and 64% in the hydrops cases. The neonatal survival rates in MCDA twins, red‐cell alloimmunization, and parvovirus B19 infection were 75%, 93.8%, and 70%, respectively. Conclusions IUT was performed for mainly three indications in Japan: MCDA twins, red‐cell alloimmunization, and parvovirus B19 infection. The incidences of severe adverse events seemed very low. The outcomes after IUT were favorable with variations in survival rates according to indications. However, further studies with long‐term follow‐up will be required to assess the effectiveness of IUT, especially for complicated MCDA twins.

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Treatment and outcome of 370 cases with spontaneous or post‐laser twin anemia–polycythemia sequence managed in 17 fetal therapy centers

Cited by 38 publications

References 23 publications

Post-Laser Twin Anemia Polycythemia Sequence: Diagnosis, Management, and Outcome in an International Cohort of 164 Cases

Post-Laser Twin Anemia Polycythemia Sequence: Diagnosis, Management, and Outcome in an International Cohort of 164 Cases

Outcome of radiofrequency ablation for selective fetal reduction before vs at or after 16 gestational weeks in complicated monochorionic pregnancy

Nationwide survey of intrauterine blood transfusion for fetal anemia in Japan

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