What is the impact of placental tissue damage after laser surgery for twin-twin transfusion syndrome? A secondary analysis of the Solomon trial

Abstract

Placental damage is positively associated with more laser energy but negatively associated with higher power setting. More placental damage was associated with a lower GA at birth, shorter laser-to-delivery interval and higher PPROM rate. Whether these results should lead to a change in surgical technique requires more research, both further ex-vivo experiments on human placentas and clinical studies.

Preterm premature rupture of membranes is a collateral effect of improvement in perinatal outcomes following fetoscopic coagulation of chorionic vessels for twin–twin transfusion syndrome: a retrospective observational study of 1092 cases

“…21,22 Nonetheless, there are concerns that the amount of coagulation required to complete the procedure could lead to significant placental damage, increasing the occurrence of PPROM and preterm birth. 8 In our cohort, surgeries progressively shifted towards the use of a complete 'Solomon' technique between 2012 and 2013, which coincides with a steep rise in perinatal survival ( Figure 2), therefore suggesting a causal relationship. Gradual improvement in skill is also the only reasonable explanation for the survival patterns we observe over time in cases with PPROM (Figure 3, upper panel): it is likely that improving our ability to anticipate and visualise the vascular equator while avoiding breaking through the placenta is especially critical for survival in early cases at high risk of PPROM.…”

“…PPROM at <34 weeks occurs in 28-40% of the cases. 8 In this study, we take advantage of a large cohort of >1000 cases of TTTS operated by fetoscopic laser surgery in a single centre over a 16-year period to describe the impact of improving surgical technique on the outcome and how this affects the incidence of PPROM. Although possible risk factors include access port diameter 2,3,5 and chorionic membrane separation at entry site, 6,7 the impact of refining surgical technique has not been studied, except perhaps for recent reports suggesting an increased risk of PPROM using the 'Solomon' technique.…”

“…Although possible risk factors include access port diameter 2,3,5 and chorionic membrane separation at entry site, 6,7 the impact of refining surgical technique has not been studied, except perhaps for recent reports suggesting an increased risk of PPROM using the 'Solomon' technique. 8 In this study, we take advantage of a large cohort of >1000 cases of TTTS operated by fetoscopic laser surgery in a single centre over a 16-year period to describe the impact of improving surgical technique on the outcome and how this affects the incidence of PPROM. Using survival analyses, we found a continuous increase in PPROM rate together with an overall increase in survival over time.…”

Risk Profiling of the Solomon Technique versus Selective Technique of Fetoscopic Laser Surgery for Twin–Twin Transfusion Syndrome

“…Indeed, the incidence of pPROM after FLS using the selective technique was 34% (46/135), while that after FLS using the Solomon technique was 42% (57/137), which did not amount to a statistically significant difference (OR 1.38,95% CI [.84,2.26]), probably due to the small sample size (Slaghekke et al, 2014). Placental damage is reportedly more frequent in patients undergoing FLS using the Solomon technique than in those using selective technique, and greater placental damage was associated with a higher incidence of pPROM before 32 weeks (Akkermans et al, 2017). Our study additionally confirmed that the Solomon technique was associated with an increased risk of pPROM after FLS.…”

“…However, concerns remain regarding adverse events associated with the Solomon technique as it involves coagulation of the entire vascular equator, including many normal areas of the placenta that lack vascular anastomoses. There have been only two reports describing the adverse events associated with the Solomon technique: one regarding placental abruption (Lanna et al, 2017) and the other regarding preterm premature rupture of the membranes (pPROM; Akkermans et al, 2017). The adverse effects associated with the use of the Solomon technique in the treatment of TTTS remain unclear.…”