Obstet Gynecol Sci.  2018 Jul;61(4):461-467. 10.5468/ogs.2018.61.4.461.

Fetoscopic laser photocoagulation for twin-to-twin transfusion syndrome treatment: initial experience in tertiary reference center in Brazil

• Barbosa MM
• Martins Santana EF
• Milani HJ
• Elito Júnior J
• Araujo Júnior E
• Moron AF
• Nardozza L

• KMID: 2439719
• DOI: http://doi.org/10.5468/ogs.2018.61.4.461

Abstract

OBJECTIVE
To evaluate the initial maternal and perinatal outcomes of fetoscopic laser photocoagulation for the treatment of twin-to-twin transfusion syndrome (TTTS) in a referral center in Brazil.
METHODS
This prospective observational study analyzed 24 fetoscopic laser photocoagulation procedures at 18-26 weeks of gestation. TTTS severity was determined using the Quintero classification. Blood vessels that crossed the interamniotic membrane were nonselectively photocoagulated. The χ2 test and Mann-Whitney U test were used for the statistical analysis.
RESULTS
The mean (±standard deviation) age of pregnant women, gestational age at surgery, surgical time, gestational age at birth, and newborn weight were 32.2±4.1 years, 20.7±2.9 weeks, 51.8±16.7 minutes, 30.5±4.1 weeks, and 1,531.0±773.1 g, respectively. Using the Quintero classification, there was a higher percentage of cases in stage III (54.2%), followed by stages IV (20.8%), II (16.7%), and I (8.3%). Ten (41.7%) donor fetuses died and 14 (58.3%) donor fetuses survived until the end of gestation. Placental insertion location (anterior vs. posterior) did not affect the incidence of iatrogenic septostomy, surface bleeding, and premature rupture of membranes until the end of gestation. The death rate of donor and recipient fetuses before 24th gestational week increased with severity of TTTS.
CONCLUSION
The maternal and perinatal outcomes resulting from the implementation of a new minimally invasive surgical technique are in line with those obtained in major centers worldwide, considering the learning curves and infrastructures.

Keyword

Twin-to-twin transfusion syndrome; Fetoscopy; Lasers; Perinatal mortalities

MeSH Terms

Blood Vessels
Brazil*
Classification
Female
Fetofetal Transfusion*
Fetoscopy
Fetus
Gestational Age
Hemorrhage
Humans
Incidence
Infant, Newborn
Learning Curve
Light Coagulation*
Membranes
Mortality
Observational Study
Operative Time
Parturition
Perinatal Mortality
Pregnancy
Pregnant Women
Prospective Studies
Referral and Consultation
Rupture
Tissue Donors

Reference

1. Lewi L, Deprest J, Hecher K. The vascular anastomoses in monochorionic twin pregnancies and their clinical consequences. Am J Obstet Gynecol. 2013; 208:19–30.

2. Lewi L, Jani J, Blickstein I, Huber A, Gucciardo L, Van Mieghem T, et al. The outcome of monochorionic diamniotic twin gestations in the era of invasive fetal therapy: a prospective cohort study. Am J Obstet Gynecol. 2008; 199:514.e1–514.e8.

3. Saade GR, Belfort MA, Berry DL, Bui TH, Montgomery LD, Johnson A, et al. Amniotic septostomy for the treatment of twin oligohydramnios-polyhydramnios sequence. Fetal Diagn Ther. 1998; 13:86–93.

4. de Villiers SF, Slaghekke F, Middeldorp JM, Walther FJ, Oepkes D, Lopriore E. Arterio-arterial vascular anastomoses in monochorionic placentas with and without twin-twin transfusion syndrome. Placenta. 2012; 33:652–654.

5. Lewi L, Gucciardo L, Huber A, Jani J, Van Mieghem T, Doné E, et al. Clinical outcome and placental characteristics of monochorionic diamniotic twin pairs with early- and late-onset discordant growth. Am J Obstet Gynecol. 2008; 199:511.e1–511.e7.

6. Quintero RA, Morales WJ, Allen MH, Bornick PW, Johnson PK, Kruger M. Staging of twin-twin transfusion syndrome. J Perinatol. 1999; 19:550–555.

7. Senat MV, Deprest J, Boulvain M, Paupe A, Winer N, Ville Y. Endoscopic laser surgery versus serial amnioreduction for severe twin-to-twin transfusion syndrome. N Engl J Med. 2004; 351:136–144.

8. Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med. 2005; 142:260–273.

9. Chang YL, Chao AS, Chang SD, Hsieh PC, Su SY, Chen KJ, et al. Outcome of twin-twin transfusion syndrome treated by laser therapy in Taiwan’s single center: role of Quintero staging system. Taiwan J Obstet Gynecol. 2016; 55:700–704.

10. Slaghekke F, Lopriore E, Lewi L, Middeldorp JM, van Zwet EW, Weingertner AS, et al. Fetoscopic laser coagulation of the vascular equator versus selective coagulation for twin-to-twin transfusion syndrome: an open-label randomised controlled trial. Lancet. 2014; 383:2144–2151.

11. Papanna R, Block-Abraham D, Mann LK, Buhimschi IA, Bebbington M, Garcia E, et al. Risk factors associated with preterm delivery after fetoscopic laser ablation for twin-twin transfusion syndrome. Ultrasound Obstet Gynecol. 2014; 43:48–53.

12. Rustico MA, Lanna MM, Faiola S, Schena V, Dell’avanzo M, Mantegazza V, et al. Fetal and maternal complications after selective fetoscopic laser surgery for twin-to-twin transfusion syndrome: a single-center experience. Fetal Diagn Ther. 2012; 31:170–178.

13. Chmait RH, Kontopoulos EV, Korst LM, Llanes A, Petisco I, Quintero RA. Stage-based outcomes of 682 consecutive cases of twin-twin transfusion syndrome treated with laser surgery: the USFetus experience. Am J Obstet Gynecol. 2011; 204:393.e1–393.e6.

14. Valsky DV, Eixarch E, Martinez-Crespo JM, Acosta ER, Lewi L, Deprest J, et al. Fetoscopic laser surgery for twin-to-twin transfusion syndrome after 26 weeks of gestation. Fetal Diagn Ther. 2012; 31:30–34.

15. Skupski DW, Luks FI, Walker M, Papanna R, Bebbington M, Ryan G, et al. Preoperative predictors of death in twin-to-twin transfusion syndrome treated with laser ablation of placental anastomoses. Am J Obstet Gynecol. 2010; 203:388.e1–388.11.

16. Ruano R, Rodo C, Peiro JL, Shamshirsaz AA, Haeri S, Nomura ML, et al. Fetoscopic laser ablation of placental anastomoses in twin-twin transfusion syndrome using ‘Solomon technique’. Ultrasound Obstet Gynecol. 2013; 42:434–439.

17. Baschat AA, Barber J, Pedersen N, Turan OM, Harman CR. Outcome after fetoscopic selective laser ablation of placental anastomoses vs equatorial laser dichorionization for the treatment of twin-to-twin transfusion syndrome. Am J Obstet Gynecol. 2013; 209:234.e1–234.e8.

18. Papanna R, Biau DJ, Mann LK, Johnson A, Moise KJ Jr. Use of the learning curve-cumulative summation test for quantitative and individualized assessment of competency of a surgical procedure in obstetrics and gynecology: fetoscopic laser ablation as a model. Am J Obstet Gynecol. 2011; 204:218.e1–218.e9.

19. Peeters SH, Van Zwet EW, Oepkes D, Lopriore E, Klumper FJ, Middeldorp JM. Learning curve for fetoscopic laser surgery using cumulative sum analysis. Acta Obstet Gynecol Scand. 2014; 93:705–711.