Ultrasound Assessment prior to Laser Photocoagulation for Twin-Twin Transfusion Syndrome for Predicting Intrauterine Fetal Demise after Surgery in Japanese Patients
Yamaguchi University, Yamaguti, Yamaguchi, Japan Fetal Diagnosis and Therapy
(Impact Factor: 2.94).
02/2007; 22(2):149-54. DOI: 10.1159/000097116
To evaluate the use of ultrasound before selective laser photocoagulation of communicating vessels (SLPCV) for twin-twin transfusion syndrome in predicting intrauterine fetal demise (IUFD).
Fifty-five patients underwent SLPCV in Japan. Fetal biometry and Doppler studies of the umbilical artery, ductus venosus, and umbilical vein were performed prior to SLPCV. The visualization of the bladder and hydrops was recorded. Association between the parameters and IUFD was analyzed using multiple logistic regression analysis. The study was approved by the Institutional Review Board and patients gave their informed consent.
The IUFD incidence was 25.5% (14/55) in the donors and 12.7% (7/55) in the recipients. Twelve donors and 4 recipients of them ended in unexplainable IUFD. In the analysis of 53 donors, absent or reversed end-diastolic flow of umbilical artery (UAAREDF) was only associated with IUFD (p = 0.016). No parameters could predict IUFD in 52 recipients.
UAAREDF may be useful for predicting IUFD of the donor after SLPCV.
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- "For comparison , control twins were identified as the smaller twin (smaller) or the larger twin (larger). In cases of TTTS, the ratio of intertwin UVVF could be altered by significant intertwin transfusion (Gratacos et al., 2002; Ishii et al., 2007; Yamamoto et al., 2007). As a result, pregnancies with signs of TTTS, as defined by severe oligohydramnios in one twin (maximum vertical pocket of amniotic fluid, < 2 cm) and polyhydramnios in another twin (maximum vertical pocket, > 8 cm) (Quintero et al., 1999), were not included in this study. "
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ABSTRACT: This study was conducted to investigate the relationship among umbilical venous volume flow, birthweight and placental share in monochorionic twins with or without selective growth restriction. Having excluded cases complicated with twin-to-twin transfusion syndrome and one co-twin suffering intrauterine fetal death, a total of 51 monochorionic twin pregnancies were divided into two groups as with (group 1) and without (group 2) selective intrauterine growth restriction. Umbilical venous volume flow was calculated by multiplying the umbilical vein cross-sectional area by half of the maximal velocity around mid-trimester. The placentas were cut along the vascular equator into two individual placental masses. The discordance of birthweight was calculated as [(birthweight of larger twin-birthweight of smaller twin)/birthweight of larger twin 100%]. The discordances of umbilical venous volume flow and placental share were calculated in a similar fashion. The median umbilical venous volume flow discordances (68.4% and 15.3% in groups 1 and 2 monochorionic twins, respectively) were similar and correlated well with the placental share discordances (66.6% and 18.5% in groups 1 and 2 monochorionic twins, respectively) but not with the birthweight discordance (28.6% and 6.4% in groups 1 and 2 monochorionic twins, respectively) in both groups. We concluded that the umbilical venous volume flow discordance reflects the placental share discordance rather than the birthweight discordance in monochorionic twin pregnancies.
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ABSTRACT: In order to assess the outcome of pregnancies complicated by severe second trimester twin-twin transfusion syndrome (TTTS) undergoing treatment with endoscopic laser surgery, we reviewed our experience following the implementation of an institutional fetal surgery program.
Patients presenting with monochorionic-diamniotic twin pregnancies complicated by severe TTTS before 26 weeks of gestation were offered endoscopic laser surgery to coagulate placental vascular anastomoses. Using regional anesthesia and guided by real-time sonography, anastomoses were identified and selectively coagulated. At the end of the procedure, amniodrainage was performed to restore normal amniotic fluid volume. Follow-up and delivery were carried out at the referring institutions. Six-month follow-up was performed in all cases.
During a 3-year period from September 2003 to December 2006, 33 consecutive cases of severe TTTS were operated on at a median gestational age of 21 weeks (range 17-25). Nine (27.3%) cases were classified as stage II, 21 (63.6%) as stage III, and three (9.1%) as stage IV. The placenta was anterior or predominantly anterior in 15 (45.5%) of the cases. Overall, both twins were born alive in 16 (48.5%) cases, only one twin was born alive in 11 (33.3%), and neither was born alive in the remaining six (18.2%). Therefore, 81.8% (27 of 33) of the pregnancies resulted in at least one liveborn infant. Among them, the mean gestational age at delivery was 32 weeks (range 23-38) and the mean birthweight of the liveborn infants was 1591 g (range 350-3800). Thirty-four infants survived the perinatal period, yielding an overall perinatal survival rate of 51.5%, with 75.8% (25 of 33) of the pregnancies resulting in at least one perinatal survivor. All neonatal deaths were associated with extreme prematurity.
This preliminary experience suggests that selective laser coagulation appears to be a good treatment option in cases of monochorionic twin pregnancies complicated by severe TTTS. However, technical skills and adequate equipment are required for implementing a fetal surgery program. Auditing outcomes during the learning curve would help in identifying potential problems.
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ABSTRACT: Twin-to-twin transfusion syndrome (TTTS) is a severe fetal condition that has regained attention since surgical endoscopic treatment proved beneficial in a randomized controlled trial. Our objective is to review published series of cases treated with fetoscopic surgery. Diagnostic criteria, surgical technique, and perinatal outcome of series of TTTS cases treated by laser were reviewed. Over 1300 cases from 17 publications have been included, with a median perinatal survival rate of 57% (50-100%); brain lesions were present in 2-7% of the survivors at the age of 1-6 months. The percutaneous technique has gained wide acceptance, with an acceptable risk of maternal morbidity but a significant risk of miscarriage or preterm rupture of the membranes, presenting in 6.8-23% and 5-30%, respectively. The conclusion is that standardization of the technique and stability to improvement of the initial results should broaden the use of this technique. The overall survival rate at birth was 66% (1894/2869). However, variations in survival rates between centres and inconsistency in the reporting of complications call for more homogeneity in the pre- and post-operative assessment.
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