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
Source: PubMed


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: 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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