Research
Obstetrics
Timing of delivery following selective laser photocoagulation for twin-to-twin transfusion syndrome

https://doi.org/10.1016/j.ajog.2012.06.042Get rights and content

Objective

We sought to compare intrauterine risks with postnatal outcome in monochorionic pregnancies operated by fetoscopic laser surgery for twin-to-twin transfusion syndrome.

Study Design

A cohort of 602 consecutive cases was analyzed. Unexpected prenatal adverse events were identified when a fatal or potentially fatal event occurred that could have been avoided by timely delivery.

Results

The prospective risk of an unexpected adverse event dropped from 16.8% (95% confidence interval [CI], 13.6–20.5%) to 0% (95% CI, 0–11%) between 26-36 weeks. At 32 weeks, the residual risk was 1 in 17 (95% CI, 1/28–1/11). The perinatal rate of death or severe brain lesions dropped from 35% (25-47%) in infants delivered at 26-28 weeks down to 3% (1-6%) at 34-36 weeks.

Conclusion

Our results did not identify an optimal cut-off for elective preterm delivery in laser-operated twin-to-twin transfusion syndrome. Perinatal morbidity appears low from ≥32 weeks and the decision for elective delivery should be based upon medical history, parental demand, and expert assessment.

Section snippets

Patients

All consecutive cases referred to our center for TTTS operated upon by selective laser coagulation of anastomotic vessels from 16-26 weeks were reviewed over a 6-year period (June 2004 through September 2010). Surgery was performed under fetoscopic control as described elsewhere.2 Patients were discharged 48 hours after surgery and followed up until delivery on a weekly basis in our institution or the referral center, allowing for early detection and accurate timing of any subsequent

Results

Over the study period, 648 cases of TTTS underwent operation between 16-26 weeks of gestation. Forty-six cases were lost to follow-up, leaving 602 cases for analysis. Quintero stages were distributed as follows: 14%, stage 1; 38%, stage 2; 45%, stage 3; and 3%, stage 4. Median gestational age at treatment was 21 weeks (interquartile range, 19–23 weeks), with 17% of cases ≤18 weeks' gestation. At the time of surgery, the placenta was considered anterior in 47% of cases with 19% of transplacental

Comment

We have presented the determinants that rule the balance of risks for deciding on the timing of an elective delivery in monochorionic pregnancies operated by fetoscopic laser for TTTS. Our results show that the residual risk of a potentially fatal event in late gestation is high despite close follow-up. At 32 weeks, the 1-in-17 prospective risk of subsequent unexpected adverse event was found very close to the 1-in-23 residual risk of stillbirth in uncomplicated monochorionic pregnancies

References (22)

  • N. Tul et al.

    Prospective risk of stillbirth in monochorionic-diamniotic twin gestations: a population-based study

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      2022, American Journal of Obstetrics and Gynecology MFM
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    The authors report no conflict of interest.

    Cite this article as: Stirnemann JJ, Quibel T, Essaoui M, et al. Timing of delivery following selective laser photocoagulation for twin-to-twin transfusion syndrome. Am J Obstet Gynecol 2012;207:127.e1-6.

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