Role of gestational age at time of placental laser surgery in outcomes of twin-to-twin transfusion syndrome.

There are conflicting data on whether fetoscopic laser photocoagulation of placental anastomoses (FLP) for treating twin-to-twin transfusion syndrome (TTTS) is associated with lower rates of overall survival. The objective of this study is to characterize survival and other associated morbidity after FLP across gestational ages of FLP. This is a secondary analysis of prospectively collected data on patients with monochorionic-diamniotic twins that had FLP for TTTS at two centers between 2011 and 2022. Patients were divided into gestational age epochs for FLP before 18 wks, 18 0/7 - 19 6/7 wks, 20 0/7 - 21 6/7 wks, 22 0/7 - 23 6/7 wks, 24 0/7 - 25 6/7 wks and after 26 wks. Demographic characteristics, sonographic characteristics of TTTS and operative characteristics were compared across the gestational age epochs. Outcomes including overall survival, preterm delivery, preterm prelabor rupture of membranes (PPROM), intrauterine fetal demise (IUFD) and neonatal demise (NND) were also compared across gestational age epochs. Multivariate analysis was performed by fitting logistic regression models for these outcomes. Kaplan-Mejer curves were constructed to compare the interval from PPROM to delivery for each gestational age epoch. There were 768 patients that met inclusion criteria. The dual survival rate was 61.3% for FLP performed prior to 18 weeks compared to 78.0% - 86.7% across later gestational age epochs. This appears to be related to increased rates of donor IUFD following FLP performed before, versus after 18 weeks (28.0% vs. 9.3% - 14.1%). Rates of recipient IUFD/NND and donor NND were similar regardless of gestational age of FLP. Rates of PPROM were higher for earlier FLP, ranging from 45.6% for FLP before 18 weeks to 11.9% for FLP at 24 - 26 weeks gestational age. However, the gestational age of delivery was similar across gestational age epochs with a median of 31.7 weeks. In multivariate analysis, donor loss was independently associated with FLP before 18 weeks after adjusting for selective fetal growth restriction, Quintero stage and other covariates. PPROM and PTD were also associated with FLP before 18 weeks after adjusting for cervical length, placental location, trocar size, laser energy and amnioinfusion. FLP performed at earlier gestational ages is associated with lower overall survival, which is driven by higher risk of donor IUFD, as opposed to differences in PPROM or PTD. Counseling regarding survival should account for gestational age of presentation. This article is protected by copyright. All rights reserved.

Brock CO ，Backley S ，Snowise S ，Bergh EP ，Johnson A ，Fisher J ，Espinoza J ，Eyerly-Webb S ，Juckel N ，Nisius E ，Hernandez-Andrade EA ，Papanna R ... -  《-》

Management of monochorionic diamniotic twin gestation affected by Type-II selective fetal growth restriction: cost-effectiveness analysis.

Monochorionic twin gestations affected by Type-II selective fetal growth restriction (sFGR) are at increased risk of intrauterine fetal demise, extreme preterm birth, severe neurodevelopmental impairment (NDI) and neonatal death of one or both twins. In the absence of a consensus on the optimal management strategy, we chose to evaluate which strategy was cost-effective in the setting of Type-II sFGR. A decision-analytic model was used to compare expectant management (EM), bipolar cord occlusion (BCO), radiofrequency ablation (RFA) and fetoscopic laser photocoagulation (FLP) for a hypothetical cohort of 10 000 people with a monochorionic diamniotic twin pregnancy affected by Type-II sFGR. Probabilities and utilities were derived from the literature. Costs were derived from the Healthcare Cost and Utilization Project and adjusted to 2023 USD. The analytic horizon, taken from the perspective of the pregnant patient, extended throughout the life of the child or children. An incremental cost-effectiveness ratio of 50 000 USD per quality-adjusted life year defined the willingness-to-pay threshold. One-way and probabilistic sensitivity analysis was also performed. For base-case estimates, RFA was the most cost-effective strategy compared with all of the other interventions included, with an incremental cost-effectiveness ratio of 14 243 USD per quality-adjusted life year. One-way sensitivity analysis demonstrated that the utilities assigned to fetal demise and severe NDI, as well as the costs of preterm birth before 32 weeks, most strongly impacted the model outcomes. On probabilistic sensitivity analysis, RFA was the most cost-effective strategy in 78% of runs, followed by BCO at 20%, EM at 2% and FLP in 0% of runs. When compared with EM, RFA led to 58 fewer births before 28 weeks' gestation, 273 fewer cases of severe NDI and 22 more deliveries after 32 weeks. When compared with FLP, RFA resulted in 259 fewer cases of severe NDI and 3177 more births after 32 weeks. When compared with BCO, RFA resulted in 1786 more neurologically intact neonates and 34 fewer cases of severe NDI. On base-case analysis, RFA was found to be the most cost-effective strategy in the management of monochorionic diamniotic twin pregnancies affected by Type-II sFGR. However, these findings were not robust on sensitivity analysis, indicating the potential benefit of BCO and EM. In the absence of large clinical trials, these data should not be taken to guide management. Future studies should evaluate management strategies for Type-II sFGR related to long-term neonatal outcomes, inclusive of quality-of-life indicators, in a prospective multicenter cohort. © 2024 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Morgan JC ，Rios J ，Kahl T ，Prasad M ，Rausch A ，Longman R ，Mehra S ，Shaaban A ，Premkumar A ... -  《-》

Resolution of selective fetal growth restriction after laser surgery for twin-to-twin transfusion syndrome can be predicted by predisease growth discordance.

To determine if the resolution of fetal growth discordance after laser surgery in pregnancies with twin-to-twin transfusion syndrome (TTTS) and coexisting selective fetal growth restriction (sFGR) can be predicted by estimated fetal weight (EFW) discordance recorded prior to the development of TTTS (pre-TTTS). This was a single-center, retrospective analysis of prospectively collected data on monochorionic twins with concurrent TTTS and sFGR that underwent laser surgery and had available growth ultrasound records from a pre-TTTS ultrasound evaluation. Maternal demographics, pregnancy characteristics and birth outcomes were compared between three outcome groups: double twin survival with resolved sFGR determined by birth weight discordance (BWD) < 20%; double twin survival with ongoing sFGR determined by BWD ≥ 20%; and single or double fetal demise after laser surgery. One-way analysis of variance or the Kruskal-Wallis test was used for continuous variables. The chi-square test or Fisher's exact test was used for categorical variables. A multivariate logistic regression model was constructed based on univariate associations. Ninety-seven patients with TTTS and concurrent sFGR underwent same- or next-day laser surgery after a TTTS staging ultrasound at a median gestational age of 19.4 (interquartile range (IQR), 18.0-22.3) weeks, with a median EFW discordance of 28.8% (IQR, 22.9-34.0%). At delivery, 34 (35.1%) patients had resolved sFGR with a median BWD of 7.7% (IQR, 3.5-13.0%), 34 (35.1%) had ongoing sFGR with a median BWD of 30.6% (IQR, 24.4-43.9%) and 29 (29.9%) had a single or double fetal demise. Although some characteristics available at the time of TTTS diagnosis, such as the donor umbilical artery end-diastolic velocity (P = 0.0087) and donor umbilical artery pulsatility index (P = 0.0061), also correlated with growth outcome, multivariate logistic regression analysis identified EFW discordance at the pre-TTTS ultrasound as the primary determinant of the odds of resolved growth discordance at birth (P = 0.0063). In patients undergoing laser surgery for TTTS with coexisting sFGR, a history of concordant growth at the pre-TTTS scan prior to the development of TTTS was associated with the resolution of fetal growth discordance at birth. These findings suggest that TTTS pathophysiology can contribute to growth discordance noted at the time of TTTS diagnosis. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

Uribe KA ，Birk A ，Shantz C ，Miller JL ，Kush ML ，Olson S ，Voegtlin KE ，Baschat AA ，Rosner M ... -  《-》

Pre- and Periviable PPROM after Fetoscopic Laser Surgery: Are Survival Outcomes Better than We Think?

Limited data exist regarding outcomes when pre- and periviable PPROM (PPROM ≤26 weeks of gestation) occurs as a complication of fetoscopic laser surgery (FLS) for twin-twin transfusion syndrome (TTTS). This is a retrospective cohort study of FLS cases performed at a single institution between January 2015 and May 2021. Study inclusion was limited to patients with monochorionic-diamniotic twin pregnancies complicated by TTTS who underwent FLS. Patients were grouped by pPPROM status, and further stratified to those continuing with expectant management, and outcomes were compared between groups. The primary outcome was survival to live birth of at least one twin. During the study period, 171 patients underwent FLS and a total of 96 (56.1%) subjects satisfied inclusion criteria. Among included subjects, 18 (18.8%) experienced pPPROM after FLS and 78 (81.2%) did not. Baseline characteristics were similar between groups. Among patients with pPPROM, 11 (61.1%) pursued expectant management and 7 (38.9%) opted for pregnancy termination. Among expectantly managed subjects, median pPPROM-to-delivery interval was 47.0 days (6.0-66.0 IQR) with a median gestational age at delivery of 29+1 weeks (24 + 4-33 + 6 IQR). Rates of survival to live birth of at least one twin (90.9% vs. 96.2% p = 0.42) were similar between those with pPPROM undergoing expectant management and those without pPPROM. Dual survivorship (45.5% vs. 78.2%, p = 0.03), perinatal survival to live birth (68.2% vs. 87.2%, p = 0.05), and perinatal survival to newborn hospital discharge (59.1% vs. 85.9%, p = <0.01) were all significantly lower among those with pPPROM. Gestational age at delivery was lower among those continuing with pregnancies complicated by pPPROM (29 + 1 vs. 32+5 weeks, p = <0.01). Survival of at least one twin to live birth remained high among those pursing expectant management after experiencing post-FLS pPPROM, suggesting that the outlook after this complication is not necessarily poor. However, this complication was associated with lower chances of dual survival and greater prematurity.

Breslin N ，Jacob T ，Baptiste C ，Thompson J ，Chen C ，Bejerano S ，Fung-Masson C ，Nhan-Chang CL ，Simpson LL ，Miller R ... -  《-》

Perinatal outcomes following fetoscopic laser surgery for early twin-to-twin transfusion syndrome: Systematic review and meta-analysis.

Our objective was to investigate outcomes in twin-to-twin transfusion syndrome (TTTS) treated with fetoscopic laser surgery (FLS) at <18 weeks vs ≥18 weeks, and to conduct subgroup analysis of TTTS with FLS at <16 weeks vs 16-18 weeks. PubMed, Scopus and Web of Science were searched systematically from inception until May 2023. Primary outcome was survival, and secondary outcomes included preterm premature rupture of membranes (PPROM), preterm birth and gestational age (GA) at delivery. Nine studies encompassing 1691 TTTS pregnancies were included. TTTS stage III was significantly more common in TTTS pregnancies treated with FLS at <18 weeks (odds ratio [OR] 2.84, 95% confidence interval [CI] 1.24-6.54), and procedure duration was shorter at <18 weeks (MD -5.27 minutes, 95% CI -9.19 to -1.34). GA at delivery was significantly earlier in TTTS pregnancies treated with FLS at <18 weeks (MD -3.12 weeks, 95% CI -6.11 to -0.13). There were no significant differences in outcomes, including PPROM, PPROM at <7 days post-FLS, preterm birth at <28 and <32 weeks, delivery at <7 days post-FLS, and survival outcomes, including fetal demise, live birth and neonatal survival. Similarly, TTTS stage III was more common in TTTS with FLS at <16 weeks than at 16-18 weeks (OR 2.95, 95% CI 1.62-5.35), with no significant differences in the aforementioned outcomes. In early TTTS treated with FLS, outcomes were comparable between those treated at <18 weeks compared with ≥18 weeks except for GA at delivery, which was 3 weeks earlier. In the subset treated at <16 weeks vs 16-18 weeks, the procedure was feasible without an increased risk of very early preterm birth or perinatal mortality.

Mustafa HJ ，Aghajani F ，Patrick E ，Baerz MM ，Arias-Sánchez P ，Khalil A ... -  《-》