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Introduction: To examine the association of preoperative absent end-diastolic velocity (AEDV) and percent AEDV (%AEDV) in the umbilical artery (UA) with donor twin intrauterine fetal demise (IUFD) after laser surgery for twin-twin transfusion syndrome (TTTS).Methods: We performed a retrospective study of stage III/IV TTTS patients who underwent laser surgery from 2006 to 2016. Donors were classified as having preoperative persistent AEDV (yes/no). %AEDV was calculated for those with AEDV as 100× the proportion of the total cardiac cycle in AEDV. Using multiple logistic regression, we tested for an association between the outcome donor IUFD and AEDV risk factors (part 1) and %AEDV (part 2). We stratified these analyses by estimated fetal weight (EFW) discordance ≥20 versus <20%.Results: Of 344 cases, 153 (44.5%) donors had AEDV. Part 1 did not confirm an independent association between AEDV and donor IUFD. In the part 2 analysis of the 153 patients with AEDV, %AEDV was a positive risk factor for donor IUFD only in those with discordance (n = 129) (OR 1.04, 95% CI 1.01-1.08, p = 0.0278) when adjusting for %EFW discordance, presence of arterioarterial anastomoses, and multiparity.Discussion: Among stage III/IV TTTS patients with AEDV, %AEDV was a risk factor for donor IUFD only in the presence of EFW discordance. [ABSTRACT FROM AUTHOR]

Objective: To describe the antenatal course of selective intrauterine growth restriction (SIUGR) type III patients.Study Design: Retrospective study of monochorionic diamniotic twins with SIUGR type III. Patients were divided into those who did and did not progress to SIUGR type II or twin-twin transfusion syndrome (TTTS) (Groups A and B, respectively). Patient characteristics and perinatal survival were compared by Group, and continuous data are reported as median (range).Results: Forty-eight patients were studied; Group A [26 (54.2%)] and Group B [22 (45.8%)]. The difference in 30-day survivorship for the appropriate for gestational age twin (88.5 vs. 100%, p = .2394) and for the SIUGR twin (73.1 vs. 95.5%, p = .0551) was not statistically significant. However, dual survivorship was lower in Group A compared to Group B (69.2 vs. 95.4%, p = .0276).Conclusions: Approximately half of the SIUGR type III patients had antenatal progression. Lack of antenatal progression was associated with 95% dual survivorship.Rationale: The antenatal course of monochorionic diamniotic twins complicated by SIUGR type III is not well-understood and antenatal management remains a clinical dilemma. We provide pregnancy outcomes in a referred group of SIUGR type III patients, including the rate of progression to SIUGR type II and TTTS. [ABSTRACT FROM AUTHOR]

Introduction: Management options for treatment of twin-twin transfusion syndrome (TTTS) with severe donor intrauterine growth restriction (IUGR) include fetoscopic laser surgery and umbilical cord occlusion (UCO). We studied perinatal survival outcomes in this select group after laser surgery, stratifying patients by preoperative estimated fetal weight (EFW) discordance.Methods: In this retrospective study of monochorionic diamniotic twin gestations with TTTS and selective donor IUGR who underwent laser surgery (2006-2017), preoperative EFW discordance was calculated ([(larger twin - smaller twin)/(larger twin)] × 100) and cases were divided into discordance strata. Severe EFW discordance was defined as >35%. The primary outcome was 30-day donor twin neonatal survival.Results: The 371 cases were distributed by discordance strata: ≤20% (74 [19.9%]), 21-25% (49 [13.2%]), 26-30% (68 [18.3%]), 31-35% (53 [14.3%]), 36-40% (51 [13.7%]), 41-45% (38 [10.2%]), >45% (38 [10.2%]). Donor 30-day survival declined as the discordance strata increased: 86.5, 85.7, 83.8, 75.5, 64.7, 63.2, and 65.8% (p = 0.0046); 30-day survival was inversely associated with severe discordance (>35%) (64.6 vs. 83.2%, p < 0.0001).Discussion: In TTTS cases complicated by donor IUGR with severe growth discordance, laser surgery was associated with donor survivorship greater than 60% suggesting that, in this setting, laser surgery remains a reasonable alternative treatment to UCO. [ABSTRACT FROM AUTHOR]

Introduction: Incidental septostomy, or inadvertent perforation of the twins' dividing membranes, can create a functional monoamniotic twin pregnancy. Our aim was to describe the perinatal outcomes and antenatal management of patients with incidental septostomy after laser surgery for twin-twin transfusion syndrome (TTTS).Materials and Methods: Monochorionic diamniotic multiple gestations with a gestational age (GA) between 16 and 26 weeks that underwent laser surgery from March 2006 to December 2015 were studied retrospectively. Perinatal outcomes were compared for patients with and without an incidental septostomy. A subgroup analysis was performed to evaluate antenatal management.Results: Of 532 TTTS patients who underwent laser surgery, incidental septostomy occurred in 34 (6.4%). Compared to all others, patients with a septostomy had an earlier median (range) GA at delivery (30.8 [18.6-37.9] vs. 34.0 [19.3-40.4] weeks, p < 0.0001) and lower 30-day survival of at least one twin (85.3 vs. 94.6%, p = 0.0452). We found no evidence that inpatient fetal surveillance was protective.Discussion: Incidental septostomy in TTTS patients treated via laser surgery appeared to be associated with lower GA at delivery and perinatal survival of at least one twin. Further study is required to determine the optimal antenatal surveillance strategy. [ABSTRACT FROM AUTHOR]

Objective The objective of this study was to assess whether the location of the trocar insertion site for laser treatment of twin-twin transfusion syndrome was associated with preterm-premature rupture of membranes (PPROM) and preterm birth (PTB). Study Design In this study trocar location was documented in the operating room. Lower uterine segment (LUS) location was defined as any insertion <10 cm vertically from the pubic symphysis. Lateral location was defined as ≥5 cm horizontally from the midline. Patient characteristics were tested against three outcomes: PPROM ≤ 21 days postoperative, PTB < 28 weeks, and PTB < 32 weeks. For each outcome, multiple logistic models were fitted to examine the effect of trocar location, controlling for potential risk factors. Results A total of 743 patients were studied. Patients with LUS location were twice as likely as those with a more superior location to have PPROM ≤ 21 days (OR = 2.33, 1.12-4.83, p = 0.0236). Patients with both a LUS and Lateral location were over six times more likely to have PPROM ≤ 21 days (OR = 6.66, 2.36-18.78, p = 0.0003). Trocar insertion site was not associated with PTB. Conclusion We found that trocar insertion in the LUS, particularly the lateral LUS, was associated with an increased risk of PPROM. [ABSTRACT FROM AUTHOR]

The objective of this study was to describe the management and perinatal outcomes of patients with twin-twin transfusion syndrome (TTTS) and an extremely short cervical length (CL). This retrospective study examined 17 patients with TTTS and a preoperative CL ≤1.0 cm who had undergone laser surgery and perioperative cervical cerclage placement successfully. In this subset of patients, the median interval between surgery and delivery was 9.6 (range 2.1-13.9) weeks and only one patient had PPROM within 3 weeks of surgery. The median gestational age at delivery was 30.9 (range 23.1-37.6) weeks, 30-day survival of at-least-one twin was 88.2% and dual survivorship was 82.4%. Overall, patients with TTTS and a preoperative CL ≤1.0 cm who were able to undergo successful laser surgery and emergent cerclage placement had favourable outcomes. Impact statement The management of patients with twin-twin transfusion syndrome (TTTS) and extremely short cervical length (CL) varies between foetal surgery centres. This study demonstrates that laser surgery and cerclage placement in such patients are not only technically feasible, but also can result in favourable perinatal outcomes. Patients with an extremely short CL should not be uniformly excluded from laser surgery for TTTS. [ABSTRACT FROM AUTHOR]

Objectives To evaluate risk for congenital heart disease (CHD) in recipient twins with circular shunt physiology (CSP). Methods This prospective study enrolled twin-twin transfusion syndrome (TTTS) cases from 2006 to 2015. Fetal echocardiography (FE) was performed before laser surgery when cardiac involvement was suspected. Diagnosis of recipient twin CSP required tricuspid and pulmonary regurgitation, right ventricular dysfunction, and flow reversal in the ductus arteriosus. Outcomes were assessed at 30 days after birth. Results Of the 496 TTTS pregnancies, 20 (4%) met the criteria for CSP. Among those born alive, who had documented cardiac outcomes (n = 457), patients with CSP were more likely to have CHD, specifically right ventricular outflow tract obstruction (5 of 18 [27.8%] versus 22 of 439 [5.0%], odd ratio [OR] 7.29, 95% confidence interval [CI] 2.05-24.72, P = .0025). Of the recipient twins with preoperative FE (n = 259, 52%) who were born alive and had documented cardiac outcomes (n = 242), those with CSP were still more likely to have right ventricular outflow tract obstruction (5 of 18 [27.8%] versus 14 of 224 [6.3%], OR 5.77, CI 1.54-20.92, P = .0077). With both analyses, twins with CSP had higher Quintero stage, but similar patient characteristics and 30-day mortality compared with those without CSP. Subgroup analyses of the CSP cohort identified no differences in preoperative characteristics or FE findings predictive of CHD. Conclusions Recipient twins with preoperative CSP were at increased risk for postnatal right ventricular outflow tract obstruction, but appeared to have comparable survival after fetal laser surgery despite these dramatic pathophysiological prenatal findings. Preoperative FE in TTTS remains important for prediction of postnatal CHD. [ABSTRACT FROM AUTHOR]

Introduction: We examined placental weight characteristics associated with donor selective intrauterine growth restriction (SIUGR) among patients with twin-twin transfusion syndrome (TTTS) who underwent laser surgery.Materials and Methods: Fresh placental specimens were studied. Pregnancies with higher-order multiples, fetal demise, or disrupted or nonsubmitted placental specimens were excluded. Placental characteristics prospectively collected included total placental weight, individual placental weight, and placental share. Data were compared between pregnancies with SIUGR (TTTS + SIUGR group) and those without SIUGR (TTTS-only group).Results: Of 369 consecutive patients who underwent laser surgery for TTTS, 155 (42%) met inclusion criteria: 91 with TTTS + SIUGR and 64 with TTTS-only. Compared to the TTTS-only group, patients in the TTTS + SIUGR group had a lower total placental weight (608 ± 163 vs. 687 ± 224 g, p = 0.012), with a lower donor individual placental weight (237 ± 91 vs. 291 ± 124 g, p = 0.002), but no apparent difference in the individual placental weight of recipient twins (371 ± 109 vs. 396 ± 133 g, p = 0.211). Donor placental share was smaller in those pregnancies affected by SIUGR (38.7 ± 9.6 vs. 42.3 ± 9.8%, p = 0.029).Discussion: TTTS patients with SIUGR had a lower total placental weight and a lower donor individual placental weight compared to those without SIUGR. These findings suggest that differences in donor individual placental weights for SIUGR gestations may not solely be related to differences in placental share. [ABSTRACT FROM AUTHOR]

Introduction: Twin-twin transfusion syndrome (TTTS) and twin anemia-polycythemia sequence (TAPS) are classified as distinct clinical disorders associated with unbalanced blood flow through placental vascular communications. Typically, TAPS placentas demonstrate few <1 mm arteriovenous (AV) communications, and at fetoscopy the twins are visibly pale and plethoric. Materials and Methods: In a cohort of TTTS patients who underwent laser surgery, those with preoperative findings suggestive of anemia/polycythemia (AP) were compared to those with TTTS alone. AP was defined as middle cerebral artery peak systolic velocity in one twin >1.5 multiples of the median (MoM), and <1.0 MoM in the other. Results: Of 369 TTTS patients, 9 (2.4%) met criteria for preoperative AP. The mean number (±SD) of AV communications in the TTTS + AP group was 5.6 ± 5.7, compared with 8.8 ± 4.8 in the TTTS-alone group (p = 0.013). Five TTTS + AP patients (56%) had a few thin AV communications (mean 2.8 ± 1.6); all 5 had visibly pale and plethoric twins. The remaining 4 (44%) had large or numerous anastomoses (mean 10.5 ± 6.8); none had fetal skin color discordance. Discussion: Preoperative AP affected 2% of TTTS patients. Of these, approximately half had placental and skin color findings typically reported with isolated TAPS. © 2015 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Objective. To describe our experience with preferential use of sequential selective laser photocoagulation of communicating vessels (SQLPCV) in women with twin-twin transfusion syndrome (TTTS). Methods. Women with TTTS received treatment using the SQLPCV technique whenever possible. SQLPCV mandates ablation of all donor-to-recipient arteriovenous communications first, in comparison to the standard non-sequential selective technique. Results. Of 99 consecutive women treated, 64 received SQLPCV. Overall survival of one or both twins was 91% and dual survival was 72%. Higher dual survival rates (80 vs. 57%, p = 0.0317) and donor survival rates (83 vs. 63%, p = 0.0489) were noted in the SQLPCV group. Multivariable logistic regression demonstrated that the SQLPCV technique was highly associated with dual survivorship (OR = 4.64 [1.57–13.74], p = 0.0056), when controlling for gestational age at surgery, duration of laser treatment and number of anastomoses lasered. Neither Quintero stage, placental location, preoperative discordance prior to surgery, nor preoperative cervical length contributed to this equation. The SQLPCV technique was also associated with donor survivorship (OR = 4.43 [1.44–13.67], p = 0.0095), when controlling for the same covariates. Conclusion. Treatment of TTTS via SQLPCV technique was associated with higher dual survival and donor twin survival rates as compared to standard SLPCV. [ABSTRACT FROM AUTHOR]

Objective To identify risk factors for development of twin-twin transfusion syndrome (TTTS) in monochorionic diamniotic multiple gestations complicated by midtrimester isolated polyhydramnios (iPoly). Study Design A retrospective study of patients referred for possible TTTS between 16 and 26 gestational weeks was performed. IPoly was defined as a maximum vertical pocket of ≥8 cm in the iPoly twin's sac and >2 and <8 cm in the co-twin's sac on the consultative ultrasound. Results Of 628 consecutive patients referred for possible TTTS, 74 were diagnosed with iPoly. The majority of these patients (n = 52, 70.3%) were not subsequently diagnosed with TTTS, and of these, 40 were managed expectantly and 12 had amnioreductions because of symptomatic iPoly; 30-day perinatal survival of at-least-one twin in the non-TTTS group was 93.0% (40/43). TTTS developed in the 22 remaining patients, of which 63.6% were of advanced Quintero Stage. Nineteen underwent laser surgery; 30-day perinatal survival of at-least-one twin was 84.2% (16/19). In a multivariate logistic regression model, 2 characteristics were associated with the development of TTTS: (1) gestational age <20 weeks at the time of diagnosis of iPoly (odds ratio, 13.48; 95% confidence interval, 3.40–53.48; P = .0002); and (2) intrauterine growth restriction of the co-twin (odds ratio, 7.28; 95% confidence interval, 1.72–30.88; P = .0071). Conclusion Among referred patients with midtrimester iPoly, 29.7% subsequently developed TTTS. Early diagnosis (<20 weeks) and/or co-twin intrauterine growth restriction were significant risk factors for development of TTTS in these patients. [ABSTRACT FROM AUTHOR]

Objective: To identify perioperative risk factors for preterm delivery (PTD) in laser-treated patients with twin-twin transfusion syndrome (TTTS). Study Design: Twin-twin transfusion syndrome patients who underwent laser surgery were followed prospectively. Univariate and multivariate analyses were performed to identify gestational and surgical characteristics associated with preterm delivery. Results: Of 318 eligible patients, the mean (SD) gestational age of delivery was 32.8 (4.2) weeks. The number of days from laser surgery to delivery had a bimodal distribution; group I delivered within 21 days and group II delivered after 21 days of surgery. Eighteen patients (5.7%) were in group I and demonstrated the following risk factors for delivery within 21 days: incomplete laser surgery suspected (odds ratio [OR], 11.14; P = .0106), preoperative subchorionic hematoma (OR, 7.92, P = .0361), preoperative cervical length <2.0 cm (OR, 4.71; P = .0117), and recipient's maximum vertical pocket ≥14 cm (OR, 3.23; P = .0335). In group II, 92 of 300 patients (30.7%) delivered <32 weeks, and 25 (8.3%) delivered <28 weeks; multivariate logistic regression analyses identified 5 risk factors for delivery <32 weeks: incomplete laser surgery suspected (OR, 10.0; P = .0506); incidental septostomy (OR, 4.4; P = .0009); triplet gestation (OR, 2.6; P = .0689); postoperative membrane detachment (OR, 2.4; P = .0393); and nonposterior placental location (OR, 1.8; P = .0282). Conclusion: Timing of delivery after laser for twin-twin transfusion syndrome has a bimodal distribution with distinct gestational and surgical risk factors. This information may be useful in counseling patients and in directing future avenues of research. [Copyright &y& Elsevier]

Objective: We sought to describe stage-specific perinatal outcomes after selective laser photocoagulation of communicating vessels (SLPCV) for twin-twin transfusion syndrome. Study design: Patients with twin-twin transfusion syndrome underwent SLPCV preferentially using sequential vs standard laser technique. Patient characteristics and outcome data were examined by Quintero stage. Results: Of 682 consecutive women studied, the Quintero stage distribution was: 114 stage I (17%), 177 stage II (26%), 328 stage III (48%), and 63 stage IV (9%). Perinatal survival of at least 1 twin did not differ according to stage (I-92%, II-93%, III-88%, IV-92%; P = .30). However, dual twin survival differed by stage (I-79%, II-76%, III-59%, IV-68%; P < .01), primarily because stage III pregnancies were associated with decreased donor twin survival (P < .01). Sequential SLPCV was associated with improved donor survival, independent of stage (odds ratio, 1.67; 95% confidence interval, 1.16–2.40; P < .01). Conclusion: Stage-specific perinatal outcomes after laser therapy may assist physicians in patient counseling and in planning future studies. [ABSTRACT FROM AUTHOR]

Objective: The objective of the study was to compare twin weight discordance and prevalence of intrauterine growth restriction (IUGR) before laser therapy and after birth in pregnancies complicated by twin-twin transfusion syndrome (TTTS). Study Design: Women with TTTS who underwent laser therapy with dual neonatal survivors born at least 28 days after surgery were studied. Estimated fetal weight (EFW) discordance at the preoperative sonogram and birthweight (BW) discordance were calculated. Weights below gestational age–corrected 10th percentile at sonogram and at birth for each twin were designated as IUGR. Results: Among 211 women studied, the mean EFW discordance measured 26.6% and mean BW discordance was 18.4%, yielding a mean 8.2% decrease in weight discordance (P < .001). Comparing IUGR diagnoses before surgery and at birth, the recipient''s proportion was unchanged (9.5% vs 7.1%, P = .353), whereas the donor''s proportion decreased (64.5% vs 28.9%, P < .001). Conclusion: Twin weight discordance and donor fetus IUGR appear to improve after laser therapy for TTTS. [Copyright &y& Elsevier]