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Chapter 13 - Management of Twin–Twin Transfusion Syndrome

Published online by Cambridge University Press:  11 October 2022

By
Christian Bamberg  and
Kurt Hecher
Edited by
Leanne Bricker ,
Julian N. Robinson  and
Baskaran Thilaganathan
Leanne Bricker
Affiliation:
Corniche Hospital, Abu Dhabi
Julian N. Robinson
Affiliation:
Brigham & Women's Hospital, Boston
Baskaran Thilaganathan
Affiliation:
St George's Hospital Medical School, University of London
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Summary

Twin-twin transfusion syndrome (TTTS) is a severe complication that affects 10-15% of monochorionic multiple pregnancies. It is caused by an imbalanced blood flow through communicating placental vessels on the chorionic surface between the donor and recipient twin circulations. Regarding treatment, evidence demonstrates that fetoscopic laser ablation is superior to serial amnioreductions in terms of survival and neurological outcome for stage II-IV TTTS. However, the optimal management of stage I TTTS remains controversial. It is well established that all chorionic plate anastomoses should be closed by laser. Compared to the selective laser method, the Solomon technique yields a significant reduction of recurrent TTTS and post-laser twin anemia-polycythemia sequence (TAPS). Over the past 25 years, survival rates after fetoscopic laser surgery have significantly increased. High-volume centers report up to 70% double survival, and >90% survival of at least one twin after laser treatment of TTTS. About 10% of laser surgery survivors exhibit long-term neurodevelopmental delay. In this chapter, we discuss TTTS pathophysiology, diagnosis, and optimal treatment, as well as long-term outcomes after laser intervention.

Type
Chapter
Information
Management of Multiple Pregnancies
A Practical Guide
 , pp. 135 - 146
Publisher: Cambridge University Press
Print publication year: 2022

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References

Benirschke, K, Masliah, E. The placenta in multiple pregnancy: outstanding issues. Reprod Fertil Dev 2001;13:615–22.Google Scholar
Zhao, DP, de Villiers, SF, Slaghekke, F et al. Prevalence, size, number and localization of vascular anastomoses in monochorionic placentas. Placenta 2013;34:589–93.CrossRefGoogle ScholarPubMed
Sebire, NJ, Talbert, D, Fisk, NM. Twin-to-twin transfusion syndrome results from dynamic asymmetrical reduction in placental anastomoses: a hypothesis. Placenta 2001;22:383–91.CrossRefGoogle ScholarPubMed
Bamberg C, Hecher K. Twin-to-twin transfusion syndrome: Controversies in the diagnosis and management. Best Pract Res Clin Obstet Gynaecol 2022; doi: 10.1016/j.bpobgyn.2022.03.013. Online ahead of print.CrossRefGoogle Scholar
Khalil, A, Rodgers, M, Baschat, A et al. ISUOG practice guidelines: role of ultrasound in twin pregnancy. Ultrasound Obstet Gynecol 2016;47:247–63.Google Scholar
Mogra, R, Saaid, R, Tooher, J, Pedersen, L, Kesby, G, Hyett, J. Prospective validation of first-trimester ultrasound characteristics as predictive tools for twin–twin transfusion syndrome and selective intrauterine growth restriction in monochorionic diamniotic twin pregnancies. Fetal Diagn Ther 2020;47(4):321–7.CrossRefGoogle ScholarPubMed
Cimpoca, B, Syngelaki, A, Litwinska, E, Muzaferovic, A, Nicolaides, KH. Increased nuchal translucency at 11–13 weeks’ gestation and outcome in twin pregnancy. Ultrasound Obstet Gynecol 2020;55:318–25.CrossRefGoogle ScholarPubMed
Stagnati, V, Zanardini, C, Fichera, A et al. Early prediction of twin-to-twin transfusion syndrome: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2017;49:573–82.CrossRefGoogle ScholarPubMed
Bamberg, C, Diemert, A, Glosemeyer, P, Tavares de Sousa, M, Hecher, K. Discordance of umbilical coiling index between recipients and donors in twin–twin transfusion syndrome. Placenta 2019;76:19–22.CrossRefGoogle ScholarPubMed
Quintero, RA, Morales, WJ, Allen, MH, Bornick, PW, Johnson, PK, Kruger, M. Staging of twin–twin transfusion syndrome. J Perinatol 1999;19:550–5.CrossRefGoogle ScholarPubMed
Diehl, W, Diemert, A, Grasso, D, Sehner, S, Wegscheider, K, Hecher, K. Fetoscopic laser coagulation in 1020 pregnancies with twin–twin transfusion syndrome demonstrates improvement in double-twin survival rate. Ultrasound Obstet Gynecol 2017;50:728–35.CrossRefGoogle ScholarPubMed
Michelfelder, E, Gottliebson, W, Border, W et al. Early manifestations and spectrum of recipient twin cardiomyopathy in twin–twin transfusion syndrome: relation to Quintero stage. Ultrasound Obstet Gynecol 2007;30:965–71.CrossRefGoogle ScholarPubMed
Rychik, J, Tian, Z, Bebbington, M et al. The twin–twin transfusion syndrome: spectrum of cardiovascular abnormality and development of a cardiovascular score to assess severity of disease. Am J Obstet Gynecol 2007;197(392):e1–e8.Google Scholar
Berghella, V, Kaufmann, M. Natural history of twin–twin transfusion syndrome. J Reprod Med 2001;46:480–4.Google ScholarPubMed
Senat, MV, Deprest, J, Boulvain, M, Paupe, A, Winer, N, Ville, Y. Endoscopic laser surgery versus serial amnioreduction for severe twin-to-twin transfusion syndrome. N Engl J Med 2004;351:136–44.Google Scholar
Sacco, A, Van der Veeken, L, Bagshaw, E et al. Maternal complications following open and fetoscopic fetal surgery: a systematic review and meta-analysis. Prenat Diagn 2019;39:251–68.CrossRefGoogle ScholarPubMed
Groene, SG, Tollenaar, LSA, Van Klink, JMM et al. Twin–twin transfusion syndrome with and without selective fetal growth restriction prior to fetoscopic laser surgery: short- and long-term outcome. J Clin Med 2019 Jul 3;8(7):969.CrossRefGoogle ScholarPubMed
Snowise, S, Moise, KJ, Johnson, A, Bebbington, MW, Papanna, R. Donor death after selective fetoscopic laser surgery for twin–twin transfusion syndrome. Obstet Gynecol 2015;126:74–80.CrossRefGoogle ScholarPubMed
Skupski, DW, Luks, FI, Walker, M et al. Preoperative predictors of death in twin-to-twin transfusion syndrome treated with laser ablation of placental anastomoses. Am J Obstet Gynecol 2010;203(388):e1–e11.CrossRefGoogle ScholarPubMed
Stirnemann, J, Djaafri, F, Kim, A et al. Preterm premature rupture of membranes is a collateral effect of improvement in perinatal outcomes following fetoscopic coagulation of chorionic vessels for twin–twin transfusion syndrome: a retrospective observational study of 1092 cases. BJOG 2018;125:1154–62.CrossRefGoogle ScholarPubMed
Habli, M, Bombrys, A, Lewis, D et al. Incidence of complications in twin–twin transfusion syndrome after selective fetoscopic laser photocoagulation: a single-center experience. Am J Obstet Gynecol 2009;201(417):e1–e7.CrossRefGoogle ScholarPubMed
Robyr, R, Lewi, L, Salomon, LJ et al. Prevalence and management of late fetal complications following successful selective laser coagulation of chorionic plate anastomoses in twin-to-twin transfusion syndrome. Am J Obstet Gynecol 2006;194:796–803.Google Scholar
Akkermans, J, Peeters, SH, Klumper, FJ, Lopriore, E, Middeldorp, JM, Oepkes, D. Twenty-five years of fetoscopic laser coagulation in twin–twin transfusion syndrome: a systematic review. Fetal Diagn Ther 2015;38:241–53.CrossRefGoogle ScholarPubMed
Hecher, K, Gardiner, HM, Diemert, A, Bartmann, P. Long-term outcomes for monochorionic twins after laser therapy in twin-to-twin transfusion syndrome. Lancet Child Adolesc Health 2018;2:525–35.CrossRefGoogle ScholarPubMed
Stirnemann, J, Chalouhi, G, Essaoui, M et al. Fetal brain imaging following laser surgery in twin-to-twin surgery. BJOG 2018;125:1186–91.Google Scholar
Van Klink, JM, Koopman, HM, Rijken, M, Middeldorp, JM, Oepkes, D, Lopriore, E. Long-term neurodevelopmental outcome in survivors of twin-to-twin transfusion syndrome. Twin Res Hum Genet 2016;19:255–61.CrossRefGoogle ScholarPubMed
Spruijt, MS, Lopriore, E, Tan, R et al. Long-term neurodevelopmental outcome in twin-to-twin transfusion syndrome: is there still room for improvement? J Clin Med 2019 Aug 15;8(8):1226. https://doi.org/10.3390/jcm8081226CrossRefGoogle ScholarPubMed
Herberg, U, Bolay, J, Graeve, P, Hecher, K, Bartmann, P, Breuer, J. Intertwin cardiac status at 10-year follow-up after intrauterine laser coagulation therapy of severe twin–twin transfusion syndrome: comparison of donor, recipient and normal values. Arch Dis Child Fetal Neonatal Ed 2014;99:F380–F385.Google Scholar
Khalil, A, Cooper, E, Townsend, R, Thilaganathan, B. Evolution of stage 1 twin-to-twin transfusion syndrome (TTTS): systematic review and meta-analysis. Twin Res Hum Genet 2016;19:207–16.CrossRefGoogle ScholarPubMed
Bamberg et al. Neither the differentiation between twin-twin transfusion syndrome Stages I and II nor III and IV makes a difference regarding the probability of double survival after laser therapy. Ultrasound Obstet Gynecol 2020.Google Scholar
Papanna, R, Habli, M, Baschat, AA et al. Cerclage for cervical shortening at fetoscopic laser photocoagulation in twin–twin transfusion syndrome. Am J Obstet Gynecol 2012;206(425):e1–e7.CrossRefGoogle ScholarPubMed
Salomon, LJ, Nasr, B, Nizard, J et al. Emergency cerclage in cases of twin-to-twin transfusion syndrome with a short cervix at the time of surgery and relationship to perinatal outcome. Prenat Diagn 2008;28:1256–61.CrossRefGoogle Scholar
Aboudiab, MS, Chon, AH, Korst, LM, Llanes, A, Ouzounian, JG, Chmait, RH. Management of twin–twin transfusion syndrome with an extremely short cervix. J Obstet Gynaecol 2018;38:359–62.CrossRefGoogle ScholarPubMed
Lopriore, E, Middeldorp, JM, Oepkes, D, Klumper, FJ, Walther, FJ, Vandenbussche, FP. Residual anastomoses after fetoscopic laser surgery in twin-to-twin transfusion syndrome: frequency, associated risks and outcome. Placenta 2007;28:204–8.Google Scholar
Slaghekke, F, Lopriore, E, Lewi, L et al. Fetoscopic laser coagulation of the vascular equator versus selective coagulation for twin-to-twin transfusion syndrome: an open-label randomised controlled trial. Lancet 2014;383:2144–51.CrossRefGoogle ScholarPubMed
Quintero, RA, Kontopoulos, E, Chmait, RH. Laser treatment of twin-to-twin transfusion syndrome. Twin Res Hum Genet 2016;19:197–206.CrossRefGoogle ScholarPubMed
Lanna, MM, Faiola, S, Consonni, D, Rustico, MA. Increased risk of placental abruption after Solomon laser treatment of twin–twin transfusion syndrome. Placenta 2017;53:54–6.Google Scholar
D’Antonio, F, Thilaganathan, B, Toms, J et al. Perinatal outcome after fetoscopic laser surgery for twin-to-twin transfusion syndrome in triplet pregnancies. BJOG 2016;123:328–36.Google ScholarPubMed
Baud, D, Windrim, R, Keunen, J et al. Fetoscopic laser therapy for twin–twin transfusion syndrome before 17 and after 26 weeks’ gestation. Am J Obstet Gynecol 2013;208(197):e1–e7.CrossRefGoogle ScholarPubMed

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