Endoscopic laser surgery versus serial amniocenteses in the treatment of severe twin-twin transfusion syndrome,☆☆

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Abstract

Objective: Severe twin-twin transfusion can be treated by either serial amniocenteses with removal of large volumes of amniotic fluid or by endoscopic laser coagulation of the communicating vessels. We investigated the benefit of laser surgery in comparison to serial amniocenteses in terms of pregnancy outcome. Study Design: The data used in this comparative study were collected from 116 patients with severe twin-twin transfusion syndrome between 17 and 25 weeks’ gestation. The patients were grouped according to the treatment center. The first group comprised 73 patients (median gestational age 20.7 weeks) treated in Hamburg by fetoscopic laser coagulation of the vascular placental anastomoses between January 1995 and May 1997. The second group comprised 43 patients (median gestational age 20.4 weeks), fulfilling identical diagnostic criteria and treated in Bonn by serial amniocenteses between 1992 and 1996. Results: The overall fetal survival rate was not significantly different (61%, 89/146, vs 51%, 44/86; P = .239). There was a significantly higher proportion of pregnancies with ≥1 survivor in the laser-treated group (79%, 58/73, vs 60%, 26/43; P = .033). The number of cases with spontaneous intrauterine fetal death of both fetuses was significantly lower in the laser-treated group (3%, 2/73, vs 19%, 8/43; P = .003). The incidence of abnormal ultrasonographic findings in the brain was significantly lower among surviving neonates after laser surgery than after amniocenteses (6%, 5/89, vs 18%, 8/44; P = .03). For pregnancies with ≥1 live-born baby, a significantly longer interval between first intervention and delivery (median 90 vs 72 days, P = .022) leading to a significantly higher gestational age at delivery (median 33.7 vs 30.7 weeks, P = .018) was observed for the laser-treated group. The birth weights of the donor fetuses were significantly higher in the laser-treated group (median 1750 vs 1145 g, P = .034), and a trend toward higher birth weight was also found for recipient fetuses (median 2000 vs 1560 g, P = .076). Conclusions: These findings indicate that endoscopic laser coagulation of placental vascular anastomoses offers a more effective alternative to serial amniocenteses as a treatment of severe second-trimester twin-twin transfusion syndrome. (Am J Obstet Gynecol 1999;180:717-24.)

Section snippets

Material and methods

Between January 1995 and May 1997 we performed endoscopic laser coagulation of the vascular placental anastomoses in 73 patients with severe twin-twin transfusion syndrome who were referred to our center in Hamburg. The results of the first 18 cases have been included in a previous report of a multicenter study.18 In all cases the parents gave written consent after intensive counseling and the study was approved by the ethics committee of the hospital. The following entry criteria for

Results

Patients treated with the laser coagulation method required just a single intervention in all but 1 case, whereas the median number of interventions in the group treated by serial amniocenteses was 3 (range 1-15) and 81% of continuing pregnancies needed >1 amniocentesis. The patient in whom polyhydramnios reoccurred after laser therapy was subsequently treated with serial amniocenteses.

Obstetric data at the time of laser coagulation or first amniocentesis are given in Table I.

. Obstetric data at

Comment

As far as we are aware, this is the first study to directly compare pregnancy outcome after endoscopic laser surgery and after serial amniocenteses in the treatment of severe second trimester twin-twin transfusion syndrome. Each treatment group represents the largest number of cases reported from a single fetal medicine center. Laser surgery was associated with a higher chance of having ≥1 surviving twin per pregnancy, with a more advanced gestational age at delivery and with a higher birth

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    Reprint requests: Kurt Hecher, MD, Department of Prenatal Diagnosis and Therapy, AK Barmbek, Rübenkamp 148, 22291 Hamburg, Germany.

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