Emanuel Gaziano, MD Multiple Gestation Pregnancies Monochorionic Twins and Twin Transfusion Syndrome Emanuel P. Gaziano, M.D. Minnesotal Perinatal Physicians Abbott Northwestern Hospital, Minneapolis Professor, Department of Ob/Gyn University of Minnesota
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Emanuel Gaziano, MD Multiple Gestation Pregnancies Monochorionic Twins and Twin Transfusion Syndrome Emanuel P. Gaziano, M.D. Minnesotal Perinatal Physicians.
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Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Monochorionic Twins and Twin Transfusion SyndromeMonochorionic Twins and
membrane• Equalizes fluid pressure• Usually small holes
punctured in the dividing membrane
• Risk for cord entanglement
Septostomy• Separates the dividing
membrane• Equalizes fluid pressure• Usually small holes
punctured in the dividing membrane
• Risk for cord entanglement
Amnioreduction• Reduce amniotic fluid
volume in the recipient sac.
• Usually for Stage I or II• Decompress when DVP
>11• Decompress to normal
range <DVP of 8• Risk: infection
Amnioreduction• Reduce amniotic fluid
volume in the recipient sac.
• Usually for Stage I or II• Decompress when DVP
>11• Decompress to normal
range <DVP of 8• Risk: infection
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Technique similar to genetic amnio: larger
needle and vacuum bottle.Technique similar to genetic amnio: larger
needle and vacuum bottle.
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Prospective randomized trial comparing amnioreduction to septostomy
Prospective randomized trial comparing amnioreduction to septostomy
• Survival in each group was 65%
• No data on neurologic outcome
Saade GR, Moise K, Dormar KA et al: Randomized trial of septostomy verses amnioreduction in the treatment of twin oligohydramnios polyhydramnios sequence (TOPS). American Journal of Obstetrics
and Gynecology (abstr) 187: 3, 2003.
• Survival in each group was 65%
• No data on neurologic outcome
Saade GR, Moise K, Dormar KA et al: Randomized trial of septostomy verses amnioreduction in the treatment of twin oligohydramnios polyhydramnios sequence (TOPS). American Journal of Obstetrics
and Gynecology (abstr) 187: 3, 2003.
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
DeLia 1995 N=26 Severe TTTS by LaserDeLia 1995 N=26 Severe TTTS by Laser
• Surviving fetuses were delivered for obstetric reasons at a mean of 32.2 weeks (range, 26 to 37 weeks).
• Fifty-three percent (28 of 53) of fetuses survived• 96% (27 of 28) showed normal development at a
mean of 35.8 months of follow-up (range, 1 to 68 months).
• DeLia JE, et al: Fetoscopic laser ablation of placental vessels in severe previable twin-twin transfusion syndrome. American Journal of Obstetrics and Gynecology 172:1202, 1995.
• Surviving fetuses were delivered for obstetric reasons at a mean of 32.2 weeks (range, 26 to 37 weeks).
• Fifty-three percent (28 of 53) of fetuses survived• 96% (27 of 28) showed normal development at a
mean of 35.8 months of follow-up (range, 1 to 68 months).
• DeLia JE, et al: Fetoscopic laser ablation of placental vessels in severe previable twin-twin transfusion syndrome. American Journal of Obstetrics and Gynecology 172:1202, 1995.
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Laser vs AmnioreductionLaser vs Amnioreduction
• N=73 women were treated between 1995 and 1997 in one center by fetoscopic laser photocoagulation
• N=43 patients were treated at another center between 1992 and 1996 by serial amnioreduction.
•
Hecher K, et al: Endoscopic laser surgery versus serial amniocentesis in the treatment of severe twin-twin transfusion syndrome. American Journal of Obstetrics and Gynecology 180:717, 1999.
• N=73 women were treated between 1995 and 1997 in one center by fetoscopic laser photocoagulation
• N=43 patients were treated at another center between 1992 and 1996 by serial amnioreduction.
•
Hecher K, et al: Endoscopic laser surgery versus serial amniocentesis in the treatment of severe twin-twin transfusion syndrome. American Journal of Obstetrics and Gynecology 180:717, 1999.
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Hecher K, et al: Endoscopic laser surgery versus serial amniocentesis in the treatment of severe twin-twin transfusion syndrome. American Journal
of Obstetrics and Gynecology 180:717, 1999
Hecher K, et al: Endoscopic laser surgery versus serial amniocentesis in the treatment of severe twin-twin transfusion syndrome. American Journal
of Obstetrics and Gynecology 180:717, 1999
Laser versus Amnioreduction for Severe TTTS
0
20
40
60
80
100
Survival IUFD Abn HeadUS
GA atBirth
Laser
Amnio
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Long-term neurodevelopmental outcome of children born after laser for severe TTTS
Long-term neurodevelopmental outcome of children born after laser for severe TTTS
N=167 follow up to 3 years and 2months
• 145 (86.8%) showed normal development,
• 12 infants (7.2%) showed minor neurologic abnormalities,
• 10 infants (6.0%) major neurologic abnormalities.
N=167 follow up to 3 years and 2months
• 145 (86.8%) showed normal development,
• 12 infants (7.2%) showed minor neurologic abnormalities,
• 10 infants (6.0%) major neurologic abnormalities.
Graef C. Am J Obstet Gynecol. 2006 Feb;194(2):303-8.
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Long-term neurodevelopmental outcome of children born after Laser for severe TTTS
Long-term neurodevelopmental outcome of children born after Laser for severe TTTS
No difference in outcome for the former donors/recipients (P = .349)
CONCLUSION: intrauterine laser coagulation seems to be the best treatment option for severe twin-twin transfusion syndrome.
No difference in outcome for the former donors/recipients (P = .349)
CONCLUSION: intrauterine laser coagulation seems to be the best treatment option for severe twin-twin transfusion syndrome.
Graef C. Am J Obstet Gynecol. 2006 Feb;194(2):303-8.
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Perinatal death rate higher when laser used for treatment of TTTS in Stage I and II (p=.02)
Perinatal death rate higher when laser used for treatment of TTTS in Stage I and II (p=.02)
Quintero et al, Am J Obstet Gynecol 2003;188:1333
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Perinatal death rate lower when laser used for treatment of TTTS in Stage III and IV (p=.02)Perinatal death rate lower when laser used for treatment of TTTS in Stage III and IV (p=.02)
Quintero et al, Am J Obstet Gynecol 2003;188:1333
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Two prospective randomized clinical trials
Two prospective randomized clinical trials
• The Eurofetus trial in Europe
• The National-Institutes-of-Health-sponsored trial in the United States
• Compare aggressive serial amnioreduction to fetoscopic laser photocoagulation.
• The Eurofetus trial in Europe
• The National-Institutes-of-Health-sponsored trial in the United States
• Compare aggressive serial amnioreduction to fetoscopic laser photocoagulation.
2011 NIH Trial2011 NIH Trial
• The trial had uncovered higher mortality among recipient twins who received laser treatment. But overall, survival of one or both twins of the same pregnancy was no different between the two treatments. In addition, there was no difference between survival rates of donor twins and recipient twins.
• The trial had uncovered higher mortality among recipient twins who received laser treatment. But overall, survival of one or both twins of the same pregnancy was no different between the two treatments. In addition, there was no difference between survival rates of donor twins and recipient twins.
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Cochrane ReviewCochrane Review
• Laser coagulation resulted in less overall death (48% vs. 59%) when compared with amnioreduction.
• The results suggest that endoscopic laser coagulation of anastomotic vessels should be considered in the treatment of all stages of TTTS to improve perinatal and neonatal
outcome
• Laser coagulation resulted in less overall death (48% vs. 59%) when compared with amnioreduction.
• The results suggest that endoscopic laser coagulation of anastomotic vessels should be considered in the treatment of all stages of TTTS to improve perinatal and neonatal
outcome
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Emanuel Gaziano, MDMultiple Gestation Pregnancies
Treatment SummaryTreatment Summary
• Most studies show outcomes for laser separation superior to amnioreduction.
• Always exceptions due to the small placental mass and complications due to velamentous insertions in some MC pregnancies.
• Spontaneous improvement occurs in some cases (anastomoses change)
• Most studies show outcomes for laser separation superior to amnioreduction.
• Always exceptions due to the small placental mass and complications due to velamentous insertions in some MC pregnancies.
• Spontaneous improvement occurs in some cases (anastomoses change)