Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea.
Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, Seoul, Republic of Korea.
J Matern Fetal Neonatal Med. 2022 Dec;35(25):5595-5606. doi: 10.1080/14767058.2021.1888286. Epub 2021 Apr 20.
This single-center study aimed to assess the perinatal outcomes and its associated factors in fetuses with twin-to-twin transfusion syndrome (TTTS) treated by fetoscopic laser coagulation (FLC).
In this retrospective study, we included fetuses prenatally diagnosed with TTTS at Asan Medical Center, Seoul, Korea, between October 2011 and December 2018. All patients with TTTS stage II or higher and those with stage I TTTS coupled with symptomatic polyhydramnios or cardiac dysfunction were eligible for FLC.
A total of 172 cases of monochorionic diamniotic twins and one case of dichorionic triamniotic triplets were prenatally diagnosed with TTTS and treated with FLC. The median gestational ages (GAs) at diagnosis and FLC were 20.3 and 20.5 weeks, respectively. The median GA of survivors at delivery was 32.5 weeks. The overall at least one twin- and double-survival rates within 28 days after birth were 82.1% and 55.5%, respectively. The GAs at diagnosis and FLC, Quintero stage, inter-twin weight discordance, associated selective intrauterine growth restriction (sIUGR), procedure time, volume of amnioreduction, preterm prelabor rupture of membranes (PPROM) within one week after FLC, intraoperative intrauterine bleeding, and chorioamnionitis were significant predictive factors of perinatal death. Associated sIUGR, absent end-diastolic flow of umbilical artery, and abnormal cord insertion were significantly associated with donor demise , whereas lower GA at diagnosis and FLC, smaller twins at FLC, pulsatile umbilical vein, and presence of mitral regurgitation were significantly associated with recipient demise . Since the application of the Solomon technique, the survival rate has improved from 75.4% to 88.8%. The FLC before 17 weeks was associated with PPROM within one week after FLC and lower survival rate, whereas that after 24 weeks was associated with twin anemia-polycythemia sequence and higher survival rate. We reached a survival rate of 82% for at least one survival with only 12 procedures.
FLC is an effective treatment for TTTS. The learning curve reached the acceptable target faster than in previous studies. Several prenatal parameters are identified as predictive factors of fetal survival in TTTS treated with FLC.
本单中心研究旨在评估经胎儿镜激光凝固（FLC）治疗的双胎输血综合征（TTTS）胎儿的围产结局及其相关因素。
在这项回顾性研究中，我们纳入了 2011 年 10 月至 2018 年 12 月期间在韩国首尔 Asan 医疗中心产前诊断为 TTTS 的胎儿。所有 TTTS Ⅱ期或更高级别患者以及 TTTS Ⅰ期合并症状性羊水过多或心功能障碍的患者均符合 FLC 治疗条件。
共有 172 例单绒毛膜双羊膜囊双胞胎和 1 例双绒毛膜三羊膜囊三胞胎被产前诊断为 TTTS，并接受了 FLC 治疗。诊断时和 FLC 时的中位孕龄（GA）分别为 20.3 周和 20.5 周。分娩时幸存者的中位 GA 为 32.5 周。出生后 28 天内至少有 1 个双胎和双胎存活的总存活率分别为 82.1%和 55.5%。诊断时和 FLC 时的 GA、Quintero 分期、双胎体重差异、相关选择性宫内生长受限（sIUGR）、手术时间、羊水减少量、FLC 后 1 周内早产胎膜早破（PPROM）、术中宫内出血和绒毛膜羊膜炎是围产儿死亡的显著预测因素。相关 sIUGR、脐动脉舒张末期血流缺失和脐带插入异常与供体死亡显著相关，而诊断时和 FLC 时的 GA 较低、FLC 时的双胞胎较小、搏动性脐静脉和二尖瓣反流与受体死亡显著相关。自 Solomon 技术应用以来，存活率从 75.4%提高到了 88.8%。17 周前进行的 FLC 与 FLC 后 1 周内发生的 PPROM 及较低的存活率相关，而 24 周后进行的 FLC 与双胎贫血-多血症序列和较高的存活率相关。我们仅通过 12 次手术就达到了至少有 1 个存活的 82%的存活率。
FLC 是 TTTS 的有效治疗方法。学习曲线比以往研究更快地达到了可接受的目标。在接受 FLC 治疗的 TTTS 胎儿中，有几个产前参数被确定为胎儿存活的预测因素。
