Fetal Medicine and Surgery Center, Medicina Fetal Mexico, Hospital San José, Querétaro, Mexico.
Fetal Medicine Mexico Institute, Guadalajara, Mexico.
Fetal Diagn Ther. 2023;50(2):106-114. doi: 10.1159/000528815. Epub 2023 Feb 3.
Identification of intertwin anastomosis may be challenging during fetoscopy in cases with complete anterior placenta. The aim of this study was to describe the technique, feasibility, and outcomes of flexible video fetoscopy for laser coagulation in monochorionic (MC) twin pregnancies with twin-to-twin transfusion syndrome (TTTS) presenting with inaccessible anterior placenta.
From April 2021 to March 2022, a prospective cohort of consecutive MC twin pregnancies complicated with TTTS presenting with anterior placenta after 20 weeks was recruited. Cases with inaccessible anterior placenta during standard technique were converted into flexible video fetoscopy for completion of laser coagulation of placental anastomoses using a 270° flexible video endoscope through the same uterine port. Descriptive analysis includes feasibility, remaining anastomoses requiring laser photocoagulation, and perinatal outcomes.
A total of 45 pregnancies with TTTS were treated with fetoscopic laser therapy during the 1-year study period. Twenty-one pregnancies presented with anterior placenta after 20 weeks, in which an inaccessible vascular equator was observed in 33.3% (7/21). Flexible video fetoscopy was successfully performed in all 7 cases at a median gestational age of 22+2 (20+0-27+1) weeks+days. Visualization of the entire placental surface, coagulation of selected vessels, and exploration of the entire vascular equator were achieved in all cases. Six cases (85.7%) required additional laser coagulation due to either vascular patency despite initial coagulation with conventional fetoscopy (1/6, 16.7%) and/or remaining noncoagulated anastomoses (5/6, 83.3%). Perinatal survival of at least one twin and both twins was achieved in 85.7% and 57.1%, respectively.
Flexible video fetoscopy for completion of laser coagulation of placental anastomoses is feasible and represents a good option for TTTS cases presenting after 20 weeks with inaccessible anterior placenta.
在完全前置胎盘的情况下，通过胎儿镜识别吻合支可能具有挑战性。本研究的目的是描述一种技术，探讨在 20 周后出现前置胎盘且无法进行常规操作的完全性前置胎盘前置胎盘胎儿镜下激光凝固治疗单绒毛膜双胎妊娠（MC）双胎输血综合征（TTTS）的可行性、安全性和结局。
从 2021 年 4 月至 2022 年 3 月，连续前瞻性招募了一组在 20 周后出现前置胎盘且存在 TTTS 的 MC 双胎妊娠病例。对于无法进行标准操作的病例，通过同一个子宫端口使用 270°的柔性视频内窥镜完成胎盘吻合支的激光凝固。描述性分析包括可行性、需要激光凝固的剩余吻合支以及围产儿结局。
在 1 年的研究期间，共有 45 例 TTTS 妊娠接受了胎儿镜激光治疗。21 例妊娠在 20 周后出现前置胎盘，其中 33.3%（7/21）观察到血管赤道不可触及。在所有 7 例病例中，均在中位孕龄 22+2（20+0-27+1）周+天成功进行了柔性视频胎儿镜检查。所有病例均能清晰显示整个胎盘表面，对选定的血管进行凝固，并探查整个血管赤道。由于初始常规胎儿镜检查凝固后血管再通（1/6，16.7%）和/或存在未凝固吻合支（5/6，83.3%），6 例（85.7%）需要进一步激光凝固。至少有 1 个胎儿存活和 2 个胎儿均存活的围产儿生存率分别为 85.7%和 57.1%。
对于 20 周后出现前置胎盘且无法进行常规操作的 TTTS 病例，完成胎盘吻合支激光凝固的柔性视频胎儿镜检查是可行的，是一种很好的选择。
