Chorioamniotic Membrane Separation after Fetoscopic Laser Photocoagulation

Takano, Mayumi; Nakata, Masahiko; Murata, Susumu; Sumie, Masahiro; Morita, Mineto

doi:10.1159/000472713

Cited by 22 publications

(28 citation statements)

References 14 publications

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“…The ruptured floating sheets of amnion may form strings and entrap the upper and lower extremities. In accordance with our results, Ortiz et al 24 and Takano et al 25 reported an increased risk of chorioamniotic membrane separation when fetoscopy occurred before 18 and 20 weeks of gestation, respectively (OR, 2.94; 95% CI, 1.64e5.28 and OR, 3.38; 95% CI, 1.44e7.93). A possible association between chorioamniotic membrane separation and PABDS after intrauterine interventions (eg, amniocentesis or fetoscopy for diaphragmatic hernia) has been hypothesized previously by Graf et al 5 and Lewi et al 26 To the best of our knowledge, this is the first study to show an association between chorioamniotic membrane separation and PABDS in TTTS after laser surgery.…”

Section: Discussionsupporting

confidence: 92%

Prevalence, risk factors, and outcome of postprocedural amniotic band disruption sequence after fetoscopic laser surgery in twin-twin transfusion syndrome: a large single-center case series

Knijnenburg

Slaghekke

Tollenaar

et al. 2020

American Journal of Obstetrics and Gynecology

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BACKGROUND: Postprocedural amniotic band disruption sequence is a condition that is associated with intrauterine interventions, and it is characterized by a constriction of the limbs or umbilical cord by fibrous strands, leading to edema, amputation, and/or fetal demise. OBJECTIVE: To evaluate the prevalence of, risk factors for, and the outcome of postprocedural amniotic band disruption sequence after fetoscopic laser surgery in twin-twin transfusion syndrome cases. STUDY DESIGN: : All consecutive cases of twin-twin transfusion syndrome treated with fetoscopic laser coagulation of the vascular anastomoses at our center between January 2002 and March 2019 were included in the study. The occurrence of postprocedural amniotic band disruption sequence in these cases was recorded, and the potential risk factors were analyzed. RESULTS: Postprocedural amniotic band disruption sequence was detected, at birth, in 2.2% (15/672) of twin-twin transfusion syndrome cases treated with fetoscopic laser surgery, in both the recipients (10/15, 67%) and the donors (5/15, 33%). Postprocedural amniotic band disruption sequence primarily affected the lower extremities (11/15, 73%) and, less frequently, the upper extremities (2/15, 13%), both the upper and lower extremities (1/15, 7%), or the umbilical cord (1/15, 7%).Postprocedural amniotic band disruption sequence led to the amputation of toes in 5 of 15 cases (33%) and resulted in fetal demise because of constriction of the umbilical cord in 1 case (7%). The independent risk factors identified for postprocedural amniotic band disruption sequence were lower gestational age at laser surgery (odds ratio per week, 1.43; 95% confidence interval, 1.12e1.79; P¼.003) and the presence of postprocedural chorioamniotic membrane separation on antenatal ultrasound examination (odds ratio, 41.66; 95% confidence interval, 5.44e319.25; P<.001). CONCLUSION: The prevalence of postprocedural amniotic band disruption sequence is low, but, when present, it may lead to severe consequences, with amputation of extremities or fetal demise occurring in more than one-third of the cases. Lower gestational age at the time of laser therapy and chorioamniotic membrane separation are independent risk factors for the postprocedural amniotic band disruption sequence.

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Section: Discussionsupporting

confidence: 92%

Prevalence, risk factors, and outcome of postprocedural amniotic band disruption sequence after fetoscopic laser surgery in twin-twin transfusion syndrome: a large single-center case series

Knijnenburg

Slaghekke

Tollenaar

et al. 2020

American Journal of Obstetrics and Gynecology

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“…Limitations of our study include its retrospective design and that we did not have data on the rate of CAS following LPA, which is a known risk factor for PPROM 28,29 . However, the effect of CAS in our study is likely minimal, given the results of a recent large study that demonstrated that CAS following LPA in TTTS cases does not increase rates of preterm delivery or reduce neonatal survival 18 . There is also a potential for ascertainment bias in our study because of the possibility that some surgeons may have decided to postpone LPA in less severe TTTS cases under the assumption that LPA at or after 18 weeks is safer.…”

Section: Discussionmentioning

confidence: 93%

Early laser surgery is not associated with very preterm delivery or reduced neonatal survival in TTTS

Espinoza

Belfort

Shamshirsaz

et al. 2021

Ultrasound in Obstet & Gyne

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Objective To evaluate the association of laser photocoagulation of placental anastomoses (LPA) prior to 18 weeks' gestation (early LPA) with very preterm delivery and neonatal survival in pregnancies with twin–twin transfusion syndrome (TTTS). Methods This was a retrospective cohort study of monochorionic diamniotic twin pregnancies with TTTS undergoing LPA between 2002 and 2018 at two institutions. The rates of delivery < 28, < 30 and < 32 weeks' gestation, preterm prelabor rupture of membranes (PPROM) and 30‐day survival of one or both infants were compared between pregnancies undergoing early LPA and those undergoing LPA ≥ 18 weeks' gestation. Regression analysis was performed to determine the association of early LPA with very preterm delivery and 30‐day survival, adjusted for Quintero stage, study phase, selective fetal growth restriction, gestational age at delivery, maternal age ≥ 35 years, body mass index > 35 kg/m2, placental location, use of Seldinger method to place the operative trocar, size of the trocar, participating center, use of Solomon technique, cerclage and PPROM. Survival analysis using the Cox proportional hazard model was applied to examine the LPA‐to‐delivery interval according to the timing of surgery, adjusted for confounding variables. Results A total of 414 TTTS pregnancies were included in the study, of which 68 (16.4%) underwent early LPA. In the total cohort, the incidence of delivery at < 28, < 30 and < 32 weeks' gestation was 22.7%, 39.6% and 53.4%, respectively. Survival of both twins and survival of at least one twin at 30 days were 67.5% and 90.8%, respectively. No significant difference was noted between pregnancies that underwent early LPA and those that had LPA ≥ 18 weeks in the rate of delivery < 28 weeks (19.1% vs 23.4%; P = 0.4), < 30 weeks (38.2% vs 39.9%; P = 0.8) and < 32 weeks (44.1% vs 55.2%; P = 0.1) and PPROM (29.0% vs 24.1%; P = 0.4), or in the incidence of double‐twin survival (63.9% vs 68.1%; P = 0.5) and survival of at least one infant (91.8% vs 90.6%; P = 0.7) at 30 days. Early LPA was not associated with very preterm delivery or neonatal survival in the regression analyses. Early LPA was associated with a longer LPA‐to‐delivery interval compared with LPA performed ≥ 18 weeks (median, 106.9 days (range, 2–164 days) vs median, 69.3 days (range, 0–146 days); P < 0.001) when adjusted for confounding variables (hazard ratio, 2.56 (95% CI, 1.76–3.73); P < 0.001). Conclusion Laser surgery before 18 weeks is not associated with an increased rate of very preterm delivery and PPROM or with reduced neonatal survival when compared with LPA after 18 weeks. © 2020 International Society of Ultrasound in Obstetrics and Gynecology

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“…7,18 Other reported risk factors include septostomy [19][20][21][22] and chorioamnion separation. [23][24][25][26] In our study, the multivariate regression analysis showed that none of these factors were significant independent predictors for PTB while LIT was the only significant independent protective factor in preventing PTB. Early gestational age at intervention (<18 weeks), on the other hand, has not been found to increase the risk for PTB in this population 27 , similarly to what our study showed.…”

Section: Discussionmentioning

confidence: 46%

Efficacy of Long Term Indomethacin Therapy in Prolonging Pregnancy After Fetoscopic Laser Surgery for Twin-to-Twin Transfusion Syndrome: a Collaborative Cohort Study

Mustafa

Krispin

Tadbiri

et al. 2021

Preprint

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Objective: To evaluate the efficacy of long-term indomethacin therapy (LIT) in prolonging pregnancy and reducing spontaneous preterm birth (PTB) in patients undergoing fetoscopic laser surgery (FLS) for the management of twin-to-twin transfusion syndrome (TTTS). Design: Retrospective cohort study of prospectively collected data. Setting: Collaborative multicenter study Population: 557 consecutive TTTS cases that underwent FLS Methods: LIT was defined as indomethacin use for at least 48 hours. Log-binomial regression was used to estimate the relative risk (RR) of PTB in LIT compared to non-LIT group. Cox regression was used to evaluate the association between LIT use and FLS-to-delivery survival. Main outcome measures: gestational age (GA) at delivery Results: Among the 411 pregnancies included, a total of 180 patients (43.8%) received LIT after FLS and 231 patients (56.2%) did not. Median GA at fetal intervention did not differ between groups (20.4 weeks). Median GA at delivery was significantly higher in the LIT group (33.6 weeks) compared to the non-LIT group (31.1weeks), p<0.001. FLS-to-delivery interval was significantly longer in the LIT group (P<0.001). The risk of PTB prior to 34, 32, 28, and 26 weeks gestation were all significantly lower in the LIT group compared to the non-LIT group (RR=0.69, 0.51, 0.37, and 0.18, respectively). The number needed to treat (NNT) with LIT to prevent one PTB<32 weeks gestation was 4, and to prevent one PTB<34 weeks was 5. Conclusion: Long-term indomethacin after FLS for TTTS was found to be associated with prolongation of pregnancy and reducing the risk for PTB.

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Chorioamniotic Membrane Separation after Fetoscopic Laser Photocoagulation

Cited by 22 publications

References 14 publications

Prevalence, risk factors, and outcome of postprocedural amniotic band disruption sequence after fetoscopic laser surgery in twin-twin transfusion syndrome: a large single-center case series

Prevalence, risk factors, and outcome of postprocedural amniotic band disruption sequence after fetoscopic laser surgery in twin-twin transfusion syndrome: a large single-center case series

Early laser surgery is not associated with very preterm delivery or reduced neonatal survival in TTTS

Efficacy of Long Term Indomethacin Therapy in Prolonging Pregnancy After Fetoscopic Laser Surgery for Twin-to-Twin Transfusion Syndrome: a Collaborative Cohort Study

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