Maternal Complications and Hemodynamic Changes Following Intrauterine Interventions for Twin-to-Twin Transfusion Syndrome in Monochorionic Diamniotic Twin Pregnancies

Abstract

Twin-to-twin transfusion syndrome (TTTS) is a challenging complication in monochorionic diamniotic (MCDA) twins. Intrauterine interventions, such as fetoscopic laser ablation and cord occlusion followed by amniodrainage, are established treatments. Little is known about maternal complications and hemodynamics following these interventions. We performed a retrospective analysis of maternal procedure-related complications and the impact of such procedures on maternal hemodynamics and blood characteristics. Within the study period, 100 women with severe TTTS treated by fetoscopic laser ablation (FLA) or cord occlusion (CO) were identified. Clinically relevant maternal complications were reported in four (4%) cases. There was a significant decrease in hemoglobin, hematocrit, and albumin between admission and postoperative measurements (all p < 0.001). Systolic and diastolic blood pressure, as well as maternal heart rate, decreased from time of skin suture to postoperative measurements (all p < 0.001). Within a 24 h interval, there was a positive correlation between hematocrit (Spearman’s rho 0.325; p = 0.003), hemoglobin (Spearman’s rho 0.379; p < 0.001), and albumin (Spearman’s rho 0.360; p = 0.027), and the amount of amniodrainage during the intervention. Maternal procedure-related complications are relatively rare. Significant hemodynamic alterations and maternal hemodilution are common clinical findings following intrauterine interventions.

Amniodrainage-Induced Circulatory Dysfunction in Women Treated for Twin-To-Twin Transfusion Syndrome

“…In a previous study, we observed that high volume amniodrainage was significantly correlated with maternal hemodilution and hemodynamic alterations [ 5 ]. We could confirm those findings in the current prospective cohort, by demonstrating a drop in hemoglobin concentration and hematocrit in the absence of clinical blood loss, suggesting an expansion of blood volume by 18.0 ± 7.0 % (Hct).…”

“…FLA was performed in a standardized fashion as previously described [ 5 ]. All FLA procedures were completed by amniodrainage from the recipient‘s amniotic sac until a DVP of about 6 cm was achieved.…”

“…In contrast to the high number of scientific reports on fetal outcome and treatment options, data on maternal hemodynamic changes or adverse side effects following FLA procedures are scarce. Clinical signs suggestive of maternal hemodilution were described in cases of mid-trimester TTTS managed by FLA and subsequent amniodrainage, providing evidence that such interventions have a significant impact on the maternal compartment [ 5 , 6 , 7 ]. A variety of observations including maternal hemodynamic adaptations, decrease in intrauterine pressure and increase in placental volume have been described following high volume amniodrainage [ 8 , 9 ].…”

“…In a previous retrospective study, we observed that high volume amniodrainage was significantly correlated with maternal hemodilution and hemodynamic alterations [ 5 ]. Thus, we hypothesized that the frequent observation of hemodilution is caused by high volume amniodrainage after FLA procedures.…”

Monochorionic Twins: A Delicate Balance

“…The best treatment for twin-twin transfusion syndrome (TTTS) is fetoscopic laser coagulation of the vascular anastomoses, preferably using the Solomon laser technique [2]. Greimel et al show that this surgical intervention is safe and rarely associated with maternal procedure-related complications [3]. Importantly, TTTS should not be viewed as a homogeneous disorder and may coexist with selective fetal growth restriction (sFGR) and/or twin anemia-polycythemia sequence (TAPS).…”