Outcome of twin–twin transfusion syndrome according to Quintero stage of disease: systematic review and meta‐analysis

Abstract

Objectives To report the outcome of pregnancies complicated by twin–twin transfusion syndrome (TTTS) according to Quintero stage. Methods MEDLINE, EMBASE and CINAHL databases were searched for studies reporting the outcome of pregnancies complicated by TTTS stratified according to Quintero stage (I–V). The primary outcome was fetal survival rate according to Quintero stage. Secondary outcomes were gestational age at birth, preterm birth (PTB) before 34, 32 and 28 weeks' gestation and neonatal morbidity. Outcomes are reported according to the different management options (expectant management, laser therapy or amnioreduction) for pregnancies with Stage‐I TTTS. Only cases treated with laser therapy were considered for those with Stages‐II–IV TTTS and only cases managed expectantly were considered for those with Stage‐V TTTS. Random‐effects head‐to‐head meta‐analysis was used to analyze the extracted data. Results Twenty‐six studies (2699 twin pregnancies) were included. Overall, 610 (22.6%) pregnancies were diagnosed with Quintero stage‐I TTTS, 692 (25.6%) were Stage II, 1146 (42.5%) were Stage III, 247 (9.2%) were Stage IV and four (0.1%) were Stage V. Survival of at least one twin occurred in 86.9% (95% CI, 84.0–89.7%) (456/552) of pregnancies with Stage‐I, in 85% (95% CI, 79.1–90.1%) (514/590) of those with Stage‐II, in 81.5% (95% CI, 76.6–86.0%) (875/1040) of those with Stage‐III, in 82.8% (95% CI, 73.6–90.4%) (172/205) of those with Stage‐IV and in 54.6% (95% CI, 24.8–82.6%) (5/9) of those with Stage‐V TTTS. The rate of a pregnancy with no survivor was 11.8% (95% CI, 8.4–15.8%) (69/564) in those with Stage‐I, 15.0% (95% CI, 9.9–20.9%) (76/590) in those with Stage‐II, 18.6% (95% CI, 14.2–23.4%) (165/1040) in those with Stage‐III, 17.2% (95% CI, 9.6–26.4%) (33/205) in those with Stage‐IV and in 45.4% (95% CI, 17.4–75.2%) (4/9) in those with Stage‐V TTTS. Gestational age at birth was similar in pregnancies with Stages‐I–III TTTS, and gradually decreased in those with Stages‐IV and ‐V TTTS. Overall, the incidence of PTB and neonatal morbidity increased as the severity of TTTS increased, but data on these two outcomes were limited by the small sample size of the included studies. When stratifying the analysis of pregnancies with Stage‐I TTTS according to the type of intervention, the rate of fetal survival of at least one twin was 84.9% (95% CI, 70.4–95.1%) (94/112) in cases managed expectantly, 86.7% (95% CI, 82.6–90.4%) (249/285) in those undergoing laser therapy and 92.2% (95% CI, 84.2–97.6%) (56/60) in those after amnioreduction, while the rate of double survival was 67.9% (95% CI, 57.0–77.9%) (73/108), 69.7% (95% CI, 61.6–77.1%) (203/285) and 80.8% (95% CI, 62.0–94.2%) (49/60), respectively. Conclusions Overall survival in monochorionic diamniotic pregnancies affected by TTTS is higher for earlier Quintero stages (I and II), but fetal survival rates are moderately high even in those with Stage‐III or ‐IV TTTS when treated with laser therapy. Gestational age at birth was similar in pregnancies with Sta...

Controlled Amnioreduction for Twin-to-Twin Transfusion Syndrome: Perinatal and Long-Term Neurodevelopmental Outcome

“…Furthermore, it seems that gradual reduction of the amniotic volume, as well as decreasing the amniotic pressure on the placental chorionic vessels result in more moderate impact on the cardiovascular system for both fetuses. Nevertheless, the controlled AR procedure resulted in a higher survival rate and positive long-term outcomes compared to other studies 10,11,13,[26][27][28] .…”

“…Examples of mild neurologic anomalies included the following functioning areas: vision, speech, dexterity, learning and remembering. The results of the survival rate and long-term neurodevelopmental outcomes were compared with the AR and FLA procedures' results published by other authors 10,11,13,[26][27][28] and are presented in Tables 2.…”

Influence of Indications on Perinatal Outcomes After Radio Frequency Ablation in Complicated Monochorionic Pregnancies: A Retrospective Cohort Study

“…RFA is also recommended for sIUGR in which laser may not be a desirable choice for large vessel anastomosis 5,20,21 . Although foetoscopic laser photocoagulation is currently the best available approach for TTTS stages II-IV [22][23][24] , selective foetal reduction is still required in some patients for technical or maternal aspects such as history of caesarean section, cervical incompetence, increased maternal age or worry about foetal outcome 25,26 . However, the effects of these indications on the pregnancy outcome following RFA remain unde ned.…”

Influence of Indications on Perinatal Outcomes After Radio frequency Ablation in Complicated Monochorionic Pregnancies: A Retrospective Cohort Study

“…RFA is also recommended for sIUGR in which laser may not be a desirable choice for large vessel anastomosis 5,20,21 . Although foetoscopic laser photocoagulation is currently the best available approach for TTTS stages II-IV [22][23][24] , selective foetal reduction is still required in some patients for technical or maternal aspects such as history of caesarean section or cervical incompetence, increased maternal age or worry about foetal outcome 25,26 . However, the effects of these indications on the pregnancy outcome following RFA remain unde ned.…”