Perinatal outcomes of twin pregnancies complicated by late twin‐twin transfusion syndrome: A systematic review and meta‐analysis

Abstract

Introduction Untreated twin‐to‐twin transfusion syndrome (TTTS) is associated with a high risk of perinatal mortality and morbidity. Laser surgery is recommended before 26 weeks of gestation. However, the optimal management in case of late TTTS (occurring after 26 weeks of gestation) is yet to be established. Material and methods We conducted a systematic review and meta‐analysis to evaluate the outcomes of monochorionic‐diamniotic twin pregnancies complicated by late TTTS according to different management options (expectant, laser therapy, amnioreduction, or delivery). The primary outcome was mortality, including single and double intrauterine, neonatal, and perinatal death. Secondary outcomes were composite morbidity, neuromorbidity, respiratory distress syndrome, admission to neonatal intensive care unit, intact survival (ie, free from neurological complications), and preterm birth before <32 weeks of gestation. Outcomes were reviewed according to the management and reported for the overall population of twins and disease status (ie, donor and recipient separately). Random‐effect meta‐analyses of proportions were used to analyze the data. Results Nine studies including 796 twin pregnancies affected by TTTS were included. No randomized controlled trials were available for inclusion. TTTS occurred at ≥26 weeks of gestation in 8.7% (95% CI 6.9%‐10.9%; 67/769) of cases reporting TTTS at all gestations. Intrauterine death occurred in 17.7% (95% CI 4.9%‐36.2%) of pregnancies managed expectantly, 5.3% (95% CI 0.9%‐12.9%) of pregnancies treated with laser, and 0% (95% CI 0%‐9%) after amnioreduction. Neonatal death occurred in 42.5% (95% CI 17.5%‐69.7%) of pregnancies managed expectantly, in 2.8% (95% CI 0.3%‐7.7%) of cases treated with laser, and in 20.2% (95% CI 6%‐40%) after amnioreduction. Only one study (10 cases) reported data on immediate delivery after diagnosis with no perinatal deaths. Perinatal death incidence was 55.7% (95% CI 31.4%‐78.6%) in twin pregnancies managed expectantly, 5.6% (95% CI 0.5%‐15.3%) in those treated with laser, and 20.2% (95% CI 6%‐40%) in those after amnioreduction. Intact survival was reported in 44.4%, 96.4%, and 78% of fetuses managed expectantly, with laser or amnioreduction, respectively. Conclusions Evidence regarding perinatal mortality and morbidity in twin pregnancies complicated by late TTTS according to the different managements was of very low quality. Therefore further high‐quality research in this field is needed to elucidate the optimal management of these pregnancies.

Controlled amnioreduction for twin-to-twin transfusion syndrome

“…Nevertheless, this outcome is in agreement with previous reports on higher fetal mortality in cases of AEDF in either, the donor or the recipient. 6,7,20,41 The post-AR S/D ratio changed to be within the normal range in 63.8% of cases, below it in four cases (11.2%) and above it in the remaining nine cases (25%).…”

“…This range is within the published data of volumes from 400 to 7500 mL, which are as high as four times of the mean volume for any given gestational age. 20 , 31 – 33 The huge range of the removed volume of fluid clearly demonstrated that the TTTS is patient-dependent, and consequently, the intervention should be tailored to the patient’s measurable physical characteristics.…”

“…4,[16][17][18] All in all, the AR procedure is still in clinical practice either before the more invasive FLA 12 or at the end of the FLA protocol 2 or when post-FLA repeated intervention is required, and when TTTS is diagnosed beyond the 26th week of gestation. 19,20 The mean amniotic fluid volume (with significant variations) in normal singleton journals.sagepub.com/home/reh Therapeutic Advances in Reproductive Health 16 pregnancies increases with the gestational age from of about 250 mL in week 18 to a peak of about 1000 mL around weeks 30-35, and then, it descends to about 750 mL in week 40. [21][22][23][24] Measurements of the amniotic pressure in normal singleton pregnancies demonstrated a wide band of variability with mean values progressively increase from 3 mmHg in week 10 to 6 mmHg in week 34.…”

Obstetric and perinatal aspects of multiple pregnancy

“…Cиндром фето-фетальної трансфузії -СФФТ (Twin-to-Twin Transfusion Syndrome) є специфічним ускладненням БВ, пов'язаним з високим ризиком перинатальної захворюваності і смертності, а клінічні прояви мають широкий спектр [29,91]. Він зумовлений скидом крові від одного плода (донора) до іншого (реципієнта) та виникає тільки у монохоріальної двійні, за якої плоди мають однакову стать.…”

Management of Late Twin-to-Twin Transfusion Syndrome beyond 26 Weeks: Comparison between Fetoscopic Laser Therapy versus Traditional Management

“…The Food and Drug Administration (FDA) in the USA approved in 2006 the use of the fetoscope under the Humanitarian Device Exemption Program for the treatment of TTTS exclusively "between 16 and 26 weeks," adding possible legal consequences to its use out of that GA window [7], and therefore, FLC has long been confined to cases presenting before 26 weeks. However, in up to ~9% of the cases TTTS can appear after 26 weeks [8]. Those late TTTS cases represent a therapeutic dilemma since the benefits of FLC beyond 26 weeks have not been demonstrated in a randomized control trial and there is concern among experts regarding possible technical complications at this GA [7].…”