Selective feticide in complicated monochorionic twin pregnancies using ultrasound‐guided bipolar cord coagulation

Abstract

Objective To review our experience with selective feticide in complicated monochorionic (MC) twin pregnancies, using ultrasound-guided cord coagulation with a bipolar forceps. Design Retrospective analysis.Setting All consecutive umbilical cord coagulations performed at our institution in the second trimester of pregnancy between November 1999 and 2003. Population Consecutive cases of complicated MC pregnancies with an indication for selective termination.Methods Ultrasound-guided coagulation of the umbilical cord with a 2.5-mm bipolar forceps under local anaesthesia. Main outcome measures Indications, gestational age at the procedure, perinatal outcome and neonatal follow up. Results Forty-six patients with MC twin pregnancies underwent this procedure. Indications included twin reverse arterial perfusion sequence (n ¼ 17), severe malformation in one twin (n ¼ 7) and agonal presentation or cerebral anomalies of one twin in twin-to-twin transfusion syndrome (TTTS) after laser treatment or serial amniodrainage (n ¼ 22). The procedure resulted in six intrauterine fetal demise (IUFD, 13%), with a rate of 41% and 3% when performed at 16 -17 weeks or later, respectively (Fisher P ¼ 0.002). Preterm rupture of the membranes (PROM) before 28 weeks and between 28 and 34 weeks occurred in 9% and 14% of the cases, respectively. All neonatal deaths (four) occurred in cases with PROM at 28 weeks or earlier. Paediatric follow up showed that all infants discharged alive but one were neurologically normal at 3 -42 months, which corresponds to 70% of the 46 cases. Conclusions This technique is effective when the natural history is likely to severely affect the development of the normal co-twin. The overall intact survival rate was 70% and our results support justification of later surgery. Prematurity remains a significant complication of the procedure.

Long‐term neurodevelopmental outcome after selective feticide in monochorionic pregnancies

“…7,[10][11][12][13] In a series of 36 children, Robyr et al 11 reported one case with 'some form of developmental delay' at 18 months. Followup was obtained from a clinical evaluation by the referring paediatrician, a specification of delay was not described, and developmental tests were lacking.…”

“…Developmental delay is reported in up to 12%. 7,[10][11][12][13] However, in these studies standardised developmental tests and detailed specifications of a developmental delay were often lacking. In addition, besides evident impairments such as cerebral palsy or severe cognitive delay, more subtle impairments including behavioural difficulties require attention in order to obtain an integrated picture of the long-term outcome in surviving twins.…”

Comparison between laparoscopically assisted and standard fetoscopic laser ablation in patients with anterior and posterior placentation in twin‐twin transfusion syndrome: a single center study

“…A distribution plot of the laser time showed no evidence of a skewed pattern. The number of anastomoses ablated was not significantly different between the three groups [7 (5-12) in SAP vs 6 (5-11) in LAP and 8 (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16) in SPP, p = 0.47]. There were no significant differences seen between the three groups in terms of the amount of fluid either removed or infused during the case.…”

“…1 An anterior placenta is found in approximately 45% of patients with a monochorionic twin pregnancy who present with TTTS in the second trimester. [2][3][4] Ultrasound-directed percutaneous fetoscopic laser photocoagulation of placental anastomoses has become the standard treatment for TTTS diagnosed before 26 weeks of gestation. [5][6][7] The same percutaneous technique has traditionally been used in cases of both anterior and posterior placentation.…”

Twins discordant for fetal skeletal abnormalities: a natural confrontation between the two siblings

“…In monochorionic pregnancies, this should be performed using cord occlusion techniques in specialized centers (Robyr et al, 2005).…”