Treatment of Complicated Spontaneous Twin Anemia-Polycythemia Sequence via Fetoscopic Laser Ablation of the Vascular Communications

Abstract

Monochorionic diamniotic twins share a single placenta and have intertwin vascular communications that link the circulatory systems of the twins together. Twin anemia-polycythemia sequence (TAPS) is an atypical form of twin-twin transfusion syndrome (TTTS) caused by net transfer of blood from one fetus to the other and is characterized by large intertwin hemoglobin differences in the absence of oligohydramnios and polyhydramnios. This condition may develop spontaneously (sTAPS) or as a result of residual vascular communications after prior laser surgery. Because of the relatively low prevalence and lack of clinical awareness, the natural history of sTAPS is unclear and the antenatal treatment remains controversial. Case series of sTAPS have described expectant management with timed delivery, intrauterine blood transfusion, and fetoscopic laser treatment. Favorable outcomes have been described in cases of uncomplicated sTAPS that underwent conservative measures. However, we believe that there may be a subgroup of high-risk or complicated sTAPS patients that may benefit from definitive treatment afforded by fetoscopic laser therapy. We describe 3 complicated cases of sTAPS successfully treated with selective laser photocoagulation of communicating vessels. In 2 of the cases, placental pathology identified thrombosed fetal vessels of the polycythemic twin.

Monochorionic diamniotic twins: What do I tell the prospective parents?

“…Fetoscopic laser is sometimes also offered to treat selected cases of TAPS or for Type II-III sFGR. [49][50][51] At present, no randomized studies exist to support this approach. For TAPS, which is also a transfusion imbalance, the rationale is that coagulation of the tiny anastomoses will cure the disease.…”

Twin Anemia Polycythemia Sequence: Current Views on Pathogenesis, Diagnostic Criteria, Perinatal Management, and Outcome

“…Moreover, placental anastomoses in TAPS are known to be only few and minuscule and may therefore be missed during fetoscopy (Slaghekke et al, 2010). Different case reports show the feasibility of fetoscopic laser coagulation in TAPS placentas (Abdel-Sattar et al, 2014; Assaf et al, 2011; Diehl et al, 2013; Groussolles et al, 2012; Ishii et al, 2014). In a retrospective study where laser treatment for antenatally detected TAPS is compared to IUT or expectant management, laser therapy appeared to improve perinatal outcome by prolonging pregnancy and reducing respiratory distress syndrome (Slaghekke, Favre et al, 2014).…”

Prenatally Acquired Multiple Limb Ischemia in a Very Low Birth Weight Monochorionic Twin

“…Monochorionic twin pregnancy suffers from an increased risk of serious complications for the fetuses and for the mother, especially if TTTS or TAPS is present [1] .…”