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Twin-twin transfusion syndrome and the definition of recipient polyhydramnios

      Background

      Controversy exists regarding the threshold of recipient twin polyhydramnios required to diagnose twin-twin transfusion syndrome at a gestational age of ≥20 weeks. One criterion set (Quintero staging) requires the amniotic fluid maximum vertical pocket for the recipient twin to measure ≥8 cm, whereas another (European) system uses a maximum vertical pocket for the recipient twin of ≥10 cm.

      Objective

      This study aimed to characterize the patients with twin-twin transfusion syndrome who were treated with laser surgery and would be excluded from laser surgery according to the European criteria.

      Study Design

      A total of 366 monochorionic diamniotic twins diagnosed with twin-twin transfusion syndrome from 20 to 26 weeks’ gestation who underwent laser surgery at our center were studied. A maximum vertical pocket for the recipient twin of ≥8 cm was used to diagnose twin-twin transfusion syndrome. Patients were retrospectively divided into the following 2 groups: group A with a maximum vertical pocket for the recipient twin of ≥8 cm and <10 cm and group B with a maximum vertical pocket for the recipient twin of ≥10 cm. The association of each of the groups with the survivorship outcomes was tested. Bivariate associations between the patient characteristics and the 30-day donor twin and dual survivorship outcomes were evaluated. Tests used in the analysis were chi-square or Fisher exact tests as appropriate for categorical variables and Kruskal-Wallis tests for continuous variables. Multiple logistic regression models for each of the survivorship outcomes were then assessed. The results are reported as mean±standard deviation.

      Results

      Of the 366 studied patients, 53 (14.5%) had a maximum vertical pocket for the recipient twin of ≥8 and <10 cm (group A) and 313 (85.5%) had a maximum vertical pocket for the recipient twin of ≥10 cm (group B). Groups A and B did not differ in the Quintero stage. Notably, 60.4% (32 of 53) of group A patients were stage III or IV. When compared with group B, group A was diagnosed with twin-twin transfusion syndrome at an earlier gestational age (21.7±1.6 vs 22.3±1.6 weeks; P=.0037) and had a higher prevalence of donor growth restriction (81.1% [43 of 53] vs 65.5% [205 of 313]; P=.0260). Rates of at least 1 twin and dual twin survival between group A and B were similar (98.1% [52 of 53] vs 95.8% [300 of 313]; P=.7023, and 79.2% [42 of 53] vs 83.4% [261 of 313]; P=.4369, respectively). Logistic regression models adjusted for perioperative characteristics showed no difference in the outcomes between the groups (group B as reference) (donor twin survival odds ratio, 0.64; 95% confidence interval, 0.29–1.42; P=.2753; and dual survivor odds ratio, 0.90; 95% confidence interval, 0.42–1.91; P=.7757).

      Conclusion

      Restriction of the definition of twin-twin transfusion syndrome to a maximum vertical pocket for the recipient of ≥10 cm beyond 20 weeks gestational age would potentially exclude 14.5% of patients from laser surgery, the majority of whom had advanced stage twin-twin transfusion syndrome. A unifying criterion of a maximum vertical pocket for the recipient of ≥8 cm regardless of gestational age would allow inclusion of these patients and access to surgical management.

      Key words

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      References

        • Quintero R.A.
        • Morales W.J.
        • Allen M.H.
        • Bornick P.W.
        • Johnson P.K.
        • Kruger M.
        Staging of twin-twin transfusion syndrome.
        J Perinatol. 1999; 19: 550-555
        • Lewi L.
        • Van Schoubroeck D.V.
        • Gratacós E.
        • Witters I.
        • Timmerman D.
        • Deprest J.
        Monochorionic diamniotic twins: complications and management options.
        Curr Opin Obstet Gynecol. 2003; 15: 177-194
        • Sebire N.J.
        • Souka A.
        • Skentou H.
        • Geerts L.
        • Nicolaides K.H.
        Early prediction of severe twin-to-twin transfusion syndrome.
        Hum Reprod. 2000; 15: 2008-2010
        • Acosta-Rojas R.
        • Becker J.
        • Munoz-Abellana B.
        • et al.
        Twin chorionicity and the risk of adverse perinatal outcome.
        Int J Gynaecol Obstet. 2007; 96: 98-102
        • Blickstein I.
        The twin-twin transfusion syndrome.
        Obstet Gynecol. 1990; 76: 714-722
        • Simpson L.L.
        • Society for Maternal-Fetal Medicine
        Twin-twin transfusion syndrome.
        Am J Obstet Gynecol. 2013; 208: 3-18
        • Achiron R.
        • Rosen N.
        • Zakut H.
        Pathophysiologic mechanism of hydramnios development in twin transfusion syndrome. A case report.
        J Reprod Med. 1987; 32: 305-308
        • Naeye R.L.
        Human intrauterine parabiotic syndrome and its complications.
        N Engl J Med. 1963; 268: 804-809
        • Khalil A.
        • Rodgers M.
        • Baschat A.
        • et al.
        ISUOG Practice Guidelines: role of ultrasound in twin pregnancy.
        Ultrasound Obstet Gynecol. 2016; 47: 247-263
        • Urig M.A.
        • Clewell W.H.
        • Elliott J.P.
        Twin-twin transfusion syndrome.
        Am J Obstet Gynecol. 1990; 163: 1522-1526
        • Chalouhi G.E.
        • Stirnemann J.J.
        • Salomon L.J.
        • Essaoui M.
        • Quibel T.
        • Ville Y.
        Specific complications of monochorionic twin pregnancies: twin-twin transfusion syndrome and twin reversed arterial perfusion sequence.
        Semin Fetal Neonatal. 2010; 15: 349-356
      1. Practice Bulletin No. 169 Summary: multifetal gestations: twin, triplet, and higher-order multifetal pregnancies.
        Obstet Gynecol. 2016; 128: 926-928
        • Dekoninck P.
        • Deprest J.
        • Lewi P.
        • et al.
        Gestational age-specific reference ranges for amniotic fluid assessment in monochorionic diamniotic twin pregnancies.
        Ultrasound Obstet Gynecol. 2013; 41: 649-652
        • Bamberg C.
        • Hecher K.
        Update on twin-to-twin transfusion syndrome.
        Best Pract Res Clin Obstet Gynaecol. 2019; 58: 55-65
        • Townsend R.
        • Khalil A.
        Ultrasound surveillance in twin pregnancy: an update for practitioners.
        Ultrasound. 2018; 26: 193-205
        • Senat M.V.
        • Deprest J.
        • Boulvain M.
        • Paupe A.
        • Winer N.
        • Ville Y.
        Endoscopic laser surgery versus serial amnioreduction for severe twin-to-twin transfusion syndrome.
        N Engl J Med. 2004; 351: 136-144
        • National Institute for Health and Care Excellence
        Twin and triplet pregnancy.
        (Available at:) (Accessed Mar. 4, 2020)
        • FIGO Working Group on Good Clinical Practice in Maternal-Fetal Medicine
        Good clinical practice advice: management of twin pregnancy.
        Int J Gynaecol Obstet. 2019; 144: 330-337
        • Minakami H.
        • Maeda T.
        • Fujii T.
        • et al.
        Guidelines for obstetrical practice in Japan: Japan Society of Obstetrics and Gynecology (JSOG) and Japan Association of Obstetricians and Gynecologists (JAOG) 2014 edition.
        J Obstet Gynaecol Res. 2014; 40: 1469-1499
        • Yamamoto M.
        • El Murr L.
        • Robyr R.
        • Leleu F.
        • Takahashi Y.
        • Ville Y.
        Incidence and impact of perioperative complications in 175 fetoscopy-guided laser coagulations of chorionic plate anastomoses in fetofetal transfusion syndrome before 26 weeks of gestation.
        Am J Obstet Gynecol. 2005; 193: 1110-1116
        • Lewi L.
        • Jani J.
        • Blickstein I.
        • et al.
        The outcome of monochorionic diamniotic twin gestations in the era of invasive fetal therapy: a prospective cohort study.
        Am J Obstet Gynecol. 2008; 199: 514.e1-514.e8
        • Chmait R.H.
        • Kontopoulos E.V.
        • Quintero R.A.
        Sequential laser surgery for twin-twin transfusion syndrome.
        Am J Perinatol. 2014; 31: S13-S18
        • Gordon B.J.
        • Chon A.H.
        • Korst L.M.
        • Llanes A.
        • Miller D.A.
        • Chmait R.H.
        Incidental septostomy after laser surgery for twin-twin transfusion syndrome: perinatal outcomes and antenatal management.
        Fetal Diagn Ther. 2018; 44: 285-290
        • Assaf S.A.
        • Randolph L.M.
        • Benirschke K.
        • Wu S.
        • Samadi R.
        • Chmait R.H.
        Discordant blood chimerism in dizygotic monochorionic laser-treated twin-twin transfusion syndrome.
        Obstet Gynecol. 2010; 116: 483-485
        • Magann E.F.
        • Sanderson M.
        • Martin J.N.
        • Chauhan S.
        The amniotic fluid index, single deepest pocket, and two-diameter pocket in normal human pregnancy.
        Am J Obstet Gynecol. 2000; 182: 1581-1588
        • Chau A.C.
        • Kjos S.L.
        • Kovacs B.W.
        Ultrasonographic measurement of amniotic fluid volume in normal diamniotic twin pregnancies.
        Am J Obstet Gynecol. 1996; 174: 1003-1007
        • Magann E.F.
        • Doherty D.A.
        • Ennen C.S.
        • et al.
        The ultrasound estimation of amniotic fluid volume in diamniotic twin pregnancies and prediction of peripartum outcomes.
        Am J Obstet Gynecol. 2007; 196: 570.e1-570.e6
        • Habli M.
        • Bombrys A.
        • Lewis D.
        • et al.
        Incidence of complications in twin-twin transfusion syndrome after selective fetoscopic laser photocoagulation: a single-center experience.
        Am J Obstet Gynecol. 2009; 201: 417.e1-417.e7
        • Stirnemann J.
        • Slaghekke F.
        • Khalek N.
        • et al.
        Intrauterine fetoscopic laser surgery versus expectant management in stage 1 twin-to-twin transfusion syndrome: an international randomized trial.
        Am J Obstet Gynecol. 2021; 224: 528.e1-528.e12