Background
Several studies have assessed preoperative and operative factors associated with fetal
demise after laser for TTTS, yet these findings are not completely conclusive.
Objective
This study aimed to identify risk factors for single fetal demise (recipient and donor
twins) after fetoscopic laser photocoagulation for twin-to-twin transfusion syndrome.
Study Design
We searched PubMed, Scopus, and Web of Science systematically from the inception of
the database to June 2020. We conducted a systemic review on studies investigating
risk factors for fetal demise (donor and/or recipient) after fetoscopic laser photocoagulation
in monochorionic pregnancies complicated with twin-to-twin transfusion syndrome. Initially,
we investigated the cohort of women with twin-to-twin transfusion syndrome that underwent
fetoscopic laser photocoagulation at our 2 high-volume fetal centers between 2012
and 2020 to identify risk factors for donor demise and recipient demise. Furthermore,
we conducted a systematic review of the literature to better characterize these factors.
Among studies that met the entry criteria, multiple preoperative and operative factors
were tabulated. The random-effect model was used to pool the standardized mean differences
or odds ratios and corresponding 95% confidence intervals. Heterogeneity was assessed
using the I2 value.
Results
A total of 514 pregnancies with twin-to-twin transfusion syndrome managed with fetoscopic
laser photocoagulation were included in the final analysis. Following the logistic
regression, factors that remained significant for donor demise were selective fetal
growth restriction (odds ratio, 1.9; 95% confidence interval, 1.3–2.8; P=.001) and umbilical artery blood flow with absent or reversed end-diastolic velocity
of the donor (odds ratio, 2.06; 95% confidence interval, 1.2–3.4; P=.004). A significant factor associated with recipient demise was absent or reversed
a-wave in the ductus venosus of the recipient (odds ratio, 1.74; 95% confidence interval,
1.07–3.13; P=.04). Data from 23 studies and our current cohort were included. A total of 4892
pregnancies with twin-to-twin transfusion syndrome managed with fetoscopic laser photocoagulation
were analyzed for risk factors for donor demise, and 4594 pregnancies with twin-to-twin
transfusion syndrome were analyzed for recipient demise. Among studies, the overall
incidence rates ranged from 10.9% to 35.8% for donor demise and 7.3% to 24.5% for
recipient demise. Significant risk factors for donor demise were intertwin estimated
fetal weight discordance of >25% (odds ratio, 1.86; 95% confidence interval, 1.44–2.4;
I2, 0.0%), selective fetal growth restriction (odds ratio, 1.78; 95% confidence interval,
1.4–2.27; I2, 0.0%), twin-to-twin transfusion syndrome stage III (odds ratio, 2.18; 95% confidence
interval, 1.53–3.12; I2, 0.0%), umbilical artery blood flow with absent or reversed end-diastolic velocity
of the donor (odds ratio, 2.31; 95% confidence interval, 1.9–2.8; I2, 23.7%), absent or reversed a-wave in the ductus venosus of the donor (odds ratio,
1.83; 95% confidence interval, 1.45–2.3; I2, 0.0%), and presence of arterioarterial anastomoses (odds ratio, 2.81; 95% confidence
interval, 1.35–5.85; I2, 90.7%). Sequential selective coagulation was protective against donor demise (odds
ratio, 0.31; 95% confidence interval, 0.16–0.58; I2, 0.0%). Significant risk factors for recipient demise were twin-to-twin transfusion
syndrome stage IV (odds ratio, 2.18; 95% confidence interval, 1.01–4.6; I2, 16.5%), umbilical artery blood flow with absent or reversed end-diastolic velocity
of the recipient (odds ratio, 2.68; 95% confidence interval, 1.91–3.74; I2, 0.0%), absent or reversed a-wave in the ductus venosus of the recipient (odds ratio,
2.37; 95% confidence interval, 1.55–3.64; I2, 60.2%), and middle cerebral artery peak systolic velocity of >1.5 multiple of the
median (odds ratio, 3.06; 95% confidence interval, 1.36–6.88; I2, 0.0%).
Conclusion
Abnormal blood flow patterns represented by abnormal Doppler studies and low fetal
weight were associated with single fetal demise in women with twin-to-twin transfusion
syndrome undergoing laser therapy. Although sequential selective coagulation was protective
against donor demise, the presence of arterioarterial anastomoses was considerably
associated with donor demise. This meta-analysis extensively investigated the association
of a wide range of preoperative and operative factors with fetal demise. These findings
may be important inpatient counseling, in further understanding the disease, and perhaps
in improving surgical techniques.
Key words
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- The roles of superficial anastomoses in twin-twin transfusion syndrome.Placenta. 2019; 82: 5-9
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- Factors associated to early intrauterine fetal demise after laser for TTTS by preoperative fetal heart and Doppler ultrasound.Prenat Diagn. 2018; 38: 523-530
- Preoperative prediction of the individualized risk of early fetal death after laser therapy in twin-to-twin transfusion syndrome.Prenat Diagn. 2013; 33: 1033-1038
- Prediction of single fetal demise after laser therapy for twin-twin transfusion syndrome.Ultrasound Obstet Gynecol. 2016; 47: 356-362
- Impact of recipient twin preoperative myocardial performance index in twin-twin transfusion syndrome treated with laser.J Matern Fetal Neonatal Med. 2017; 30: 767-771
- Doppler assessment of patients with twin-to-twin transfusion syndrome and survival following fetoscopic laser surgery.Int J Gynaecol Obstet. 2017; 137: 241-245
- Stage-related outcome after fetoscopic laser ablation in twin-to-twin transfusion syndrome.Fetal Diagn Ther. 2014; 36: 287-292
- Ultrasound assessment prior to laser photocoagulation for twin-twin transfusion syndrome for predicting intrauterine fetal demise after surgery in Japanese patients.Fetal Diagn Ther. 2007; 22: 149-154
- Percent absent end-diastolic velocity in the umbilical artery waveform as a predictor of intrauterine fetal demise of the donor twin after selective laser photocoagulation of communicating vessels in twin-twin transfusion syndrome.Ultrasound Obstet Gynecol. 2007; 30: 35-39
- Fetal survival immediate after fetoscopic laser ablation in twin to twin transfusion syndrome.J Korean Med Sci. 2019; 34: e20
- Aortic isthmus flow recording predicts the outcome of the recipient twin after laser coagulation in twin-twin transfusion syndrome.Fetal Diagn Ther. 2018; 44: 135-141
- Modified sequential laser photocoagulation of placental communicating vessels for twin-twin transfusion syndrome to prevent fetal demise of the donor twin.J Obstet Gynaecol Res. 2009; 35: 640-647
- Abnormal umbilical artery Doppler findings in the recipient twin before laser surgery for twin-twin transfusion syndrome.J Ultrasound Med. 2015; 34: 843-846
- Postnatal survival after endoscopic equatorial laser for the treatment of twin-to-twin transfusion syndrome.Am J Obstet Gynecol. 2016; 214: 533.e1-533.e7
- Sequential selective laser photocoagulation of communicating vessels in twin-twin transfusion syndrome.J Matern Fetal Neonatal Med. 2007; 20: 763-768
- Preoperative predictors of death in twin-to-twin transfusion syndrome treated with laser ablation of placental anastomoses.Am J Obstet Gynecol. 2010; 203: 388.e1-388.e11
- Donor death After selective fetoscopic laser surgery for twin-twin transfusion syndrome.Obstet Gynecol. 2015; 126: 74-80
- Time-interval analysis of ductus venosus flow velocity waveforms in twin-to-twin transfusion syndrome treated with laser surgery.Ultrasound Obstet Gynecol. 2015; 45: 544-550
- Evaluation of the measurement of the middle cerebral artery peak systolic velocity before and after placental laser coagulation in twin-to-twin transfusion syndrome.Prenat Diagn. 2012; 32: 127-130
- The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials.BMJ. 2011; 343: d5928
- Fetoscopic laser coagulation of the vascular equator versus selective coagulation for twin-to-twin transfusion syndrome: an open-label randomised controlled trial.Lancet. 2014; 383: 2144-2151
Article Info
Publication History
Published online: March 03, 2022
Accepted:
February 28,
2022
Received in revised form:
February 27,
2022
Received:
December 10,
2021
Footnotes
The authors report no conflict of interest.
This study received no external funding.
This systematic review is registered on the International Prospective Register of Systematic Reviews (registration number: CRD42021271115).
This study is submitted for fast-track manuscript submission.
Cite this article as: Mustafa HJ, Javinani A, Goetzinger K, et al. Single fetal demise following fetoscopic ablation for twin-to-twin transfusion syndrome—cohort study, systematic review, and meta-analysis. Am J Obstet Gynecol 2022;226:843.e1-28.
Identification
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