Table 1. Comparison Between Laser Therapy and Amnioreduction.

Bermúdez C, Becerra CH, Bornick PW, Allen MH, Arroyo J, Quintero RA. Placental types and twin–twin transfusion syndrome. Am. J. Obstet. Gynecol. 187(2),489–494 ( 2002).
Diehl W, Hecher K, Zikulnig L, Vetter M, Hackelöer BJ. Placental vascular anastomoses visualized during fetoscopic laser surgery in severe mid-trimester twin–twin transfusion syndrome. Placenta 22(10),876–881 ( 2001).
Weiner CP, Ludomirski A. Diagnosis, pathophysiology, and treatment of chronic twin-to-twin transfusion syndrome. Fetal. Diagn. Ther. 9(5),283–290 (1994).
Lewi L, Cannie M, Blickstein I et al. Placental sharing, birth weight discordance, and vascular anastomoses in monochorionic diamniotic twin placentas. Am. J. Obstet. Gynecol. 197(6),587.e1–587.e8 (2007).
Machin G, Still K, Lalani T. Correlations of placental vascular anatomy and clinical outcomes in 69 monochorionic twin pregnancies. Am. J. Med. Genet. 61(3),229–236 (1996).
Guilherme R, Patrier S, Gubler MC, Lemercier D, Guimiot F, Dommergues M. Very early twin-to-twin transfusion syndrome and discordant activation of the rennin–angiotensin system. Placenta 30(8),731–734 ( 2009).
Quintero RA, Morales WJ, Allen MH, Bornick PW, Johnson PK, Kruger M. Staging of twin–twin transfusion syndrome. J. Perinatol. 19(8 Pt 1),550–555 (1999).
•• The merit to standardize the definition and assessment of twin–twin transfusion syndrome.
Senat MV, Bernard JP, Loizeau S, Ville Y. Management of single fetal death in twin-to-twin transfusion syndrome: a role for fetal blood sampling. Ultrasound Obstet. Gynecol. 20(4),360–363 (2002).
Rossi AC, D’Addario V. Laser therapy and serial amnioreduction as treatment for twin–twin transfusion syndrome: a meta-analysis and review of literature. Am. J. Obstet. Gynecol. 198(2),147–152 ( 2008).
• Meta-analysis that shows the efficacy of laser therapy over amnioreduction.
Hubinont C, Bernard P, Pirot N, Biard J, Donnez J. Twin-to-twin transfusion syndrome: treatment by amniodrainage and septostomy. Eur. J. Obstet. Gynecol. Reprod. Biol. 92(1),141–144 ( 2000).
Saade GR, Belfort MA, Berry DL et al. Amniotic septostomy for the treatment of twin oligohydramnios–polyhydramnios sequence. Fetal. Diagn. Ther. 13(2),86–93 ( 1998).
Johnson JR, Rossi KQ, O’Shaughnessy RW. Amnioreduction versus septostomy in twin–twin transfusion syndrome. Am. J. Obstet. Gynecol. 185(5),1044–1047 (2001).
Moise KJ Jr, Dorman K, Lamvu G et al. A randomized trial of amnioreduction versus septostomy in the treatment of twin–twin transfusion syndrome. Am. J. Obstet. Gynecol. 193(3 Pt 1),701–707 (2005).
• Although septostomy is no longer used, this is an interesting randomized study.
De LiaJE, Cruikshank DP, Keye WR Jr. Fetoscopic neodymium:YAG laser occlusion of placental vessels in severe twin–twin transfusion syndrome. Obstet. Gynecol. 75(6),1046–1053 (1990).
•• Pioneer study about laser therapy for twin–twin transfusion syndrome.
Ville Y, Hyett J, Hecher K, Nicolaides K. Preliminary experience with endoscopic laser surgery for severe twin–twin transfusion syndrome. N. Engl. J. Med. 332(4),224–227 (1995).
Quintero RA, Comas C, Bornick PW, Allen MH, Kruger M. Selective versus non-selective laser photocoagulation of placental vessels in twin-to-twin transfusion syndrome. Ultrasound Obstet. Gynecol. 16(3),230–236 (2000).
•• The laser technique is actually performed in this article.
Rossi AC, Kaufman MA, Bornick PW, Quintero RA. General vs local anesthesia for the percutaneous laser treatment of twin–twin transfusion syndrome. Am. J. Obstet. Gynecol. 199,137.e1–137.e7 (2008).
• Shows that laser therapy can be performed under local anesthesia.
Senat MV, 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. 351(2),136–144 (2004).
•• Randomized study about laser versus amnioreduction.
Rossi AC, Vanderbilt D, Chmait RH. Neurodevelopmental outcomes after laser therapy for twin–twin transfusion syndrome: a systematic review and meta-analysis. Obstet. Gynecol. 118(5),1145–1150 (2011).
•• Important for counseling parents of twins undergoing laser therapy.
Beck V, Lewi P, Gucciardo L, Devlieger R. Preterm prelabor rupture of membranes and fetal survival after minimally invasive fetal surgery: a systematic review of the literature. Fetal. Diagn. Ther. 31(1),1–9 ( 2012).
Cruz-Martinez R, Van Mieghem T, Lewi L et al. Incidence and clinical implications of early inadvertent septostomy after laser therapy for twin–twin transfusion syndrome. Ultrasound Obstet. Gynecol. 37(4),458–462 (2011).
Merz W, Tchatcheva K, Gembruch U, Kohl T. Maternal complications of fetoscopic laser photocoagulation (FLP) for treatment of twin–twin transfusion syndrome (TTTS).
Sepulveda W, Corral E, Aiello H et al. Intrafetal alcohol chemosclerosis of acardiac twins: a multicenter experience. Fetal. Diagn. Ther. 19(5),448–452 (2004).
Rossi AC, D’Addario V. Umbilical cord occlusion for selective feticide in complicated monochorionic twins: a systematic review of literature. Am. J. Obstet. Gynecol. 200(2),123–129 (2009).

Papers of special note have been highlighted as:
• of interest
•• of considerable interest

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Author

A. Cristina Rossi, MD

Department of Obstetrics and Gynecology, University of Bari, Bari, Italy

Disclosures

Disclosure: A. Cristina Rossi, MD, has disclosed no relevant financial relationships.

Editor

Elisa Manzotti

Publisher, Future Science Group, London, United Kingdom

Disclosures

Disclosure: Elisa Manzotti has disclosed no relevant financial relationships.

CME Author

Charles P. Vega, MD

Health Sciences Clinical Professor; Residency Director, Department of Family Medicine, University of California, Irvine

Disclosures

Disclosure: Charles P. Vega, MD, has disclosed no relevant financial relationships.

CME Reviewer

Nafeez Zawahir, MD

CME Clinical Director, Medscape, LLC

Disclosures

Disclosure: Nafeez Zawahir, MD, has disclosed no relevant financial relationships.

CME

Treatment of Twin-Twin Transfusion Syndrome

Authors: A. Cristina Rossi, MD
CME Released: 10/12/2012
THIS ACTIVITY HAS EXPIRED FOR CREDIT
Valid for credit through: 10/12/2013

Start Activity

Target Audience and Goal Statement

This activity is intended for obstetrician gynecologists and other physicians who manage multiple pregnancies.

The goal of this activity is to evaluate interventions for pregnant women with TTTS.

Upon completion of this activity, participants will be able to:

Distinguish ultrasound findings characteristic of TTTS
Evaluate interventions to reduce amniotic volume in cases of TTTS
Assess the efficacy and safety of laser therapy for TTTS
Compare techniques of selective infanticide in cases of TTTS

Disclosures

Author

A. Cristina Rossi, MD

Department of Obstetrics and Gynecology, University of Bari, Bari, Italy

Disclosures

Disclosure: A. Cristina Rossi, MD, has disclosed no relevant financial relationships.

Editor

Elisa Manzotti

Publisher, Future Science Group, London, United Kingdom

Disclosures

Disclosure: Elisa Manzotti has disclosed no relevant financial relationships.

CME Author

Charles P. Vega, MD

Health Sciences Clinical Professor; Residency Director, Department of Family Medicine, University of California, Irvine

Disclosures

Disclosure: Charles P. Vega, MD, has disclosed no relevant financial relationships.

CME Reviewer

Nafeez Zawahir, MD

CME Clinical Director, Medscape, LLC

Disclosures

Disclosure: Nafeez Zawahir, MD, has disclosed no relevant financial relationships.

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For Physicians

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Septostomy

Septostomy is the intentional rupture of the intertwin septum by ultrasound guidance and is aimed at balancing the amniotic fluid pressure in the two sacs leading to a correction of the placental circulation, mainly in the donor twin’s vessels. In addition, filling the amniotic sac of the donor twin decreases cord compression, improves fetal hemodynamics and increases urine production by the donor twin.^[10] Similarly, in serial amnioreduction, septostomy has the disadvantage of removing the clinical sign (polyhydramnios) but not the etiology of TTTS (placental anastomoses). Adverse effects of septostomy are similar to those described for serial amnioreduction, such as preterm labor and premature rupture of membranes. An additional risk is represented by the creation of a monoamniotic pregnancy that can be associated with cord entanglement. The incidence of survival rate following septostomy for TTTS varies widely from 36^[10] to 83%.^[11] A possible explanation might be the differing severity of TTTS at the time of intervention. Although there is a trend toward increasing gestational age at delivery with septostomy compared with amnioreduction,^[12] a randomized trial of amnioreduction versus septostomy showed that overall perinatal survival was similar between the two groups, and septostomy offered the advantage of requiring a single procedure.^[13]

Because of lower survival rates and higher risk of neonatal morbidity compared with laser therapy, septostomy is not commonly performed as treatment of TTTS.

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Page 3 of 9

Laser Therapy

CME Information

Abstract and Introduction
Amnioreduction
Septostomy
Laser Therapy
Selective Feticide by Umbilical Cord Occlusion
Conclusion
Expert Commentary
Five-year View
Key Issues

References

Table 1. Comparison Between Laser Therapy and Amnioreduction.

CME

Treatment of Twin-Twin Transfusion Syndrome

Target Audience and Goal Statement

Disclosures

Author

A. Cristina Rossi, MD

Editor

Elisa Manzotti

CME Author

Charles P. Vega, MD

CME Reviewer

Nafeez Zawahir, MD

Accreditation Statements

For Physicians

Instructions for Participation and Credit

Treatment of Twin-Twin Transfusion Syndrome: Septostomy

Septostomy

Table of Contents

Table 1. Comparison Between Laser Therapy and Amnioreduction.

References

Faculty and Disclosures

Author

A. Cristina Rossi, MD

Editor

Elisa Manzotti

CME Author

Charles P. Vega, MD

CME Reviewer

Nafeez Zawahir, MD

CME

Treatment of Twin-Twin Transfusion Syndrome

Target Audience and Goal Statement

Disclosures

Author

A. Cristina Rossi, MD

Editor

Elisa Manzotti

CME Author

Charles P. Vega, MD

CME Reviewer

Nafeez Zawahir, MD

Accreditation Statements

For Physicians

Instructions for Participation and Credit

Treatment of Twin-Twin Transfusion Syndrome: Septostomy

Septostomy

Table of Contents