Introduction: Chorioamniotic membrane separation (CAS), preterm prelabor rupture of membranes (PPROM), and preterm delivery (PTD) remain as major complications of fetoscopic laser photocoagulation (FLP) for twin-to-twin transfusion syndrome (TTTS). We sought to examine whether use of Quincke-tip needles for initial entry during FLP reduces the risk of these complications. Methods: This is a secondary analysis of prospectively collected data from patients that had FLP for TTTS at a single tertiary care center (2011–2021). We excluded patients for whom direct trocar entry was used. Patients for whom a Quincke-tip needle was used were compared to those for whom a diamond-tip needle was used during Seldinger entry. Demographics, ultrasound findings and operative characteristics were compared between groups. Postoperative outcomes and complications (including CAS, PPROM, and PTD) were also compared. Multivariate logistic regression models were fit to assess independent risk factors for complications. Results: 386 patients met inclusion criteria; Quincke-tip needles were used in 81 (21.0%) cases, while diamond-tip needles were used in 305 (79.0%). Rates of CAS (11.1 vs. 9.5%, p = 0.67) and PPROM (44.4 vs. 41.0%, p = 0.57) were similar between groups. Patients in the Quincke-tip group delivered 1.5 weeks earlier than those in the diamond-tip group (30.5 vs. 32.0 weeks, p = 0.01). However, these patients were more likely to be delivered for maternal (35.9 vs. 19.0%) and fetal (23.1 vs. 15.3%) indications (p < 0.01). In multivariate analysis, needle type was not identified as an independent risk factor for PPROM. However, Quincke-tip needle use was associated with PTD less than 32 weeks (aOR 1.74, 95% CI: 1.02–2.97, p = 0.043). Conclusion: Membrane complications following FLP were not associated with the needle type used for entry. Earlier delivery in the Quincke-tip group was likely attributable to higher rates of delivery for maternal and fetal indications, and not membrane complications. The needle chosen for entry is likely best determined by operator preference.

Keywords:
Fetal surgery, Twin-to-twin transfusion syndrome, Prenatal diagnosis, Monochorionic twins
1.
Bianchi DW, Crombleholme TM, D’Alton ME, Malone FD. Fetology: diagnosis and management of the fetal patient. 2010.
2.
Chmait RH, Chon AH, Korst LM, Llanes A, Kontopoulos EV., Quintero RA. Risks of preterm premature rupture of membranes and preterm birth post fetoscopy based on location of trocar insertion site. Am J Perinatol. 2018;35(8):801–8.
https://doi.org/10.1055/s-0037-1620268
3.
Lewi L, Jani J, Blickstein I, Huber A, Gucciardo L, Van Mieghem T, 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(5):514.e1–8.
https://doi.org/10.1016/j.ajog.2008.03.050
4.
Malshe A, Snowise S, Mann LK, Boring N, Johnson A, Bebbington MW, et al. Preterm delivery after fetoscopic laser surgery for twin–twin transfusion syndrome: etiology and risk factors. Ultrasound Obstet Gynecol. 2017;49(5):612–6.
https://doi.org/10.1002/uog.15972
5.
Habli M, Bombrys A, Lewis D, Lim FY, Polzin W, Maxwell R, 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(4):417.e1–7.
https://doi.org/10.1016/j.ajog.2009.07.046
6.
Snowise S, Mann LK, Moise KJ, Johnson A, Bebbington MW, Papanna R. Preterm prelabor rupture of membranes after fetoscopic laser surgery for twin–twin transfusion syndrome. Ultrasound Obstet Gynecol. 2017;49(5):607–11.
https://doi.org/10.1002/uog.15958
7.
de Zoysa MY, Chon AH, Korst LM, Llanes A, Chmait RH. Membrane separation and perinatal outcomes after laser treatment for twin-twin transfusion syndrome. Fetal Diagn Ther. 2020;47(4):307–14.
https://doi.org/10.1159/000504361
8.
Brock CO, Bergh EP, Hernandez-Andrade EA, Papanna R, Ruano R, Johnson A. Risk factors and outcomes following septostomy during fetoscopic surgery for twin-to-twin transfusion syndrome. J Clin Med. 2021;10(16):3693.
https://doi.org/10.3390/jcm10163693
9.
Bergh EP, Moise KJ, Johnson A, Papanna R. Pregnancy outcomes associated with chorioamnion membrane separation severity following fetoscopic laser surgery for twin-twin transfusion syndrome. Prenat Diagn. 2020;40(8):1020–7.
https://doi.org/10.1002/pd.5725
10.
Baud D, Windrim R, Keunen J, Kelly EN, Shah P, van Mieghem T, et al. Fetoscopic laser therapy for twin-twin transfusion syndrome before 17 and after 26 weeks’ gestation. Am J Obstet Gynecol. 2013;208(3):197.e1–7.
https://doi.org/10.1016/j.ajog.2012.11.027
11.
Bartin R, Colmant C, Bourgon N, Ville Y, Stirnemann J. Effect of gestational age at laser therapy on perinatal outcome in monochorionic diamniotic pregnancies affected by twin to twin transfusion syndrome. BJOG. 2022;129(12):2028–37. Published online May 21
https://doi.org/10.1111/1471-0528.17228
12.
Papanna R, Mann LK, Moise KJ, Kyriakides T, Johnson A, Garcia E, et al. Histologic changes of the fetal membranes after fetoscopic laser surgery for twin-twin transfusion syndrome. Pediatr Res. 2015;78(3):247–55.
https://doi.org/10.1038/pr.2015.105
13.
Lei H, Furth EE, Kalluri R, et al. A program of cell death and extracellular matrix degradation is activated in the amnion before the onset of labor. J Clin Invest. 1996 Nov 1;98(9):1971–8. https://doi: 10.1172/JCI119001.
14.
George RB, Kalich J, Yonish B, Murtha AP. Apoptosis in the chorion of fetal membranes in preterm premature rupture of membranes. Am J Perinatol. 2008;25(1):29–32.
https://doi.org/10.1055/s-2007-1004828
15.
Petersen SG, Gibbons KS, Luks FI, Lewi L, Diemert A, Hecher K, et al. The impact of entry technique and access diameter on prelabour rupture of membranes following primary fetoscopic laser treatment for twin-twin transfusion syndrome. Fetal Diagn Ther. 2016;40(2):100–9.
https://doi.org/10.1159/000441915
16.
Espinoza J, Belfort MA, Shamshirsaz AA, Nassr AA, Sanz Cortes M, Donepudi R, et al. Early laser surgery is not associated with very preterm delivery or reduced neonatal survival in TTTS. Ultrasound Obstet Gynecol. 2021;58(2):207–13.
https://doi.org/10.1002/uog.22190
17.
Donepudi R, Akkermans J, Mann L, Klumper FJ, Middeldorp JM, Lopriore E, et al. Impact of cannula size on recurrent twin–twin transfusion syndrome and twin anemia: polycythemia sequence after fetoscopic laser surgery. Ultrasound Obstet Gynecol. 2018;52(6):744–9.
https://doi.org/10.1002/uog.18904
18.
Quintero RA, Morales WJ, Allen MH, Bornick PW, Johnson PK, Kruger M. Staging of twin-twin transfusion syndrome. J Perinatol. 1999 Dec;19(8 Pt 1):550–5.
https://doi.org/10.1038/sj.jp.7200292
19.
Slaghekke F, Kist WJ, Oepkes D, Pasman SA, Middeldorp JM, Klumper FJ, et al. Twin anemia-polycythemia sequence: diagnostic criteria, classification, perinatal management and outcome. Fetal Diagn Ther. 2010;27(4):181–90.
https://doi.org/10.1159/000304512
20.
Slaghekke F, Lewi L, Middeldorp JM, Weingertner AS, Klumper FJ, Dekoninck P, et al. Residual anastomoses in twin-twin transfusion syndrome after laser: the Solomon randomized trial. Am J Obstet Gynecol. 2014;211(3):285.e1–7.
https://doi.org/10.1016/j.ajog.2014.05.012
21.
Chmait RH, Korst LM, Llanes A, Mullin P, Lee RH, Ouzounian JG. Perioperative characteristics associated with preterm birth in twin-twin transfusion syndrome treated by laser surgery. Am J Obstet Gynecol. 2013;209:264.e1–8.
https://doi.org/DOI:10.1016/j.ajog.2013.05.025
22.
Shih T, Peneva D, Xu X, Sutton A, Triche E, Ehrenkranz RA, et al. The rising burden of preeclampsia in the United States impacts both maternal and child Health. Am J Perinatol. 2016;33(4):329–38.
https://doi.org/10.1055/s-0035-1564881
23.
Kanazawa S, Ozawa K, Muromoto J, Sugibayashi R, Wada Y, Wada S, et al. Risk profiling of the Solomon technique versus selective technique of fetoscopic laser surgery for twin-twin transfusion syndrome. Twin Res Hum Genet. 2021;24(1):42–8.
https://doi.org/10.1017/thg.2020.94
24.
Knijnenburg PJC, Lopriore E, Ge Y, Scholl IM, van Klink JMM, Haak MC, et al. Placental abruption after fetoscopic laser surgery in twin-twin transfusion syndrome: the role of the Solomon technique. Fetal Diagn Ther. 2021;48(9):660–6.
https://doi.org/10.1159/000517800
25.
Slaghekke F, Oepkes D. Solomon technique versus selective coagulation for twin-twin transfusion syndrome. Twin Res Hum Genet. 2016;19(3):217–21.
https://doi.org/10.1017/thg.2016.25
26.
Pathak B, Khan A, Assaf SA, Miller DA, Chmait RH. Amniopatch as a treatment for rupture of membranes following laser surgery for twin-twin transfusion syndrome. Fetal Diagn Ther. 2010;27(3):134–7.
https://doi.org/10.1159/000275685
27.
Chmait RH, Kontopoulos EV, Chon AH, Korst LM, Llanes A, Quintero RA. Amniopatch treatment of iatrogenic preterm premature rupture of membranes (iPPROM) after fetoscopic laser surgery for twin–twin transfusion syndrome. J Matern Fetal Neonatal Med. 2017;30(11):1349–54.
https://doi.org/10.1080/14767058.2016.1214123
© 2023 S. Karger AG, Basel
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
2023
You do not currently have access to this content.