Abstract
Introduction: Limited data exist regarding outcomes when pre- and periviable PPROM (PPROM ≤26 weeks of gestation) occurs as a complication of fetoscopic laser surgery (FLS) for twin-twin transfusion syndrome (TTTS). Methods: This is a retrospective cohort study of FLS cases performed at a single institution between January 2015 and May 2021. Study inclusion was limited to patients with monochorionic-diamniotic twin pregnancies complicated by TTTS who underwent FLS. Patients were grouped by pPPROM status, and further stratified to those continuing with expectant management, and outcomes were compared between groups. The primary outcome was survival to live birth of at least one twin. Results: During the study period, 171 patients underwent FLS and a total of 96 (56.1%) subjects satisfied inclusion criteria. Among included subjects, 18 (18.8%) experienced pPPROM after FLS and 78 (81.2%) did not. Baseline characteristics were similar between groups. Among patients with pPPROM, 11 (61.1%) pursued expectant management and 7 (38.9%) opted for pregnancy termination. Among expectantly managed subjects, median pPPROM-to-delivery interval was 47.0 days (6.0–66.0 IQR) with a median gestational age at delivery of 29+1 weeks (24 + 4–33 + 6 IQR). Rates of survival to live birth of at least one twin (90.9% vs. 96.2% p = 0.42) were similar between those with pPPROM undergoing expectant management and those without pPPROM. Dual survivorship (45.5% vs. 78.2%, p = 0.03), perinatal survival to live birth (68.2% vs. 87.2%, p = 0.05), and perinatal survival to newborn hospital discharge (59.1% vs. 85.9%, p = <0.01) were all significantly lower among those with pPPROM. Gestational age at delivery was lower among those continuing with pregnancies complicated by pPPROM (29 + 1 vs. 32+5 weeks, p = <0.01). Conclusion: Survival of at least one twin to live birth remained high among those pursing expectant management after experiencing post-FLS pPPROM, suggesting that the outlook after this complication is not necessarily poor. However, this complication was associated with lower chances of dual survival and greater prematurity.
Plain Language Summary
Prelabor premature rupture of membranes (PPROM) commonly occurs after fetoscopic laser surgery (FLS) and may occur in the gestational time period where survival to and beyond birth is precarious. In those that do experience pre or periviable PPROM, termination is offered, but for those who wish to continue the pregnancy, data on survival outcomes of at least one twin are limited. In this retrospective study, we aimed to determine the survival outcomes for patients who opted for expectant management following pre- or periviable PPROM after FLS at a single institution from Jan 2015 to May 2021. Of 96 included subjects, 18 experienced this complication and 11 of these opted to continue the pregnancy. We compared outcomes of these 11 patients with the 76 patients who did not experience pre or periviable PPROM. We found that expectantly managed pre- and periviable PPROM after FLS is associated with decreased gestational age at delivery and lower rates of dual survival when compared to similarly treated pregnancies unaffected by pre- and periviable PPROM. However, survival to live birth of at least one twin was similar between groups.
