Abstract：
OBJECTIVE: We aimed to investigate the prevalence and clinical outcomes of twin-to-twin transfusion syndrome (TTTS) with proximate cord insertions.
METHODS: This was retrospective cohort study of TTTS cases managed at single fetal center between 2012 and 2020. Presence of proximate cord insertions was defined as a distance of equal or less than 4 cm between placental cord insertions that was recorded based on sonographic and fetoscopic examinations. Clinical outcomes were investigated compared to unmatched cohort and to 1:2 matched controls using preoperative variables including Quintero staging, selective fetal growth restriction, anterior placenta, preoperative cervical length, and gestational age at fetal intervention. Systematic review and meta-analysis were conducted following PRSMA guidelines through searching PubMed, Scopus, CINAHL, and Medline databases from inception until January 2021.
RESULTS: The prevalence of proximate cord insertions in monochorionic placentas with TTTS was 2% (5/246). All 5 cases were managed by fetoscopic laser surgery (FLS). Procedure time was significantly longer (mean: 61.4 min in proximate cord vs. 37.5 min in nonproximate cord, p < 0.001), and amnioinfusion was significantly more common (100% in proximate cord vs. 43% in nonproximate cord, p = 0.01). Perinatal survival and neonatal outcomes were not different between groups. Similar findings were seen following 1:2 control matching. Systematic review yielded total of 19 case reports of which different management options were applied including FLS (n = 13), amniodrainage (n = 3), and selective reduction (n = 3). Clinical outcomes results were mixed and inconsistent. FLS was described as technically challenging and residual anastomosis was common. Overall fetal and neonatal survival following FLS was 85% and 80%, respectively.
CONCLUSIONS: Presence of proximate cords in TTTS cases poses serious technical challenges even for highly experienced surgeons. Feasibility should be only determined by fetoscopic examination.
METHODS: This was retrospective cohort study of TTTS cases managed at single fetal center between 2012 and 2020. Presence of proximate cord insertions was defined as a distance of equal or less than 4 cm between placental cord insertions that was recorded based on sonographic and fetoscopic examinations. Clinical outcomes were investigated compared to unmatched cohort and to 1:2 matched controls using preoperative variables including Quintero staging, selective fetal growth restriction, anterior placenta, preoperative cervical length, and gestational age at fetal intervention. Systematic review and meta-analysis were conducted following PRSMA guidelines through searching PubMed, Scopus, CINAHL, and Medline databases from inception until January 2021.
RESULTS: The prevalence of proximate cord insertions in monochorionic placentas with TTTS was 2% (5/246). All 5 cases were managed by fetoscopic laser surgery (FLS). Procedure time was significantly longer (mean: 61.4 min in proximate cord vs. 37.5 min in nonproximate cord, p < 0.001), and amnioinfusion was significantly more common (100% in proximate cord vs. 43% in nonproximate cord, p = 0.01). Perinatal survival and neonatal outcomes were not different between groups. Similar findings were seen following 1:2 control matching. Systematic review yielded total of 19 case reports of which different management options were applied including FLS (n = 13), amniodrainage (n = 3), and selective reduction (n = 3). Clinical outcomes results were mixed and inconsistent. FLS was described as technically challenging and residual anastomosis was common. Overall fetal and neonatal survival following FLS was 85% and 80%, respectively.
CONCLUSIONS: Presence of proximate cords in TTTS cases poses serious technical challenges even for highly experienced surgeons. Feasibility should be only determined by fetoscopic examination.
摘要：
目的：我们的目的是调查双胎对双胎输血综合征（TTTS）伴脐带近端插入的患病率和临床结局。
方法：这是2012年至2020年在单个胎儿中心管理的TTTS病例的回顾性队列研究。邻近脐带插入的存在定义为基于超声和胎儿镜检查记录的胎盘脐带插入之间的距离等于或小于4cm。使用包括Quintero分期在内的术前变量，与不匹配的队列和1：2匹配的对照进行临床结果调查。选择性胎儿生长受限,前胎盘,术前宫颈长度,和胎儿干预时的胎龄。根据PRSMA指南，通过搜索PubMed，Scopus,CINAHL,和Medline数据库从成立到2021年1月。
结果：伴TTTS的单绒毛膜胎盘脐带插入的患病率为2%(5/246)。5例均采用胎儿镜激光手术（FLS）治疗。手术时间明显更长（平均：近端脐带61.4分钟与非近线37.5分钟，p<0.001)，羊膜输注明显更常见(100%在近端脐带与43%在不接近的脐带中，p=0.01)。两组之间的围产期生存率和新生儿结局没有差异。在1:2对照匹配后观察到类似的发现。系统评价共产生19例病例报告，其中应用了不同的管理方案，包括FLS（n=13），羊膜引流（n=3），和选择性还原（n=3）。临床结果混合且不一致。FLS被描述为技术上具有挑战性，残余吻合很常见。FLS后胎儿和新生儿的总生存率分别为85％和80％，分别。
结论：即使对于经验丰富的外科医生来说，TTTS病例中存在近线也构成了严重的技术挑战。可行性只能通过胎儿镜检查来确定。
方法：这是2012年至2020年在单个胎儿中心管理的TTTS病例的回顾性队列研究。邻近脐带插入的存在定义为基于超声和胎儿镜检查记录的胎盘脐带插入之间的距离等于或小于4cm。使用包括Quintero分期在内的术前变量，与不匹配的队列和1：2匹配的对照进行临床结果调查。选择性胎儿生长受限,前胎盘,术前宫颈长度,和胎儿干预时的胎龄。根据PRSMA指南，通过搜索PubMed，Scopus,CINAHL,和Medline数据库从成立到2021年1月。
结果：伴TTTS的单绒毛膜胎盘脐带插入的患病率为2%(5/246)。5例均采用胎儿镜激光手术（FLS）治疗。手术时间明显更长（平均：近端脐带61.4分钟与非近线37.5分钟，p<0.001)，羊膜输注明显更常见(100%在近端脐带与43%在不接近的脐带中，p=0.01)。两组之间的围产期生存率和新生儿结局没有差异。在1:2对照匹配后观察到类似的发现。系统评价共产生19例病例报告，其中应用了不同的管理方案，包括FLS（n=13），羊膜引流（n=3），和选择性还原（n=3）。临床结果混合且不一致。FLS被描述为技术上具有挑战性，残余吻合很常见。FLS后胎儿和新生儿的总生存率分别为85％和80％，分别。
结论：即使对于经验丰富的外科医生来说，TTTS病例中存在近线也构成了严重的技术挑战。可行性只能通过胎儿镜检查来确定。
