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Abstract：
BACKGROUND: Perforation of the intertwin membrane can occur as a complication of fetoscopic laser surgery for twin-twin transfusion syndrome (TTTS). Data on the occurrence and the risk of subsequent cord entanglement are limited. The objective of this study was to assess the prevalence, risk factors and outcome of intertwin membrane perforation, and cord entanglement after laser surgery for TTTS.
METHODS: In this multicenter retrospective study, we included all TTTS pregnancies treated with laser surgery in two fetal therapy centers, Shanghai (China) and Leiden (the Netherlands) between 2002 and 2020. We evaluated the occurrence of intertwin membrane perforation and cord entanglement after laser, based on routine fortnightly ultrasound examination and investigated the risk factors and the association with adverse short- and long-term outcomes.
RESULTS: Perforation of the intertwin membrane occurred in 118 (16%) of the 761 TTTS pregnancies treated with laser surgery and was followed by cord entanglement in 21% (25/118). Perforation of the intertwin membrane was associated with higher laser power settings, 45.8 Watt versus 42.2 Watt (p = 0.029) and a second fetal surgery procedure 17% versus 6% (p < 0.001). The group with intertwin membrane perforation had a higher rate of caesarean section (77% vs. 31%, p < 0.001) and a lower gestational age at birth (30.7 vs. 33.3 weeks of gestation, p < 0.001) compared to the group with an intact intertwin membrane. Severe cerebral injury occurred more often in the group with intertwin membrane perforation, 9% (17/185) versus 5% (42/930), respectively (p = 0.019). Neurodevelopmental outcome at 2 years of age was similar between the groups with and without perforation of the intertwin membrane and between the subgroups with and without cord entanglement.
CONCLUSIONS: Perforation of the intertwin membrane after laser occurred in 16% of TTTS cases treated with laser and led to cord entanglement in at least 1 in 5 cases. Intertwin membrane perforation was associated with a lower gestational age at birth and a higher rate of severe cerebral injury in surviving neonates.
METHODS: In this multicenter retrospective study, we included all TTTS pregnancies treated with laser surgery in two fetal therapy centers, Shanghai (China) and Leiden (the Netherlands) between 2002 and 2020. We evaluated the occurrence of intertwin membrane perforation and cord entanglement after laser, based on routine fortnightly ultrasound examination and investigated the risk factors and the association with adverse short- and long-term outcomes.
RESULTS: Perforation of the intertwin membrane occurred in 118 (16%) of the 761 TTTS pregnancies treated with laser surgery and was followed by cord entanglement in 21% (25/118). Perforation of the intertwin membrane was associated with higher laser power settings, 45.8 Watt versus 42.2 Watt (p = 0.029) and a second fetal surgery procedure 17% versus 6% (p < 0.001). The group with intertwin membrane perforation had a higher rate of caesarean section (77% vs. 31%, p < 0.001) and a lower gestational age at birth (30.7 vs. 33.3 weeks of gestation, p < 0.001) compared to the group with an intact intertwin membrane. Severe cerebral injury occurred more often in the group with intertwin membrane perforation, 9% (17/185) versus 5% (42/930), respectively (p = 0.019). Neurodevelopmental outcome at 2 years of age was similar between the groups with and without perforation of the intertwin membrane and between the subgroups with and without cord entanglement.
CONCLUSIONS: Perforation of the intertwin membrane after laser occurred in 16% of TTTS cases treated with laser and led to cord entanglement in at least 1 in 5 cases. Intertwin membrane perforation was associated with a lower gestational age at birth and a higher rate of severe cerebral injury in surviving neonates.
摘要：
背景：双胎输血综合征（TTTS）的胎儿镜激光手术可能会发生双胎膜穿孔。关于随后脐带缠结的发生和风险的数据有限。这项研究的目的是评估患病率，TTTS激光手术后双膜间穿孔和脐带缠结的危险因素和结局。
方法：在这项多中心回顾性研究中，我们纳入了在两个胎儿治疗中心接受激光手术治疗的所有TTTS妊娠，2002年至2020年期间，上海（中国）和莱顿（荷兰）。我们评估了激光后双膜穿孔和脐带缠结的发生，基于常规的每两周超声检查，并调查了危险因素以及与不良短期和长期结局的关系。
结果：在接受激光手术治疗的761例TTTS妊娠中，118例（16％）发生双胎膜穿孔，其次是21％（25/118）的脐带缠结。孪生膜的穿孔与更高的激光功率设置有关，45.8瓦特对42.2瓦特(p=0.029)和第二次胎儿手术程序17%对6%(p<0.001)。双膜间穿孔组剖宫产率较高(77%对31%,p<0.001）和较低的出生胎龄（妊娠30.7周与33.3周，p<0.001）与具有完整孪生膜的组相比。严重脑损伤更常见于双膜间穿孔组，分别为9%(17/185)和5%(42/930)(p=0.019)。有和没有双膜穿孔的组之间以及有和没有脐带缠结的亚组之间，两岁时的神经发育结果相似。
结论：用激光治疗的TTTS病例中，有16％发生激光后双膜穿孔，并导致5例中至少1例脐带缠结。双胎膜穿孔与出生时的胎龄较低和存活新生儿的严重脑损伤发生率较高有关。
方法：在这项多中心回顾性研究中，我们纳入了在两个胎儿治疗中心接受激光手术治疗的所有TTTS妊娠，2002年至2020年期间，上海（中国）和莱顿（荷兰）。我们评估了激光后双膜穿孔和脐带缠结的发生，基于常规的每两周超声检查，并调查了危险因素以及与不良短期和长期结局的关系。
结果：在接受激光手术治疗的761例TTTS妊娠中，118例（16％）发生双胎膜穿孔，其次是21％（25/118）的脐带缠结。孪生膜的穿孔与更高的激光功率设置有关，45.8瓦特对42.2瓦特(p=0.029)和第二次胎儿手术程序17%对6%(p<0.001)。双膜间穿孔组剖宫产率较高(77%对31%,p<0.001）和较低的出生胎龄（妊娠30.7周与33.3周，p<0.001）与具有完整孪生膜的组相比。严重脑损伤更常见于双膜间穿孔组，分别为9%(17/185)和5%(42/930)(p=0.019)。有和没有双膜穿孔的组之间以及有和没有脐带缠结的亚组之间，两岁时的神经发育结果相似。
结论：用激光治疗的TTTS病例中，有16％发生激光后双膜穿孔，并导致5例中至少1例脐带缠结。双胎膜穿孔与出生时的胎龄较低和存活新生儿的严重脑损伤发生率较高有关。
