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OBJECTIVE: To investigate the clinical outcomes and Doppler patterns changes in monochorionic diamniotic (MCDA) twins with selective fetal growth restriction (sFGR).
METHODS: We retrospectively analyzed 362 sFGR cases from January 2010 to May 2016 at a single tertiary referral center. The Doppler waveforms of umbilical artery end-diastolic flow were collected, and all neonates were subjected to an early neonatal brain scan.
RESULTS: A total of 66/100 (66 %) type I cases were stable, whereas 25/100 (25 %) cases changed to type II and 9/100 (9 %) changed to sFGR complicated twin-twin transfusion syndrome (TTTS). A total of 48.9 % (22/45) sFGR cases were complicated with polyhydramnios and 30.4 % (7/23) sFGR cases were complicated with oligohydramnios, both of which were progressed to sFGR with TTTS. Mild cerebral injury was significantly associated with Doppler flow abnormalities, earlier gestational age at delivery and type of sFGR diagnosis. Severe cerebral injury was significantly associated with gestational age at delivery (31.6 vs. 34.1, p=0.002) and larger birthweight discordance (43.9 vs. 29.3 %, p=0.011).
CONCLUSIONS: Doppler patterns in sFGR can gradually change, with important consequences with regard to management and outcomes. Along with abnormal Doppler findings, earlier occurrence of sFGR and delivery are associated with subsequent neonatal cerebral injury.

Fetoscopy laser photocoagulation is a widely adopted procedure for treating Twin-to-Twin Transfusion Syndrome (TTTS). The procedure involves photocoagulation pathological anastomoses to restore a physiological blood exchange among twins. The procedure is particularly challenging, from the surgeon\'s side, due to the limited field of view, poor manoeuvrability of the fetoscope, poor visibility due to amniotic fluid turbidity, and variability in illumination. These challenges may lead to increased surgery time and incomplete ablation of pathological anastomoses, resulting in persistent TTTS. Computer-assisted intervention (CAI) can provide TTTS surgeons with decision support and context awareness by identifying key structures in the scene and expanding the fetoscopic field of view through video mosaicking. Research in this domain has been hampered by the lack of high-quality data to design, develop and test CAI algorithms. Through the Fetoscopic Placental Vessel Segmentation and Registration (FetReg2021) challenge, which was organized as part of the MICCAI2021 Endoscopic Vision (EndoVis) challenge, we released the first large-scale multi-center TTTS dataset for the development of generalized and robust semantic segmentation and video mosaicking algorithms with a focus on creating drift-free mosaics from long duration fetoscopy videos. For this challenge, we released a dataset of 2060 images, pixel-annotated for vessels, tool, fetus and background classes, from 18 in-vivo TTTS fetoscopy procedures and 18 short video clips of an average length of 411 frames for developing placental scene segmentation and frame registration for mosaicking techniques. Seven teams participated in this challenge and their model performance was assessed on an unseen test dataset of 658 pixel-annotated images from 6 fetoscopic procedures and 6 short clips. For the segmentation task, overall baseline performed was the top performing (aggregated mIoU of 0.6763) and was the best on the vessel class (mIoU of 0.5817) while team RREB was the best on the tool (mIoU of 0.6335) and fetus (mIoU of 0.5178) classes. For the registration task, overall the baseline performed better than team SANO with an overall mean 5-frame SSIM of 0.9348. Qualitatively, it was observed that team SANO performed better in planar scenarios, while baseline was better in non-planner scenarios. The detailed analysis showed that no single team outperformed on all 6 test fetoscopic videos. The challenge provided an opportunity to create generalized solutions for fetoscopic scene understanding and mosaicking. In this paper, we present the findings of the FetReg2021 challenge, alongside reporting a detailed literature review for CAI in TTTS fetoscopy. Through this challenge, its analysis and the release of multi-center fetoscopic data, we provide a benchmark for future research in this field.

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.

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Through a systematic review and meta-analyses, we aimed to analyze the impact of chorionicity on neurodevelopment outcomes.
We conducted a comprehensive search strategy through Medline, Embase, Web of Science, and reference lists of the retrieved studies until August 2022. Studies that examined the association between chorionicity and children\'s neurodevelopment outcomes were included.
Twelve studies were included. Monochorionic (MC) twins increased the odds of neurodevelopment impairment, cerebral palsy compared to dichorionic (DC) twins. The differences in neurodevelopmental impairment and cerebral palsy between the two groups disappeared after excluding infants with twin-twin transfusion (TTTS). After fetoscopic laser surgery (FLS) for MC twins, there were no differences too.
Compared to DC twins, MC twins were associated with an increased risk of neurodevelopment impairment. MC twins complicated by TTTS were at high risk of neurologic disability, and FLS was an acceptable treatment modality for them.

Selective fetoscopic laser photocoagulation (SFLP) for twin-to-twin transfusion syndrome (TTTS) is challenging for new surgeons at the start of their learning curve. We described an approach utilising telementoring and team-based training to facilitate rapid attainment of the skills required for safe and efficient practice with a limited caseload.
We conducted a prospective observational study of SFLP performed by the novice primary surgical team in three stages: under direct on-site supervision from an expert mentor (Group 1), with remote tele-guidance from that mentor (Group 2) and independently (Group 3), at an academic tertiary hospital in Singapore. The primary team undertook regular training on high-fidelity tissue models to accelerate skills acquisition and complement the surgical performance.
9 patients diagnosed with Stage 2 TTTS were assessed for procedural characteristics, surgical outcomes and perinatal survival following SFLP. There were no significant differences in operative duration, anastomoses ablated, gestational age or birth weight at delivery. The complications observed were: recurrent TTTS (22.2% of pregnancies), twin anaemia polycythaemia sequence (33.3%), preterm prelabour membrane rupture (22.2%) and delivery at < 32 weeks (44.4%). ≥ 1 twin was live-born in 88.9% of cases, while postnatal survival to six months of ≥ 1 twin occurred in 77.8% of cases.
Systematic mentoring and specialised skills training are useful in aiding new surgeons to negotiate the steep learning curve and achieve good outcomes at the start of a new practice, particularly in the setting of low patient numbers. This is best paired with dedicated model training to achieve and maintain surgical dexterity for this complex procedure.

This study aimed to investigate the relationship between the characteristics and diameters of residual anastomoses and the occurrence of twin anemia-polycythemia sequence (TAPS) in twin-to-twin transfusion syndrome (TTTS) patients with placental vascular injection after fetoscopic laser surgery (FLS).
A total of 90 cases of pregnant women who underwent FLS owing to TTTS were collected in the university hospital from May 2018 to December 2020. Therein, 40 cases received placental injection and were divided into the TAPS group and non-TAPS group according to the postoperative complications. The number of residual superficial anastomoses was counted and the diameter was measured.
Among the placentae of nine patients in the TAPS group, two cases had no superficial anastomoses, and seven cases had 16 superficial anastomoses, including eight arterio-venous (AV) anastomoses, two veno-arterial (VA) anastomoses, three arterio-arterial (AA) anastomoses and three veno-venous (VV) anastomoses. Among the placentae of 31 patients in the non-TAPS group, 19 cases had no superficial anastomoses, and 12 cases had 18 superficial anastomoses, including two AV anastomoses, five VA anastomoses, seven AA anastomoses, and four VV anastomoses; and both the two cases of AV anastomoses were accompanied by AA anastomoses. The number of AV anastomoses in the placentae of the TAPS group was significantly elevated compared with that in the non-TAPS group (p<0.05). While there was no significant difference in the numbers of placentae with superficial anastomoses, the numbers of blood vessels with VA anastomoses, VV anastomoses, and AA anastomoses between the two groups (p>0.05). Through analyzing the diameters of 34 superficial anastomoses in the two groups, it was shown that the diameters of AA anastomoses in the non-TAPS group were significantly larger than those in the TAPS group (Z=1.97, p<0.05). There was no statistical difference in the diameters of AV anastomoses (Z=0.52, p>0.05), VA anastomoses (Z=0.98, p>0.05), and VV anastomoses (Z=0.36, p>0.05). The differences of the birth weight and inter-twin hemoglobin difference were statistically significant (p<0.05). The result indicated that the differences between age, gestational weeks at operation, delivery, and mean operating times were not statistically significant (p>0.05).
The increase in the number of AV anastomoses could obviously elevate the incidence of TAPS. The probability of TAPS occurrence is reduced following the increased diameters of AA anastomoses, demonstrating that AA anastomosis has a protective effect on TTTS patients.

This study was developed to evaluate the relative placental characteristics and pregnancy outcomes associated with monochorionic diamniotic (MCDA) twins with and without proximate umbilical cord insertion (PCI).
All MCDA twins delivered with complete placentas for whom placental characteristics were assessed via dye injection between April 1, 2013 and April 1, 2021 were included in the present cohort study. Cases were separated into PCI and non-PCI groups, and pregnancy outcomes and placental characteristics were then compared between these groups.
Birthweight discordance rates were significantly lower in the PCI group relative to the non-PCI group (7.3 ± 7.5% vs 29.9 ± 16.8%, P＜0.001), while relative to the non-PCI group, rates of artery-artery (AA), vein-vein (VV), thick AA, and thick VV anastomoses were significantly higher in the PCI group (95.5% vs 67.0%, P = 0.008, 59.1% vs 16.4, P＜0.001,90.5% vs 34.9%, P＜0.001, 54.5% vs 10.5%, P＜0.001). Significantly more anastomoses were observed in the PCI group (7 (3,11) vs 6 (3,15), P = 0.015), and they were significantly larger on average than those in the non-PCI group 12.8 (6.7,21.3) mm vs 11.9 (3.4, 24.6) mm, P = 0.009). Significantly lower placental territory discordance and UCI ratios were evident in the PCI group relative to the non-PCI group (23.5 (15.0,51.0) % vs 60.0 (2.0,80.0) %, P＜0.001, 13.3 ± 5.8% vs 56.1 ± 18.0%, P < 0.001). Marginal cord insertion rates were lower in the PCI group relative to the non-PCI group (13.6% vs 77.5%, P < 0.001).
The placental structure of MCDA twins with PCI is distinct from that of twins without PCI, and these results suggest PCI may be indicative of the more even distribution of placental territory between MCDA fetuses.