UNASSIGNED: Prognosis of twin-to-twin transfusion syndrome (TTTS) varies depending on the Quintero stage and fetal cardiac function. The purpose of our study was to evaluate fetal cardiac function before and after different intrauterine treatments of TTTS through myocardial performance index (MPI).
UNASSIGNED: In this retrospective study, data were collected from August 2016 to December 2022. Totals of 68 cases of TTTS and 68 monochorionic diamniotic (MCDA) twins without TTTS were included. MPI was collected and compared between TTTS and MCDA twins without TTTS before intrauterine treatments. TTTS cases were divided into 3 groups according to different intrauterine treatments: (I) amnioreduction (34 cases), (II) fetoscopic laser photocoagulation (FLPC; 20 cases), and (III) selective reduction (14 cases). The MPI of the left ventricle (LV) and right ventricle (RV) in each surviving fetus were measured 48 hours before and after treatments by pulse Doppler ultrasound. One-way analysis of variance (ANOVA) was employed to assess whether there were statistical differences in LV-MPI and RV-MPI among the donors, recipients, and the control group. Paired t-test analysis was used to compare whether there were differences in MPI before and after intrauterine treatments.
UNASSIGNED: The MPIs of the LV and RV in the recipients were significantly higher than those in the MCDA twins without TTTS (P<0.05). After the amnioreduction treatment of TTTS, no significant differences were observed in the MPI of either the LV or the RV before and after treatment. At 48 hours after FLPC treatment, the value of the LV-MPI in donors was 0.25±0.08, and the value of the RV-MPI in recipients was 0.58±0.17. Both of them were significantly lower than those before the treatment (P<0.05). In the selective reduction group, the value of the RV-MPI in surviving recipients significantly decreased compared to that before treatment (P<0.05).
UNASSIGNED: MPI is an effective indicator to evaluate fetal cardiac function of TTTS and assess the efficacy of intrauterine treatments of TTTS.

OBJECTIVE: Fetoscopic laser coagulation of placental anastomoses is usually performed for a treatment of twin-to-twin transfusion syndrome (TTTS). A common complication of fetoscopic laser coagulation for TTTS is preterm preliminary rupture of fetal membranes (PPROM) aggravating the neonatal outcome significantly. However, use of an flexible 1 mm fetoscope with an curved sheath could reduce iatrogenic damage of the amniotic membrane and improve neonatal outcomes after laser treatment. The aim of this study was to compare neonatal outcomes using this flexible fetoscope with curved sheath vs. use of a standard lens technique.
METHODS: Outcomes were retrospective analyzed after use of a standard lens fetoscope of 2 mm (sheath 6.63 mm2 or 11.27 mm2 for anterior placenta) and a flexible fetoscope of 1 mm or 1.2 mm (sheath 2.65 mm2 or 3.34 mm2) in two German centers of fetal surgery, performed during 2006-2019.
RESULTS: Neonatal outcome of 247 TTTS patients were analyzed including the rates of double and single fetal survival. The survival of at least one fetus was 97.2 % in the group with the ultrathin technique (n=154) compared to 88.3 % (n=93) in the group with the standard lens fetoscope (p=0.008). Survival of both fetuses was not different between groups (81.0 vs. 75.3 %). The procedure to delivery interval was significantly increased using the ultrathin fetoscope (89.1±35.0 d vs. 71.4±35.4 d, p=0.001) resulting in an increased gestational age at delivery by 11 days on average (231.9±28.1 d vs. 221.1±32.7 d, p=0.012).
CONCLUSIONS: Fetal survival can be significantly increased following TTTS using flexible fetoscope of 1 mm or 1.2 mm (sheath 2.65 mm2 or 3.34 mm2).

UNASSIGNED: Brain injury (BI) is prevalent in premature infants with twin-to-twin transfusion syndrome (TTTS), while risk factors of BI in these patients remains unknown. Our study aims to discern potential risk factors that contribute to BI in premature infants with TTTS.
UNASSIGNED: We conducted a retrospective cohort and analyzed clinical data of premature infants diagnosed with TTTS at the Northwest Women\'s and Children\'s Hospital between January 1, 2015 and January 1, 2020. Data included the infants\' perinatal information, key postnatal examinations, laboratory tests, and treatments.
UNASSIGNED: Of the 84 patients enrolled in the study, 22 (26.2%) were categorized in the BI group and 62 (73.8%) in the non-BI group, based on cranial imaging. No significant differences were found at baseline between the groups in relation to the proportion of males (40.9% vs. 35.5%, P=0.845), median gestational age (weeks) [31.9 (31.5, 33.4) vs. 34.2 (31.6, 35.4), P=0.061], average weight (g) (1,676.4±567.5 vs. 1,845.2±511.7, P=0.200), maternal age (years) [29.5 (26.0, 31.0) vs. 28.5 (27.8, 31.0), P=0.656], the proportion of in-vitro fertilization (9.1% vs. 16.1%, P=0.648), cesarean sections (86.4% vs. 93.5%, P=0.549) or TTTS donor infants (50.0% vs. 51.6%, P=0.897). Multivariate logistic regression analysis indicated that invasive mechanical ventilation [invasive mechanical ventilation (IMV); odds ratio (OR) =4.365; 95% confidence interval (CI): 1.066-17.870; P=0.040], [necrotizing enterocolitis (NEC); OR =8.632; 95% CI: 1.542-48.318; P=0.014], [single intrauterine fetal demise (sIUFD); OR =14.067; 95% CI: 1.298-224.421; P=0.031], and a 5-minute Apgar score <9 (OR =4.663; 95% CI: 1.015-21.419; P=0.048) were strongly associated with BI in TTTS premature infants.
UNASSIGNED: Our study identifies IMV, NEC, sIUFD, and a 5-minute Apgar score <9 as independent risk factors for BI in premature infants with TTTS.

OBJECTIVE: To review experience with fetoscopic laser ablation of placental anastomoses to treat monochorionic diamniotic (MCDA) twin pregnancies complicated by twin-to-twin transfusion syndrome (TTTS) in a single centre over a ten-year period.
METHODS: A retrospective study on 142 MCDA twin pregnancies complicates by TTTS treated with equatorial laser ablation of placental anastomoses (2008-2018). Solomon technique was also applied after 2013. Survival rates, neonatal outcome, intraoperative and post-laser complications were recorded, and prognostic factors analysed.
RESULTS: A total of 133 cases were included in the final analysis; 41 patients were at stage II (30.8%), 73 were at stage III (62.9%), while only 12 (9%) at stage I and two patients (1.7%) at stage IV. Solomon technique was applied in 39 cases (29.3%). Survival of both twins was 51.1% (68/133), of a single twin 20.3% (27/133), and of at least one 71.5% (95/133), with an overall survival of 61.3% (163/266). TAPS and recurrent TTTS occurred in 8 (6%) and 15 (11.3%) patients. Survival of both fetuses increased over time (44.6 vs. 57.3%). A posterior placenta (p<0.003) and the use of the Solomon technique (p<0.02) were more frequent in cases with survival of both fetuses, while TTTS recurrence was significantly associated to the loss of one or two fetuses (p<0.01). Such associations were confirmed at logistic regression analysis.
CONCLUSIONS: Survival of both twins can improve over time and seems to be favourably associated with a placenta in the posterior location and the use of the Solomon technique.

The study aims to expound upon the imaging-based diagnostic methodologies aimed at identifying twin-to-twin transfusion syndrome (TTTS), a serious, somewhat rare prenatal condition that takes place in pregnancies where identical twins, or other multiples, share a placenta (monochorionic placenta), highlighting how medico-legal outcomes can be affected by provable compliance with consolidated diagnostic guidelines or best practices. It is of utmost importance to produce a prompt identification of TTTS instances; an early diagnosis is in fact critical in order to effectively treat and manage TTTS. By virtue of TTTS being a highly progressive condition, a delay in diagnosis can result in disastrous outcomes; just a few weeks delay in the diagnosis of TTTS can turn out fatal for one or both twins. Hence, most TTTS malpractice claims involve allegations of medical negligence, namely the failure to recognize the condition in a timely fashion, or to proceed with adequate diagnostic and therapeutic pathways. In that regard, case law databases have been pored over (Justia, Lexis, Leagle), and five significant court cases have been examined and discussed in an attempt to identify objective medico-legal standards and bring to the forefront relevant forensic dynamics. In fact, when health professionals are capable of proving adherence to guidelines or best practices, this can shield them from malpractice allegations and ensuing litigation.

Twin-to-twin transfusion syndrome (TTTS) is a condition that results in unbalanced blood flow between two fetuses. Patients diagnosed with TTTS can experience maternal or fetal morbidity and mortality. Depending on the severity of TTTS, laser ablation of placental anastomoses may be the most effective treatment. The preferred treatment method requires percutaneous entry to the uterus; however, some patient circumstances (eg, placenta location) require a laparoscopic-assisted procedure. During the preoperative appointments, clinicians assess the condition of the fetuses and patients may participate in genetic counseling. Intraoperative care involves an interdisciplinary team that may include a pediatric general surgeon, maternal-fetal medicine specialists, an RN circulator, a scrub person, and an anesthesia professional. Perioperative nurses should have knowledge of the pathophysiology of TTTS, including its natural progression. They also should understand preoperative and intraoperative patient care requirements to provide safe and effective care for patients undergoing laparoscopic-assisted fetoscopic placental laser photocoagulation procedures.

During Twin-to-Twin Transfusion Syndrome (TTTS), abnormal vascular anastomoses in the monochorionic placenta can produce uneven blood flow between the fetuses. In the current practice, this syndrome is surgically treated by closing the abnormal connections using laser ablation. Surgeons commonly use the inter-fetal membrane as a reference. Limited field of view, low fetoscopic image quality and high inter-subject variability make the membrane identification a challenging task. However, currently available tools are not optimal for automatic membrane segmentation in fetoscopic videos, due to membrane texture homogeneity and high illumination variability.
To tackle these challenges, we present a new deep-learning framework for inter-fetal membrane segmentation on in-vivo fetoscopic videos. The framework enhances existing architectures by (i) encoding a novel (instance-normalized) dense block, invariant to illumination changes, that extracts spatio-temporal features to enforce pixel connectivity in time, and (ii) relying on an adversarial training, which constrains macro appearance.
We performed a comprehensive validation using 20 different videos (2000 frames) from 20 different surgeries, achieving a mean Dice Similarity Coefficient of 0.8780±0.1383.
The proposed framework has great potential to positively impact the actual surgical practice for TTTS treatment, allowing the implementation of surgical guidance systems that can enhance context awareness and potentially lower the duration of the surgeries.

OBJECTIVE: Fetoscopic laser photocoagulation is a minimally invasive surgical procedure used to treat twin-to-twin transfusion syndrome (TTTS), which involves localization and ablation of abnormal vascular connections on the placenta to regulate the blood flow in both fetuses. This procedure is particularly challenging due to the limited field of view, poor visibility, occasional bleeding, and poor image quality. Fetoscopic mosaicking can help in creating an image with the expanded field of view which could facilitate the clinicians during the TTTS procedure.
METHODS: We propose a deep learning-based mosaicking framework for diverse fetoscopic videos captured from different settings such as simulation, phantoms, ex vivo, and in vivo environments. The proposed mosaicking framework extends an existing deep image homography model to handle video data by introducing the controlled data generation and consistent homography estimation modules. Training is performed on a small subset of fetoscopic images which are independent of the testing videos.
RESULTS: We perform both quantitative and qualitative evaluations on 5 diverse fetoscopic videos (2400 frames) that captured different environments. To demonstrate the robustness of the proposed framework, a comparison is performed with the existing feature-based and deep image homography methods.
CONCLUSIONS: The proposed mosaicking framework outperformed existing methods and generated meaningful mosaic, while reducing the accumulated drift, even in the presence of visual challenges such as specular highlights, reflection, texture paucity, and low video resolution.

OBJECTIVE: Fetoscopic laser photocoagulation is a minimally invasive surgery for the treatment of twin-to-twin transfusion syndrome (TTTS). By using a lens/fibre-optic scope, inserted into the amniotic cavity, the abnormal placental vascular anastomoses are identified and ablated to regulate blood flow to both fetuses. Limited field-of-view, occlusions due to fetus presence and low visibility make it difficult to identify all vascular anastomoses. Automatic computer-assisted techniques may provide better understanding of the anatomical structure during surgery for risk-free laser photocoagulation and may facilitate in improving mosaics from fetoscopic videos.
METHODS: We propose FetNet, a combined convolutional neural network (CNN) and long short-term memory (LSTM) recurrent neural network architecture for the spatio-temporal identification of fetoscopic events. We adapt an existing CNN architecture for spatial feature extraction and integrated it with the LSTM network for end-to-end spatio-temporal inference. We introduce differential learning rates during the model training to effectively utilising the pre-trained CNN weights. This may support computer-assisted interventions (CAI) during fetoscopic laser photocoagulation.
RESULTS: We perform quantitative evaluation of our method using 7 in vivo fetoscopic videos captured from different human TTTS cases. The total duration of these videos was 5551 s (138,780 frames). To test the robustness of the proposed approach, we perform 7-fold cross-validation where each video is treated as a hold-out or test set and training is performed using the remaining videos.
CONCLUSIONS: FetNet achieved superior performance compared to the existing CNN-based methods and provided improved inference because of the spatio-temporal information modelling. Online testing of FetNet, using a Tesla V100-DGXS-32GB GPU, achieved a frame rate of 114 fps. These results show that our method could potentially provide a real-time solution for CAI and automating occlusion and photocoagulation identification during fetoscopic procedures.

Twin-to-twin transfusion syndrome (TTTS) is a challenging complication in monochorionic diamniotic (MCDA) twins. Intrauterine interventions, such as fetoscopic laser ablation and cord occlusion followed by amniodrainage, are established treatments. Little is known about maternal complications and hemodynamics following these interventions. We performed a retrospective analysis of maternal procedure-related complications and the impact of such procedures on maternal hemodynamics and blood characteristics. Within the study period, 100 women with severe TTTS treated by fetoscopic laser ablation (FLA) or cord occlusion (CO) were identified. Clinically relevant maternal complications were reported in four (4%) cases. There was a significant decrease in hemoglobin, hematocrit, and albumin between admission and postoperative measurements (all p < 0.001). Systolic and diastolic blood pressure, as well as maternal heart rate, decreased from time of skin suture to postoperative measurements (all p < 0.001). Within a 24 h interval, there was a positive correlation between hematocrit (Spearman\'s rho 0.325; p = 0.003), hemoglobin (Spearman\'s rho 0.379; p < 0.001), and albumin (Spearman\'s rho 0.360; p = 0.027), and the amount of amniodrainage during the intervention. Maternal procedure-related complications are relatively rare. Significant hemodynamic alterations and maternal hemodilution are common clinical findings following intrauterine interventions.