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Monochorionic twin pregnancies complicated by twin-to-twin transfusion syndrome are typically treated with fetoscopic laser coagulation. Postoperative complications can occur due to residual vascular anastomoses on the placenta. We aimed to assess the efficacy and safety of a novel surgery technique that uses laser coagulation of the entire vascular equator (Solomon technique). We undertook an open-label, international, multicentre, randomised controlled trial at five European tertiary referral centres. Women with twin-to-twin transfusion syndrome were randomly assigned by online randomisation (1:1) with permuted blocks to the Solomon technique or standard laser coagulation. The primary outcome was a composite of incidence of twin anaemia polycythaemia sequence, recurrence of twin-to-twin transfusion syndrome, perinatal mortality, or severe neonatal morbidity. Analyses were by intention to treat, with results expressed as odds ratios (ORs) and 95% CIs. This trial is registered with the Dutch Trial Registry, number NTR1245. Between March 11, 2008, and July 12, 2012, 274 women were randomly assigned to either the Solomon group (n=139) or the standard treatment group (n=135). The primary outcome occurred in 94 (34%) of 274 fetuses in the Solomon group versus 133 (49%) of 270 in the standard treatment group (OR 0·54; 95% CI 0·35–0·82). The Solomon technique was associated with a reduction in twin anaemia polycythaemia sequence (3% vs 16% for the standard treatment; OR 0·16, 95% CI 0·05–0·49) and recurrence of twin-to-twin transfusion syndrome (1% vs 7%; 0·21, 0·04–0·98). Perinatal mortality and severe neonatal morbidity did not differ significantly between the two groups. Outside of the common and well-known complications of twin-to-twin transfusion syndrome and its treatment, no serious adverse events occurred. Fetoscopic laser coagulation of the entire vascular equator reduces postoperative fetal morbidity in severe twin-to-twin transfusion syndrome. We recommend that fetoscopic surgeons consider adopting this strategy for treatment of women with twin-to-twin transfusion syndrome. Netherlands Organization for the Health Research and Development (ZonMw 92003545).

In a randomized trial of women with severe twin-to-twin transfusion syndrome during midgestation, fetoscopic laser therapy (coagulation of placental vascular anastomoses) resulted in significantly higher survival rates of at least one twin and lower rates of neurologic abnormalities at six months of age than did amnioreduction (repeated removal of large volumes of amniotic fluid). As compared with serial amnioreduction, endoscopic laser ablation of anastomoses may improve outcomes. Monochorionic twin pregnancies complicated by severe twin-to-twin transfusion syndrome 1 before 26 weeks of gestation are associated with high risks of fetal loss, perinatal death, and subsequent handicap in the survivors. 2 – 5 The prognosis for untreated severe twin-to-twin transfusion syndrome is dismal, 6 with perinatal mortality rates of up to 90 percent. 7 The optimal initial treatment of this complication remains controversial. Uncontrolled series have suggested that two approaches reduce mortality. Serial amnioreduction is widely available and involves the repetitive removal of large volumes of amniotic fluid. The rationale for this technique is to prevent preterm delivery related to polyhydramnios and to improve . . .

Objective: We observed influences of different doses of intravenous midazolam on mother and fetus in fetoscopic surgery for twin-to-twin transfusion syndrome (TTTS). Methods: A total of 18 pregnant women with TTTS were randomly divided into groups M1 and M2 according to differing doses of midazolam. Some parameters were respectively recorded as prior to administration of midazolam (T0), instantly after anesthesia induction (T1), at incision (T2), instantly after laser coagulation (T3) and at the end of surgery (T4). Results: There was no statistical difference in oxygen saturation and respiratory rate between groups M1 and M2 (all p > 0.05); but mean arterial pressure, heart rate, anxiety visual analog test, Observer's Assessment of Alertness/Sedation scale values and Kreb's scores were significantly lower in group M2 than in group M1 from T1 to T4 (all p < 0.05). In both groups, there was no fetal movement during laser coagulation. Conclusion: We propose that the appropriate dose for midazolam be 0.02 mg/kg in fetoscopic surgery for TTTS.

Introduction We aimed to investigate the incidence, prenatal factors and outcomes of twin‐to‐twin transfusion (TTTS) with right ventricular outflow tract obstruction (RVOTO). Material and methods A systematic search was conducted to identify relevant studies published until February 2023 in English using the databases PubMed, Scopus and Web of Science. Studies reporting on pregnancies with TTTS and RVOTO were included. The random‐effect model pooled the mean differences or odds ratios (OR) and the corresponding 95% confidence intervals. Heterogeneity was assessed using the I2 value. Results A total of 17 studies encompassing 4332 TTTS pregnancies, of which 225 cases had RVOTO, were included. Incidence of RVOTO at time of TTTS diagnosis was 6%. In all, 134/197 (68%) had functional pulmonary stenosis and 62/197 (32%) had functional pulmonary atresia. Of these, 27% resolved following laser and 55% persisted after birth. Of those persisting, 27% required cardiac valve procedures. Prenatal associations were TTTS stage III (53% vs 39% in no‐RVOTO), stage IV TTTS (28% in RVOTO vs 12% in no‐RVOTO) and ductus venosus reversed a‐wave (60% in RVOTO vs 19% in no‐RVOTO). Gestational age at laser and gestational age at delivery were comparable between groups. Survival outcomes were also comparable between groups, including fetal demise of 26%, neonatal death of 12% and 6‐month survival of 82% in RVOTO group. Findings were similar when subgroup analysis was done for studies including head‐to‐head analysis. Conclusions RVOT occurs in about 6% of the recipient twins with TTTS, especially in stages III and IV and those with reversed ductus venosus a‐wave. The findings from this systematic review support the need for a thorough cardiac assessment of pregnancies complicated by TTTS, both before and after laser, to maximize perinatal outcome, and the importance of early diagnosis of TTTS and timely management. Incidence of right ventricular outflow tract obstruction among TTTS pregnancies is 6% (68% had functional pulmonary stenosis and 32% had pulmonary atresia). Significant prenatal associations were TTTS stage III–IV and ductus venosus a‐wave reversal. Survival was comparable to those without outflow obstruction.

Introduction Our objective was to investigate outcomes in twin‐to‐twin transfusion syndrome (TTTS) treated with fetoscopic laser surgery (FLS) at <18 weeks vs ≥18 weeks, and to conduct subgroup analysis of TTTS with FLS at <16 weeks vs 16–18 weeks. Material and methods PubMed, Scopus and Web of Science were searched systematically from inception until May 2023. Primary outcome was survival, and secondary outcomes included preterm premature rupture of membranes (PPROM), preterm birth and gestational age (GA) at delivery. Results Nine studies encompassing 1691 TTTS pregnancies were included. TTTS stage III was significantly more common in TTTS pregnancies treated with FLS at <18 weeks (odds ratio [OR] 2.84, 95% confidence interval [CI] 1.24–6.54), and procedure duration was shorter at <18 weeks (MD −5.27 minutes, 95% CI −9.19 to −1.34). GA at delivery was significantly earlier in TTTS pregnancies treated with FLS at <18 weeks (MD −3.12 weeks, 95% CI −6.11 to −0.13). There were no significant differences in outcomes, including PPROM, PPROM at <7 days post‐FLS, preterm birth at <28 and <32 weeks, delivery at <7 days post‐FLS, and survival outcomes, including fetal demise, live birth and neonatal survival. Similarly, TTTS stage III was more common in TTTS with FLS at <16 weeks than at 16–18 weeks (OR 2.95, 95% CI 1.62–5.35), with no significant differences in the aforementioned outcomes. Conclusions In early TTTS treated with FLS, outcomes were comparable between those treated at <18 weeks compared with ≥18 weeks except for GA at delivery, which was 3 weeks earlier. In the subset treated at <16 weeks vs 16–18 weeks, the procedure was feasible without an increased risk of very early preterm birth or perinatal mortality. Although gestational age at delivery was 3 weeks earlier in twin‐to‐twin transfusion syndrome with FLS at <18 weeks, there was no difference in outcomes, including very early preterm birth, premature rupture of membranes and survival with similar findings in the subset that underwent laser surgery at <16 weeks.

Background To investigate the characteristics of right ventricular outflow tract obstruction (RVOTO) in recipient twins of twin-to-twin transfusion syndrome (TTTS), including its prevalence, perinatal outcomes, and the impact of fetoscopic laser coagulation (FLC) on postnatal RVOTO status. Methods This retrospective study included recipient twins of TTTS treated with FLC at the Asan Medical Center between January 2011 and December 2023. Among those diagnosed with RVOTO, the recipient twins were categorized into two groups based on postnatal outcomes: RVOTO improvement versus persistence. Prenatal ultrasound findings and neonatal outcomes were compared between the groups. To identify the predisposing factors for RVOTO, the entire recipient population was divided into RVOTO and non-RVOTO groups, followed by univariate and multivariable logistic regression analyses. Results Among the 284 TTTS cases, 24 recipient twins (8.5%) were diagnosed with RVOTO. RVOTO improved following FLC in 7 cases (29.2%). In the remaining 17 cases with persistent RVOTO, six were stillbirths. In the 11 survivors, five had mild RVOTO and required no intervention, while six underwent intervention (four with balloon valvuloplasty and two with surgical correction). Multivariate analysis identified the initial Quintero stage (odds ratio [OR] 2.64), pulsatile umbilical vein (OR 3.44), and tricuspid regurgitation (OR 30.66) as significant independent risk factors for RVOTO. Conclusions RVOTO is a relatively common cardiac complication in advanced TTTS. Timely FLC may lead to postnatal improvement. Serial ultrasound assessment is essential for early detection, risk stratification, and individualized counseling.

Introduction Our objective was to investigate the association between the presence of placental anastomoses and intertwin differences in renin‐angiotensin‐aldosterone activation in monochorionic twins using amniotic fluid aldosterone (AF‐ALD) levels. In addition, this study also examined the association between AF‐ALD and the ALD levels in the umbilical cord blood (UCB‐ALD) in monochorionic twins. Material and Methods This prospective study included monochorionic diamniotic (MD) twin pregnancies that were not complicated by twin‐to‐twin transfusion syndrome (TTTS) at delivery. Amniotic fluid and umbilical cord vein blood samples were collected from each twin at delivery, and the ALD levels were measured subsequently. The MD twins were divided into two groups: those with placental anastomoses and those without anastomoses owing to fetoscopic laser surgery. The differences in the AF‐ALD levels between the larger and smaller twins were analyzed. Results The AF‐ALD levels showed a strong and significant positive correlation with UCB‐ALD levels in 131 MD twins (r = 0.804, p < 0.001). Intertwin differences were examined in 41 and 28 pairs of MD twins with and without placental anastomoses, respectively. The AF‐ALD levels in the smaller twins were significantly higher than those in the larger twins among the pairs of MD twins with placental anastomoses (p = 0.003); however, no statistically significant intertwin differences were observed among the twins without placental anastomoses (p > 0.05). Conclusions The AF‐ALD levels reflect the UCB‐ALD levels in MD twins. The presence of placental anastomoses led to intertwin discordance in the ALD levels in MD twins even uncomplicated with TTTS. It was considered that monochorionic twins have this clinical background, and it leads to the development of TTTS. An association of placental anastomoses with the intertwin discordance in the amniotic fluid aldosterone levels in monochorionic twins was found. The findings provide insights into the pathophysiology of RAAS upregulation and the development of twin‐to‐twin transfusion syndrome.

Background Fetoscopic laser photocoagulation (FLP) has been performed as first-line approach for twin-to-twin transfusion syndrome (TTTS) in monochorionic twin pregnancies. The majority of researches are focusing on advances in fetal treatment and long-term outcome, few researches on maternal surgery-related complications are reported. This study is to compare the maternal blood dynamic changes in women with and without persistent compression on the uterine insertion after the FLP procedure. Methods This was a retrospective study conducted at two tertiary referral centers in China between November 2018 and July 2023. TTTS-cases undergoing FLP surgery were enrolled and divided into two groups upon whether having compression on the uterine insertion after FLP. The changes of maternal hemoglobin, hematocrit before and after the procedure were compared between the two groups. Results A total of 111 TTTS-cases were finally analyzed including 46 cases with persistent compression and 65 cases without persistent compression. The two groups had similar values of hemoglobin (10.7 ± 1.1 versus 10.5 ± 1.2 g/dl, p  = 0.513) and hematocrit (32.3 ± 3 versus 31.3 ± 3.2, p  = 0.099) before FLP. A similar volume of amniodrainage during the surgery was observed in the two groups (710 ml versus 850 ml, p  = 0.255). The decrease in hemoglobin in TTTS-cases with persistent compression was significantly lower than that in TTTS cases without continuous compression (1.1 g/dL versus 1.5 g/dL, p  = 0.014). A decrease trend in change of hematocrit was observed between cases with persistent compression (3.1%) and those without persistent compression (4.0%), while it did not achieve a significant difference ( p  = 0.050). The blood transfusion rate in TTTS-cases with and without compression was 2.2% and 7.7% respectively ( p  = 0.205). Conclusion The decrease in hemoglobin and hematocrit could be mitigated by persistent compression on the uterine insertion site after FLP, which is an economical, simple and convenient method.

Objectives: The natural history of stage 1 Twin-to-twin transfusion syndrome (TTTS) remains unclear and its optimal management is yet to be established. The main aims of this meta-analysis were to quantify the incidence of progression in stage 1 TTTS and to ascertain survival in these pregnancies. Methods: MEDLINE, EMBASE, and The Cochrane Library were searched. Reference lists within each article were hand-searched for additional reports. The outcomes included incidence of progression and survival in stage 1 TTTS. Randomized controlled trials, cohort and case-control studies were included. Case reports, studies including three or fewer cases of stage 1 TTTS, and editorials were excluded. Proportion meta-analysis was used for analysis (Registration number: CRD42016036190). Results: The search yielded 3,085 citations; 18 studies were included in the review (172 pregnancies to assess progression and 433 pregnancies to assess the survival). The pooled incidence of progression in stage 1 TTTS was 27% [95% CI 16–39%]. The pooled overall survival, double survival and at least one survival in the pregnancies managed expectantly were 79% [95% CI 62–92%], 70% [95% CI 54–84%] and 87% [95% CI 69–98%], respectively. In those undergoing amnioreduction, the corresponding figures were 77% [95% CI 68–85%], 67% [95% CI 57–76%] and 86% [95% CI 76–94%], respectively. The survival rates were 68% [95% CI 54–81%], 54% [95% CI 36–72%], and 81% [95% CI 69–90%], when laser surgery was performed. Conclusions: The optimal initial management of stage 1 TTTS remains in equipoise. The ongoing randomized trial comparing immediate laser surgery versus conservative management should provide a definitive answer.

Preterm prelabor rupture of membranes (PPROM) following fetoscopic laser photocoagulation (FLP) is a rare but potentially life-threatening complication. The occurrence of PPROM with a uterine puncture site–amniotic cavity fistula and localized fluid collection in the vesicouterine pouch has not been previously reported, and its diagnosis and management present significant clinical challenges. A 27-year-old primiparous woman with monochorionic diamniotic (MCDA) twin pregnancy was diagnosed at 17 weeks of gestation with Quintero stage I twin–twin transfusion syndrome (TTTS) complicated by type I selective fetal growth restriction (sFGR), an adherent donor twin, and velamentous cord insertion. Following multidisciplinary consultation and comprehensive counseling, she underwent FLP using the SOLOMON technique at 17 weeks and 1 day of gestation. Routine postoperative ultrasound surveillance at 19 weeks and 6 days revealed a slit-like defect in the anterior uterine wall with an adjacent fluid collection, initially raising suspicion of amniotic sac prolapse. Fetal MRI at 20 weeks confirmed PPROM with uterine puncture site–amniotic cavity fistula, localized amniotic fluid accumulation in the vesicouterine pouch, and intracranial abnormalities in both fetuses—including right lateral ventriculomegaly and, in the recipient twin, focal parenchymal atrophy and abnormal signal intensity in the right cerebral hemisphere. Serial ultrasound examinations demonstrated progressive enlargement of the uterine wall defect, increasing fluid accumulation in the vesicouterine pouch, and worsening oligohydramnios. After repeated multidisciplinary discussions and thorough counseling, the patient elected termination of pregnancy. Post-induction laparoscopic exploration confirmed a healed puncture scar on the anterior uterine wall with no overlying amniotic membrane. This case highlights a rare but serious fistulous complication after FLP for stage I TTTS with sFGR. It underscores the importance of systematic postoperative imaging surveillance and the critical role of MRI in definitive diagnosis. The report also prompts reflection on the timing of intervention in borderline-indication cases and the need for individualized counseling that includes expectant management as a potential alternative.