AMNIOTIC LASER

PHOTOCAGGULATION
Dichorion-Diamnion
Monochorion-Diamnion
Monochorion-Monoamnion
Twin to Twin Transfusion Syndrome
 Twin-Twin Transfusion Syndrome
(TTTS)
•Laser therapy for TTTS has been the most commonly used example of
fetoscopic surgery
•With this procedure, laser energy ablates pathological vascular
anastomoses within a monochorionic twin placenta
•Even with such therapy, evaluation and management of TTTS remains
challenging.
•For example, the relationship between placental angioarchitecture
and pregnancy outcome is not fully understood, and neurological
complications and preterm birth remain common.
•Treatment is even less likely to be successful in pregnancy after 26
weeks.
•Fetal cardiovascular compromise plays a significant role in perinatal
outcome.
 TTTS is typically staged
• Stage I–discordant amnionic fluid volumes as
described above, but urine still visible
sonographically within the donor twin's bladder
• Stage II–criteria of stage I, but urine is not visible
within the donor's bladder
• Stage III–criteria of stage II and abnormal Doppler
studies of the umbilical artery, ductus venosus, or
umbilical vein
• Stage IV–ascites or frank hydrops in either twin;
and
• Stage V–demise of either fetus.
 Sonographic findings as being
suggestive of this diagnosis of TTTS

(1) monochorionicity
(2) same-sex gender
(3) hydramnios defined if the largest vertical pocket is > 8 cm
in one twin and oligohydramnios defined if the largest
vertical pocket is < 2 cm in the other twin
(3) umbilical cord size discrepancy
(4) cardiac dysfunction in the recipient twin with hydramnios
(5) abnormal umbilical vessel or ductus venosus Doppler
velocimetry, and
(6) significant growth discordance.
Twin Reversed Arterial Perfusion
Sequence
Serial amnioreductions
Amnioseptostomy
Laser Photocoagulation
 Several therapies are currently used
for TTTS
• Amnioreduction
• Laser ablation of vascular anastomoses,
• Selective feticide, and
• Septostomy (intentional creation of a
communication in the dividing amnionic
membrane)
 Laser vs Amnioreduction
• In a randomized trial of 142 women with severe TTTS diagnosed
before 26 weeks, Senat and colleagues (2004) reported increased
survival of at least one twin to age 6 months with laser ablation of
vascular anastomoses compared with serial amnioreduction–76
versus 51 percent, respectively
• Moreover, analyses of randomized studies by Roberts and
colleagues (2008) and Rossi and D'Addario (2008) showed better
neonatal outcomes with laser therapy compared with selective
amnioreduction.
• In contrast, Crombleholme and colleagues (2007), in a randomized
trial of 42 women, found equivalent rates of 30-day survival of one
or both twins treated with either amnioreduction or selective
fetoscopic laser ablation–75 versus 65 percent, respectively.
 Amnioreduction vs Septostomy
• Moise and colleagues (2005) compared
amnioreduction and septostomy in a
multicentered randomized trial of 73 women.
Repeated procedures were performed for
symptoms or if the greatest vertical pocket of
amnionic fluid met the original inclusion criteria
of > 8 to 12 cm, depending on gestational age.
Perinatal outcomes were the same in each group,
with at least one survivor in 80 percent of
pregnancies. The average number of additional
procedures was two in each group.
 Selective reduction
• Selective reduction has generally been considered if severe
amnionic fluid and growth disturbances develop before 20 weeks.
In such cases, both fetuses typically will die without intervention.
Selection of which twin is to be terminated is based on evidence of
damage to either fetus and comparison of their prognoses. Any
substance injected into one twin may affect the other twin because
of shared circulations.
• Therefore, feticidal techniques may include injection of an occlusive
substance into the selected twin's umbilical vein or radiofrequency
ablation, fetoscopic ligation, laser coagulation, monopolar
coagulation, or bipolar cautery of one umbilical cord (Challis, 1999;
Donner, 1997; Weiner, 1987; Wittmann, 1986, and all their
colleagues). Even after these procedures, however, the risks to the
remaining fetus are still appreciable (Rossi and D'Addario, 2009).
Selective fetal reduction
Selective fetal reduction