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Background Monochorionic twin pregnancies complicated by severe twin-to-twin transfusion syndrome at midgestation can be treated by either serial amnioreduction (removal of large volumes of amniotic fluid) or selective fetoscopic laser coagulation of the communicating vessels on the chorionic plate. We conducted a randomized trial to compare the efficacy and safety of these two treatments.
Methods Pregnant women with severe twin-to-twin transfusion syndrome before 26 weeks of gestation were randomly assigned to laser therapy or amnioreduction. We assessed perinatal survival of at least one twin (a prespecified primary outcome), survival of at least one twin at six months of age, and survival without neurologic complications at six months of age on the basis of the number of pregnancies or the number of fetuses or infants, as appropriate.
Results The study was concluded early, after 72 women had been assigned to the laser group and 70 to the amnioreduction group, because a planned interim analysis demonstrated a significant benefit in the laser group. As compared with the amnioreduction group, the laser group had a higher likelihood of the survival of at least one twin to 28 days of age (76 percent vs. 56 percent; relative risk of the death of both fetuses, 0.63; 95 percent confidence interval, 0.25 to 0.93; P=0.009) and 6 months of age (P=0.002). Infants in the laser group also had a lower incidence of cystic periventricular leukomalacia (6 percent vs. 14 percent, P=0.02) and were more likely to be free of neurologic complications at six months of age (52 percent vs. 31 percent, P=0.003).
Conclusions Endoscopic laser coagulation of anastomoses is a more effective first-line treatment than serial amnioreduction for severe twin-to-twin transfusion syndrome diagnosed before 26 weeks of gestation.
Source Information
From the Department of Obstetrics and Gynecology, Université Paris–Ouest Versailles–St. Quentin, Centre Hospitalier Intercommunale Poissy–St. Germain, Poissy, France (M.-V.S., A.P., Y.V.); the Department of Obstetrics and Gynecology, Katholieke Universiteit Leuven, University Hospital Gasthuisberg, Leuven, Belgium (J.D.); the Department of Obstetrics and Gynecology, University of Geneva, Geneva University Hospitals, Geneva (M.B.); and the Department of Obstetrics and Gynecology, Central Hospitalier Universitaire de Nantes, Nantes, France (N.W.).
Address reprint requests to Dr. Ville at the Service de Gynécologie Obstétrique, Université Versailles St. Quentin, CHI Poissy, Rue du Champ Gaillard, 78300 Poissy, France, or at yville{at}wanadoo.fr.
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