The Pediatric Surgeons’ Approach To In-Utero Treatment Of Feto-Fetal Transfusion Syndrome
*Francois I Luks, *Stephen R Carr, *Christopher S Muratore, *Barbara M O'Brien, Thomas F Tracy, Jr.
Alpert Medical School, Brown University, Providence, RI
OBJECTIVE(S): Feto-fetal transfusion syndrome (FFTS) is a condition of identical twins that, if progressive and left untreated, leads to 100% mortality. The best treatment option is obliteration of the intertwin placental anastomoses, but fetal surgery carries significant maternal and fetal risks. Even if successful, percutaneous endoscopic laser ablation of these placental vessels (LASER) causes premature rupture of membranes (PROM) in 10-20% of pregnancies. Patient selection is particularly critical because the progression of the disease is unpredictable. This has prompted many to intervene early, yielding survival rates of ≥1 twin of 75-80%.
METHODS: We developed a minimally invasive approach to fetal surgery, a unique membrane sealing technique and a conservative algorithm that reserves intervention for severe FFTS. Pregnancies with FFTS (stages I-IV) managed in the last 8 years were reviewed. LASER was offered in stage III/IV only.
RESULTS: From 2000 to 2008, 88 cases of FFTS were managed in a pediatric surgeons-driven Fetal Treatment Program -- 36 were observed and 52 underwent LASER. Stage distribution, % surgical interventions and survival rates are compared with two large perinatology series (table). PROM rate was 4%.
CONCLUSIONS: Reserving LASER treatment for severe FFTS results in outcomes similar to, or better than, LASER for all stages. Applying fetal surgery-specific endoscopic techniques, including port-site sealing, reduce postoperative complications.
|Current Series||Senat 2004||Middeldorp 2007||P*|
|Stage III+IV (%)||52.3||48.6||48.0||0.72|
|≥1 survivor - all stages (%)||80.7||76.4||81.0||0.61|