Impact of laser coagulation in severe twin-twin transfusion syndrome on fetal Doppler indices and venous blood flow volume.
OBJECTIVE
To evaluate the impact of fetoscopic laser coagulation of placental anastomoses in severe twin-twin transfusion syndrome on fetal Doppler indices and umbilical vein blood flow volume as calculated with Doppler and two-dimensional ultrasound.


METHODS
Thirty-two cases of second-trimester severe twin-twin transfusion undergoing laser therapy were examined with serial ultrasound before and 1, 3 and 5 days after therapy. Pulsatility indices in the umbilical artery and ductus venosus were measured. Blood volume flow at the level of the intra-abdominal umbilical vein was calculated by means of Doppler and two-dimensional ultrasound. The development of hydropic signs in donors was recorded. Perinatal outcome in terms of neonatal survival was recorded for all cases.


RESULTS
In recipients, ductus venosus pulsatility index decreased progressively after therapy and, by day 5, median pulsatility index was significantly lower than that before therapy (0.97 vs. 0.82, P < 0.0001). Umbilical vein blood flow volume in recipient twins showed no significant variations before and after laser. In donors, umbilical artery pulsatility index decreased significantly by the first day following therapy (2.1 vs. 1.6, P < 0.0001). Previously absent or reverse umbilical end-diastolic flow reappeared after therapy in 46% (7/15) of donors. Ductus venosus pulsatility index in donors increased significantly by day 1 after therapy (0.99 vs. 1.35, P < 0.0001) but, over days 3 and 5, it returned towards preoperative values. Umbilical vein flow volume measurements (mL/min/kg) in the donor increased by approximately 50% the day after treatment (151 vs. 232, P < 0.0001) and remained elevated. Umbilical vein flow volume before laser therapy was significantly lower in donors compared to recipients (151 vs. 260, P < 0.0001), but the difference was non-significant after treatment (240 vs. 267). One or more hydropic signs developed in eight (25%) donors during the 5 days' observation after therapy.


CONCLUSIONS
Laser therapy induced important changes in fetal hemodynamic parameters, resulting in a reversion of the disturbances associated with severe twin-twin transfusion syndrome. The recipient twin showed a progressive improvement of previous signs of right cardiac overload. The donor experienced a substantial increase in umbilical vein blood volume flow accompanied by a transitory state of relative right overload, which may explain the development of transient hydropic signs in a proportion of donors.
Gratacós
E
E
Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Spain. egratacos@meditex.es
Van Schoubroeck
D
D
Carreras
E
E
Devlieger
R
R
Roma
E
E
Cabero
L
L
Deprest
J
J
D005260:Female; D005330:Fetofetal Transfusion / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D005332:Fetoscopy; D006439:Hemodynamics; D006801:Humans; D017075:Laser Coagulation; D010920:Placenta / Q000098:blood supply; D011247:Pregnancy; D011256:Pregnancy Outcome; D011673:Pulsatile Flow; D012039:Regional Blood Flow; D013577:Syndrome; D018608:Ultrasonography, Doppler; D016216:Ultrasonography, Prenatal; D014469:Umbilical Arteries / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D014471:Umbilical Veins / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*