Treatment and outcome of 370 cases with spontaneous or post-laser twin anemia-polycythemia sequence managed in 17 fetal therapy centers

L S A Tollenaar, F Slaghekke, L Lewi, Y Ville, M Lanna, A Weingertner, G Ryan, S Arévalo, A Khalil, C O Brock, P Klaritsch, K Hecher, G Gardener, E Bevilacqua, K V Kostyukov, M O Bahtiyar, M D Kilby, E Tiblad, D Oepkes, E Lopriore, Collaborators, J M Middeldorp, M C Haak, F J C M Klumper, J Akkermans, H Delagrange, V Pandya, S Faiola, R Favre, S R Hobson, C Rodo, B Thilaganathan, R Papanna, P Greimel, M Tavares de Sousa, A Carlin, K A Gladkova, J A Copel, L S A Tollenaar, F Slaghekke, L Lewi, Y Ville, M Lanna, A Weingertner, G Ryan, S Arévalo, A Khalil, C O Brock, P Klaritsch, K Hecher, G Gardener, E Bevilacqua, K V Kostyukov, M O Bahtiyar, M D Kilby, E Tiblad, D Oepkes, E Lopriore, Collaborators, J M Middeldorp, M C Haak, F J C M Klumper, J Akkermans, H Delagrange, V Pandya, S Faiola, R Favre, S R Hobson, C Rodo, B Thilaganathan, R Papanna, P Greimel, M Tavares de Sousa, A Carlin, K A Gladkova, J A Copel

Abstract

Objective: To investigate the antenatal management and outcome in a large international cohort of monochorionic twin pregnancies with spontaneous or post-laser twin anemia-polycythemia sequence (TAPS).

Methods: This study analyzed data of monochorionic twin pregnancies diagnosed antenatally with spontaneous or post-laser TAPS in 17 fetal therapy centers, recorded in the TAPS Registry between 2014 and 2019. Antenatal diagnosis of TAPS was based on fetal middle cerebral artery peak systolic velocity > 1.5 multiples of the median (MoM) in the TAPS donor and < 1.0 MoM in the TAPS recipient. The following antenatal management groups were defined: expectant management, delivery within 7 days after diagnosis, intrauterine transfusion (IUT) (with or without partial exchange transfusion (PET)), laser surgery and selective feticide. Cases were assigned to the management groups based on the first treatment that was received after diagnosis of TAPS. The primary outcomes were perinatal mortality and severe neonatal morbidity. The secondary outcome was diagnosis-to-birth interval.

Results: In total, 370 monochorionic twin pregnancies were diagnosed antenatally with TAPS during the study period and included in the study. Of these, 31% (n = 113) were managed expectantly, 30% (n = 110) with laser surgery, 19% (n = 70) with IUT (± PET), 12% (n = 43) with delivery, 8% (n = 30) with selective feticide and 1% (n = 4) underwent termination of pregnancy. Perinatal mortality occurred in 17% (39/225) of pregnancies in the expectant-management group, 18% (38/215) in the laser group, 18% (25/140) in the IUT (± PET) group, 10% (9/86) in the delivery group and in 7% (2/30) of the cotwins in the selective-feticide group. The incidence of severe neonatal morbidity was 49% (41/84) in the delivery group, 46% (56/122) in the IUT (± PET) group, 31% (60/193) in the expectant-management group, 31% (57/182) in the laser-surgery group and 25% (7/28) in the selective-feticide group. Median diagnosis-to-birth interval was longest after selective feticide (10.5 (interquartile range (IQR), 4.2-14.9) weeks), followed by laser surgery (9.7 (IQR, 6.6-12.7) weeks), expectant management (7.8 (IQR, 3.8-14.4) weeks), IUT (± PET) (4.0 (IQR, 2.0-6.9) weeks) and delivery (0.3 (IQR, 0.0-0.5) weeks). Treatment choice for TAPS varied greatly within and between the 17 fetal therapy centers.

Conclusions: Antenatal treatment for TAPS differs considerably amongst fetal therapy centers. Perinatal mortality and morbidity were high in all management groups. Prolongation of pregnancy was best achieved by expectant management, treatment by laser surgery or selective feticide. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Keywords: TAPS; expectant management; intrauterine transfusion; laser surgery; monochorionic twins; selective feticide; treatment; twin anemia-polycythemia sequence.

© 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

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