Post-Laser Twin Anemia Polycythemia Sequence: Diagnosis, Management, and Outcome in an International Cohort of 164 Cases

Lisanne S A Tollenaar, Enrico Lopriore, Stefano Faiola, Mariano Lanna, Julien Stirnemann, Yves Ville, Liesbeth Lewi, Roland Devlieger, Anne Sophie Weingertner, Romain Favre, Sebastian R Hobson, Greg Ryan, Carlota Rodo, Silvia Arévalo, Philipp Klaritsch, Patrick Greimel, Kurt Hecher, Manuela Tavares de Sousa, Asma Khalil, Basky Thilaganathan, Eric P Bergh, Ramesha Papanna, Glenn J Gardener, Andrew Carlin, Elisa Bevilacqua, Victorya A Sakalo, Kirill V Kostyukov, Mert O Bahtiyar, Abigail Wilpers, Mark D Kilby, Eleonor Tiblad, Dick Oepkes, Johanna M Middeldorp, Monique C Haak, Frans J C M Klumper, Joost Akkermans, Femke Slaghekke, Lisanne S A Tollenaar, Enrico Lopriore, Stefano Faiola, Mariano Lanna, Julien Stirnemann, Yves Ville, Liesbeth Lewi, Roland Devlieger, Anne Sophie Weingertner, Romain Favre, Sebastian R Hobson, Greg Ryan, Carlota Rodo, Silvia Arévalo, Philipp Klaritsch, Patrick Greimel, Kurt Hecher, Manuela Tavares de Sousa, Asma Khalil, Basky Thilaganathan, Eric P Bergh, Ramesha Papanna, Glenn J Gardener, Andrew Carlin, Elisa Bevilacqua, Victorya A Sakalo, Kirill V Kostyukov, Mert O Bahtiyar, Abigail Wilpers, Mark D Kilby, Eleonor Tiblad, Dick Oepkes, Johanna M Middeldorp, Monique C Haak, Frans J C M Klumper, Joost Akkermans, Femke Slaghekke

Abstract

The aim of this study was to investigate the management and outcome in the post-laser twin anemia polycythemia sequence (TAPS). Data of the international TAPS Registry, collected between 2014 and 2019, were used for this study. The primary outcomes were perinatal mortality and severe neonatal morbidity. Secondary outcomes included a risk factor analysis for perinatal mortality and severe neonatal morbidity. A total of 164 post-laser TAPS pregnancies were included, of which 92% (151/164) were diagnosed antenatally and 8% (13/164) postnatally. The median number of days between laser for TTTS and detection of TAPS was 14 (IQR: 7-28, range: 1-119). Antenatal management included expectant management in 43% (62/151), intrauterine transfusion with or without partial exchange transfusion in 29% (44/151), repeated laser surgery in 15% (24/151), selective feticide in 7% (11/151), delivery in 6% (9/151), and termination of pregnancy in 1% (1/151). The median gestational age (GA) at birth was 31.7 weeks (IQR: 28.6-33.7; range: 19.0-41.3). The perinatal mortality rate was 25% (83/327) for the total group, 37% (61/164) for donors, and 14% (22/163) for recipients (p < 0.001). Severe neonatal morbidity was detected in 40% (105/263) of the cohort and was similar for donors (43%; 51/118) and recipients (37%; 54/145), p = 0.568. Independent risk factors for spontaneous perinatal mortality were antenatal TAPS Stage 4 (OR = 3.4, 95%CI 1.4-26.0, p = 0.015), TAPS donor status (OR = 4.2, 95%CI 2.1-8.3, p < 0.001), and GA at birth (OR = 0.8, 95%CI 0.7-0.9, p = 0.001). Severe neonatal morbidity was significantly associated with GA at birth (OR = 1.5, 95%CI 1.3-1.7, p < 0.001). In conclusion, post-laser TAPS most often occurs within one month after laser for TTTS, but may develop up to 17 weeks after initial surgery. Management is mostly expectant, but varies greatly, highlighting the lack of consensus on the optimal treatment and heterogeneity of the condition. Perinatal outcome is poor, particularly due to the high rate of perinatal mortality in donor twins.

Keywords: TAPS; TTTS; fetal demise; laser surgery; management; monochorionic twins; neonatal morbidity; perinatal mortality; twin anemia polycythemia sequence; twin-twin transfusion syndrome.

Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Weeks between fetoscopic laser surgery for twin-twin transfusion syndrome and diagnosis of post-laser twin anemia polycythemia sequence.

References

    1. Lopriore E., Middeldorp J.M., Oepkes D., Kanhai H.H., Walter F.J., Vandenbussche F.P. Twin anemia-polycythemia sequence in two monochorionic twin pairs without oligo-polyhydramnios sequence. Placenta. 2007;28:47–51. doi: 10.1016/j.placenta.2006.01.010.
    1. Slaghekke F., Lopriore E., Lewi L., Middeldorp J.M., van Zwet E.W., Weingertner A.S., Klumper F.J., Dekoninck P., Devlieger R., Kilby M.D., et al. Fetoscopic laser coagulation of the vascular equator versus selective coagulation for twin-to-twin transfusion syndrome: An open-label randomised controlled trial. Lancet. 2014;383:2144–2151. doi: 10.1016/S0140-6736(13)62419-8.
    1. Lewi L., Jani J., Blickstein I., Huber A., Gucciardo L., Van Mieghem T., Done E., Boes A.S., Hecher K., Gratacos E., et al. The outcome of monochorionic diamniotic twin gestations in the era of invasive fetal therapy: A prospective cohort study. Am. J. Obstet. Gynecol. 2008;199:514. doi: 10.1016/j.ajog.2008.03.050.
    1. Lewi L., Jani J., Cannie M., Robyr R., Ville Y., Hecker K., Gratacos E., Vandecruys H., Vandecaveye V., Dymarkowski S., et al. Intertwin anastomoses in monochorionic placentas after fetoscopic laser coagulation for twin-to-twin transfusion syndrome: Is there more than meets the eye? Am. J. Obstet. Gynecol. 2006;194:790–795. doi: 10.1016/j.ajog.2005.08.062.
    1. Knijnenburg P.J.C., Slaghekke F., Tollenaar L.S.A., van Klink J.M., Zhao D.P., Middeldorp J.M., Haak M.C., Klumper F.J., Oepkes D., Lopriore E. Incidence of and Risk Factors for Residual Anastomoses in Twin-Twin Transfusion Syndrome Treated with Laser Surgery: A 15-Year Single-Center Experience. Fetal. Diagn. Ther. 2019;45:13–20. doi: 10.1159/000485932.
    1. Slaghekke F., Lewi L., Middeldorp J.M., Weingertner A.S., Klumper F.J., Dekoninck P., Devlieger R., Lanna M.M., Deprest J., Favre R., et al. Residual anastomoses in twin-twin transfusion syndrome after laser: The Solomon randomized trial. Am. J. Obstet. Gynecol. 2014;211:285 e1–285 e7. doi: 10.1016/j.ajog.2014.05.012.
    1. Tollenaar L.S., Slaghekke F., Middeldorp J.M., Klumper F.J., Haak M.C., Oepkes D., Lopriore E. Twin Anemia Polycythemia Sequence: Current Views on Pathogenesis, Diagnostic Criteria, Perinatal Management, and Outcome. Twin Res. Hum. Genet. 2016;19:222–233. doi: 10.1017/thg.2016.18.
    1. Tollenaar L.S.A., Slaghekke F., Lewi L., Colmant C., Lanna M.M., Weingertner A.S., Ryan G., Arevalo S., Tavares de Sousa M. Spontaneous Twin Anemia Polycythemia Sequence: Management and Outcome in a Large International Cohort of 249 Cases. Submitted.
    1. Slaghekke F., Pasman S., Veujoz M., Middeldorp J.M., Lewi L., Devlieger R., Favra R., Lopriore E., Oepkes D. Middle cerebral artery peak systolic velocity to predict fetal hemoglobin levels in twin anemia-polycythemia sequence. Ultrasound Obstet. Gynecol. 2015;46:432–436. doi: 10.1002/uog.14925.
    1. Lopriore E., Slaghekke F., Oepkes D., Middeldorp J.M., Vandenbussche F.P., Walther F.J. Hematological characteristics in neonates with twin anemia-polycythemia sequence (TAPS) Prenat. Diagn. 2010;30:251–255.
    1. Lopriore E., Slaghekke F., Middeldorp J.M., Klumper F.J., Van Lith J.M., Walther F.J., Oepkes D. Accurate and simple evaluation of vascular anastomoses in monochorionic placentas using colored dye. J. Vis. Exp. 2011;55:e3208. doi: 10.3791/3208.
    1. Trieu N.T., Weingertner A.S., Guerra F., Dautun D., Kohler M., Vayssiere C., Nisand I., Favre R. Evaluation of the measurement of the middle cerebral artery peak systolic velocity before and after placental laser coagulation in twin-to-twin transfusion syndrome. Prenat. Diagn. 2012;32:127–130. doi: 10.1002/pd.2907.
    1. Slaghekke F., Kist W.J., Oepkes D., Pasman S.A., Middeldorp J.M., Klumper F.J., Walther F.J., Vandenbussche F.P., Lopriore E. Twin anemia-polycythemia sequence: Diagnostic criteria, classification, perinatal management and outcome. Fetal Diagn. Ther. 2010;27:181–190. doi: 10.1159/000304512.
    1. Bell M.J., Ternberg J.L., Feigin R.D., Keating J.P., Marshall R., Barton L., Brotherton T., Neonatal necrotizing enterocolitis Therapeutic decisions based upon clinical staging. Ann. Surg. 1978;187:1–7. doi: 10.1097/00000658-197801000-00001.
    1. An international classification of retinopathy of prematurity The Committee for the Classification of Retinopathy of Prematurity. Arch. Ophthalmol. 1984;74:127–133.
    1. Volpe J.J. Intraventricular hemorrhage and brain injury in the premature infant. Diagn. Progn. Prev. Clin. Perinatol. 1989;16:387–411. doi: 10.1016/S0095-5108(18)30638-9.
    1. Levene M.I. Measurement of the growth of the lateral ventricles in preterm infants with real-time ultrasound. Arch. Dis. Child. 1981;56:900–904. doi: 10.1136/adc.56.12.900.
    1. De Vries L.S., Eken P., Dubowitz L.M. The spectrum of leukomalacia using cranial ultrasound. Behav. Brain Res. 1992;49:1–6. doi: 10.1016/S0166-4328(05)80189-5.
    1. Hoftiezer L., Hof M.H.P., Dijs-Elsinga J., Hogeveen M., Hukkelhoven C., van Lingen R.A. From population reference to national standard: New and improved birthweight charts. Am. J. Obstet. Gynecol. 2019;220:383. doi: 10.1016/j.ajog.2018.12.023.
    1. Lopriore E., Hecher K., Vandenbussche F.P., van den Wijngaard J.P., Klumper F.J., Oepkes D. Fetoscopic laser treatment of twin-to-twin transfusion syndrome followed by severe twin anemia-polycythemia sequence with spontaneous resolution. Am. J. Obstet. Gynecol. 2008;198:e4–e7. doi: 10.1016/j.ajog.2007.08.073.
    1. Khalil A., Rodgers M., Baschat A., Bhide A., Gratacos E., Hecher K., Kilby M.D., Lewi L., Nicolaides K.H., Oepkes D., et al. ISUOG Practice Guidelines: Role of ultrasound in twin pregnancy. Ultrasound Obstet. Gynecol. 2016;47:247–263.
    1. Slaghekke F., van Klink J.M., Koopman H.M., Middeldorp J.M., Oepkes D., Lopriore E. Neurodevelopmental outcome in twin anemia-polycythemia sequence after laser surgery for twin-twin transfusion syndrome. Ultrasound Obstet. Gynecol. 2014;44:316–321. doi: 10.1002/uog.13387.
    1. Senat M.V., Deprest J., Boulvain M., Paupe A., Winer N., Ville Y. Endoscopic laser surgery versus serial amnioreduction for severe twin-to-twin transfusion syndrome. N. Engl. J Med. 2004;351:136–144. doi: 10.1056/NEJMoa032597.
    1. De, Villiers S.F., Slaghekke F., Middeldorp J.M., Walther F.J., Oepkes D., Lopriore E. Placental characteristics in monochorionic twins with spontaneous versus post-laser twin anemia-polycythemia sequence. Placenta. 2013;34:456–459. doi: 10.1016/j.placenta.2013.02.005.
    1. Lopriore E., Oepkes D., van den Wijngaard J.P., van Gemert M.J., Middeldorp J.M., Vandenbussche F.P. Twin anemia-polycythemia sequence (TAPS) without a cause. Prenat. Diagn. 2008;28:559–560. doi: 10.1002/pd.2011.
    1. Tollenaar L.S.A., Slaghekke F., Lewi L., Ville Y., Lanna M., Weingertner A., Ryan G., Arevalo S., Khalil A., Brock C.O., et al. Treatment and outcome in 370 cases with spontaneous or post-laser twin anemia polycythemia sequence managed in 17 different fetal therapy centers. Ultrasound Obstet. Gynecol. 2020 doi: 10.1002/uog.22042.

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