Early-onset twin-twin transfusion syndrome: Case series and systematic review

Bronacha Mylrea-Foley; Caroline J Shaw; Nirupama Harikumar; Sophie Legg; Shireen Meher; Christoph C Lees

doi:10.1002/ajum.12176

Early-onset twin-twin transfusion syndrome: Case series and systematic review

Australas J Ultrasound Med. 2019 Aug 30;22(4):286-294. doi: 10.1002/ajum.12176. eCollection 2019 Nov.

Authors

Bronacha Mylrea-Foley¹, Caroline J Shaw², Nirupama Harikumar², Sophie Legg², Shireen Meher³, Christoph C Lees^{2

4}

Affiliations

¹ Queen Charlotte's and Chelsea Hospital Imperial College Healthcare NHS Trust London UK.
² Institute of Reproductive and Developmental Biology Imperial College London London W12 0HS UK.
³ Birmingham Women's and Children's NHS Foundation Trust Birmingham UK.
⁴ Department of Development & Regeneration KU Leuven Belgium.

Abstract

Introduction: Data on the outcomes of early-onset twin-twin transfusion syndrome (TTTS), diagnosed before 18 weeks gestational age (GA), are sparse. We aimed to review the diagnosis, management and outcomes of early-onset TTTS.

Material and methods: Pregnancy records at a single referral unit 2010-6 were reviewed. In early-onset TTTS cases, data for pregnancy characteristics, interventions and outcomes were collected. PubMed and Scopus databases were searched for studies including pregnant women with early-onset TTTS. The primary outcome measure was livebirths.

Results: Case series: 58 cases of early-onset TTTS 2010-6, with full outcome data in 44. Diagnostic criteria were variable. Median GA at intervention was 17⁺⁴ (range 15⁺⁰-28⁺¹); 67% of patients had laser therapy (39/58). Overall survival: 60% (53/88). At least one livebirth: 86% (38/44), Two livebirths: 34% (15/44); No survivors: 14% (6/44). GA at delivery was 32^+1.5 (range 16⁺²-37⁺⁴). Systematic review: 16 studies included (n = 171 pregnancies). Diagnostic criteria varied widely: 79% of studies used Quintero staging. Most offered laser (89%) at median 17⁺⁰ weeks (range 16⁺⁰-21⁺⁶). GA at delivery was 23⁺⁰-39⁺⁵ weeks. Overall survival: 69% (129/186). At least one livebirth: 74% (127/171). Two livebirths: 59% (55/93). No survivors: 26% (44/171).

Conclusions: In comparison with the commonly accepted overall survival for TTTS treated after 18 weeks of 60-90%, outcomes in early-onset TTTS were at the lower bound of this range. Gestational age at intervention is similar to that of later onset TTTS, indicating a lack of therapeutic options when a diagnosis is made before 18 weeks.

Keywords: diagnostic imaging criteria; fetal therapies; multiple pregnancy; pregnancy outcome; twin–twin transfusion syndrome.