Treatment of twin–twin transfusion syndrome: an evidence-based analysis
Management of twin–twin transfusion syndrome (TTTS) has encompassed a wide spectrum of options, including expectant management, medical therapy, and surgery, as well as pregnancy termination.
Over the past few years, significant emphasis has been given to the development of clinical practice guidelines that are derived from evidence-based medicine.
Levels of evidence have been classified by the US Preventive Services Task Force according to their strength (Table 11.1). The purpose of this chapter is to review the available literature on the management of TTTS with regard to the level of evidence of each management alternative.
EXPECTANT MANAGEMENT
The best article summarizing expectant management was published by Saunders et al.1 In this publication, 8 articles with a total of 106 patients managed expectantly were identified. Only 5/106 (4.7%) patients managed expectantly were associated with fetal survival. Fifteen articles with a total of 96 patients managed with serial amniocentesis were identified. Survival with serial amniocentesis was 33/96 (34%). This difference is statistically significant (p < 0.001). The authors managed an additional 21 patients.
One patient had a voluntary termination of pregnancy and another miscarried within a week of expectant management. Eight of the remaining 19 (42%) patients treated with serial amniocentesis were associated with at least one survivor. Overall, in this report, 5/107 (4.6%) managed expectantly compared unfavorably with 41/115 (35%) of patients managed with serial amniocentesis (p < 0.001). Level of evidence: III. More recently, Van Gemert has summarized the experience with expectant management for 1990–2000. Table 11.2 shows the contributing reports, with an overall survival rate of 36.9% (69/187).
Interestingly, survival rate with expectant management in this collective series was as high as that with serial amniocentesis as reported by Saunders. As can be seen, of the 11 series reported, only one used the current sonographic definition of TTTS as a maximum vertical pocket (MVP) ?8 cm in the sac of the recipient and ?2 cm in the sac of the donor twin.2 Moreover, the gestational age (GA) at treatment included patients up to 34 weeks’ gestation, which is beyond the 26-week mark typically used in analyzing outcomes of laser therapy. Therefore, historical data on expectant management cannot be used for comparison with other current approaches. Level of evidence: III.
The 26 weeks' Timepoint in analysing the efficacy of Laser Remodeling of placental angioarchitecture can be considered obsolete at this time. Several SLPCV procedures performed by Pappanna & Johnson at CMH Houston tend to support this assertion. Expectant Management of severe TTTS has consistently been a very Lossy approach indeed.
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