OP-10 Selective fetal reduction with intrafetal laser in twin-twin transfusion syndrome

Objective

Twin-twin transfusion syndrome (TTTS) is a condition that complicates 10-15% of monochorionic twin pregnancies. Fetoscopic laser photocoagulation section in the 28th week after preterm premature rupture of membranes (PPROM). Cord coagulation was performed in the second case at the 19th week, and she was delivered at 34 weeks with a weight of 2350 g due to preterm labor. Case 3 underwent radiofrequency ablation at 16 weeks, and was delivered by cesarean section at 36 weeks due to preterm labor. Intrafetal laser was applied to the fourth case in the 15th week. She was delivered in the 28th week by cesarean section due to PPROM, weighing 1110 grams. The last case resulted in neonatal death. (FLP) is an established treatment. Selective fetal reduction (SFR) is one of the treatment options for TTTS. SFR can be performed by various methods. Intrafetal laser is a medical procedure that uses lasers to treat certain conditions in fetuses while they are still in the womb. TTTS is used to treat conditions such as selective intrauterine growth restriction (sFGR), twins with reverse arterial perfusion (TRAP) and fetal tumours. Here we report a rare case of intrafetal laser for SFR in a late-gestation MCDA twin pregnancy complicated by TTTS. 

Case

A 26-year-old woman was referred to our clinic with a G2P1Y1, MCDA twin pregnancy at 20 weeks and 5 days. The first-trimester ultrasound was unremarkable. We diagnosed Quintero stage 4 by ultrasound. The following day, the patient underwent fetoscopic laser photocoagulation under general anaesthesia. The procedure was surgically successful and no intra- or post-operative complications were observed. Worsening hydrops in the recipient fetus and Doppler flow abnormalities in the ductus venosus were noted at 3 weeks after the procedure. The selective fetal reduction was offered to the recipient fetus. SFR was performed by intrafetal laser at 24 weeks gestation. Pregnancy is currently ongoing. At 34 weeks, the fetus currently has FGR. However, pregnancy followup will continue as Doppler flow is good.

Discussion

TTTS is a serious complication of monochorionic twin pregnancies. SFR is a treatment option for TTTS, especially in late stages or with a poor prognosis. SFR can be performed using several techniques, including umbilical cord occlusion, radiofrequency ablation, bipolar coagulation and intrafetal laser therapy. Intrafetal laser therapy is an innovative approach that uses ultrasound guidance to deliver laser energy to the body or organs of a specific twin fetus. This treatment modality has been shown to treat a variety of conditions including TTTS, Selective Fetal Growth Restriction (sFGR), Twin Reverse Arterial Perfusion Sequence (TRAP) and fetal tumours. It is well known that intrafetal laser is usually performed between 12-18 weeks of gestation. In this case, we have shown that intrafetal laser can be performed at 24 weeks of gestation. 

Conclusion

We performed selective fetal reduction with intrafetal laser at 24 weeks gestational age. We did not observe any complications. This case may be encouraging for the use of intrafetal laser in later weeks. However, as it is a single case, more cases are needed to see the real effect and to evaluate possible adverse outcomes.

Keywords

Monochorionic twin, fetoscopic laser, ttts

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