Monochorionic twin pregnancies have an increased risk of morbidity and mortality. Due to the advancements in screening and treatment strategies, mortality rates have decreased. Improving survival... Show moreMonochorionic twin pregnancies have an increased risk of morbidity and mortality. Due to the advancements in screening and treatment strategies, mortality rates have decreased. Improving survival rates demands a shift in scope toward long-term outcomes. In this review, we focus on neurodevelopmental outcome in survivors from complicated monochorionic twin pregnancies, including twinetwin transfusion syndrome (TTTS), twin anemia-polycythemia sequence (TAPS), acute peripartum TTTS, acute perimortem TTTS, selective fetal growth restriction (sFGR) and monoamnionicity. Our aim is to provide an overview of the current knowledge on the long-term outcome in survivors, including psychomotor development and quality of life, and provide recommendations for future research and follow-up programs. (c) 2022 Published by Elsevier Ltd. Show less
Introduction: Twin-twin transfusion syndrome (TTTS) is a complication in monochorionic twin pregnancies which is preferably treated with fetoscopic laser surgery. A few small studies suggested a... Show moreIntroduction: Twin-twin transfusion syndrome (TTTS) is a complication in monochorionic twin pregnancies which is preferably treated with fetoscopic laser surgery. A few small studies suggested a possible association between the Solomon laser technique and placental abruption. Methods: The objective of this study is to compare the rate of and to explore potential risk factors for placental abruption in TTTS treated with fetoscopic laser surgery according to the Selective and Solomon laser technique. We conducted a large retrospective cohort study of consecutive TTTS-cases treated with fetoscopic laser surgery in Shanghai, China, and Leiden, The Netherlands treated with either the Selective laser technique (Selective group) or Solomon laser technique (Solomon group). Results: The rate of placental abruption in the Selective group versus the Solomon group was 1.7% (5/289) and 3.4% (15/441), respectively (p = 0.184). No risk factors for placental abruption were identified. Placental abruption was associated with lower gestational age at birth (p = 0.003) and severe cerebral injury (p = 0.003). Conclusion: The prevalence of placental abruption in TTTS after fetoscopic laser surgery is low, although it appears higher than in the overall population. Placental abruption is associated with a lower gestational age at birth, which is associated with severe cerebral injury. The rate of placental abruption was not significantly increased with the use of the Solomon technique. Continued research of placental abruption in TTTS is necessary to determine why the rate is higher than in the overall population. Show less
With the studies described in this thesis, we were able to investigate cardiovascular compromise in complicated monochorionic twin pregnancy in great detail.All clinicians caring for monochorionic... Show moreWith the studies described in this thesis, we were able to investigate cardiovascular compromise in complicated monochorionic twin pregnancy in great detail.All clinicians caring for monochorionic twins should perform an echocardiogram at mid‑gestation and should carefully examine both neonates at birth. In case of abnormal perioperative fetal Dopplers in twin-twin transfusion syndrome (TTTS), we should be aware of the increased risk of fetal demise or neurodevelopmental impairment. In all surviving TTTS twins, but also in twin pregnancies with selective fetal growth restriction, cardiac abnormalities should be ruled out by follow-up fetal and neonatal echocardiography. Routine long‑term follow-up should be available to all TTTS twins, since TTTS may also have an impact beyond the perinatal phase.Furthermore, both color‑coded Tissue Doppler Imaging (cTDI) and myocardial performance index (MPI) are potentially valuable techniques which can be used in the risk stratification in monochorionic twins. Show less
This thesis consists of a series of studies on technical and procedural aspects of laser surgery for the treatment of twin-twin transfusion syndrome (TTTS), a causal treatment modality first... Show moreThis thesis consists of a series of studies on technical and procedural aspects of laser surgery for the treatment of twin-twin transfusion syndrome (TTTS), a causal treatment modality first described by De Lia et al. in 1990. TTTS is caused by unbalanced blood flow across placental vascular communications between both twins called anastomoses. The aim of the treatment is to close of all anastomoses in order to separate both fetal circulations. In part one, we give a general introduction to the subject and its challenges. Part two consists of studies evaluating current practice with the aim to identify potential areas of improvement. Part three deals with several techniques, the impact of laser energy and placental damage and, it introduces a model to investigate different technical parameters of the laser procedure. Finally, in part four, we discuss the development of a standardized training model for fetoscopic laser surgery. Show less
An increasing number of fetal diseases are being detected prior to birth due to major improvements in prenatal ultrasound examinations and the wide implementation of screening programs. For various... Show moreAn increasing number of fetal diseases are being detected prior to birth due to major improvements in prenatal ultrasound examinations and the wide implementation of screening programs. For various diseases, fetal therapy may be a life-saving option or an alternative to postnatal treatment, to prevent permanent organ damage. A major breakthrough in fetal therapy was the introduction of intrauterine blood transfusion for severe fetal anemia in the early 1960s. Since then, fetal therapy has gradually evolved resulting in a dramatic increase in overall survival in several fetal diseases. In the Netherlands, fetal surgical interventions are concentrated in one center, the LUMC, a tertiary medical center which serves as the national referral center for fetal therapy. Although an increasing number of children are being born alive after fetal therapy, reliable data on the long-term neurodevelopmental outcome remain scarce. Follow-up studies are of paramount importance to increase our knowledge on the quality of long-term survival and to identify potential risk factors for adverse outcome. In this thesis, studies on the long-term neurodevelopmental outcome after fetal therapy for various fetal diseases are presented including intrauterine transfusion for fetal anemia, fetoscopic laser surgery for twin-twin transfusion syndrome and selective reduction in complicated monochorionic pregnancies. Show less
Fetoscopic surgery is a surgical technique that is used to treat fetus(es) that are still inside the pregnant uterus. Coming years, more fetoscopic surgery will be performed. The most commonly... Show moreFetoscopic surgery is a surgical technique that is used to treat fetus(es) that are still inside the pregnant uterus. Coming years, more fetoscopic surgery will be performed. The most commonly performed procedure is laser surgery for twin-twin transfusion syndrome. This thesis shows learning curves for this procedure and current practice in relation to technical aspects and pregnancy outcomes. We show how to monitor performance and address specific subgroups in which laser surgery can be more complicated. Since teaching and training in fetoscopic surgery is challenging, we create and validate an evidence-based evaluation tool for the laser procedure. To conclude, we develop a standardized training curriculum with a high fidelity simulator model. Show less
