(146) TTTS + sFGR + TAPS: Does “triple disease” lead to worse outcomes in TTTS?

Thursday, January 30, 2025

10:30 AM – 12:30 PM

Submitting Author and Presenting Author(s)

Braxton Forde, MD

Assistant Professor
University of Cincinnati College of Medicine
Cincinnati, OH, United States

Coauthor(s)

MH

Mounira Habli, MD

Associate Professor
Cincinnati Children's Hospital Medical Center
Cincinnati, Ohio, United States
David McKinney, MD (he/him/his)

Assistant Professor
University of Cincinnati College of Medicine
Cincinnati, Ohio, United States
Kara B. Markham, MD (she/her/hers)

Associate Professor
University of Cincinnati College of Medicine
Cincinnati, Ohio, United States
MH

Mallory Hoffman, MD

Maternal Fetal Medicine Specialist
Trihealth
Cincinnati, Ohio, United States
Jose L. Peiro, MBA, MD, PhD

Program Director
Cincinnati Children's Fetal Care Center
Cincinnati, Ohio, United States
BR

Beth Rymeski, DO

Cincinnati Children's Hospital Medical Center
Cincinnati, Ohio, United States
LG

Laura Galganski, MD

Resident, Department of Surgery
Cincinnati Children's Hospital Medical Center
Cincinnati, Ohio, United States
Foong-Yen Lim, MD (he/him/his)

Surgical Director of Fetal Care Center, Professor of Pediatric Surgery
Cincinnati Children's Hospital
Cincinatti, Ohio, United States

Objective: Twin-twin transfusion syndrome (TTTS) is often diagnosed with selective fetal growth restriction (sFGR). Concomitant TTTS + sFGR is believed to worsen outcomes, but the impact of TAPS upon TTTS + sFGR, i.e. “triple disease,” is unknown. Thus we sought to evaluate these patients’ outcomes relative to the TTTS and TTTS + sFGR populations.

Study Design: IRB-approved retrospective cohort at a single institution from 2011-2024. Inclusion criteria were patients who underwent fetoscopic laser photocoagulation (FLP) for monochorionic twins and had both middle cerebral artery peak systolic velocity (MCA-PSV) and estimated fetal weight (EFW) calculated by ultrasound. Three groups were analyzed: TTTS alone, TTTS + sFGR, and TTTS + sFGR + TAPS. sFGR was defined by ≥2 of the following: EFW or abdominal circumference (AC) of one twin < 10th percentile, EFW discordance of ≥25%, or umbilical artery pulsatility index of the smaller twin >95th percentile. TAPS was defined by an MCA-PSV delta >0.5 between the twins. Preoperative, operative, and postoperative characteristics were compared, with primary outcomes being fetal survivorship and gestational age at delivery.

Results: Out of 942 patients who underwent FLP, 780 met study criteria: 392 with TTTS, 296 with TTTS + sFGR, and 92 with TTTS + sFGR + TAPS. The TTTS + sFGR + TAPS group had a later gestational age at surgery and higher rates of Stage IV disease (Table 1). Outcomes varied significantly between groups. Fetal survival (i.e. live birth) of 2 infants was 88% for TTTS, 76% for TTTS + sFGR, and 68% for TTTS + sFGR + TAPS (p < 0.001). The gestational age at delivery was latest in the TTTS + sFGR + TAPS group (mean 33.1 weeks, 95% CI 32.4-33.8) compared to TTTS alone (30.1 weeks, 95% CI 29.8-30.4, p < 0.001). This later age correlated with higher birthweights for both donors and recipients (Figure 1). Donor birthweight was lowest in the TTTS + sFGR group (Table 1).

Conclusion: TTTS + sFGR + TAPS is associated with worse survival but longer pregnancy duration compared to TTTS + sFGR and TTTS alone. This information is valuable for preoperative counseling.