Intrafetal laser treatment for twin reversed arterial perfusion sequence: cohort study and meta-analysis.
Pagani G., D'Antonio F., Khalil A., Papageorghiou A., Bhide A., Thilaganathan B.
OBJECTIVES: To ascertain the outcome of twin reversed arterial perfusion (TRAP) sequence cases managed in our unit and to review systematically cases reported in the literature treated with intrafetal laser therapy. METHODS: This was a retrospective cohort study of all TRAP sequence cases identified from 2000 to 2012 at our center. Pregnancy management and outcomes were ascertained from maternal and neonatal records. We also performed a meta-analysis of the literature on the use of intrafetal laser therapy for the treatment of TRAP. Adverse pregnancy outcome was defined as a composite of intrauterine death (IUD) and preterm birth before 37 weeks' gestation. RESULTS: Twenty-three cases of TRAP were identified during the study period. Six were managed conservatively and 17 were treated with laser therapy. All cases managed conservatively were complicated by IUD at a median gestational age of 14 + 4 (interquartile range (IQR), 12 + 4 to 16 + 5) weeks. Among the treated cases, 14 (82%) delivered a healthy twin at a median gestational age of 37 + 1 (IQR, 34 + 0 to 38 + 3) weeks. Ten studies were reviewed in detail and the data were combined with those from the current study. The overall neonatal survival was 80%. Adverse pregnancy outcome was significantly lower when the treatment was performed before 16 weeks' gestation (19 vs 66%, P = 0.0025). CONCLUSION: The study data demonstrate a high risk of spontaneous fetal demise in early pregnancy, lack of accurate prognostic markers and improved pregnancy outcome after laser therapy in cases of TRAP. In these cases we recommend elective treatment with intrafetal laser therapy at between 13 and 16 weeks' gestation.