Outcome of TRAP Sequence Treated in the First Trimester – A Ten-Year Single-Center Experience

Abstract

Purpose To evaluate the outcome of first trimester intervention by intrafetal laser (IFL) in pregnancies complicated by twin reversed arterial perfusion (TRAP).

Materials and Methods For a 10-year study period, all patients with TRAP diagnosed < 14.0 weeks of gestation were retrospectively analyzed for intrauterine course and outcome. Monoamniotic pregnancies were excluded. Patients were offered either intervention by IFL in the first trimester, expectant management, or termination of pregnancy (TOP). Adverse outcome was defined as either intrauterine death (IUD), neonatal death, or preterm birth.

Results In 45 cases TRAP was diagnosed. 17 monoamniotics were excluded. The cohort was divided into two groups according to management. Group A: 24 cases underwent IFL and group B: 4 cases were managed expectantly. No patient opted for TOP. In group A, 70.8 % of pump twins were born alive, including one preterm delivery, and 29.2 % died within four days after the intervention. All 4 expectantly managed cases in group B had an adverse outcome (1 preterm delivery, 3 IUDs < 15.0 weeks). There were no neonatal deaths. In cases treated by IFL, a comparison of survivors and non-survivors identified no significant differences in gestational age at IFL or any of the assessed biometrical and functional parameters. There was a trend towards better outcome in the second half of the study period.

Conclusion IFL in first trimester TRAP sequence is technically feasible but is associated with significant mortality, albeit less than previously reported. No risk stratification is possible using the investigated parameters. However, there seems to be a learning curve.

Zusammenfassung

Ziel Evaluation des Outcomes von Schwangerschaften mit Twin Reverse Arterial Perfusion (TRAP) nach intrafetaler Laserung (IFL) im 1. Trimester.

Material und Methode Innerhalb einer 10-jährigen Studienperiode wurden alle TRAP-Sequenzen, diagnostiziert vor 14 + 0 SSW, hinsichtlich des intrauterinen Verlaufs und Outcomes retrospektiv evaluiert. Monoamniote Schwangerschaften wurden ausgeschlossen. Primäre Endpunkte waren intrauteriner Fruchttod (IUD), perinatale Mortalität und SSW bei Geburt.

Ergebnisse 45 TRAP-Sequenzen wurden diagnostiziert. 17 Monoamniote wurden ausgeschlossen. Die übrigen 28 Fälle wurden je nach Vorgehen in 2 Gruppen eingeteilt. Gruppe A: 24 Fälle mit IFL im 1. Trimester und Gruppe B: 4 Fälle mit exspektativem Management. Es erfolgte kein Schwangerschaftsabbruch (TOP). In Gruppe A wurden 70,8 % der Zwillinge lebend geboren (eine Frühgeburt), 29,2 % starben innerhalb von 4 Tagen nach Intervention. In Gruppe B hatten alle ein ungünstiges Outcome (1 Frühgeburt, 3 spontane IUD < 15 + 0 SSW). Es gab keine neonatalen Todesfälle. Ein Vergleich Überlebender und Verstorbener bezüglich SSW bei Intervention sowie biometrischer und funktioneller Parameter ergab keine signifikanten Unterschiede. Lediglich die Analyse des Überlebens in Gruppe A, stratifiziert nach dem Jahr der Intervention, ergab einen Trend Richtung eines besseren Outcomes in der zweiten Hälfte des Studienzeitraums.

Schlussfolgerungen IFL bei TRAP-Sequenz im 1. Trimester ist sinnvoll, aber mit einer signifikanten Mortalität behaftet, wenn auch geringer als vorbeschrieben. Eine Risikostratifikation anhand der untersuchten Parameter ist nicht möglich. Allerdings scheint es eine Lernkurve zu geben.

Key words

TRAP sequence - intrafetal laser - monochorionic pregnancy - first trimester - twin reversed arterial perfusion

Publication History

Received: 06 February 2021

Accepted: 06 June 2021

Article published online:
29 June 2021

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