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Intervention Review

Interventions for the treatment of twin-twin transfusion syndrome

  1. Devender Roberts1,*,
  2. James P Neilson2,
  3. Mark Kilby3,
  4. Simon Gates4

Editorial Group: Cochrane Pregnancy and Childbirth Group

Published Online: 23 JAN 2008

Assessed as up-to-date: 30 JAN 2008

DOI: 10.1002/14651858.CD002073.pub2


How to Cite

Roberts D, Neilson JP, Kilby M, Gates S. Interventions for the treatment of twin-twin transfusion syndrome. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD002073. DOI: 10.1002/14651858.CD002073.pub2.

Author Information

  1. 1

    Liverpool Women's NHS Foundation Trust, Obstetrics Directorate, Liverpool, Merseyside, UK

  2. 2

    The University of Liverpool, School of Reproductive and Developmental Medicine, Division of Perinatal and Reproductive Medicine, Liverpool, UK

  3. 3

    Birmingham Women's Hospital, University of Birmingham, Birmingham, UK

  4. 4

    University of Warwick, Warwick Clinical Trials Unit, Coventry, UK

*Devender Roberts, Obstetrics Directorate, Liverpool Women's NHS Foundation Trust, Crown Street, Liverpool, Merseyside, L8 7SS, UK. devender.roberts@lwh.nhs.uk .

Publication History

  1. Publication Status: New search for studies and content updated (no change to conclusions)
  2. Published Online: 23 JAN 2008

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This is not the most recent version of the article. View current version (30 JAN 2014)

 

Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Background

Twin-twin transfusion syndrome, a condition affecting monochorionic twin pregnancies, is associated with a high risk of perinatal mortality and morbidity. A number of treatments have been introduced to treat the condition but it is unclear which intervention improves maternal and fetal outcome.

Objectives

The objective of this review was to evaluate the impact of treatment modalities in twin-twin transfusion syndrome.

Search methods

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2008) and the Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 4). We also searched conference proceedings and made personal contact with experts active in the area of the review.

Selection criteria

Randomised and quasi-randomised studies of amnioreduction versus laser coagulation, septostomy versus laser coagulation or septostomy versus amnioreduction.

Data collection and analysis

One review author assessed eligibility and extracted data, which were checked by a second author. We contacted study authors for additional information.

Main results

Two studies (213 women) were included. This review shows that laser coagulation of anastomotic vessels results in less death of both infants per pregnancy (relative risk (RR) 0.49; 95% confidence interval (CI) 0.30 to 0.79, one trial), less perinatal death (RR 0.59; 95% CI 0.0.40 to 0.87 adjusted for cluster, one trial) and less neonatal death (RR 0.29; 95% CI 0.14 to 0.61 adjusted for cluster, one trial) than in pregnancies treated with amnioreduction. There is no difference in perinatal outcome between amnioreduction and septostomy. A third study is awaiting assessment.

More babies were alive without neurological abnormality at the age of six months in the laser group than the amnioreduction groups (RR 1.66; 95% CI 1.17 to 2.35 adjusted for clustering, one trial). This difference did not persist beyond six months of age. There was no significant difference in the babies alive at six months with neurological abnormality treated by laser coagulation or amnioreduction (RR 0.58; 95% CI 0.18 to 1.86 adjusted for clustering, one trial).

Authors' conclusions

Endoscopic laser coagulation of anastomotic vessels should be considered in the treatment of all stages of twin-twin transfusion syndrome to improve perinatal outcome. Further research on the effect of treatment on milder forms of twin-twin transfusion syndrome (Quintero stage 1 and 2) are required. The long-term outcomes of survivors from the studies included in this review are required.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Interventions for the treatment of twin-twin transfusion syndrome

Limited evidence suggests the best way to save babies with twin-to-twin transfusion syndrome is to perform laser treatment to the placenta.

Identical twins occur in about one in 320 pregnancies. Sometimes identical twins share the same placenta and blood flow, and the proportion of blood shared between the twins is usually equal. Twin-to-twin transfusion syndrome happens when the blood flow is uneven and passes from one twin (the donor) to the other (the recipient). This can happen when the placenta has deep artery-to-vein connections. The donor twin usually has very little amniotic fluid, and frequently does not grow well and is very small. The recipient twin has excessive amniotic fluid, and often has a distended bladder and other medical problems. The risk of death for both twins is high, around 80% if there is no treatment. There is also risk of physical or neurological damage to both twins if they survive. Various options for treatment exist. These include (1) the repeated removal of excessive amniotic fluid (amnioreduction); (2) laser treatment of the abnormal vessels in the placenta (endoscopic laser surgery); (3) puncture of the membrane between the twins (septostomy); and (4) the selective ending of one twin's life (selective feticide). The review found two trials, involving 213 women and 430 babies. There were no studies on laser treatment versus puncturing the membrane, nor on selective feticide. The evidence showed that laser treatment was associated with fewer babies dying when compared to removing the excess amniotic fluid. However, where there is insufficient expertise to perform laser surgery, amnioreduction is then the treatment of choice. None of the studies assessed morbidity for the mother. Further research is needed on mild forms of the problem.

 

摘要

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

背景

雙胞胎輸血症候群的介入治療

雙胞胎輸血症候群(twintwin transfusion syndrome),一種發生在單一絨毛膜雙胞胎妊娠的疾病,與造成高風險的周產期罹病率和死亡率有關。許多的治療方法已經用來治療這個疾病但現階段並不清楚何種介入治療可以改善母親與胎兒的預後

目標

本篇文章的宗旨是評估各式治療方式對雙胞胎輸血症候群的影響

搜尋策略

我們搜尋在the Cochrane Pregnancy and Childbirth Group's Trials Register(2008年1月)及the Cochrane Central Register of Controlled Trials(考科藍資料庫2007,期號4)。我們也搜尋相關的研討會紀錄及私下聯繫參與著作本篇文章並專精於這方面的專家

選擇標準

與羊水減量術(amnioreduction)雷射燒灼術(laser coagulation)的比較,羊膜中膈造口術(septostomy)雷射燒灼術的比較或羊膜中膈造口術(septostomy)羊水減量術的比較有關的隨機化和似隨機化的研究

資料收集與分析

請當中的一位作者評估合適和摘錄的資料,之後再由另一位作者審核。我們與研究的作者取得聯繫並取得額外的資訊

主要結論

兩篇研究(213位女性)被包含進來。本文發現針對吻合血管的雷射燒灼術與羊水減量術的比較上在每一個孕婦當中將導致較低的胎兒死亡(RR值 0.49;95% 的信賴區間 0.30對上 0,79,單一試驗)周產期死亡(RR值 0.59;95% 的信賴區間 0.40對上 0.87 校正群體, 單一試驗)以及較低的新生兒死亡(RR值 0.29;95% 的信賴區間 0.14對上0.61校正群體,單一試驗)。在羊水減量術與羊膜中膈造口術的周產期預後的比較上,兩者並無差異。有一篇研究正期待評估。在雷射治療組與羊水減量組的比較上,有較多的活產的嬰兒在六個月時無神經學方面的異常(RR值 .66;95% 的信賴區間 1.17對上2.35校正群體,單一試驗)。這項差異在比較六個月後的嬰兒就不存在了。在產生六月個內的神經異常的嬰兒方面,在雷射燒灼術與羊水減量術之間並無顯著的差異(RR值 0.58;95% 的信賴區間 0.18對上1.86校正群體,單一試驗)

作者結論

內視鏡吻合血管雷射燒灼術(Endoscopic laser coagulation of anastomotic vessels)應被考慮使用在治療各分期的雙胞胎輸血症候群來改善周產期的預後。更進一步關於治療較輕微的雙胞胎輸血症候群(Quintero分期1和2)療效的研究是必須的。在被包含進研究中的生存者的長期預後的評估也是必須的

翻譯人

本摘要由周產期醫學會(Taiwan Society of Perinatology)林孝祖翻譯

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌

總結

有限的證據建議最佳方法去拯救雙胞胎輸血症候群的嬰兒即是針對胎盤施行雷射治療。同卵雙胞胎大約發生ㄧ例在320個懷孕當中。有時同卵雙胞胎共同使用同ㄧ個胎盤和血流,而分配在兩個胎兒之間的血液也通常是平均的。雙胞胎輸血症候群發生在當血流分配不均,從一個胎兒(供應血流者)到另一個胎兒(血流接受者)。這可能發生在當胎盤有深層動脈到靜脈(arterytovein)的聯結。在血液提供者的胎兒通常羊水很少,而且多半生長的不好而很小。在血液接受者的胎兒有過多的羊水,而且通常有一個膨脹的膀胱和其他的內科問題。對雙胞胎中的兩個胎兒的死亡危險性是高的,如不治療的話有80% 。假如胎兒存活下來的話也會有身體或神經方面傷害的危險。多樣治療選擇存在。其中包含了(1)反覆的移除過多的羊水(羊水減量術)(2)針對胎盤上異常血管的雷射治療(內視鏡雷射手術)(3)在雙胞胎之間的羊膜上穿刺(羊膜中膈造口術)(4)選擇性的終止其中ㄧ個胎兒的性命(選擇性減胎)(selective feticide)。這篇文章找出兩個試驗,包含了213位女性與430個胎兒。當中沒有關於雷射治療和羊膜中膈造口的比較,也沒有關於雷射治療和選擇性減胎的比較。證據指出雷射治療當與羊膜減量術的比較時造成較少胎兒的死亡。然而,並沒有足夠的專業技術去施行雷射手術,羊膜減量術還是治療的選擇。沒有研究去評估母親的罹病率。在此疾病中的輕症還需要進ㄧ步的研究