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OBJECTIVES: We aimed to perform a systematic review and network meta-analysis to evaluate the preventive strategies for preterm birth in twin-to-twin transfusion syndrome. METHODS: PubMed, Embase and Cochrane Central were searched from inception to December 2023 with no filters. Additionally, the reference lists of the included studies were manually examined to identify any supplementary studies. We selected randomized controlled trials and cohorts comparing interventions to prevent preterm birth in twin pregnancies complicated by twin-to-twin transfusion syndrome. A random-effects frequentist network meta-analysis was performed using RStudio version 4.3.1. Randomized controlled trials and cohorts were assessed respectively using the Risk of Bias in Non-randomized Studies of interventions tool and Cochrane Collaboration's tool for assessing risk of bias in randomized trials. RESULTS: In this systematic review and meta-analysis, we included eight studies comprising a total of 719 patients. Compared with expectant management, cerclage stood out as the only intervention associated with an increase in the survival of at least one twin (risk ratio 1.12; 95 % confidence interval 1.01-1.23). Our subgroup analysis based on different thresholds for short cervix demonstrated a significant reduction in the risk of preterm birth before 32 weeks with ultrasound-indicated cerclage using a 15 mm criterion (risk ratio 0.65; 95 % confidence interval 0.47-0.92). CONCLUSIONS: Our study suggests the potential benefit of cerclage as a preventive strategy for preterm birth in pregnancies complicated by twin-to-twin transfusion syndrome. These findings highlight the necessity for further investigation to corroborate our results and address the optimal threshold for ultrasound-indicated cerclage.

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INTRODUCTION: A proportion of monochorionic diamniotic (MCDA) twin pregnancies complicated by twin-to-twin transfusion syndrome (TTTS) can present after 26 weeks of gestation. The aim of this study was to compare perinatal outcomes of late TTTS treated by fetoscopic laser coagulation versus traditional management with amniodrainage and/or emergency preterm cesarean delivery (CD). METHODS: Retrospective cohort from January 2012 to January 2023 of consecutive MCDA twin pregnancies complicated by TTTS after 26 weeks and evaluated in our referring centers. We analyzed perinatal outcomes of cases treated with fetoscopic laser surgery at our national referral fetal surgery center in Queretaro, Mexico, and compared them with those managed with traditional management (amniodrainage and/or emergency preterm CD). The primary outcome was survival at discharge and the secondary outcome was gestational age (GA) at birth. RESULTS: Among the study population, 46 TTTS cases were treated by fetoscopy at 27+6 (26+0-31+0) weeks+days and were compared with a group of 39 cases who underwent emergency preterm CD. In comparison to the group who underwent traditional management, the group treated by laser fetoscopy showed a significantly higher GA at birth (32+3 vs. 29+1 weeks+days, p < 0.001), lower frequency of preterm delivery below 37 weeks (91.3% vs. 100%, p = 0.06), 34 weeks (63.0% vs. 100%, p < 0.001), 32 weeks (50% vs. 74.4%, p = 0.02), or 30 weeks (28.3% vs. 53.8%, p = 0.01), and significantly higher perinatal survival (89.1% vs. 71.8%, p < 0.05 of at least one twin; and 65.2% vs. 38.5%, p = 0.01 of both twins, respectively). CONCLUSION: MCDA twins complicated with TTTS can be treated with fetoscopic laser surgery between 26 and 31 weeks of gestation, which is a feasible and safe option, and such cases are associated with a higher GA at birth and better perinatal survival than those managed with amniodrainage and/or emergency preterm CD.

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El síndrome de transfusión feto-fetal (STFF) es una complicación propia de los embarazos gemelares monocoriales, con mortalidad perinatal del 80 a 100%. Ocurre por un desequilibrio en el flujo sanguíneo placentario entre ambos gemelos. El diagnóstico se basa en la discordancia del líquido amniótico y luego se clasifica en estadios según los criterios de Quintero. El tratamiento principal es la fetoscopia y fotoablación con energía láser (FFL) de las anastomosis placentarias. Presentamos un caso de gestación gemelar monocorial biamniótica tratado con FFL en plena cuarentena e inmovilización de la pandemia COVID-19 en Perú, que incluyó diagnóstico oportuno y referencia rápida para recibir el tratamiento especializado.

The twin-to-twin transfusion syndrome (TTTS) is a potentially lethal complication that can occur in monochorionic twin pregnancies due to an imbalance in placental blood flow. Diagnosis is based on amniotic fluid discordance and classified using the Quintero staging system. The primary treatment is fetoscopic laser photocoagulation (FLP) of placental anastomoses. A successful case of FLP treatment in a monochorionic diamniotic twin pregnancy with TTTS during COVID-19 pandemic in Peru is presented.

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INTRODUCTION: Identification of intertwin anastomosis may be challenging during fetoscopy in cases with complete anterior placenta. The aim of this study was to describe the technique, feasibility, and outcomes of flexible video fetoscopy for laser coagulation in monochorionic (MC) twin pregnancies with twin-to-twin transfusion syndrome (TTTS) presenting with inaccessible anterior placenta. METHODS: From April 2021 to March 2022, a prospective cohort of consecutive MC twin pregnancies complicated with TTTS presenting with anterior placenta after 20 weeks was recruited. Cases with inaccessible anterior placenta during standard technique were converted into flexible video fetoscopy for completion of laser coagulation of placental anastomoses using a 270° flexible video endoscope through the same uterine port. Descriptive analysis includes feasibility, remaining anastomoses requiring laser photocoagulation, and perinatal outcomes. RESULTS: A total of 45 pregnancies with TTTS were treated with fetoscopic laser therapy during the 1-year study period. Twenty-one pregnancies presented with anterior placenta after 20 weeks, in which an inaccessible vascular equator was observed in 33.3% (7/21). Flexible video fetoscopy was successfully performed in all 7 cases at a median gestational age of 22+2 (20+0-27+1) weeks+days. Visualization of the entire placental surface, coagulation of selected vessels, and exploration of the entire vascular equator were achieved in all cases. Six cases (85.7%) required additional laser coagulation due to either vascular patency despite initial coagulation with conventional fetoscopy (1/6, 16.7%) and/or remaining noncoagulated anastomoses (5/6, 83.3%). Perinatal survival of at least one twin and both twins was achieved in 85.7% and 57.1%, respectively. DISCUSSION: Flexible video fetoscopy for completion of laser coagulation of placental anastomoses is feasible and represents a good option for TTTS cases presenting after 20 weeks with inaccessible anterior placenta.

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OBJECTIVE: To investigate the neurodevelopmental outcome at age 2 and 5 years in survivors of twin-twin transfusion syndrome (TTTS) treated with fetoscopic laser surgery and born premature and/or small for gestational age. STUDY DESIGN: At 2 and 5 years of age, standardized neurologic, motor, and cognitive assessments were performed by a neonatologist, a pediatric physical therapist, and a psychologist. Behavior was assessed using a validated questionnaire completed by parents. RESULTS: Neurodevelopmental assessment at both time points was available for 73 survivors of TTTS. Mild to moderate neurodevelopmental impairment (NDI) was detected in 34% of survivors (25 of 73) at 5 years, compared with 25% (18 of 73) at 2 years (P = .178). Severe NDI was observed in 12% (9 of 73) at 5 years and in 3% (2 of 73) at 2 years (P = .035). Mean cognitive score was lower at the 5-year follow-up (90.7 ± 12.3 vs 95.6 ± 13.1 at 2 years; P = .001), and more children were diagnosed with mild cognitive impairment at 5 years (29% vs 11% at 2 years; P = .007). When comparing individual outcomes at both time points, 35% (25 of 71) moved from a normal outcome or mild to moderate impairment at 2 years toward more severe impairment at 5 years. CONCLUSIONS: A high rate of mild to moderate cognitive impairment and severe NDI at age 5 years was not identified at age 2 years. Our data highlight the importance of longitudinal follow-up of survivors of TTTS beyond age 2 years and emphasize the precautions that should be taken when diagnosing an absence of impairment before school age.

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Introduction: The monochorionic biamniotic twin pregnancy (MCBA) corresponds to approximately 15% of all twin pregnancies and an estimate of 10-15% develop complications proper of these types of pregnancies, such as selective intrauterine fetal growth restriction (IUGRs) and feto-fetal transfusion syndrome (FFTS). Laser fetal surgery allows treatment of these hemodynamic alterations of MCBA by fulguration of placental anastomoses, and it is currently considered the first-choice therapy for FFTS and some IUGR cases. Objectives: To highlight the general aspects of laser fetal surgery and to describe current evidence of its efficacy and safety in FFTS and IUGRs. Methods: Review of articles published during the last five years in indexed journals from the following databases: PUBMED, MEDLINE, EMBASE and Cochrane Library. Review papers, original papers, and systemic reviews were included. Classic relevant papers on fetal surgery history were also included. Results: By means of this nonsystematic review of the literature, 43 articles were considered for the present paper. Conclusion: This review evidences that laser fetal surgery improves the prognosis of FFTS fetuses. The use of this therapy in IUGRs cases has not improved survival.

Introducción. El embarazo gemelar monocorial biamniótico (MCBA) corresponde aproximadamente al 15% de los embarazos gemelares y, de estos, se estima que 10 a 15% desarrollan complicaciones propias de este tipo de embarazos, como la restricción selectiva del crecimiento intrauterino (RCIUS) y el síndrome de transfusión feto (STFF). La cirugía fetal láser permite tratar la causa de estas alteraciones hemodinámicas propias de los embarazos MCBA a través de la coagulación de las anastomosis placentarias, y es considerada actualmente la terapia de elección en el STFF y aplicable en algunos casos de RCIUS. Objetivos. Resaltar los aspectos generales de la cirugía fetal láser y describir la evidencia actual de la eficacia y seguridad de su uso en el STFF y la RCIUS. Metodología. Se realizó una búsqueda de la literatura de artículos publicados en revistas indexadas en las siguientes bases de datos: PUBMED, MEDLINE, EMBASE, Cochrane Library. Se incluyeron revisiones de tema, investigaciones originales y revisiones sistemáticas de la literatura, publicadas en los últimos 5 años. Además, se incluyen artículos clásicos relevantes en la historia de la cirugía fetal. Resultados. Producto de la revisión no sistemática de la literatura, se incluyeron 43 para la construcción de la presente revisión. Conclusiones. La presente revisión evidencia que la cirugía láser fetal mejora el pronóstico de los fetos con STFF. El uso de dicha terapia para los casos de restricción de crecimiento intrauterino selectivo no ha mejorado la sobrevida.

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OBJECTIVE: To evaluate the initial maternal and perinatal outcomes of fetoscopic laser photocoagulation for the treatment of twin-to-twin transfusion syndrome (TTTS) in a referral center in Brazil. METHODS: This prospective observational study analyzed 24 fetoscopic laser photocoagulation procedures at 18-26 weeks of gestation. TTTS severity was determined using the Quintero classification. Blood vessels that crossed the interamniotic membrane were nonselectively photocoagulated. The χ2 test and Mann-Whitney U test were used for the statistical analysis. RESULTS: The mean (±standard deviation) age of pregnant women, gestational age at surgery, surgical time, gestational age at birth, and newborn weight were 32.2±4.1 years, 20.7±2.9 weeks, 51.8±16.7 minutes, 30.5±4.1 weeks, and 1,531.0±773.1 g, respectively. Using the Quintero classification, there was a higher percentage of cases in stage III (54.2%), followed by stages IV (20.8%), II (16.7%), and I (8.3%). Ten (41.7%) donor fetuses died and 14 (58.3%) donor fetuses survived until the end of gestation. Placental insertion location (anterior vs. posterior) did not affect the incidence of iatrogenic septostomy, surface bleeding, and premature rupture of membranes until the end of gestation. The death rate of donor and recipient fetuses before 24th gestational week increased with severity of TTTS. CONCLUSION: The maternal and perinatal outcomes resulting from the implementation of a new minimally invasive surgical technique are in line with those obtained in major centers worldwide, considering the learning curves and infrastructures.

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Twin-to-twin transfusion syndrome (TTTS) complicates 10% of monochorionic twin pregnancies and it is consequence of an unbalanced exchange blood through the vascular anastomoses at placental surface. If not treated, mortality rates in TTTS may be as high as 80-100%. Laser photocoagulation of the placental anastomoses is the first treatment option; however, in some situations, the damage of the placenta in the postpartum may become difficult the residual anastomoses identification. We propose a new non-invasive technique to assess the residual anastomoses using computed tomography (CT) scan data to generate a three-dimensional (3D) virtual placentoscopy.

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Twin-to-twin transfusion syndrome (TTTS) is thought to result from an unbalanced exchange of blood through inter-twin vascular anastomoses. Laser photocoagulation of communicating vessels has been used to prevent the development of the syndrome. Some authors have proposed that vessels crossing the membrane are "suspicious" to participate in the development of the syndrome and the laser photocoagulation of these vessels would reverse the syndrome. We present two cases of TTTS where the communicating vessels did not cross the dividing membrane, which were successfully treated with laser.

El síndrome de transfusión intergemelar (STIG) resulta de un intercambio desbalanceado de sangre a través de anastomosis vasculares entre las circulaciones de ambos fetos en embarazos monocoriales. La fotocoagulación láser de vasos comunicantes se ha utilizado para detener el desarrollo del síndrome. Algunos autores han propuesto que los vasos que cruzan la membrana divisoria son 'sospechosos' de participar en el desarrollo del síndrome y que la fotocoagulación láser de estos es capaz de revertirlo. Presentamos dos casos de STIG tratados exitosamente con fotocoagulación láser de anastomosis intergemelares, en los cuales los vasos comunicantes no cruzaban la membrana divisoria.

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Resumen OBJETIVO: evaluar las características placentarias de pacientes con embarazos múltiples monocoriales relacionados con el resultado obstétrico en nuestro medio. MATERIAL Y MÉTODO: estudio observacional, descriptivo, prospectivo efectuado en dos instituciones de tercer nivel de atención de Bogotá, Colombia, entre el 31 julio de 2009 y el 31 de agosto de 2011. Evaluación de pacientes con embarazos monocoriales, complicaciones, tratamientos y resultados perinatales; análisis placentarios relacionados con el número y tipo de anastomosis, forma y distancia entre las inserciones de los cordones umbilicales y distribución placentaria. RESULTADOS: se incluyeron 72 embarazos monocoriales: 93.1% correspondieron a embarazos dobles y 86.1% a biamnióticos. De las placentas analizadas, 91.6% tuvieron al menos una anastomosis, específicamente arterioarterial (70.8% de los casos). Se encontraron complicaciones propias de los embarazos monocoriales (41.6%), principalmente: restricción de crecimiento intrauterino selectivo (16 casos) y trasfusión feto-fetal (11 pares de gemelos). Se registró un caso de trasfusión arterial reversa y una muerte fetal (10.7%) provocada por síndrome de transfusión feto-fetal. Entre las causas de morbilidad neonatal se encontraron: taquipnea transitoria del recién nacido y enfermedad de membrana hialina. La mortalidad neonatal fue de 5.4%. No hubo casos de mortalidad materna. CONCLUSIÓN: las características placentarias determinan las complicaciones propias del embarazo monocorial, principalmente: síndrome de trasfusión feto-fetal, restricción de crecimiento intrauterino selectivo. La detección ecográfica prenatal de estas alteraciones es importante para ofrecer consejería y vigilancia gestacional programada.

Abstract OBJECTIVE: To evaluate placental characteristics in monochorionic multiple pregnancies in relation to obstetric outcome in our environment. MATERIAL AND METHOD: Prospective and observational study was made; carried to 31 July 2009 and 31 August 2011 in two high complexity institutions in Bogota, Colombia. We included monochorionic pregnancies for diagnosis of complications, management and perinatal outcome, placental analyzes were evaluated with respect to the number and type of anastomosis, type and distance between umbilical cord insertions and placental sharing. RESULTS: We registrered 72 monochorionic pregnancies, twin pregnancies were 93.1% and 86.1% diamniotic. Placentas analyzed 91.6% had at least one placental anastomosis, arterio-arterial mainly in 70.8% of patients. Complications of monochorionic pregnancies in 41.6% of cases mainly selective growth restriction in 16 cases, followed by twin to twin transfusion in 11 pairs of twins were found. A case of blood transfusion reverse was presented; and a fetal mortality of 10.7% remains the leading cause twin to twin transfusion syndrome. Among the causes of neonatal morbidity transient tachypnea of the newborn, followed by hyaline membrane disease were found. The neonatal mortality rate was 5.4%. There were no maternal deaths. CONCLUSION: Placental characteristics determine the complications of monochorionic pregnancy, as the presence of twin to twin transfusion syndrome selective growth restriction and perinatal outcome. Prenatal sonographic identification of these features is important for prenatal counseling and the frequency of gestational surveillance.

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El síndrome de transfusión feto fetal es una complicación grave de las gestaciones gemelares monocoriales. Su etiología se debe a la transfusión crónica de sangre del feto donante, al feto receptor; a través de las anastomosis vasculares entre los territorios placentarios de ambos. El cuadro clínico característico se evidencia en ambos fetos: receptor y donante, lo cual es consecuencia directa de las alteraciones en la volemia que padece cada uno. En el feto receptor, se observa un polihidramnios relacionado con la poliuria derivada de un estado de hipervolemia constante, que evoluciona hacia una insuficiencia cardiaca congestiva. En el feto donante, el cuadro es inverso; caracterizado por oligoamnios, oliguria, crecimiento intrauterino retardado e hipovolemia, con tasas de mortalidad sin tratamiento de entre 80-100 por ciento de los casos, que varían en función del grado de transfusión. El diagnóstico se basa en el estudio ecográfico exhaustivo de ambos fetos, procurando un diagnóstico precoz y un estadiaje correcto, ya que el pronóstico se verá muy influenciado por la actuación temprana. El tratamiento de elección es la coagulación láser de las anastomosis vasculares por fetoscopia, idealmente entre la semana 18 y 26 de embarazo. El pronóstico es variable, en función de la disponibilidad de terapia fetal y de la edad gestacional en el momento del diagnóstico; al ser, en general, de muy mal pronóstico sin tratamiento efectivo(AU)

Twin-twin transfusion syndrome is one of the most serious complications of monochorionic multiple gestations. Its etiology is due to a chronic blood transfusion from de donor twin to the recipient twin through the vascular anastomoses between the placental territories of both fetuses. The characteristic clinical presentation appears in both donor and recipient fetuses, as a direct consequence of altered volemia in each one. Polyhydramnios related to polyuria resulting from a state of constant hypervolemia is observed in the recipient twin, finally evolving into congestive heart failure. The clinical presentation in the donor twin is reversed and characterized by oligoamnios, oliguria, retarded intrauterine growth and hypovolemia, with untreated mortality rates ranging 80-100 percent of all cases, which may vary depending on the severity of the transfusion. The diagnosis is based on exhaustive echographic examination of both fetuses to make an early diagnosis and correct staging, since the prognosis depends very much on early action. The treatment of choice is fetoscopic laser coagulation of vascular anastomoses between 18 and 26 weeks of gestation. The prognosis is variable, depending on the availability of fetal therapy and the gestational age at diagnosis, being prognosis generally very poor without an effective treatment(AU)

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Abstract Mirror syndrome is a rare disease with unknown pathophysiology that can be present in different diseases that can cause fetal hydrops. The prognosis is usually bad with a high perinatal mortality. We report an unusual form of mirror syndrome that manifested itself only after a successful treatment for fetal hydrops (caused by twin-twin transfusion syndrome, in Quinteros stage IV) was performed. This syndrome was controlled by medical treatment, and despite the usually bad prognosis seen in these cases, we could extend the pregnancy from the 23rd to the 34th week of gestation, resulting in the birth of 2 live infants.

Resumo A síndrome do espelho é uma doença rara, de fisiopatologia desconhecida, que se manifesta em situações obstétricas responsáveis pela presença de hidrópsia fetal. Habitualmente o prognóstico é reservado, uma vez que se associa a elevadas taxas de mortalidade perinatal. O presente caso clínico trata de uma situação de síndrome do espelho que se manifestou, atipicamente, após o tratamento eficaz para a hidrópsia fetal associada à síndrome de transfusão feto-fetal. Apesar do mau prognóstico associado a estas situações, conseguiu-se controlar a situação apenas com tratamento médico e, desta forma, prolongar a gravidez durante 12 semanas.

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INTRODUCCIÓN: Entre 15-20% de los embarazos gemelares monocoriales biamnióticos se complican con el síndrome de transfusión feto/fetal el cual se asocia con mortalidad superior a 90% y morbilidad significativa en el 50% del gemelo sobreviviente. La técnica láser que coagula la superficie de la placa coriónica entre los principales canales a lo largo del ecuador (técnica de Solomon), se ha sugerido para disminuir la recurrencia, prevenir complicaciones secundarias sin incrementar resultados adversos. Métodos: REVISIÓN de la literatura existente en las bases de datos MEDLINE, EBSCO, OVID, PROQUEST, COCHRANE, Lilacs, SciELO, desde el año 2000 al 2015. Se incluyeron los artículos de revisión e investigaciones originales que compararon la técnica estándar de fotocoagulación secuencial con láser y la técnica de Solomon, el resultado primario fue la reducción de la incidencia Secuencia Anemia Policitemia, recurrencia del síndrome de transfusión feto/fetal, mortalidad perinatal y morbilidad neonatal severa. RESULTADOS: Se encontraron 200 artículos, se seleccionaron seis: 1 ensayo clínico y su análisis secundario, 2 estudios de cohorte retrospectivos, 1 revisión sistemática y un estudio que compara los resultados del neurodesarrollo. Los estudios sugieren una mejoría en la sobrevida de algunos de los fetos con la técnica Solomon, menor recurrencia del síndrome de transfusión feto/fetal y Secuencia Anemia Policitemia, sin la presencia de eventos adversos. CONCLUSIÓN: La técnica de Solomon mejora la sobrevida de algunos gemelos, sin embargo no puede concluirse que haya mejoría en la mortalidad pues los estudios no tienen el suficiente poder para determinarlo.

INTRODUCTION: Between 15 to 20% of monochorionic diamniotic twin pregnancies are complicated by the twin-twin transfusion syndrome. It has a mortality greater than 90% and a significant morbidity, 50% in the surviving twin. The Solomon technique (laser photocoagulation of the main vascular channels of the chorio-nic plate surface along the entire vascular equator) has been suggested to reduce the recurrence, and pre-vent secondary complications without increasing adverse results. METHODS: Systematic review of electronic searches of the literature from 2000 to 2015 (MEDLINE, EBSCO, OVID, PROQUEST, COCHRANE, Lilacs, and SciELO). We included review articles and original investigations comparing the standard photocoagulation technique with laser ablation against the Solomon technique. The primary results were reduction of Anemia Polycythemia Sequence incidence, twin-twin transfusion syndrome recurrence, perinatal mortality and severe neonatal morbidity. RESULTS: Of 200 articles, we selected six: one clinical essay and its secondary analysis, two retrospective cohort studies, one systematic review and a study comparing neurodeve-lopmental outcomes. The studies suggested a survival improvement in some fetuses using the Solomon technique, less twin-twin transfusion syndrome recurrence and Anemia Polycythemia Sequence without the presence of adverse effects. CONCLUSION: Solomon technique improves the survival of some twins, although we cannot conclude there is mortality improvement, because the studies do not have enough power to determine that.

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La fetoscopia por síndrome de transfusión feto fetal es la cirugía fetal más realizada en el mundo. Los resultados deben ser reportados, para que las pacientes puedan elegir su opción de atención. Objetivo: Determinar los resultados de cirugía fetal en el síndrome de transfusión feto-fetal. Diseño: Estudio retrospectivo. Lugar: Clínica Alemana, Santiago, Chile. Participantes: Gestantes con gemelares. Intervenciones: La cirugía fetal se realizó con anestesia local, endoscopios Storz de 3,3 mm, específicos para fetoscopia. Principales medidas de resultados: Sobrevida fetal. Resultados: La serie de casos se inició en el año 2005, y hasta la fecha se han realizado 71 cirugías, con 69 que han resuelto su embarazo. Treinta y tres mujeres tuvieron ambos hijos vivos (48%), 25 solo un hijo vivo (36%) y 11 concluyeron sin hijos vivos (16%). Conclusiones: La tasa de embarazos con uno o ambos niños vivos fue 84%, superando 90% en los últimos 30 casos. Hubo 6 pacientes de Perú, de las cuales cuatro tuvieron ambos hijos vivos.

Fetoscopy for fetal-fetal transfusion syndrome is the most frequent fetal surgery performed in the world. The results should be reported, so that the patients can choose their choice of care. Objective: To determine the results of fetal surgery on twin-to-twin transfusion syndrome. Design: Retrospective study. Setting: Clínica Alemana, Santiago, Chile. Participants: Pregnant women with twins. Interventions: Fetal surgery was performed under local anesthesia, with 3.3mm fetoscopy-specific Storz endoscopes. Main outcome measures: Fetal survival. Results: The series of cases began in the year 2005, and to date 71 surgeries were carried out, with 69 that resolved their pregnancy. Thirty-three women had both living children (48%), 25 only one living child (36%) and 11 concluded without living children (16%). Conclusions: The rate of pregnancies with one or both children born alive was 84%, exceeding 90% in the last 30 cases. There were 6 patients from Peru, of which four had two living children.

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Feto-fetal transfusion syndrome is a pathological process unique to diamniotic monochorionic pregnancies. It is the consequence of an unbalanced fetal blood flow through communicating vessels within a shared placenta. When it occurs, a polyuric, hypervolemic recipient twin co-exists with a hypovolemic oliguric donor. The presence of polyhydramnios or oligohydramnios is considered a poor prognostic indicator, whereas normal amniotic fluid volumes indicate a lack of clinically significant twintwin transfusion. In addition, the spontaneous normalization of amniotic fluid volume is usually seen as a favorable prognostic sign. Here, however, we present a case of feto-fetal transfusion in a 31 year-old primigravida at 19 week, in which the spontaneous normalization of amniotic fluid volume in the recipient twin preceded the death of the donor.

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BACKGROUND: Twin-to-twin transfusion syndrome (TTTS) is a serious complication of monochorionic twin gestation, which has a high risk of perinatal morbidity and mortality. Fetoscopic laser photocoagulation of the vascular anastomoses is the preferred treatment. Nowadays, Solomon technique which consists the vascular coagulation of all anastomoses in the placental equator is the preferable method. OBJECTIVE: To develop a method of virtual fetoscopy by means of ultrasound and resonance magnetic imaging (MRI) scan data to allow the identification of placental equator. RESULTS: MRI was performed in a twin monochorionic twin pregnancy with 28 weeks previously treated for TTTS with fetoscopic laser photocoagulation. A three-dimensional (3D) file of the placenta was created from overlapping image layers generated by MRI using Mimics software. Virtual fetoscopy allowed adequate visualization of fetuses, umbilical cord insertion and placental equator. CONCLUSION: Virtual fetoscopy is a non-invasive technique which allowed adequate identification of placental equator, and it may be an important learning method to novice fetal endoscopic surgeons in TTTS cases.

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Objetivos: Revisar el síndrome de transfusión feto fetal (STFF) en relación al diagnóstico, tratamiento y resultados comparativos de sobrevivencia y complicaciones por las técnicas utilizadas, y la situación actual del manejo de esta complicación en el Perú. Métodos: Se revisó publicaciones en fuentes bibliográficas especializadas y se analizó la experiencia en Perú y Chile sobre el manejo del síndrome. Resultados: El STFF es una complicación poco frecuente en el embarazo gemelar monocoriónico, pero con alta repercusión en la salud de ambos fetos. Existe evidencia científica clara de que el tratamiento de elección en casos severos (Quintero I-IV) es la coagulación láser de las anastomosis superficiales y profundas mediante fetoscopia entre las 18 y 26 semanas de gestación. En el Perú se presentan alrededor de 140 casos al año, siendo necesaria la implementación de esta técnica. Conclusiones: El tratamiento de elección en casos severos de STFF es la coagulación láser de las anastomosis superficiales y profundas mediante fetoscopia entre las 18 y 26 semanas de gestación. Es necesaria la implementación de esta técnica en el Perú.

Objectives: To review twin-twin transfusion syndrome (mS) comparative results by techniques used in regards to diagnosis, treatment, survival and complications, as well as current management of this complication in Peru. Methods: Articles published in specialized bibliographic sources were revised, and experience in Peru and Chile on management of this syndrome was analyzed. Results: ms is an uncommon complication of monochorionic twin pregnancy with major repercussion on the health of both fetuses. Treatment of choice of severe cases (Quintero I-IV) is fetoscopic laser photocoagulation of superficial and deep anastomoses at 18-26 weeks of pregnancy. About 140 cases per year occur in Peru and implementation ofthis technique is necessary. Conclusions: Elective treatment of severe cases of ms is fetoscopic laser photocoagulation of superficial and deep anastomoses between 18-26 weeks of gestation. This technique should be implemented in Peru.

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OBJECTIVE: To document perinatal outcomes following use of the 'Solomon technique' in the selective photocoagulation of placental anastomoses for severe twin-twin transfusion syndrome (TTTS). METHODS: Between January 2010 and July 2012, data were collected from 102 consecutive monochorionic twin pregnancies complicated by severe TTTS that underwent fetoscopic laser ablation at four different centers. We compared outcomes between subjects that underwent selective laser coagulation using the Solomon technique (cases) and those that underwent selective laser coagulation without this procedure (controls). RESULTS: Of the 102 pregnancies examined, 26 (25.5%) underwent the Solomon technique and 76 (74.5%) did not. Of the 204 fetuses, 139 (68.1%) survived up to 30 days of age. At least one twin survived in 82 (80.4%) pregnancies and both twins survived in 57 (55.9%) pregnancies. When compared with the control group, the Solomon-technique group had a significantly higher survival rate for both twins (84.6 vs 46.1%; P < 0.01) and a higher overall neonatal survival rate (45/52 (86.5%) vs 94/152 (61.8%); P < 0.01). Use of the Solomon technique remained independently associated with dual twin survival (adjusted odds ratio (aOR), 11.35 (95% CI, 3.11-53.14); P = 0.0007) and overall neonatal survival rate (aOR, 4.65 (95% CI, 1.59-13.62); P = 0.005) on multivariable analysis. There were no cases of recurrent TTTS or twin anemia-polycythemia sequence (TAPS) in the Solomon-technique group. CONCLUSIONS: Use of the Solomon technique following selective laser coagulation of placental anastomoses appears to improve twin survival and may reduce the risk of recurrent TTTS and TAPS. Our data support the idea of performing a randomized controlled trial to evaluate the effectiveness of the Solomon technique.

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Objetivo: relatar um caso de síndrome de transfusão feto-fetal (STFF), demonstrando a importância do correto eprecoce diagnóstico ultrassonográfico e quando necessário a indicação da fotocoagulação a laser fetoscópica(FCLF) como melhor conduta terapêutica. Relato do caso: mulher 18 anos, secundigesta, gestação gemelarmonocoriônica diamniótica com diagnóstico ultrassonográfico tardio de STFF, devido não realização de prénatal.Realizados dois procedimentos de amniodrenagem como medida paliativa, evoluindo para partoprematuro no oitavo dia de internação. Um dos gêmeos evoluiu a óbito na UTI neonatal. Considerações finais:percebe-se a necessidade de uma melhor assistência pré-natal, treinamento dos profissionais médicos para arealização do diagnóstico ultrassonográfico correto e de investimentos em centros de Medicina fetal no Parápara tratamento adequado

Objective: to report a case of twin-twin transfusion syndrome (TTTS), demonstrating the importance of correctand early ultrasound diagnosis and when necessary the indication of laser photocoagulation fetoscópica (FCLF)as the best therapeutic approach. Case report: 18 years woman, in her second, diamniótica monochorionic twinpregnancy with late diagnosis of TTTS, because failure to carry out prenatal care. Evolved into premature laborafter cesarean with indication of two procedures amniodrenagem. After a cesarean section withoutcomplications was death of the twins in the NICU. Final considerations: we perceive the need to support theadequacy of prenatal care, training of medical professionals to perform the correct ultrasound diagnosis andinvestments in fetal medicine centers in Pará.