Sociodemographic Factors and Perinatal Outcomes After Laser Surgery for Twin-Twin Transfusion Syndrome: A Retrospective Cohort Study.

Abstract

Objective: To evaluate the relationship between socioeconomic status (SES) and race with perinatal survival following fetoscopic laser surgery (FLS) for Twin-Twin Transfusion Syndrome (TTTS).

Design: Retrospective observational study.

Setting: Fetal therapy referral center in the US Mid-Atlantic region.

Population: Consecutive patients having FLS for TTTS between 2014 and 2024.

Methods: SES was quantified by Distress Community Index (DCI) and Area Deprivation Index (ADI) with particular consideration of race and health insurance (commercial or government funded). The DCI and ADI scores reflect the community median income, housing vacancies, education level, poverty rate, business growth, and unemployment based on the ZIP code and patient address, respectively. Scores were stratified by quartiles which indicate prosperous (0-24.9), mid-tier (25-49.9), at-risk (50-74.9) and distressed (75-100) neighbourhoods. Maternal factors, DCI, ADI, self-reported race, insurance status, TTTS severity and peri-operative factors were analysed to determine if there was an association to procedure-related complications, individual twin survival, overall perinatal survival and delivery gestational age. Bivariate and logistic regression analyses were used to identify determinants of survival at discharge from the nursery.

Main outcome measures: Double neonatal survival (DNS).

Results: In 478 patients undergoing FLS, the median DCI was 31.6% [IQR 13%-52.9%] and ADI 33% [IQR 17%-54%] which is equivalent to mid-tier socioeconomic status. In our cohort, 75.5% (n = 361) were White, 78.7% (n = 342) had commercial insurance, 75.3% (n = 360) resided out of state, and 74.5% (n = 347) had DNS. Patients with DNS were more likely to reside in prosperous or mid-tier DCI (74.8 vs. 62%) and ADI quartile neighbourhoods (74% vs. 60.3%), more likely to be White (78.7% vs. 66.1%) and have commercial insurance (81.8% vs. 71.9%, all p < 0.05). Cases of stage III TTTS had higher rates of single or no neonatal survivors (58.7% vs. 37.0%) and estimated fetal weight discordance (EFWD) > 25% (51.2% vs. 29.4%, all p < 0.001). DNS was less likely with Quintero stage III and coexisting EFWD > 25%, with previable preterm birth or membrane rupture and non-White racial group as independent contributors (r² 0.33, p < 0.001).

Conclusion: Patients with lower perinatal survival after fetoscopic laser surgery were more likely to reside in less affluent neighbourhoods, but the non-white racial group emerged as the key independent factor. Further research is needed to explore how individual sociodemographic factors influence outcomes in specialised fetal therapy.