Mini-laparotomy to avoid vascular injury during fetoscopic laser ablation in a case of twin–twin transfusion syndrome with anterior wall placenta: Report of a case complicated with renal dysplasia and cord-around-trunk in donor cotwin and review of the literature

Objective

Twin–twin transfusion syndrome (TTTS) is a special complication of monochorionic (MC) twins, with unbalanced flows through vascular anastomoses within the placenta, causing hemodynamic derangement that can adversely affect perinatal outcome. The initial clinical manifestations of TTTS may be hypovolemic and oliguric of the donor cotwin (the "struck" twin), and hypervolemia and polyureic of the recipient cotwin under prenatal ultrasound. However, the mortality rate can reach 90 % if left untreated. Fetoscopic laser ablation (FLA) is considered the golden treatment standard of TTTS. However, FLA is technically challenging in cases with anterior wall placenta.

Case report

A primigravida woman was diagnosed with TTTS stage III at 17 weeks of gestation. A detailed preoperative plan and a modified mini-laparotomy approach were used to avoid vascular injury during fetoscopic laser coagulation (FLA) in a case of MC twins pregnancy complicated by the TTTS with anterior wall placenta. There were no complications during and after the FLA procedure. During follow-up, the "stuck" twin showed poor fetal growth with the suspicion of bilateral renal dysplasia and cord-around-trunk. The case delivered at 26⁺² weeks of gestation due to maternal mirror syndrome, while donor cotwin was confirmed to have congenital renal dysplasia postnatally, which could increase the severity of TTTS when staging. The donor cotwin died after 18 days in our neonatal intensive care unit. While the recipient cotwin was discharged smoothly after 120 days of hospitalization with normal development. Our findings also highlighted a rare condition coexistence with TTTS in monochorionic diamniotic twin pregnancy, leading to a poorer prognosis.

Conclusion

Timely interventions with a detailed preoperative plan and termination of pregnancy according to the clinical symptoms of both the patient and the fetuses may prevent dismal outcome.