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Perinatal Factors Foreshadow Neurologic Deficits in TTTS


 

SAN FRANCISCO — Long-term neurologic impairment among twin-to-twin transfusion syndrome survivors is mediated by perinatal factors but not by mode of treatment, reported Dr. Lisa Ortqvist at the annual meeting of the Society for Maternal-Fetal Medicine.

Gestational age at delivery, 1-minute Apgar score, and Quintero staging each independently predicted severe neurologic abnormalities over time in a cohort of twin-to-twin-transfusion syndrome (TTTS) survivors treated with either endoscopic laser surgery or serial amnioreduction, said Dr. Ortqvist of Paris-Ouest University (France). Neither treatment modality independently predicted neurologic outcome over time, she said.

The population for this study included 135 children born to mothers who had been enrolled in the randomized Eurofetus trial, which compared aggressive serial amnioreduction for severe TTTS with fetoscopic laser ablation therapy (N. Engl. J. Med. 2004;351:136-44).

The Eurofetus trial results demonstrated a survival advantage associated with fetoscopic laser surgery with a lower risk of brain injury. The current investigation sought to evaluate the long-term neurodevelopmental outcome of children who survived beyond 6 months in both study arms, Dr. Ortqvist explained.

The study included 80 children from the laser therapy arm (29 donors, 51 recipients) and 55 children in the amnioreduction arm (29 donors, 26 recipients) followed for a median 5.3 years. Outcome data included physician-reported results from annual physical examinations and standardized neuroevaluations, parent-completed Ages and Stages Questionnaires yearly from ages 2 through 5 years, and cognitive evaluation at age 6 years using the Wechsler Intelligence Scale for Children.

Using the clinical data, the investigators classified the children into one of three groups based on degree of neurologic impairment. Group 1 included children with normal physical and neurologic examinations; group 2 included children with minor neurologic abnormalities, such as strabismus or mildly delayed motor/speech development; and group 3 included children with major neurologic abnormalities, such as cerebral palsy, hemiparesis, or spastic quadriplegia. Of the initial cohort, 11.5% were classified as having major neurologic problems, not including the children lost to follow-up, said Dr. Ortqvist.

In univariate analysis, Quintero staging, gestational age at delivery, female gender, and 1- and 5-minute Apgar scores were predictive of major neurologic problems, while procedure type, donor/recipient status, birth weight, and arterial pH values were not, Dr. Ortqvist reported.

In the multivariate analysis, “if we considered that the children lost to follow-up did not have major neurologic problems, only Quintero staging, gestational age at delivery, and 1-minute Apgar scores demonstrated a significant association with major neurodevelopmental problems,” she said.

Although there was no significant difference in neurologic impairment between laser treatment and amnioreduction, “Endoscopic laser surgery is associated with increased survival overall, and as such is associated with improved survival without long-term neurological impairment,” Dr. Ortqvist concluded.

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