2 The procedure

2.1 Indications

2.1.1 Approximately 70% of monozygotic twins are monochorionic/diamniotic (one placenta with two amniotic sacs). TTTS affects approximately 15% of these pregnancies and perinatal mortality is up to 80% if the syndrome is left untreated. TTTS results from abnormal shunting of blood between the circulations of the unborn twins through anastomoses of the vessels of the shared placenta. Blood is transfused from the donor twin, whose growth becomes restricted and who develops oligohydramnios or anhydramnios (too little or absent amniotic fluid), to the recipient, who develops circulatory overload, cardiac compromise and polyhydramnios (too much amniotic fluid). The combination of polyhydramnios in the recipient and oligo/anhydramnios in the donor squashes the donor twin against the wall of the uterus. The syndrome is generally associated with high morbidity and mortality for both twins. Morbidity among survivors includes cardiac, renal and serious neurological impairment, such as cerebral palsy. About 15% of survivors have long-term neurological sequelae.

2.1.2 The options for managing TTTS include expectant management, amnioreduction, septostomy, laser ablation, and selective fetal termination using techniques such as umbilical cord occlusion. In some cases the treatment aim is to enable one twin to survive, as the chances for both surviving are extremely poor. Some parents may choose to terminate the pregnancy because of the high risk of perinatal morbidity and mortality in both twins and the risks of serious long-term morbidity in survivors.

2.2 Outline of the procedure

2.2.1 Under local anaesthesia and ultrasound guidance, an amniocentesis needle is inserted through the maternal abdominal wall and uterine wall. The needle is then used to make a small hole in the membrane between the twins, allowing the fluid around the recipient twin to move into the donor twin's sac. Amnioreduction may also be performed before and/or after the septostomy; this is an established procedure in which excess amniotic fluid is removed via a needle passed through the uterine wall and into the amniotic sac.

2.3 Efficacy

2.3.1 In one randomised controlled trial that included 36 twin pregnancies treated with amnioreduction and 35 treated with septostomy with or without amnioreduction, perinatal survival of at least one twin (measured until hospital discharge) was similar in both groups (78% [28/36] in the amnioreduction group versus 80% [28/35] in the septostomy group; relative risk [RR] 0.94, 95% confidence interval [CI] 0.55 to 1.61, p = 0.82). Survival of both twins was 50% (18/36) in the amnioreduction group compared with 60% (21/35) in the septostomy group (RR 0.82, 95% CI 0.52 to 1.30, p = 0.40). In a cohort study, perinatal survival of both twins was 43% (3/7) in the amnioreduction group compared with 57% (4/7) in those who underwent septostomy with or without amnioreduction. Survival of at least one twin was 86% (6/7) in both groups. Overall survival for amnioreduction alone was 9/14 (64%), versus 10/14 (71%) in the septostomy group; this difference was not statistically significant.

2.3.2 In four case series, overall perinatal survival (the total number of babies born alive divided by the total number of affected fetuses) ranged from 46% (12/26) to 83% (20/24). The differences in survival reported among the studies may be attributed to varying severity of TTTS, the studies that included more severe cases reporting poorer results.

2.3.3 Mean gestational age at delivery ranged from 27 to 31 weeks. Both comparative studies reported that pregnancy was prolonged following septostomy compared with amnioreduction alone (31 and 30 weeks compared with 28 and 30 weeks, p = 0.24 and p = 0.08 respectively). Long-term neurological outcomes were not reported in the studies. For more details, refer to the 'Sources of evidence' section.

2.3.4 The Specialist Advisers commented that the best treatment for early-stage TTTS is still unclear. They noted that results from the two comparative studies indicate no significant advantage of septostomy and amnioreduction over amnioreduction alone.

2.4 Safety

2.4.1 The safety evidence is based on one randomised controlled trial and two case series. In general, safety data were not well reported in the studies.

2.4.2 In the randomised controlled trial, there were two cases of disruption of the intertwin membrane resulting in a monoamniotic twin gestation (one in each study arm) which is associated with increased risk of cord entanglement and/or cord prolapse. This complication has also been reported in two case reports. In a case series of 13 pregnancies, one woman went into spontaneous labour following septostomy and amnioreduction. This was thought to be related to placental damage. For more details, refer to the 'Sources of evidence' section.

2.4.3 One Specialist Adviser considered septostomy and amnioreduction to be a safe procedure, and noted that septostomy is often performed unintentionally during standard amnioreduction. All three Specialist Advisers highlighted that cord entanglement is a theoretical complication of septostomy.