Early unfavorable outcomes of second-trimester selective feticide for complicated monochorionic twins: single-operator experiences

Objectives: This study reviews early unfavorable outcomes following selective in-utero cord occlusion in monochorionic twin pregnancies at risk of hemodynamic accidents by a single operator. Methods: The study analyzed laser ablation (LA), laser transection (LT), radiofrequency ablation (RFA), and bipolar diathermy (BD) procedures performed between 14 and 22 weeks of gestation from 2006 to 2022. Outcomes included: (1) technical failure (abandonment before cessation of Doppler flow), (2) intraoperative events (hemodynamic instability in the woman or co-twin), and (3) complications (e.g., fluid leakage, infection, abruption, co-twin demise, or miscarriage) within 1 week post-procedure. Results: Ten LAs were performed at 14-15 weeks for discordant anomalies, all without complications. Two LTs were conducted at 20 weeks for umbilical cord knotting; with one procedure experienced technical failure. All twin reversed arterial perfusion sequence (TRAPS) (n=55) received RFA, with one procedure experienced technical failure. All twin-to-twin transfusion syndrome (TTTS) (n=25) received BD, with one procedure experienced technical failure. Selective intrauterine growth restriction (sIUGR) (n=30) received RFA (n=5) and BD (n=25), with 1 RFA (25 %) and 1 BD (4 %) experienced technical failure. (p<0.01) All four technical failure cases had extensive anterior placenta. There were no intraoperative events. McDonald cervical cerclage was performed in 8/25 TTTS cases with pre-operative cervical length of ≤25 mm and/or funneling of the internal cervical os. Early procedure-related complications were experienced in two sIUGR cases receiving BD, both of which had extensive anterior placenta. Conclusions: Early unfavorable outcomes were associated with sIUGR as an indication.