Selective feticide in complicated monochorionic twin pregnancies using ultrasound-guided bipolar cord coagulation

Objective To review our experience with selective feticide in complicated monochorionic (MC) twin pregnancies, using ultrasound-guided cord coagulation with a bipolar forceps. Design Retrospective analysis. Setting All consecutive umbilical cord coagulations performed at our institution in the second trimester of pregnancy between November 1999 and 2003. Population Consecutive cases of complicated MC pregnancies with an indication for selective termination. Methods Ultrasound-guided coagulation of the umbilical cord with a 2.5-mm bipolar forceps under local anaesthesia. Main outcome measures Indications, gestational age at the procedure, perinatal outcome and neonatal follow up. Results Forty-six patients with MC twin pregnancies underwent this procedure. Indications included twin reverse arterial perfusion sequence (n= 17), severe malformation in one twin (n= 7) and agonal presentation or cerebral anomalies of one twin in twin-to-twin transfusion syndrome (TTTS) after laser treatment or serial amniodrainage (n= 22). The procedure resulted in six intrauterine fetal demise (IUFD, 13%), with a rate of 41% and 3% when performed at 16-17 weeks or later, respectively (Fisher P= 0.002). Preterm rupture of the membranes (PROM) before 28 weeks and between 28 and 34 weeks occurred in 9% and 14% of the cases, respectively. All neonatal deaths (four) occurred in cases with PROM at 28 weeks or earlier. Paediatric follow up showed that all infants discharged alive but one were neurologically normal at 3-42 months, which corresponds to 70% of the 46 cases. Conclusions This technique is effective when the natural history is likely to severely affect the development of the normal co-twin. The overall intact survival rate was 70% and our results support justification of later surgery. Prematurity remains a significant complication of the procedure.