Distance Traveled to a Fetal Center and Pregnancy Outcomes in Twin-Twin Transfusion Syndrome

Background:Fetoscopic laser photocoagulation (FLP) is the definitive treatment for twin-twin transfusion syndrome (TTTS). Due to variability in geographic proximity to high-volume fetal centers, many patients travel great distances to receive experienced care. We sought to determine whether distance traveled (DT) is associated with gestational age (GA) at delivery and neonatal survival.Methods:A prospective cohort study of patients within the continental United States referred to our center between September 23, 2011 and July 25, 2018 undergoing planned FLP for TTTS (n= 393; GA 20.6 +/- 2.5 weeks; stage I:n= 50; stage II:n= 118; stage III:n= 208; stage IV:n= 17) was performed. The great-circle distance to our center was calculated using patients' home zip codes. DT was stratified into groups containing equal patient numbers and pregnancy outcomes assessed.Results:A total of 393 patients met the inclusion criteria. The threshold distance from our center was <250 miles (n= 181), 250-499 miles (n= 119), and >= 500 miles (n= 93). There was no significant difference between any of the preoperative variables among the three groups, with the exception of race and rural status. Furthermore, there was no significant association between DT and GA at delivery (p= 0.34), time interval from procedure to delivery (p= 0.37), and the number of neonatal survivors (p= 0.21). Preterm premature rupture of membranes (PPROM) at <34 weeks was highest (47.9%,p= 0.04) in the group traveling 250-499 miles.Conclusion:To our knowledge, this is the largest study to show that in TTTS, DT is not associated with GA at delivery, time interval from procedure to delivery, or neonatal survival. Although PPROM at <34 weeks was higher in the group traveling 250-499 miles, there was no significant difference in GA at delivery. While patients with advanced disease may choose to seek treatment based on proximity, traveling long distances does not adversely affect pregnancy outcomes.