Treatments of Twin-to-Twin Transfusion Syndrome (TTTS)
DESCRIPTION
Twin-to-twin transfusion syndrome (TTTS) occurs in cases of monozygotic monochorionic (one placenta) twins. In TTTS twins share a single placenta that contains blood vessels that abnormally connect the fetuses to each other. These connections allow blood to pass from one fetus to the other and create an imbalance of blood between the fetuses. As a result, the twin donating the blood can experience growth retardation, anemia, and oligohydramnios (reduced amniotic fluid). The twin receiving the blood can experience polyhydramnios (excessive amniotic fluid) and vascular engorgement, leading to congestive heart failure and hydrops fetalis (excessive accumulation of serous fluid in the tissues and body cavities).
Treatment options for TTTS include serial amnioreduction and fetoscopic laser photocoagulation of the placental vessels that join the fetuses. Serial amnioreduction is a variant of amniocentesis in which amniotic fluid is repeatedly removed in order to restore normal fluid volume. In fetoscopic laser photocoagulation, the abnormal connection of the placental vessels is identified endoscopically under ultrasound guidance and ablated using a laser. This separates the two fetal circulations, correcting the underlying abnormality. The alternative to prenatal intervention is conservative management, which is associated with a fetal mortality rate between 90 percent and 100 percent.
POLICY
Amnioreduction for the treatment of twin-to-twin transfusion syndrome prior to 28 weeks gestation is considered medically necessary.
Laser photocoagulation therapy for the treatment of twin-to-twin transfusion syndrome prior to 28 weeks gestation is considered medically necessary.
Amnioreduction in combination with laser photocoagulation therapy for the treatment of twin-to-twin transfusion syndrome prior to 28 weeks gestation is considered medically necessary.
Policies with similar titles: Fetal Surgery for Prenatally Diagnosed Malformations
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ADDITIONAL INFORMATION
Randomized controlled studies of serial amnioreduction and fetoscopic laser photocoagulation are difficult to undertake because of the limited numbers of candidates available at centers that provide the procedure and because of the ethical issues involved in withholding treatment to candidates in control groups in which perinatal mortality can reach 90 percent. When compared to serial amnioreduction, fetoscopic laser photocoagulation has resulted in fewer reports of neurologic morbidity in surviving children.
SOURCES
BlueCross BlueShield Association. Medical Policy Reference Manual. (3:2004). Treatment of twin-twin syndrome with amnioreduction and/or fetoscopic laser therapy (4.01.12). Retrieved February 25, 2010 from BlueWeb. (5 articles and/or guidelines reviewed)
Crombleholme, T., Shera, D., Lee, H., Johnson,M., D’Alton,M., Porter, F., et al. ( 2007). A prospective, randomized, multicenter trial of amnioreduction vs selective fetoscopic laser photocoagulation for the treatment of severe twin-twon transfusion syndrome. American Journal of Obstetrics and Gynecology, 197 (4), 396e 1 - 396e9. (Level 2 Evidence).
Gabbe., S. G., Niebyl, J. R., & Simpson, J. L. (2007). Obstetrics: Normal and problem pregnancies (5th ed., pp. 247-250). Philadelphia. Churchill Livingstone Elsevier.
Habli, M., Lim, F., & Crombleholme, T. (2009). Twin-to-twin transfusion syndrome: a comprehensive update. Clinical perinatol, 36 (2), 391 - 416. (Level 5 Evidence)
Hayes. Medical Technology Directory. (2002, June). Fetoscopic Laser surgery for twin-twin transfusion syndrome. Retrieved February 25, 2010 from www.Hayesinc.com/subscribers. (27 articles and/or guidelines reviewed)
Lenclen, R., Ciarlo, G., Paupe, A., Bussieres, L., & Ville, Y. (2009). Neurodevelopmental outcome at 2 years in children born preterm treated by amnioreduction or fetoscopic laser surgery for twin -to-twin transfusion syndrome:comparison with dichorionic twins. American Journal of Obsteterics and Gynecology, 201 (3), 291e 1 - 291e 5. (Level 5 Evidence)
Lopriore, E. Sueters, M., Middledorp, J. M., Oepkes, D., Vandenbussche, F. P., & Walthers, F. J. (2005). Neonatal outcome in twin-to-twin teransfusion syndrome treated with fetoscopic laser occlusion of vascular anastomoses. Journal of Pediatrics, 147 (5), 597-602. (38 articles and/or guidelines reviewed)
Lopriore, E., van Wezel-Meijler, G., Middledorp, J. M., Sueters, M., Vandenbussche, F. P., & Walther, F. J. (2006). Incidence, origin, and character of cerebral injury in twin-to-twin transfusion syndrome treated with fetoscopic laser surgery. American Journal of Obstetrics & Gynecology, 194 (5), 1215-1220. (24 articles and/or guidelines reviewed)
Middledorp, J. M., Sueters, M., Lopriore, E., Klumper, F. J. C. M., Oepkes, D., Devlieger, R., et al. (2007). Fetoscopic laser surgery in 100 pregnancies with severe twin-to-twin transfusion syndrome in the Netherlands. Fetal diagnosis and therapy, 22 (3) 190-194.
National Institute for Health and Clinical Excellence. (2006, December). Septostomy with or without anmioreduction for the treatment of twin-to-twin transfusion syndrome. Retrieved February 25, 2010 from http://www.nice.org.uk/nicemedia/pdf/IPG199guidance.pdf.
National Institute for Health and Clinical Excellence. (2006, December). Intrauterine laser ablation of placental vessels for the treatment of twin-to-twin transfusion syndrome. Retrieved February 25, 2009 from http://www.nice.org.uk/nicemedia/pdf/IPG198guidance.pdf.
Robyr, R., Lewi, L., Salomon, L. J., Yamamoto, M., Bernard, J. P., Depreset, J., et al. (2006). Prevalance and management of late fetal complications following successful selective laser coagulation of chorionic plate anastomoses in twin-to-twin transfusion syndrome. American Journal of Obstetrics & Gynecology, 194 (3), 796-803. (19 articles and/or guidelines reviewed)
Senat, M. V., Deprest, J., Boulvain, M., Pape, A., Winer, N., & Ville, Y. (2004). Endoscopic laser surgery versus serial amnioreduction for severe twin-to-twin transfusion syndrome. New England Journal of Medicine, 351 (2), 182-184.
Stimemann, J., Nasr, B., Quarello, E., Ortqvist, L., Nassar, M., Bernard, J., et al. (2008). a definition of selectivity in laser coagulation of chorionic plate anastomoses in twin-to-twin transfusion syndrome and its relationship to perinatal outcome. American Journal of Obstetrics and Gynecology, 198 (1), 62e 1-62e 6. (Level 5 Evidence)
U. S. Food and Drug Administration. (2006, March). Center for Devices and Radiological Health. Approval order for the Humanitarian device exemption for H040005. Retrieved February 25, 2010 from http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cftopic/pma/pma.cfm?num=H040005.
ORIGINAL EFFECTIVE DATE: 4/11/2008
MOST RECENT REVIEW DATE: 4/8/2010
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