Clinical outcomes of twin pregnancies managed with fetoscopic laser surgery

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Created On: 10/06/2026

Twin-to-twin transfusion syndrome (TTTS) diagnosed before 18 weeks of gestation is uncommon, and evidence regarding outcomes after fetoscopic laser surgery (FLS) remains limited.

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Key take away

Lower gestational age at birth and abnormal donor fetal Doppler findings are associated with reduced survival following fetoscopic laser surgery for early-onset TTTS.

Background

Twin-to-twin transfusion syndrome (TTTS) diagnosed before 18 weeks of gestation is uncommon, and evidence regarding outcomes after fetoscopic laser surgery (FLS) remains limited. This lack of data complicates counseling and clinical decision-making. The study evaluated survival outcomes and identified predictors of survival in pregnancies impacted by early-onset TTTS treated with FLS.

Method

This international multicenter retrospective cohort study included 485 monochorionic diamniotic twin pregnancies with TTTS diagnosed before 18+0 weeks' gestation and managed with FLS. The key endpoint was dual-twin survival at 28 days following birth. Secondary endpoints were survival of at least one twin and loss of both twins. Preoperative, intraoperative, and postoperative variables were assessed via multivariable logistic regression. Model performance was checked via receiver operating characteristic curve assessment.

Result

Among cases of early-onset TTTS treated with FLS, survival of at least one twin was achieved more frequently than survival of both twins, while a subset resulted in loss of both twins. Multivariable analysis identified abnormal donor umbilical artery and ductus venosus Doppler findings at diagnosis as independent predictors of reduced dual-twin survival.

In contrast, advancing gestational age at birth independently predicted improved survival of both twins and higher survival of at least one twin. The prediction model for dual-twin survival illustrated modest discriminatory ability and poor overall fit.

Conclusion

FLS for early-onset TTTS resulted in survival of at least one twin in most pregnancies. Donor umbilical artery and ductus venosus Doppler abnormalities were independent predictors of poorer dual-twin survival, whereas higher gestational age at birth was linked with improved survival. These findings may aid prenatal counseling and risk stratification, while further studies are needed to optimize surgical outcomes.