Persistent compression of uterine insertion on maternal blood dynamic change in fetoscopic laser photocoagulation surgery: a novel method

Persistent compression of uterine insertion on maternal blood dynamic change in fetoscopic laser photocoagulation surgery: a novel method | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Persistent compression of uterine insertion on maternal blood dynamic change in fetoscopic laser photocoagulation surgery: a novel method Huirong Tang, Xingbo Tian, Chenyan Dai, Ya Wang, Yuan Wang, Liang Jin, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4895638/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Background Fetoscopic laser photocoagulation (FLP) has been performed as first-line approach for twin-to-twin transfusion syndrome (TTTS) in monochorionic twin pregnancies. The majority of researches are focusing on advances in fetal treatment and long-term outcome, few reports on maternal surgery-related complications are reported. This study is to compare the maternal blood dynamic changes in women with and without persistent compression on the uterine insertion after the FLP procedure and to evaluate whether the method of persistent compression can reduce blood loss effectively in FLP surgery. Methods This was a retrospective study conducted at two tertiary referral centers in China between November 2018 and July 2023. TTTS-cases undergoing FLP surgery were enrolled and divided into two groups upon whether having compression on the uterine insertion after FLP. The changes of maternal hemoglobin, hematocrit before and after the procedure were compared between the two groups. Results A total of 111 TTTS-cases were finally analyzed including 46 cases with persistent compression and 65 cases without persistent compression. The two groups had similar values of hemoglobin (10.7 ± 1.1 versus 10.5 ± 1.2 g/dl, p = 0.513) and hematocrit (32.3 ± 3 versus 31.3 ± 3.2, p = 0.099) before FLP. There was a significant reducing of hemoglobin decreasing in TTTS-cases with persistent compression (1.1g/dL) than those without persistent compression (1.5g/dL) (p = 0.014). A decrease trend in change of hematocrit was observed between cases with persistent compression (3.1%) and those without persistent compression (4.0%), while it did not achieve a significant difference (p = 0.050). The blood transfusion rate in TTTS-cases with and without compression was 2.2% and 7.7% respectively (p = 0.205). Conclusion Prevention of hemoglobin and hematocrit decreasing could be obtained by persistent compression of uterine insertion after FLP, which is an economical, simple and convenient method. blood dynamic change fetoscopic laser photocoagulation compression Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background Over the past 25 years, fetoscopic laser photocoagulation (FLP) has been performed as first-line approach for twin-to-twin transfusion syndrome (TTTS) in monochorionic twin pregnancies, and many studies have shown that FLP can improve the neonatal outcome compared with other conventional treatments 1 – 2 . While the majority of researches are focusing on advances in fetal treatment and long-term outcome, only a limited number of reports on maternal surgery-related complications 3 – 5 . The overall rate of maternal adverse events was found to be 17% and intermediate to severe problems occurred in about 4% 6 . One of the maternal complications of FLP is bleeding from the uterine insertion flowing into the abdominal cavity. According to Sacco A’s review, bleeding during the procedure was noted in 1.74% of fetoscopic surgery cases (95% CI, 1.25-2.32) 7 . This complication is usually treated conservatively without invasive management. While, in some severe cases, blood transfusion and even hysterectomy are required 8 , 9 . Intraoperative blood transfusion was required in 0.27% undergoing fetoscopic surgery (95% CI, 0.18‐0.38) 7 . Thus, hemostasis of the wound on the uterine wall is crucial to reduce the hemorrhage. Persistent compression is an effective method to achieve hemostasis and is widely used in clinic practice. We developed a novel method of persistent compression with gauzes and bandage firmly on the endoscopic insertion position immediately after FLP. The possible mechanism of the method is to apply pressure to the endoscopic insertion on both the maternal abdominal wall and uterine, slow down the blood flow and promote blood clotting to achieve the purpose of hemostasis. In this study, we compared the maternal blood dynamic change in women with and without persistent compression on the uterine insertion and examined whether persistent compression can reduce blood loss effectively in FLP surgery. Methods Study design and participants This was a retrospective study conducted at two tertiary referral centers in China (Nanjing Drum Tower Hospital (DTH) and Chongqing Health Center for Women and Children (CQH)) between November 2018 and July 2023. All consecutive monochorionic, diamniotic twin pregnancies up to 26 weeks’ gestation complicated by TTTS (Quintero stage 2, 3, or 4) and women with Quintero stage 1 with clinical symptoms due to polyhydramnios treated with FLP were included. Cases were excluded when blood test results before or one day after surgery and the information on delivery were not available. The study was approved by the Ethics Committee of Nanjing Drum Tower Hospital and Chongqing Health Center for Women and Children (2013058, 2020YL2002) and each center’s respective institutional review board. Surgical procedure Half an hour before the procedure, patients received prophylactic intravenous antibiotics cefazolin (2.0g) with 100ml 0.9% sodium chloride or clindamycin (0.9g) with 250ml 0.9% sodium chloride for women with cefazolin allergy and indomethacin (12.5mg) transrectally. All fetoscopic laser procedures were undertaken by experienced operators (Mingming Zheng and Gongli Chen). A cannula was introduced transabdominally into the amniotic cavity of the recipient twin by sharp trocar insertion under ultrasound visualization to avoid puncturing the large blood vessels of the abdominal wall after local anaesthesia by lidocaine. FLP was performed using a 3.3 mm fetoscope (Karl Storz, Tuttlingen, Germany) with a cannula of 10 French and a 400 or 600 µm laser fiber connected to a diode or Nd:YAG laser device (Dornier MedTech, Wessling, Germany). The laser procedure was followed by draining the excessive amniotic fluid to the deepest pocket of 6–8 cm. Immediately after removing the fetoscopy, the entry point including maternal skin and uterine wall was assessed to exclude active hemorrhage by ultrasound. After the surgery, women were required to stay in hospital for observation and taking blood test before and one day after the surgery. Oral tocolysis with 10 mg nifedipine was administered three times daily for 48 h in the case of clinically apparent uterine contractions. TTTS-cases in CQH were routinely treated without persistent compression after FLP as well as cases in DTH between November 2018 and July 2021. Since August 2021 in DTH, persistent compression hemostasia was used immediately after removal of the laser with gauzes and bandage on uterine insertion for about 6 hours after FLP. TTTS-cases were divided into two groups upon whether having compression after FLP. The Fig. 1 and Fig. 2 show the details of the compression. Outcome parameters We collected the following variables from ultrasound records and medical records: TTTS stage, placental location, gestational age at laser (in weeks), laser technique, volume of amniotic fluid reduction. Maternal serum hemoglobin (Hb) and hematocrit (Hct) were measured at admission (usually 6-24hours before the intervention) and 24 h after the intervention. There was no procedure developed intra-amniotic bleeding at the end of the fetoscopy in both groups. The primary outcome was the change of hemoglobin and hematocrit of maternal blood. The secondary outcome was maternal blood transfusion during and after FLP. Statistics Data were tested for normal distribution using the Kolmogorov–Smirnov and Shapiro–Wilk tests. Correlation analyses between related parameters were performed with Spearman ́s rho if a dataset was not normally distributed. Not-related parameters were tested with the Wilcoxon test. In the case of normal distribution, Student’s t-test was performed. Maternal hemoglobin and hematocrit before and after fetoscopy were performed by paired t-test. A probability of p < 0.05 was considered statistically significant. Analyses were carried out using SPSS Statistics 26.0 (IBM, Armonk, NY, USA). Results A total of 68 cases with TTTS in CQH and 82 cases in DTH undergoing FLP were recruited. Thirty-nine (39/150, 26.0%) cases were excluded because of unavailable maternal blood results. Thus, 54 (79.4%) cases in CQH and 57 (69.5%) cases in DTH were finally enrolled for analysis. They were further divided into Group 1 of 46 cases with persistent compression and Group 2 of 65 cases without persistent compression (Fig. 3 ). Comparison of characteristics of TTTS-cases with and without persistent compression on uterine insertion after FLP The characteristics of women treated with FLP in the two groups were displayed in Table 1 . We found no significant difference between the two groups with respect to maternal age (29.0 versus 30.0 years, p = 0.768), gestational age at procedure (22.0 ± 2.9 versus 21.9 ± 2.9 weeks, p = 0.848), proportion of TTTS stages (p = 0.057) and the proportion of placenta anterior position (50.0% versus 56.3%, p = 0.237). There was also no significant difference between the volume of amniodrainage. The median volume of amniodrainage was 710 mL (100–2700mL) and 850 mL (150-3000mL) at the surgery respectively. Table 1 The characteristics of TTTS-cases with and without compression on uterine insertion after FLP. Parameters With compression (Group 1) Without compression (Group 2) P value N 46 65 - Maternal age Median, range 29.0 (23.0–42.0) 30.0 (22.0–39.0) 0.768 Gestational weeks at procedure Mean, SD 22.0, 2.9 21.9, 2.9 0.848 Indications 0.057 TTTS stage 1 n, % 11/46, 23.9 4/65, 6.2 TTTS stage 2 n, % 16/46, 34.8 31/65, 47.7 TTTS stage 3 n, % 8/46, 17.4 12/65, 18.5 TTTS stage 4 n, % 11/46, 23.9 18/65, 27.7 Placenta position 0.237 Anterior n, % 19/38, 50.0 36/64, 56.3 Posterior n, % 19/38, 50.0 28/64, 43.8 Volume of AF reduction, mL Median, range 710 (100–2700) 850 (150–3000) 0.255 GW at delivery, weeks, Mean, SD 32.1,5.1 33.2,3.2 0.277 TTTS: Twin-to-twin transfusion syndrome; FLP: Fetoscopic laser photocoagulation; AF: Amniotic fluid; GW: Gestational week; SD: Standard deviation Comparison of maternal hemodynamic change in TTTS-cases with and without persistent compression on endoscopic insertion after FLP The two groups had similar values of hemoglobin (10.7 ± 1.1 versus 10.5 ± 1.2 g/dl, p = 0.513) and hematocrit (32.3 ± 3 versus 31.3 ± 3.2, p = 0.099) before FLP. A significant difference was observed after FLP in hemoglobin (9.6 ± 1.1 versus 9.1 ± 1.2 g/dl, p = 0.025) and hematocrit (29.3 ± 3.1 versus 27.3 ± 3.2, p = 0.002) between TTTS-cases with and without persistent local pressurization respectively. What’s more, a significant difference was observed in change of hemoglobin between cases with persistent compression (1.1g/dl) and those without persistent compression (1.5g/dl) (p = 0.014). Also, in cases with compression and without compression, decrease trends were observed in hematocrit change (3.1% vs 4.0%, p = 0.050) and blood transfusion rate (2.2% vs 7.7%, p = 0.205), while they did not achieve significant differences (Table 2 ). Table 2 The values of hemoglobin and hematocrit before and after FLP in women with and without compression. Parameters With compression Without compression P value Hemoglobin before FLP, g/dl, mean, SD 10.7, 1.0 10.6, 1.2 0.513 Hemoglobin after FLP, g/dl, mean, SD 9.6, 1.1 9.1,1.2 0.025 Change of Hemoglobin, g/dl, mean, SD 1.1, 0.8 1.5, 0.7 0.014 Hematocrit before FLP, %, mean, SD 32.3, 3.0 31.3, 3.2 0.099 Hematocrit after FLP, %, mean, SD 29.3, 3.1 27.3, 3.2 0.002 Change of Hematocrit, %, mean, SD 3.1, 2.5 4.0, 2.5 0.050 Blood Transfusion after the procedure n, % 1/46, 2.2 5/65, 7.7 0.205 FLP: Fetoscopic laser photocoagulation; SD: Standard deviation The correlation between the volume of amniodrainage at surgery and changes of maternal serum hemoglobin. There was a significant correlation between the volume of amniodrainage and the effects on maternal blood characteristics. Within a 24 h interval, there was a positive correlation between hemoglobin (Spearman’s rho 0.262; p = 0.004) (see Fig. 4 ), Hematocrit (Spearman’s rho 0.214; p < 0.001) (see Fig. 5 ) and the amount of amniodrainage during the intervention. Discussion In clinic practice, a decrease of hemoglobin and hematocrit after surgery usually indicates blood loss. In 2000, De Lia et al. firstly reported maternal hemodynamic changes following FLP and amniodrainage in 109 cases of mid-trimester TTTS 10 . Subsequently, decreases in hemoglobin and hematocrit levels after FLP were often reported by literature 11 . The significant decrease was mainly reported within one day after FLP. Morikawa M’s study showed a decrease of hemoglobin from11.0 ± 1.0 to 9.3 ± 0.9 g/dL and hematocrit from 32.1 ± 3.0% to 27.3 ± 2.7% before and one day after FLP 12 . Greimel P’s study showed similar results, the mean Hb decreasing from 11.6 to 9.6 g/dl and hematocrit decreasing from 33.56–27.78% after FLP 13 . Our study data showed a similar decrease of hemoglobin from 11 to 9.5 g/dL and hematocrit from 33.4–28.3% one day after FLP in TTTS-cases. The underlying mechanism of such significant decrease of hemoglobin and hematocrit after procedure was thought as the postoperative hemodilution. While, when we further compared TTTS-cases with and without persistent compression, prevention of hemoglobin (1.1 versus 1.5g/dL, p = 0.014) and hematocrit decreasing (3.1% versus 4.0%, p = 0.05) before and after FLP were observed. Meanwhile, this data in the study showed a difference in the blood transfusion rate in TTTS-cases with and without persistent compression (7.7% versus 2.2%) although it did not achieve significance which might be due to the limited sample size. These results indicated that there was a role of persistent compression of uterine insertion after FLP on preventing hemorrhage related to the surgery besides the postoperative hemodilution. Although severe maternal complications are rare with FLP, we should be aware of the possibility of uncontrollable bleeding from the uterine wall due to endoscopic insertion. Susumu Murata reported a case required caesarean hysterectomy after FLP because of massive bleeding from the uterine wall due to endoscopic insertion for FLP8. It was clear that massive bleeding was from the endoscope entry part as the results of the failure to control bleeding at the endoscopic entry site. Thus, the authors suggested to observe for about half an hour or 1 hour in the operation or recovery room after laser surgery. Similarly, there was a pregnant woman with low platelet count treated with FLP in our facility. Hemorrhage from an injury lesion where an endoscope had been inserted was found during the emergency cesarean section. The patient was transferred to the intensive care unit and treated with a massive transfusion of 600 ml red blood cell concentrates. After this case, we invented the method of persistent compression with gauzes and bandage on the endoscopic insertion to prevent the uterine bleeding in our facility. There are some measures reported previously to reduce the risk of hemorrhage related to the surgery. In some unites, operators routinely conduct transabdominal ultrasound examinations 30 minutes after FLP to see if there is a blood clot pooling in the mother’s intraperitoneal cavity to exclude the hemorrhage from injury of the uterine wall8. In other some centers, collagen plug is placed at the insertion site to decrease such bleeding 14 . In this study, we mainly focused on the maternal blood dynamic changes while such maternal uterine compression could also play a role in decreasing the risk of amniotic fluid leakage from the amniotic cavity to the maternal peritoneal cavity, which need further evaluation. Strengths and Limitations To our knowledge, it is the first study to investigate the effect of persistent compression on maternal blood dynamic change in FLP surgery. While, this was a retrospective study in two centers, which need more prospective studies performed in lager cohort. And the effective of this method need to be further evaluated by comparison with other hemostasis methods to explore the optimal hemostasis method for procedure-related hemorrhage after FLA. Conclusion Surgeons should be aware of severe maternal postoperative complications attributable to intrauterine interventions although it was relatively rare with an incidence of 4%. Prevention of hemoglobin and hematocrit decreasing could be obtained by persistent compression on the endoscopic insertion, which is an economical, simple and convenient method. Declarations Statement of Ethics This study protocol was reviewed and approved by the Ethics committee of the Affiliated Drum Tower Hospital of Medical School of Nanjing University. The Reg No. is 2013058. The written informed consent was obtained from participants to participate in the study. Conflict of interest statement The authors report no conflict of interest. Funding Sources This work was supported by grants from Jiangsu Biobank of Clinical Resources (BM2015004), which is sponsored by the Finance department of Jiangsu Province. Author Contributions Huirong Tang, Mingming Zheng, Xingbo Tian and Gongli Chen contributed to study design. Ya Wang and Yuan Wang contributed to the implementation and analysis plan. Jie Li contributed to the cytogenic analyses. Chenyan Dai, Liang Jin and Xian Xiao played important role during fetoscopic surgery. Huirong Tang drafted the manuscript and all authors revised and approved the final manuscript. Data Sharing and Data Availability: The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy restrictions. Acknowledgements Not applicable References Senat MV, Deprest J, Boulvain M, Paupe A, Winer N, Ville Y. Endoscopic laser surgery versus serial amnioreduction for severe twin-to-twin transfusion syndrome. N Engl J Med 2004; 351: 136–44. Pandya Viral M, Stirnemann Julien, Colmant Claire, Ville Yves. Current Practice and Protocols: Endoscopic Laser Therapy for Twin-Twin Transfusion Syndrome. Maternal-Fetal Medicine 2(1):34-47, January2020. Lewi L, van Schoubroeck D, Gratacos E, Witters I, Timmer- man D, Deprest J. Monochorionic diamniotic twins: compli- cations and management options. Curr Opin Obstet Gynecol. 2003;15:177–94. Wee LY, Fisk NM. The twin-twin transfusion syndrome. Semin Neonatol. 2002;7:187–202. Yamamoto M, Ville Y. Laser treatment in twin-to-twin transfusion syndrome. Semin Fetal Neonatal Med. 2007;12:450–7. Merz W, Tchatcheva K, Gembruch U, Kohl T. Maternal complications of fetoscopic laser photocoagulation (FLP) for treatment of twin-twin transfusion syndrome (TTTS). J Perinat Med. 2010 Jul;38(4):439-43. doi: 10.1515/jpm.2010.061. PMID: 20184399. Sacco A, Van der Veeken L, Bagshaw E, Ferguson C, Van Mieghem T, David AL, Deprest J. Maternal complications following open and fetoscopic fetal surgery: A systematic review and meta-analysis. Prenat Diagn. 2019 Mar;39(4):251-268. Murata S, Matsumoto R, Nishimura H, Moriya T, Shimoya K, Sugino N. A case of total hysterectomy due to massive maternal bleeding immediately after fetoscopic laser surgery for twin-twin transfusion syndrome. J Obstet Gynaecol Res. 2021 Jun;47(6):2215-2219. doi: 10.1111/jog.14780. Epub 2021 Apr 11. PMID: 33843094. Crombleholme TM, Shera D, Lee H, Johnson M, D’Alton M, Porter F, et al. A prospective, randomized, multicenter trial of amnioreduction vs. selective fetoscopic laser photocoagu- lation for the treatment of severe twin-twin transfusion syn- drome. Am J Obstet Gynecol. 2007;197:396.e1–9. De Lia, J.E.; Kuhlmann, R.S.; Emery, M.G. Maternal metabolic abnormalities in twin-to-twin transfusion syndrome at mid-pregnancy. Twin Res. 2000, 3, 113–117. Huber, A.; Diehl, W.; Zikulnig, L.; Held, K.R.; Bregenzer, T.; Hackelöer, B.J.; Hecher, K. Amniotic Fluid and Maternal Blood Characteristics in Severe Mid-Trimester Twin–Twin Transfusion Syndrome. Fetal Diagn. Ther. 2004, 19, 504–509. Morikawa M, Yamada T, Nakagawa K, Hosokawa-Miyanishi A, Umazume T, Chiba K, Kawaguchi S, Cho K, Watari H. Maternal Anemia and Coagulation/Fibrinolysis after Fetoscopic Laser Photocoagulation for Twin-to-Twin Transfusion Syndrome. Gynecol Obstet Invest. 2019;84(5):477-484. doi: 10.1159/000499913. Epub 2019 Apr 9. PMID: 30965339. Greimel P, Klaritsch P, Simonis H, Csapó B, Pohl M, Schneditz D. Amniodrainage-Induced Circulatory Dysfunction in Women Treated for Twin-To-Twin Transfusion Syndrome. J Clin Med. 2020 Jul 2;9(7):2085. doi: 10.3390/jcm9072085. PMID: 32630792; PMCID: PMC7408784. Greimel P, Zenz A, Csapó B, Haeusler M, Lang U, Klaritsch P. Maternal Complications and Hemodynamic Changes Following Intrauterine Interventions for Twin-to-Twin Transfusion Syndrome in Monochorionic Diamniotic Twin Pregnancies. J Clin Med. 2019 May 2;8(5):605. doi: 10.3390/jcm8050605. PMID: 31052564; PMCID: PMC6572341. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4895638","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":339886387,"identity":"00272ea1-8dec-410b-952e-a28376c58b78","order_by":0,"name":"Huirong Tang","email":"","orcid":"","institution":"the Affiliated Drum and Tower Hospital of Medical School of Nanjing University","correspondingAuthor":false,"prefix":"","firstName":"Huirong","middleName":"","lastName":"Tang","suffix":""},{"id":339886388,"identity":"d1d5f1cf-f3c3-4ecd-aaeb-549a5dff27ba","order_by":1,"name":"Xingbo Tian","email":"","orcid":"","institution":"Chongqing Health 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photocoagulation\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4895638/v1/26f5af47400b621ad7101d63.jpg"},{"id":66124274,"identity":"91f7afe8-e34e-410d-b81c-3db279d655e4","added_by":"auto","created_at":"2024-10-08 02:35:14","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":71900,"visible":true,"origin":"","legend":"\u003cp\u003eThe procedure of the compression after fetoscopic laser photocoagulation surgery.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4895638/v1/3e4815d402e2193daef5e65c.jpg"},{"id":66124276,"identity":"56de9b58-9c9d-441b-aadc-d201aa3b7434","added_by":"auto","created_at":"2024-10-08 02:35:14","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":88029,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of the study\u003c/p\u003e\n\u003cp\u003eTTTS: Twin-to-twin transfusion syndrome; FLP: Fetoscopic laser photocoagulation;\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4895638/v1/0391ae0ad25c9d53c7b25ee5.jpg"},{"id":66125857,"identity":"1580f6ea-8b57-4f94-a947-a70de7e10c73","added_by":"auto","created_at":"2024-10-08 02:43:14","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":39864,"visible":true,"origin":"","legend":"\u003cp\u003eCorrelation between the volume of amniodrainage at surgery and changes of maternal serum hemoglobin.\u003c/p\u003e","description":"","filename":"Figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4895638/v1/404829e5334c39886df39e8f.jpg"},{"id":66125856,"identity":"03694e56-931a-4424-a63c-8f422499d320","added_by":"auto","created_at":"2024-10-08 02:43:14","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":43500,"visible":true,"origin":"","legend":"\u003cp\u003eCorrelation between the volume of amniodrainage at surgery and changes of maternal serum hematocrit.\u003c/p\u003e","description":"","filename":"Figure5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4895638/v1/d82cf2c676375383e91dc697.jpg"},{"id":66125872,"identity":"30bec6d3-5671-4825-8413-e26d3a0a3fc8","added_by":"auto","created_at":"2024-10-08 02:43:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":684924,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4895638/v1/0c1db5d0-b384-4d77-9cf1-0aa59a9c8fa5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Persistent compression of uterine insertion on maternal blood dynamic change in fetoscopic laser photocoagulation surgery: a novel method","fulltext":[{"header":"Background","content":"\u003cp\u003eOver the past 25 years, fetoscopic laser photocoagulation (FLP) has been performed as first-line approach for twin-to-twin transfusion syndrome (TTTS) in monochorionic twin pregnancies, and many studies have shown that FLP can improve the neonatal outcome compared with other conventional treatments\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. While the majority of researches are focusing on advances in fetal treatment and long-term outcome, only a limited number of reports on maternal surgery-related complications\u003csup\u003e\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. The overall rate of maternal adverse events was found to be 17% and intermediate to severe problems occurred in about 4%\u003csup\u003e6\u003c/sup\u003e. One of the maternal complications of FLP is bleeding from the uterine insertion flowing into the abdominal cavity. According to Sacco A\u0026rsquo;s review, bleeding during the procedure was noted in 1.74% of fetoscopic surgery cases (95% CI, 1.25-2.32)\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. This complication is usually treated conservatively without invasive management. While, in some severe cases, blood transfusion and even hysterectomy are required\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Intraoperative blood transfusion was required in 0.27% undergoing fetoscopic surgery (95% CI, 0.18‐0.38)\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Thus, hemostasis of the wound on the uterine wall is crucial to reduce the hemorrhage.\u003c/p\u003e \u003cp\u003ePersistent compression is an effective method to achieve hemostasis and is widely used in clinic practice. We developed a novel method of persistent compression with gauzes and bandage firmly on the endoscopic insertion position immediately after FLP. The possible mechanism of the method is to apply pressure to the endoscopic insertion on both the maternal abdominal wall and uterine, slow down the blood flow and promote blood clotting to achieve the purpose of hemostasis.\u003c/p\u003e \u003cp\u003eIn this study, we compared the maternal blood dynamic change in women with and without persistent compression on the uterine insertion and examined whether persistent compression can reduce blood loss effectively in FLP surgery.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy design and participants\u003c/p\u003e \u003cp\u003eThis was a retrospective study conducted at two tertiary referral centers in China (Nanjing Drum Tower Hospital (DTH) and Chongqing Health Center for Women and Children (CQH)) between November 2018 and July 2023. All consecutive monochorionic, diamniotic twin pregnancies up to 26 weeks\u0026rsquo; gestation complicated by TTTS (Quintero stage 2, 3, or 4) and women with Quintero stage 1 with clinical symptoms due to polyhydramnios treated with FLP were included. Cases were excluded when blood test results before or one day after surgery and the information on delivery were not available. The study was approved by the Ethics Committee of Nanjing Drum Tower Hospital and Chongqing Health Center for Women and Children (2013058, 2020YL2002) and each center\u0026rsquo;s respective institutional review board.\u003c/p\u003e \u003cp\u003eSurgical procedure\u003c/p\u003e \u003cp\u003eHalf an hour before the procedure, patients received prophylactic intravenous antibiotics cefazolin (2.0g) with 100ml 0.9% sodium chloride or clindamycin (0.9g) with 250ml 0.9% sodium chloride for women with cefazolin allergy and indomethacin (12.5mg) transrectally. All fetoscopic laser procedures were undertaken by experienced operators (Mingming Zheng and Gongli Chen). A cannula was introduced transabdominally into the amniotic cavity of the recipient twin by sharp trocar insertion under ultrasound visualization to avoid puncturing the large blood vessels of the abdominal wall after local anaesthesia by lidocaine. FLP was performed using a 3.3 mm fetoscope (Karl Storz, Tuttlingen, Germany) with a cannula of 10 French and a 400 or 600 \u0026micro;m laser fiber connected to a diode or Nd:YAG laser device (Dornier MedTech, Wessling, Germany). The laser procedure was followed by draining the excessive amniotic fluid to the deepest pocket of 6\u0026ndash;8 cm. Immediately after removing the fetoscopy, the entry point including maternal skin and uterine wall was assessed to exclude active hemorrhage by ultrasound. After the surgery, women were required to stay in hospital for observation and taking blood test before and one day after the surgery. Oral tocolysis with 10 mg nifedipine was administered three times daily for 48 h in the case of clinically apparent uterine contractions. TTTS-cases in CQH were routinely treated without persistent compression after FLP as well as cases in DTH between November 2018 and July 2021. Since August 2021 in DTH, persistent compression hemostasia was used immediately after removal of the laser with gauzes and bandage on uterine insertion for about 6 hours after FLP. TTTS-cases were divided into two groups upon whether having compression after FLP. The Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e show the details of the compression.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eOutcome parameters\u003c/p\u003e \u003cp\u003eWe collected the following variables from ultrasound records and medical records: TTTS stage, placental location, gestational age at laser (in weeks), laser technique, volume of amniotic fluid reduction. Maternal serum hemoglobin (Hb) and hematocrit (Hct) were measured at admission (usually 6-24hours before the intervention) and 24 h after the intervention. There was no procedure developed intra-amniotic bleeding at the end of the fetoscopy in both groups. The primary outcome was the change of hemoglobin and hematocrit of maternal blood. The secondary outcome was maternal blood transfusion during and after FLP.\u003c/p\u003e \u003cp\u003eStatistics\u003c/p\u003e \u003cp\u003eData were tested for normal distribution using the Kolmogorov\u0026ndash;Smirnov and Shapiro\u0026ndash;Wilk tests. Correlation analyses between related parameters were performed with Spearman ́s rho if a dataset was not normally distributed. Not-related parameters were tested with the Wilcoxon test. In the case of normal distribution, Student\u0026rsquo;s t-test was performed. Maternal hemoglobin and hematocrit before and after fetoscopy were performed by paired t-test. A probability of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. Analyses were carried out using SPSS Statistics 26.0 (IBM, Armonk, NY, USA).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 68 cases with TTTS in CQH and 82 cases in DTH undergoing FLP were recruited. Thirty-nine (39/150, 26.0%) cases were excluded because of unavailable maternal blood results. Thus, 54 (79.4%) cases in CQH and 57 (69.5%) cases in DTH were finally enrolled for analysis. They were further divided into Group 1 of 46 cases with persistent compression and Group 2 of 65 cases without persistent compression (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eComparison of characteristics of TTTS-cases with and without persistent compression on uterine insertion after FLP\u003c/p\u003e \u003cp\u003eThe characteristics of women treated with FLP in the two groups were displayed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. We found no significant difference between the two groups with respect to maternal age (29.0 versus 30.0 years, p\u0026thinsp;=\u0026thinsp;0.768), gestational age at procedure (22.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9 versus 21.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9 weeks, p\u0026thinsp;=\u0026thinsp;0.848), proportion of TTTS stages (p\u0026thinsp;=\u0026thinsp;0.057) and the proportion of placenta anterior position (50.0% versus 56.3%, p\u0026thinsp;=\u0026thinsp;0.237). There was also no significant difference between the volume of amniodrainage. The median volume of amniodrainage was 710 mL (100\u0026ndash;2700mL) and 850 mL (150-3000mL) at the surgery respectively.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe characteristics of TTTS-cases with and without compression on uterine insertion after FLP.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameters\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWith compression (Group 1)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWithout compression\u003c/p\u003e \u003cp\u003e(Group 2)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaternal age\u003c/p\u003e \u003cp\u003eMedian, range\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29.0\u003c/p\u003e \u003cp\u003e(23.0\u0026ndash;42.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.0\u003c/p\u003e \u003cp\u003e(22.0\u0026ndash;39.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.768\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGestational weeks at procedure\u003c/p\u003e \u003cp\u003eMean, SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.0, 2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.9, 2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.848\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eIndications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.057\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTTTS stage 1 n, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11/46, 23.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4/65, 6.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTTTS stage 2 n, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16/46, 34.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31/65, 47.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTTTS stage 3 n, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8/46, 17.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12/65, 18.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTTTS stage 4 n, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11/46, 23.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18/65, 27.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003ePlacenta position\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.237\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnterior n, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19/38, 50.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36/64, 56.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePosterior n, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19/38, 50.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28/64, 43.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVolume of AF reduction, mL\u003c/p\u003e \u003cp\u003eMedian, range\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e710\u003c/p\u003e \u003cp\u003e(100\u0026ndash;2700)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e850\u003c/p\u003e \u003cp\u003e(150\u0026ndash;3000)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.255\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGW at delivery, weeks, Mean, SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32.1,5.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33.2,3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.277\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eTTTS: Twin-to-twin transfusion syndrome; FLP: Fetoscopic laser photocoagulation; AF: Amniotic fluid; GW: Gestational week; SD: Standard deviation\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eComparison of maternal hemodynamic change in TTTS-cases with and without persistent compression on endoscopic insertion after FLP\u003c/p\u003e \u003cp\u003eThe two groups had similar values of hemoglobin (10.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1 versus 10.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2 g/dl, p\u0026thinsp;=\u0026thinsp;0.513) and hematocrit (32.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3 versus 31.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2, p\u0026thinsp;=\u0026thinsp;0.099) before FLP. A significant difference was observed after FLP in hemoglobin (9.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1 versus 9.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2 g/dl, p\u0026thinsp;=\u0026thinsp;0.025) and hematocrit (29.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1 versus 27.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2, p\u0026thinsp;=\u0026thinsp;0.002) between TTTS-cases with and without persistent local pressurization respectively. What\u0026rsquo;s more, a significant difference was observed in change of hemoglobin between cases with persistent compression (1.1g/dl) and those without persistent compression (1.5g/dl) (p\u0026thinsp;=\u0026thinsp;0.014). Also, in cases with compression and without compression, decrease trends were observed in hematocrit change (3.1% vs 4.0%, p\u0026thinsp;=\u0026thinsp;0.050) and blood transfusion rate (2.2% vs 7.7%, p\u0026thinsp;=\u0026thinsp;0.205), while they did not achieve significant differences (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe values of hemoglobin and hematocrit before and after FLP in women with and without compression.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameters\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWith compression\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWithout compression\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemoglobin before FLP, g/dl, mean, SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10.7, 1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.6, 1.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.513\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemoglobin after FLP, g/dl, mean, SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.6, 1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.1,1.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.025\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChange of Hemoglobin, g/dl, mean, SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.1, 0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.5, 0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.014\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHematocrit before FLP, %, mean, SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32.3, 3.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31.3, 3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.099\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHematocrit after FLP,\u003c/p\u003e \u003cp\u003e%, mean, SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29.3, 3.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27.3, 3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChange of Hematocrit,\u003c/p\u003e \u003cp\u003e%, mean, SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.1, 2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.0, 2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.050\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood Transfusion after the procedure\u003c/p\u003e \u003cp\u003en, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1/46, 2.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5/65, 7.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.205\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eFLP: Fetoscopic laser photocoagulation; SD: Standard deviation\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe correlation between the volume of amniodrainage at surgery and changes of maternal serum hemoglobin.\u003c/p\u003e \u003cp\u003eThere was a significant correlation between the volume of amniodrainage and the effects on maternal blood characteristics. Within a 24 h interval, there was a positive correlation between hemoglobin (Spearman\u0026rsquo;s rho 0.262; p\u0026thinsp;=\u0026thinsp;0.004) (see Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e), Hematocrit (Spearman\u0026rsquo;s rho 0.214; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (see Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e) and the amount of amniodrainage during the intervention.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn clinic practice, a decrease of hemoglobin and hematocrit after surgery usually indicates blood loss. In 2000, De Lia et al. firstly reported maternal hemodynamic changes following FLP and amniodrainage in 109 cases of mid-trimester TTTS\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. Subsequently, decreases in hemoglobin and hematocrit levels after FLP were often reported by literature\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. The significant decrease was mainly reported within one day after FLP. Morikawa M\u0026rsquo;s study showed a decrease of hemoglobin from11.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0 to 9.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9 g/dL and hematocrit from 32.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.0% to 27.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7% before and one day after FLP\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. Greimel P\u0026rsquo;s study showed similar results, the mean Hb decreasing from 11.6 to 9.6 g/dl and hematocrit decreasing from 33.56\u0026ndash;27.78% after FLP\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. Our study data showed a similar decrease of hemoglobin from 11 to 9.5 g/dL and hematocrit from 33.4\u0026ndash;28.3% one day after FLP in TTTS-cases. The underlying mechanism of such significant decrease of hemoglobin and hematocrit after procedure was thought as the postoperative hemodilution. While, when we further compared TTTS-cases with and without persistent compression, prevention of hemoglobin (1.1 versus 1.5g/dL, p\u0026thinsp;=\u0026thinsp;0.014) and hematocrit decreasing (3.1% versus 4.0%, p\u0026thinsp;=\u0026thinsp;0.05) before and after FLP were observed. Meanwhile, this data in the study showed a difference in the blood transfusion rate in TTTS-cases with and without persistent compression (7.7% versus 2.2%) although it did not achieve significance which might be due to the limited sample size. These results indicated that there was a role of persistent compression of uterine insertion after FLP on preventing hemorrhage related to the surgery besides the postoperative hemodilution.\u003c/p\u003e \u003cp\u003eAlthough severe maternal complications are rare with FLP, we should be aware of the possibility of uncontrollable bleeding from the uterine wall due to endoscopic insertion. Susumu Murata reported a case required caesarean hysterectomy after FLP because of massive bleeding from the uterine wall due to endoscopic insertion for FLP8. It was clear that massive bleeding was from the endoscope entry part as the results of the failure to control bleeding at the endoscopic entry site. Thus, the authors suggested to observe for about half an hour or 1 hour in the operation or recovery room after laser surgery. Similarly, there was a pregnant woman with low platelet count treated with FLP in our facility. Hemorrhage from an injury lesion where an endoscope had been inserted was found during the emergency cesarean section. The patient was transferred to the intensive care unit and treated with a massive transfusion of 600 ml red blood cell concentrates. After this case, we invented the method of persistent compression with gauzes and bandage on the endoscopic insertion to prevent the uterine bleeding in our facility. There are some measures reported previously to reduce the risk of hemorrhage related to the surgery. In some unites, operators routinely conduct transabdominal ultrasound examinations 30 minutes after FLP to see if there is a blood clot pooling in the mother\u0026rsquo;s intraperitoneal cavity to exclude the hemorrhage from injury of the uterine wall8. In other some centers, collagen plug is placed at the insertion site to decrease such bleeding\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn this study, we mainly focused on the maternal blood dynamic changes while such maternal uterine compression could also play a role in decreasing the risk of amniotic fluid leakage from the amniotic cavity to the maternal peritoneal cavity, which need further evaluation.\u003c/p\u003e \u003cp\u003eStrengths and Limitations\u003c/p\u003e \u003cp\u003eTo our knowledge, it is the first study to investigate the effect of persistent compression on maternal blood dynamic change in FLP surgery. While, this was a retrospective study in two centers, which need more prospective studies performed in lager cohort. And the effective of this method need to be further evaluated by comparison with other hemostasis methods to explore the optimal hemostasis method for procedure-related hemorrhage after FLA.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eSurgeons should be aware of severe maternal postoperative complications attributable to intrauterine interventions although it was relatively rare with an incidence of 4%. Prevention of hemoglobin and hematocrit decreasing could be obtained by persistent compression on the endoscopic insertion, which is an economical, simple and convenient method.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eStatement of Ethics\u003c/p\u003e\n\u003cp\u003eThis study protocol was reviewed and approved by the Ethics committee of the Affiliated Drum Tower Hospital of Medical School of Nanjing University. The Reg No. is 2013058. The written informed consent was obtained from participants to participate in the study.\u003c/p\u003e\n\u003cp\u003eConflict of interest statement\u003c/p\u003e\n\u003cp\u003eThe authors report no conflict of interest.\u003c/p\u003e\n\u003cp\u003eFunding Sources\u003c/p\u003e\n\u003cp\u003eThis work was supported by grants from Jiangsu Biobank of Clinical Resources (BM2015004), which is sponsored by the Finance department of Jiangsu Province.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthor Contributions\u003c/p\u003e\n\u003cp\u003eHuirong Tang, Mingming Zheng, Xingbo Tian and Gongli Chen contributed to study design. Ya Wang and Yuan Wang contributed to the implementation and analysis plan. Jie Li contributed to the cytogenic analyses. Chenyan Dai, Liang Jin and Xian Xiao played important role during fetoscopic surgery. Huirong Tang drafted the manuscript and all authors revised and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eData Sharing and Data Availability:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy restrictions.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSenat MV, Deprest J, Boulvain M, Paupe A, Winer N, Ville Y. Endoscopic laser surgery versus serial amnioreduction for severe twin-to-twin transfusion syndrome. N Engl J Med 2004; 351: 136\u0026ndash;44.\u003c/li\u003e\n\u003cli\u003ePandya Viral M, Stirnemann Julien, Colmant Claire, Ville Yves. Current Practice and Protocols: Endoscopic Laser Therapy for Twin-Twin Transfusion Syndrome. Maternal-Fetal Medicine 2(1):34-47, January2020.\u003c/li\u003e\n\u003cli\u003eLewi L, van Schoubroeck D, Gratacos E, Witters I, Timmer- man D, Deprest J. Monochorionic diamniotic twins: compli- cations and management options. Curr Opin Obstet Gynecol. 2003;15:177\u0026ndash;94.\u003c/li\u003e\n\u003cli\u003eWee LY, Fisk NM. The twin-twin transfusion syndrome. Semin Neonatol. 2002;7:187\u0026ndash;202.\u003c/li\u003e\n\u003cli\u003eYamamoto M, Ville Y. Laser treatment in twin-to-twin transfusion syndrome. Semin Fetal Neonatal Med. 2007;12:450\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eMerz W, Tchatcheva K, Gembruch U, Kohl T. Maternal complications of fetoscopic laser photocoagulation (FLP) for treatment of twin-twin transfusion syndrome (TTTS). J Perinat Med. 2010 Jul;38(4):439-43. doi: 10.1515/jpm.2010.061. PMID: 20184399.\u003c/li\u003e\n\u003cli\u003eSacco A, Van der Veeken L, Bagshaw E, Ferguson C, Van Mieghem T, David AL, Deprest J. Maternal complications following open and fetoscopic fetal surgery: A systematic review and meta-analysis. Prenat Diagn. 2019 Mar;39(4):251-268. \u003c/li\u003e\n\u003cli\u003eMurata S, Matsumoto R, Nishimura H, Moriya T, Shimoya K, Sugino N. A case of total hysterectomy due to massive maternal bleeding immediately after fetoscopic laser surgery for twin-twin transfusion syndrome. J Obstet Gynaecol Res. 2021 Jun;47(6):2215-2219. doi: 10.1111/jog.14780. Epub 2021 Apr 11. PMID: 33843094.\u003c/li\u003e\n\u003cli\u003eCrombleholme TM, Shera D, Lee H, Johnson M, D\u0026rsquo;Alton M, Porter F, et al. A prospective, randomized, multicenter trial of amnioreduction vs. selective fetoscopic laser photocoagu- lation for the treatment of severe twin-twin transfusion syn- drome. Am J Obstet Gynecol. 2007;197:396.e1\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eDe Lia, J.E.; Kuhlmann, R.S.; Emery, M.G. Maternal metabolic abnormalities in twin-to-twin transfusion syndrome at mid-pregnancy. Twin Res. 2000, 3, 113\u0026ndash;117.\u003c/li\u003e\n\u003cli\u003eHuber, A.; Diehl, W.; Zikulnig, L.; Held, K.R.; Bregenzer, T.; Hackel\u0026ouml;er, B.J.; Hecher, K. Amniotic Fluid and Maternal Blood Characteristics in Severe Mid-Trimester Twin\u0026ndash;Twin Transfusion Syndrome. Fetal Diagn. Ther. 2004, 19, 504\u0026ndash;509. \u003c/li\u003e\n\u003cli\u003eMorikawa M, Yamada T, Nakagawa K, Hosokawa-Miyanishi A, Umazume T, Chiba K, Kawaguchi S, Cho K, Watari H. Maternal Anemia and Coagulation/Fibrinolysis after Fetoscopic Laser Photocoagulation for Twin-to-Twin Transfusion Syndrome. Gynecol Obstet Invest. 2019;84(5):477-484. doi: 10.1159/000499913. Epub 2019 Apr 9. PMID: 30965339.\u003c/li\u003e\n\u003cli\u003eGreimel P, Klaritsch P, Simonis H, Csap\u0026oacute; B, Pohl M, Schneditz D. Amniodrainage-Induced Circulatory Dysfunction in Women Treated for Twin-To-Twin Transfusion Syndrome. J Clin Med. 2020 Jul 2;9(7):2085. doi: 10.3390/jcm9072085. PMID: 32630792; PMCID: PMC7408784.\u003c/li\u003e\n\u003cli\u003eGreimel P, Zenz A, Csap\u0026oacute; B, Haeusler M, Lang U, Klaritsch P. Maternal Complications and Hemodynamic Changes Following Intrauterine Interventions for Twin-to-Twin Transfusion Syndrome in Monochorionic Diamniotic Twin Pregnancies. J Clin Med. 2019 May 2;8(5):605. doi: 10.3390/jcm8050605. PMID: 31052564; PMCID: PMC6572341.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"blood dynamic change, fetoscopic laser photocoagulation, compression","lastPublishedDoi":"10.21203/rs.3.rs-4895638/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4895638/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eFetoscopic laser photocoagulation (FLP) has been performed as first-line approach for twin-to-twin transfusion syndrome (TTTS) in monochorionic twin pregnancies. The majority of researches are focusing on advances in fetal treatment and long-term outcome, few reports on maternal surgery-related complications are reported. This study is to compare the maternal blood dynamic changes in women with and without persistent compression on the uterine insertion after the FLP procedure and to evaluate whether the method of persistent compression can reduce blood loss effectively in FLP surgery.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis was a retrospective study conducted at two tertiary referral centers in China between November 2018 and July 2023. TTTS-cases undergoing FLP surgery were enrolled and divided into two groups upon whether having compression on the uterine insertion after FLP. The changes of maternal hemoglobin, hematocrit before and after the procedure were compared between the two groups.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 111 TTTS-cases were finally analyzed including 46 cases with persistent compression and 65 cases without persistent compression. The two groups had similar values of hemoglobin (10.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1 versus 10.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2 g/dl, p\u0026thinsp;=\u0026thinsp;0.513) and hematocrit (32.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3 versus 31.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2, p\u0026thinsp;=\u0026thinsp;0.099) before FLP. There was a significant reducing of hemoglobin decreasing in TTTS-cases with persistent compression (1.1g/dL) than those without persistent compression (1.5g/dL) (p\u0026thinsp;=\u0026thinsp;0.014). A decrease trend in change of hematocrit was observed between cases with persistent compression (3.1%) and those without persistent compression (4.0%), while it did not achieve a significant difference (p\u0026thinsp;=\u0026thinsp;0.050). The blood transfusion rate in TTTS-cases with and without compression was 2.2% and 7.7% respectively (p\u0026thinsp;=\u0026thinsp;0.205).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003ePrevention of hemoglobin and hematocrit decreasing could be obtained by persistent compression of uterine insertion after FLP, which is an economical, simple and convenient method.\u003c/p\u003e","manuscriptTitle":"Persistent compression of uterine insertion on maternal blood dynamic change in fetoscopic laser photocoagulation surgery: a novel method","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-08 02:35:09","doi":"10.21203/rs.3.rs-4895638/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-13T19:27:46+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-13T01:51:54+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-13T01:51:09+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2024-08-11T14:34:46+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c1daff34-49ad-48dc-b8eb-66b24cdb2e50","owner":[],"postedDate":"October 8th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-05T19:08:31+00:00","versionOfRecord":[],"versionCreatedAt":"2024-10-08 02:35:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4895638","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4895638","identity":"rs-4895638","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}