European Journal of Obstetrics & Gynecology and Reproductive Biology 81 (1998) 157–164 Experience with fetoscopic cord ligation a ,b , b b b a * Jan A. Deprest , Paul P. Van Ballaer ,Veerle A. Evrard , Koen H.E. Peers , Bernard Spitz , c a Erik A. Steegers , Kamiel Vandenberghe a Department of Obstetrics and Gynaecology, University Hospital ‘ Gasthuisberg’, Leuven, Belgium b Centre for Surgical Technologies, Faculty of Medicine, Katholieke Universiteit Leuven, B-3000 Leuven, Belgium c Department of Obstetrics and Gynaecology, Sint-Radboudziekenhuis, Nijmegen, The Netherlands Abstract Objective. In the case of a monochorionic multiple pregnancy with one non-viable fetus who compromises its co-twin, fetoscopic cord ligation may be performed. We describe our fetoscopic cord ligation technique and discuss the efficacy of cord ligation for salvaging the co-twin, based on available data. Study design. Descriptive case series of four cases and review of the cases published up to 1996. Results. We performed four successful ligations. Of the 23 reported cases, which include the present series, two ligations failed. Four fetuses died in utero, and 17 were born alive at a mean of 8 weeks following the procedure. Two babies died in the perinatal period, a third after 60 days. Preterm uterine contractions do not seem to be a clinical problem. Preterm prelabour rupture of the membranes (PPROM) complicates about 40% of cases, the majority occurring prior to 32 weeks. Conclusion. Fetoscopic cord ligation is a feasible procedure with a 71% survival rate and a high risk for PPROM.  1998 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Acardiac; Cord ligation; Feticide; Feto-fetal transfusion syndrome; Fetoscopy; Monochorionic twins 1. Introduction artery of the pump twin, over an arterio-arterial anas- tomosis in a reversed direction through an umbilical artery Selective feticide may be contemplated in mono- of the acardiac. The umbilical vein of the parasitic fetus chorionic (MC) multiple pregnancies where one fetus is returns the blood via a veno-venous anastomosis into the affected by a condition not compatible with ex-utero life, placenta. According to the largest available review by and where the non-affected fetus is or may otherwise Healey, the TRAP sequence is complicated by polyhy- become compromised in utero. MC gestations always dramnios in 51% of cases and by preterm labour in 75% share their placental circulations to a certain degree [1]. [4]. In-utero congestive heart failure occurs in 28% and Across anastomoses unbalanced feto-fetal shunting of intrauterine demise in 25%. The proportion of the mass of blood may occur and cause a hemodynamic and clinically the perfused fetus to the pump twin seems to be a relevant degree of feto-fetal transfusion. The most extreme predictive factor [5]. Perinatal mortality is estimated to be manifestation of feto-fetal transfusion is acardiac twin about 30%. pregnancy, occurring in 1% of monozygous twin pre- Severe mid-gestational feto-fetal transfusion syndrome gnancies [2]. In 1983,Van Allen introduced the term ‘twin (FFTS) is a more common condition. Some patients may reversed arterial perfusion’ sequence (TRAP sequence), present with one fetus having a serious congenital anomaly which describes accurately the anomalous reversal of or acquired cerebral or cardiac pathology [6–9]. Selective umbilical arterial flow [3]. Blood flows from an umbilical feticide may occasionally be considered to try to salvage the normal co-twin by preventing the complications of FFTS, such as polyhydramnios-related preterm labour or * Corresponding author. Correspondence address: Department of Ob- rupture of the membranes, fatal congestive heart failure or stetrics and Gynaecology, UZ Leuven, B-3000 Leuven, Belgium. Tel.: the consequences of in-utero fetal death of one fetus. 132-16-344215; fax: 132-16-344205; e-mail: Jan.Deprest@uz.kuleuven.ac.be Once the indication and the decision for selective 0301-2115 / 98 / $ – see front matter  1998 Elsevier Science Ireland Ltd. All rights reserved. PII: S0301-2115(98)00181-X