Antepartum hemorrhage at delivery after Solomon laser for Twin-Twin Transfusion Syndrome

The Solomon fetoscopic laser (FLS) technique for treatment of Twin-Twin transfusion syndrome (TTTS) aims to coagulate the chorionic plate along the entire vascular equator. The higher laser energy required has been implicated in subsequent placental abruption (PA) often presenting with antepartum hemorrhage (APH) at delivery. We sought to determine the relationship between Solomon FLS and antepartum hemorrhage (APH). Retrospective single center study of patients delivered after Solomon FLS. Histologically confirmed placental abruption (HCPA), and other causes of APH at delivery were related to perioperative details using nonparametric, univariate and logistic regression analyses. Between 2014-22, 368 patients met criteria. APH occurred in 50 (13.5%) patients and was due to HCPA in 15 (30%), clinically suspected PA in 25 (50%), other obstetric causes in 7 (14%), and idiopathic in 3 (6%). Patients with APH delivered earlier (29.2 weeks [27.5-31.3], p< 0.001) and at a shorter interval to delivery after FLS (9.3 weeks [7.3-10.8], p< 0.001) compared to those without APH. Preoperative fetal size discordance (p=0.032) and selective fetal growth restriction (p=0.008) was more common in patients with APH. Applied laser energy, duration of laser activation, and number of anastomoses requiring coagulation were not associated with APH at delivery. Myometrial bleeding (intrauterine or intra-abdominal) at the time of laser was the primary determinant of APH (p < 0.001, R2 = 0.37). Patients who had APH after Solomon FLS experienced poorer obstetric outcomes. Myometrial bleeding at the time of laser was the primary surgical risk factor for APH.