The Solomon Technique and Extreme Preterm Birth after Laser Surgery for Twin-Twin Transfusion Syndrome

INTRODUCTION: We compare adverse pregnancy outcomes after the Solomon technique versus selective laser surgery for twin-twin transfusion syndrome (TTTS). METHODS: Retrospective cohort study of monochorionic diamniotic (MCDA) twin pregnancies that underwent laser surgery for TTTS at two centers between 2006-2023. Pregnancy outcomes were compared between patients treated with the Solomon versus the selective laser technique. The primary outcomes were delivery <4 weeks after surgery and delivery <28 weeks. Secondary outcomes included placental abruption, and recurrent TTTS or twin anemia polycythemia sequence requiring additional surgery. Multivariable robust Poisson regression models were used to estimate relative risks (RR) for outcomes adjusted for TTTS stage, selective fetal growth restriction, and cervical length, among other covariables. Solomonization' s effect on surgery-to-delivery interval was evaluated via Cox regression. P<0.05 was used. RESULTS: Of 1,680 TTTS cases, 80 were excluded due to dual fetal death (n=47) or missing laser technique or delivery data (n=33). In the remaining 1,600 cases, 44.9% (n=719) underwent the Solomon technique. Multivariable robust Poisson regression showed that Solomonization was independently associated with delivery <4 weeks after surgery (RR: 2.46 95% CI: 1.31-4.60; p=0.005), delivery <28 weeks (RR: 1.67 95% CI: 1.15-2.51; p=0.008), and placental abruption (RR: 1.74; 95% CI: 1.02-2.97; p=0.04). Cox regression demonstrated a shorter surgery-to-delivery interval with the Solomon technique (hazard ratio: 1.66; 95% CI: 1.49-1.84; p<0.001). The Solomon group had higher laser time, energy consumption, and PPROM rates, earlier gestational age at delivery, and lower 30-day survival rate of at least one twin. Recurrent TTTS or post-laser TAPS requiring additional surgery were similar between groups. CONCLUSION: The Solomon technique is associated with increased risks, including extreme preterm delivery, shorter surgery-to-delivery interval, and placental abruption.