>> PATIENTS WHO HAVE TWIN-TWIN TRANSFUSION SYNDROME,
ESPECIALLY IF THEY HAVE POLYHYDRAMNIOS IN THE
ONE TWIN, CAN BECOME VERY UNCOMFORTABLE PHYSICALLY
WITH THIS PREGNANCY BECAUSE THE UTERUS GETS STRETCHED
BEYOND WHAT IS NORMAL FOR THAT GESTATIONAL AGE.
>> FOR OUR MOMS THAT ARE CARRYING TWINS AFFECTED
WITH TWIN-TWIN TRANSFUSION SYNDROME THAT HAVE BEEN
CLASSIFIED AS STAGE I AND ARE DEMONSTRATING SIGNS
OR SYMPTOMS OF MATERNAL DISCOMFORT OR ARE HAVING
IRREGULAR UTERINE CONTRACTIONS OR ARE DEMONSTRATING
SHORTENING OF THE CERVIX, THEN AMNIOREDUCTION
IS A THERAPY THAT CAN BE OFFERED.
THE IDEA BEHIND AMNIOREDUCTION IS PRIMARILY
AS A TEMPORIZING MEASURE WHERE WE CAN ACTUALLY DRAW
OFF THE EXCESSIVE AMOUNT OF AMNIOTIC FLUID THAT'S IN
THE RECIPIENT FETUS'S SAC IN ORDER TO PROVIDE NOT ONLY
MATERNAL COMFORT, BUT ALSO TO AVOID PRETERM
CONTRACTIONS WHICH CAN LEAD TO PRETERM DELIVERY.
>> A NEEDLE IS PASSED INTO THE AMNIOTIC SAC UNDER
ULTRASOUND GUIDANCE JUST LIKE AN AMNIOCENTESIS
WOULD BE.
AMNIOTIC FLUID IS THEN ABLE TO BE REMOVED SO THAT THIS
EXCESSIVE FLUID IS DRAWN DOWN INTO MORE NORMAL RANGE.
>> NOWADAYS AMNIOREDUCTION HAS A VERY LIMITED PLACE
IN THE MANAGEMENT OF TWIN-TWIN TRANSFUSION SYNDROME.
FOR OUR MOMS WHO ARE EXCLUDED AS OPERATIVE
CANDIDATES, EITHER BECAUSE THEY ARE STAGE I OR FOR OTHER
MATERNAL INDICATIONS, AMNIOREDUCTION CAN BE
UTILIZED. AND WHEN APPLIED TO THESE PARTICULAR PREGNANCIES
CAN ACTUALLY DEMONSTRATE A HALTING OF THE PROGRESSION
OF TWIN-TWIN TRANSFUSION SYNDROME.
>> BUT SOMETIMES YOU SEE PROGRESSION.
YOU'LL SEE THAT THE HEART OF THE RECIPIENT BABY
IS BECOMING MORE AFFECTED, THAT THE ABILITY TO PUMP BLOOD
IS WORSE, THAT THE LEAKING OF THE VALVES IS GETTING WORSE.
>> IF A PREGNANCY PROGRESSES IN TERMS OF UPSTAGING EVEN
AFTER AMNIOREDUCTION, CONTINUED ULTRASOUND
SURVEILLANCE IS WARRANTED.
AND AT THAT POINT A DISCUSSION IS HELD WITH
FAMILIES REGARDING THE NEXT OPTION OR NEXT MANAGEMENT
STRATEGY THAT CAN BE EMPLOYED.
IF GESTATIONAL AGE ALLOWS FOR IT,
THEN A SELECTIVE LASER CAN BE PERFORMED EVEN AFTER
AN AMNIOREDUCTION HAS BEEN UTILIZED.
>> THAT'S A PROCEDURE THAT'S MUCH MORE INVASIVE
TO THE PATIENT.
IT REQUIRES THAT THE PATIENT GO TO THE OPERATING ROOM.
>> WHAT HAPPENS WITH OUR MOMS IS THAT THEY
ARE ADMITTED TO THE HOSPITAL EARLY IN THE MORNING.
THEY'RE TAKEN TO THE OPERATING ROOM.
AND UNDER CONSCIOUS SEDATION AS WELL AS LOCAL ANESTHETIC
THAT'S APPLIED TO THE ABDOMEN WE CAN INTRODUCE
A FETOSCOPE, WHICH THEN ALLOWS DIRECT VISUALIZATION
OF THESE COMMUNICATIONS SO THAT WE CAN PERFORM A TARGETED
AND FOCUSED ABLATION.
>> THERE ARE BLOOD VESSEL COMMUNICATIONS OR VASCULAR
COMMUNICATIONS THAT OCCUR ALONG THE SURFACE
OF THE PLACENTA.
AND THE CHALLENGE IS TO BE ABLE TO RECOGNIZE WHERE
THOSE COMMUNICATIONS ARE.
AND SO NOW USING SOPHISTICATED ENDOSCOPIC
APPROACHES, WE'RE ABLE TO GO INTO THE SAC
OF THE RECIPIENT BABY, IDENTIFY WHERE THE UMBILICAL CORD
INSERTS INTO THE PLACENTA, AND THEN WE LITERALLY MAP
EVERY SINGLE BLOOD VESSEL ARISING FROM THAT POINT OUT.
EITHER AN ARTERY FROM ONE BABY CONNECTING STRAIGHT
INTO THE ARTERIAL SYSTEM OF THE OTHER BABY.
IT CAN BE VEINS CONNECTED TO VEINS DIRECTLY.
OR THE MOST COMMON IS WHEN A VESSEL FROM ONE BABY ENTERS
INTO THE PLACENTA AND THEN COMES OUT OF THE PLACENTA
AND GOES TO THE OPPOSITE BABY.
AND THEN USING A LASER FIBER WE'RE ACTUALLY ABLE TO
COAGULATE OR KIND OF SPOT WELD THOSE COMMUNICATIONS SHUT.
>> AFFECTIVELY SEPARATING THE SINGLE PLACENTA INTO TWO
SEPARATE COMPONENTS, ONE FOR EACH FETUS.
>> THEN EACH TWIN HAS ITS OWN PLACENTAL MASS.
THERE'S NO LONGER THIS COMMUNICATION.
AND HOPEFULLY THAT WILL INTERRUPT THE TWIN-TWIN
TRANSFUSION PROCESS AND STABILIZE THE SITUATION
UNTIL YOU CAN GET OUT TO A GESTATIONAL AGE TO DELIVER
THE BABIES WHERE THERE'S A GOOD CHANCE OF SURVIVAL.
>> ALTHOUGH FETOSCOPIC LASER COAGULATION IS A MINIMALLY
INVASIVE PROCEDURE, IT IS A SURGICAL PROCEDURE,
AND AS SUCH CARRIES WITH IT SPECIFIC RISKS.
THOSE RISKS INCLUDE PRETERM CONTRACTIONS THAT COULD
ULTIMATELY LEAD TO PRETERM LABOR AND DELIVERY.
THERE'S ALSO THE RISK OF PRETERM RUPTURE
OF MEMBRANES.
AND THE THIRD RISK IS OF MEMBRANE SEPARATION.
THE SORT OF CUMULATIVE RISKS FOR ANY ONE OF THOSE
COMPLICATIONS OCCURRING AFTER LASER SURGERY
IS IN THE NEIGHBORHOOD OF 10 TO 15%.
ALTERNATIVELY THE RISK OF NOT MOVING FORWARD WITH AN
INTERVENTION WHEN FORMALLY DIAGNOSED WITH TWIN-TO-TWIN
TRANSFUSION SYNDROME CARRIES WITH IT A RISK OF 80 TO 85%
OF LOSS OF THE PREGNANCY.
>> AND SO YOU REALLY HAVE TO WEIGH THE RISKS AGAINST
THE POTENTIAL BENEFITS.
>> WE ARE INCREDIBLY FORTUNATE TO BE OPERATING
IN A CENTER THAT HAS ALLOWED FOR THE RECEPTION
OF A TREMENDOUS VOLUME OF FAMILIES WHO ARE REFERRED
TO US FOR TWIN-TWIN TRANSFUSION SYNDROME SPECIFICALLY.
AS A RESULT WE'VE BEEN ABLE TO DEVELOP
A MULTIDISCIPLINARY PROGRAM THAT INCORPORATES ALL LEVELS
OF CARE THAT ARE SPECIFICALLY TARGETED
TOWARDS THE CARE OF FAMILIES AFFECTED BY TWIN-TWIN
TRANSFUSION SYNDROME.