Fetal Therapy

Twin-to-Twin Transfusion Syndrome (TTTS) is a condition that occurs in 10-15% of identical twins or triplets who share a single placenta where one baby donates its blood and nutrients to his/her sibling(s).

The baby who is donating his/her blood is at risk of dehydration and anemia. The baby who is receiving the extra blood is at risk for volume overload which can lead to congestive heart failure in severe cases.

Procedure: Laser Photocoagulation

MoMo twins share both the chorionic and amniotic sacs. This situation is very rare and may cause risk to the babies due to cord entanglement and other issues.

Complications that can arise in monochorionic pregnancies are due to unequal sharing of blood, blood volume, placental nutrients or a combination of these. Essentially the well-being of each twin is linked to the other. These connections are believed to be responsible for the higher rate of developmental delay found in complicated monochorionic twins.

Procedure: Laser Photocoagulation

There are a variety of reasons why a baby can become anemic during pregnancy. The most common reason is Rh blood group sensitization or isoimmunization, where a woman with Rh negative blood has a baby with Rh positive blood. The mother's body then creates antibodies that can cross the placenta and destroy the baby's blood cells, creating anemia.

Other causes include genetic syndromes, infections or vascular tumors.

Fetal anemia is diagnosed by monitoring the speed of the blood in the fetal brain by assessing a vessel called, the middle cerebral artery (MCA).

Procedure: Fetal Blood Sampling and Transfusions

LUTO is a rare birth defect where the bladder is obstructed or blocked, partially or completely. There are many reasons why this can happen, but most often in a male baby it is from posterior urethral valves (PUV) in which there is a flap of tissue blocking the urethra as it leaves the bladder.

The prognosis and treatment for each case is variable—depending on:

• The reason for the blockage
• The baby's gender (males being more favorable)
• Presence of other anomalies
• Severity of the blockage
• Kidney function

Procedure: Fetal Shunt Placement

Pleural effusion is a buildup of fluid between the lungs and the lining of the chest. The fluid can compress the developing heart and lungs. There are many causes of fetal pleural effusions, and some are amenable to treatment.

Congenital Pulmonary Airway Malformation (CPAM) is a cystic mass or tumor which can be solid or filled with fluid.
Chylothorax is a rare condition in which lymphatic fluid leaks accumulate into the chest cavity.
Bronchopulmonary Sequestration is an abnormality of the lower airway consisting of a nonfunctioning mass of lung tissue that isn't connected to the lungs in the usual fashion.

Procedure: Fetal Shunt Placement

TRAP sequence is a rare (1 in 35,000 pregnancies) condition in which there is one normal appearing baby and another with multiple anomalies.

The twin with multiple anomalies can present in various ways, but the most common is that it develops with neither a heart or a head (often referred to as the “acardiac” twin), which is incompatible with life.

The “pump twin” (or the twin pumping vital nutrients to the acardiac twin) is typically structurally normal, however the added circulatory burden can be deadly without treatment.

Procedure: Radiofrequency Ablation

Approximately 10% of monochorionic twins (or identical twins that share a placenta) encounter problems because the placenta is not shared evenly. Sometimes, the distribution is so unequal that the one twin is not getting enough nutrition from the placenta. This results in poor growth in that twin, or selective intrauterine growth restriction (SIUGR).

The presence of a single placenta in a twin pregnancy signals that the fetuses are linked by common blood vessels. SIUGR can be initially confused with Twin to Twin Transfusion Syndrome (TTTS), but differs in that only one twin is affected. To complicate matters, some pregnancies can be affected by both TTTS and SIUGR.

Procedure: Radiofrequency Ablation and Bipolar Cord Coagulation/Transection

When multiple fetuses share one placenta (monochorionic), they are called “identical”. Sometimes, however, identical twins can have different development and one twin can have abnormalities that their sibling does not have.

When we see identical twins with one twin with an anomaly, but the other appears normal, we call these discordant anomalies in a monochorionic pregnancy.

Procedure: Radiofrequency Ablation and Bipolar Cord Coagulation/Transection

This procedure is done in an operating room using spinal anesthesia, and typically takes 30-to-60 minutes.

A very thin camera, called a fetoscope, is placed into the uterus through a tiny incision in the skin. The fetoscope allows our surgeon to identify the small connecting blood vessels on the surface of the placenta.

The blood vessels are closed using laser energy from a small laser fiber through a channel on the fetoscope.

Radiofrequency ablation is a procedure that can be done for a variety of reasons to stop blood flow in a particular area.

Most often in pregnancy, it is used as a way to selectively reduce a complicated twin pregnancy in which there is a concern over a shared placenta, often related to Twin Reversed Arterial Perfusion (TRAP) Sequence or sometimes for severe discordant lethal anomalies in monochorionic pregnancies.

It is an office procedure, done under local anesthesia, in which a small needle is guided by ultrasound to the umbilical cord and the blood vessels are simultaneously sealed. 

A shunt, or a double pigtailed catheter (a tiny flexible tube that curls on either end) is inserted through the mother's uterus into the fetus to drain fluid from a fluid filled space (bladder or chest) into the amniotic cavity. 

It can be used in a variety of complex conditions to allow normal development of the baby's organs and/or to keep a normal volume of amniotic fluid around the baby. 

Percutaneous umbilical blood sampling (PUBS) is a procedure where a skilled perinatologist inserts a thin needle through the maternal uterus into the vessel of the umbilical cord of a baby to remove a small amount of fetal blood. 

Most often, this is used for to determine how anemic a baby is by testing its hemoglobin/hematocrit.

An intrauterine transfusion (IUT) is performed by transfusing blood or blood products through that same needle into the unborn baby. 

This procedure is used in twin pregnancies with a shared placenta (monochorionic) to selective terminate the life of one twin.

It is a minimally invasive procedure in which a needle is guided by ultrasound into the umbilical cord and blood flow is coagulated either by radiofrequency ablation or bipolar cautery. This interrupts the blood communication between the fetuses, and allows the remaining twin to continue as a singleton pregnancy, without the complications that could arise from a spontaneous death of their co-twin.  The demised baby remains in the amniotic cavity. 

While this is a difficult decision for families, it can be the right decision for some, as it maximizes the chances of a good outcome for the surviving twin by eliminating the risk of death or brain damage from a spontaneous death of a co-twin.