Fetal Care Center - Twin-to-Twin Procedure

Race Against Time: Innovative Treatment Saves Girls with Twin-to-Twin Transfusion Syndrome

Sixteen weeks into her pregnancy, Chelsea Donley found out from her physician in Jacksonville that the twins she carried suffered from a condition she had never heard of: twin-to-twin transfusion syndrome (TTTS). The rare and severe complication occurs in about 15% of monochorionic multiple pregnancies. It is characterized by an imbalance of blood flow between the donor and recipient twin, causing one to become hypervolemic and the other hypovolemic. TTTS is associated with very high perinatal morbidity and mortality rates and requires immediate intervention to increase the chances of survival.

Donley’s diagnosis prompted an urgent search for a Florida hospital that could perform fetoscopic laser photocoagulation (FLP). This complex, delicate surgery is intended to selectively and sequentially ablate the placental connective vessel to equalize the flow of blood and nutrients to each fetus.

The staff at University of Florida (UF) Health Jacksonville referred Donley to TGH due to its state-of-the-art TGH and USF Health Fetal Care Center, experienced in handling an array of complicated conditions, including TTTS.

Sarah Običan, MD, division director of Maternal-Fetal Medicine at TGH and an associate professor in the Department of Obstetrics and Gynecology at USF Health, and center co-director Alejandro Rodriguez, MD, have handled numerous TTTS cases and are highly skilled at FLP. They prepare meticulously, doing scan after scan, before determining the precise spot to make the incision. Once they insert the scope and laser, there is no time to waste.

“It depends on how difficult it is to find the vessels and how many there are,” Dr. Običan said. “Once you’re in, you go into the sac of the recipient twin – the one that has a lot of fluid, because that’s the bubble you’re breaching with the scope. And you’re looking for a membrane separation, the demarcation line and vascular equator of the shared vessels between the twins.

“Once you identify that, you can see the vessels that are crossing on top of the placenta and you’re looking for the vessels that are crossing from one side to the other. Then you must see how many there are and laser them at the correct location where they are merging. And after you do that, you know each baby is getting the maximum amount of the placenta it can.”

The operation increases the chances of survival for both twins to roughly 60%, and one of the twins to 80%-85%. However, not performing the surgery increases the likeli- hood that one or both twins would die to 90%.

After a successful FLP at 19 weeks, Donley went on to deliver twin girls at 31 weeks. Both girls are now thriving toddlers. She has grown accustomed to comments from strangers when she takes her adorable twins, Madison and Michelle, to the store or for walks in the stroller.

“People always say, ‘Oh you have twins, God bless you,’ ” she said. “And the first thing I say is, ‘He already did. If I told you my story, you’d understand.’ ”

The state-of-the-art TGH and USF Health Fetal Care Center is experienced in handling an array of complicated conditions, including TTTS and EXIT.