The treatment plan we recommend depends on the severity of the condition and how advanced the pregnancy is. Referring physicians are welcome to participate in this meeting, whether in person or by phone. We provide them with detailed information about all aspects of our evaluation, treatment and follow-up recommendations.
Expectant Management (Monitoring the Pregnancy)
In less severe cases, surgery may not be needed. In that event, we will use ultrasound and fetal echocardiography to monitor the babies during the pregnancy. If their condition worsens, our team will work with the patient, her family and her referring physician to decide what treatment is best. Sometimes, early delivery is the best option.
Amnioreduction (Draining Excess Amniotic Fluid)
When babies are only mildly affected by TTTS, we may recommend amnioreduction to drain the excess amniotic fluid from the recipient twin’s sac, which may improve blood flow. If amnioreduction is not effective, patients may be given the option to proceed with selective fetoscopic laser photocoagulation (SFLP), more commonly known as laser surgery.
Selective Fetoscopic Laser Photocoagulation (Laser Surgery)
When babies are more severely affected by TTTS, the team may recommend selective fetoscopic laser photocoagulation, or laser surgery. This procedure involves making a small incision in the mother’s abdomen and inserting a trocar, or small metal tube, into the uterus. The surgeon then passes a fetoscope (a kind of medical telescope) through the metal tube in order to see all of the blood vessel connections on the surface of the placenta shared by the twins.
After all of the abnormal blood vessel connections are identified, the laser is applied to seal shut these vessels and disconnect them permanently. Afterward, the surgeon drains excess amniotic fluid through the previously placed trocar. Surgery is then complete.
The location of the placenta will help determine the type of anesthesia used for the laser surgery. If the placenta is “posterior,” or located on the back wall of the uterus, we may recommend intravenous (IV) sedation and a local anesthetic. However, if the placenta is “anterior,” or located on the front wall of the uterus, we recommend intravenous sedation, a local anesthetic and possibly an epidural.
After laser surgery, the majority of patients remain in the hospital for one day until their condition stabilizes. Post-operative ultrasound and fetal echocardiography are then repeated about five days after the laser surgery to reassess the fetal condition. We will work with the patients’ maternal-fetal medicine specialist and obstetrician to ensure proper follow up once they return home.