TTTS Surgery: How TTTS Laser Surgery is Done
TTTS laser surgery is the only TTTS surgery that can destroy the connections in the shared placenta and stop the transfusion of blood from the donor to the recipient twin. This also goes for the acute or sudden transfusion, should one baby pass away or become suddenly ill.
The surgeons use a fetoscope – a long tube – with a camera at the end of it. They insert the fetoscope and a laser device into the uterus. The surgeons look for the vessels that are providing the blood flow between the two babies and blazer those vessels, so blood flow can no longer happen between them. This should enable the babies to each have their own blood supply.
Look at this video from the Fetal Care Center in the U.S showing how TTTS laser surgery is done. Many doctors believe that this type of TTTS surgery will lead to the best outcome in severe TTTS cases. Research backs this up, showing that TTTS surgery by laser is associated with a 75-80 percent survival rate of at least one twin.
Some babies develop Twin Anemia Polycythemia Sequence (TAPS) after having had laser surgery for TTTS. Studies show that the post-laser form of TAPS might affect up to 16 percent of TTTS cases. Occurrence of TAPS after laser treatment is often due to very small residual anastomoses – and is often regarded as a treatment failure.
Interview with chief physician Karin Sundberg
Karin Sundberg specializes in Obstetrics and Gynecology. She is employed at Rigshospitalet, Denmark’s largest hospital. It’s the only hospital in Denmark that treats TTTS and she is overall responsible.
How do you detect TTTS?
“The women, who are referred to us, have all been diagnosed with TTTS. Any well trained sonographer can spot TTTS during an ultrasound. Midwives can also help in order to ensure that women pregnant with twins are sent to a specialized doctor in time. If a woman’s uterus grows too fast due to an overload of amniotic fluid in the recipient twin, her stomach will usually hurt or feel very uncomfortable. It’s important not to write that off as common pregnancy discomforts. We often experience that a mother feels instantly physically relieved after we’ve done an amnioreduction,” says Karin Sundberg.
How do you classify at what stage the disease has progressed to?
“To a great extent we use Dr. Ruben Quinteros staging system. The staging system isn’t perfect, but it’s the best we’ve got. We also look at the length of the cervix. If the TTTS is at stage 1 we’re presented with a dilemma. The babies who stay at stage 1 survive, but half of the cases progress to a higher stage, where intervention is crucial. Intervention, however, has it’s own risks. Together with the parents we discuss whether we perform laser surgery or we do amnioreduction instead. Amnioreduction is not a treatment for TTTS, but helps prevent the spontaneous breaking of water and premature labor from the enlarged uterus. The cases we treat at our hospital have typically progressed to TTTS stage 2 and 3,” says Karin Sundberg.
How do you treat stage 2 and 3 TTTS?
“About half of our patients get laser surgery and half choose selective termination of one baby. This is often the case if we can determine that one of the children is brain damaged, has a neural tube defect, other malformations or a large size discrepancy. In Denmark there’s generally a very liberal attitude towards abortion and that also influences the risks a family are willing to take during a pregnancy,” says Karin Sundberg.
Are all TTTS cases eligible for laser surgery?
“No, not all severe TTTS cases can be successfully treated with laser surgery. The outcome is usually better if TTTS is detected early in a pregnancy. After 25-26 weeks we usually don’t perform laser surgery and more often have to rely on amnioreduction or premature delivery. We do experience cases, where laser surgery is a last option and where the outlook even after surgery isn’t great. This is for instance cases involving triplets or if the placenta is filled with liquid. There can also be an accumulation of blood in the uterus. Most often we perform laser surgery, even if the odds aren’t great, because if we don’t, the children die or are born extremely preterm,” says Karin Sundberg.
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