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What is Laser Photocoagulation?
 
Laser photocoagulation is the use of laser energy to seal the communicating blood vessels on the surface of the placenta.  The prevents the donation of blood and nutrients from one twin to the other. 
 
How is it done?
 
Under local/spinal anesthesia, a tiny incision is made in the skin so that a very small camera (fetoscope) can be inserted into the uterus.  Through this camera, the vessels on the surface of the placenta can be visualized.  The connecting blood vessels are identified and then "coagulated" using laser light from a small fiber alongside the camera.  This surgery is performed in an operating room and takes approximately 30-60 minutes.  This procedure is done at Evergreen Hospital Medical Center by Martin Walker, MD and Bettina Paek, MD.
 
What are the results?  
 
Without treatment, 80-100% of patients with TTTS lose the entire pregnancy.  With laser photocoagulation, we have found that 90% of our patients have at least one survivor and 60-70% of our patients have two survivors.  And sadly, in 10% of our cases, the entire pregnancy is lost.
 
What are the risks?
  • Infection of the amniotic cavity may occur.  Antibiotics are given in an attempt to avoid this complication.
  • Bleeding in the mother and/or the babies, can prevent the completion of the procedure. Extremely small instruments (2-3 mm) are used to decrease the amount of bleeding. However, if the bleeding is very heavy, an abdominal skin incision may be needed to stop it.  In extreme cases, the bleeding could be so heavy that the uterus must be removed in order to control the bleeding.  In this situation, the mother would not be able to have any more children.  
  • Injury to the mother or to the babies may occur from the procedure. Ultrasound is used as a guide throughout the procedure to help to prevent injury from occurring.
  • Premature labor or leakage of amniotic fluid may happen as a result of the surgery. The smallest instruments possible are utilzed to help minimize this risk. In addition, medications are given to relax the uterus and reduce the chance of contractions.
  • Miscarriage or Fetal death may occur as a result of this procedure.
Who is suitable for Laser Photocoagulation?
 
Pregnancies affected by TTTS are considered appropriate for laser photocoagulation when they exhibit ALL of the following:
  • Single placenta (Monochorionic) twin or triplet pregnancy.
  • Excessive fluid (polyhydramnios), which is defined as a maximum vertical pocket (ultrasound measurement of the amniotic fluid) greater than 8 cm (prior to 20 weeks) and 10 cm (after 20 weeks) around the recipient twin.
  • Low fluid (oligohydramnios), which is defined as a maximum vertical pocket (ultrasound measurement of the amniotic fluid) of less than 2 cm around the donor twin.
  • No bladder visualized by ultrasound in the donor twin.

Patients with the following situations may not be suitable for laser photocoagulation in TTTS:

  •       Pre-term labor with a short or open cervix.
  •    Previous septostomy (procedure described under alternative treatments).
  •    Abnormal genetic studies.
  •    Ruptured membranes.
  •    Infection in the amniotic fluid (chorioamniotis).
  •    Maternal carriage of Hepatits B or C infection.
  •    Maternal carriage of HIV infection.
What other treatments options are available?

Besides Laser Photocoagulation, there are a few other options for treatment of TTTS.  The best treatment option is based upon each individual case and individual's preference.

  • Serial Amnioreduction
An amnioreduction is the removal of the excessive fluid from around the recipient twin using a needle directed by ultrasound imaging.  The purpose of this procedure is to remove excess amniotic fluid from the recipient's sac in order to prevent premature birth or miscarriage.  This procedure can be done in the Maternal Fetal Medicine office and should be readily available in most sites.  Because this approach does not treat the underlying cause of TTTS, the excessive fluid may return, resulting in the need for multiple amnioreductions, or serial amniocentesis (the act of withdrawing amniotic fluid).  This technique may be useful for milder cases of TTTS occuring later in pregnancy, and is often recommended in these cases.  It is generally not effective in severe, or early (prior to 20 weeks) cases.  Generally, the need for multiple procedures has been shown to result in a 40-60% survival rate of at least one of the twins, with approximately 25% of the surviviors mentally handicapped.

 

  • Selective Cord Coagulation

Umbilical cord coagulation is an endoscopic technique that involves using energy to interrupt the flow of blood through the umbilical cord of one of the babies.  By stopping the blood flow to one of the twins, the communication between the babies is severed.  The advantage of this procedure is that the communication between the babies is definite; thereby eliminating the chance of survival for one of the twins.  The remains of this baby stay inside the uterus for the duration of the pregnancy.  Generally this option is most suitable for pregnancies in which there are other issues with one twin beyond the scope of TTTS.

     

 

 

What is Laser Photocoagulation?
 
Laser photocoagulation is the use of laser energy to seal the communicating blood vessels on the surface of the placenta.  The prevents the donation of blood and nutrients from one twin to the other. 
 
How is it done?
 
Under local/spinal anesthesia, a tiny incision is made in the skin so that a very small camera (fetoscope) can be inserted into the uterus.  Through this camera, the vessels on the surface of the placenta can be visualized.  The connecting blood vessels are identified and then "coagulated" using laser light from a small fiber alongside the camera.  This surgery is performed in an operating room and takes approximately 30-60 minutes.  This procedure is done at Evergreen Hospital Medical Center by Martin Walker, MD and Bettina Paek, MD.
 
What are the results?  
 
Without treatment, 80-100% of patients with TTTS lose the entire pregnancy.  With laser photocoagulation, we have found that 90% of our patients have at least one survivor and 60-70% of our patients have two survivors.  And sadly, in 10% of our cases, the entire pregnancy is lost.
 
What are the risks?
  • Infection of the amniotic cavity may occur.  Antibiotics are given in an attempt to avoid this complication.
  • Bleeding in the mother and/or the babies, can prevent the completion of the procedure. Extremely small instruments (2-3 mm) are used to decrease the amount of bleeding. However, if the bleeding is very heavy, an abdominal skin incision may be needed to stop it.  In extreme cases, the bleeding could be so heavy that the uterus must be removed in order to control the bleeding.  In this situation, the mother would not be able to have any more children.  
  • Injury to the mother or to the babies may occur from the procedure. Ultrasound is used as a guide throughout the procedure to help to prevent injury from occurring.
  • Premature labor or leakage of amniotic fluid may happen as a result of the surgery. The smallest instruments possible are utilzed to help minimize this risk. In addition, medications are given to relax the uterus and reduce the chance of contractions.
  • Miscarriage or Fetal death may occur as a result of this procedure.
Who is suitable for Laser Photocoagulation?
 
Pregnancies affected by TTTS are considered appropriate for laser photocoagulation when they exhibit ALL of the following:
  • Single placenta (Monochorionic) twin or triplet pregnancy.
  • Excessive fluid (polyhydramnios), which is defined as a maximum vertical pocket (ultrasound measurement of the amniotic fluid) greater than 8 cm (prior to 20 weeks) and 10 cm (after 20 weeks) around the recipient twin.
  • Low fluid (oligohydramnios), which is defined as a maximum vertical pocket (ultrasound measurement of the amniotic fluid) of less than 2 cm around the donor twin.
  • No bladder visualized by ultrasound in the donor twin.

Patients with the following situations may not be suitable for laser photocoagulation in TTTS:

  •       Pre-term labor with a short or open cervix.
  •    Previous septostomy (procedure described under alternative treatments).
  •    Abnormal genetic studies.
  •    Ruptured membranes.
  •    Infection in the amniotic fluid (chorioamniotis).
  •    Maternal carriage of Hepatits B or C infection.
  •    Maternal carriage of HIV infection.
What other treatments options are available?

Besides Laser Photocoagulation, there are a few other options for treatment of TTTS.  The best treatment option is based upon each individual case and individual's preference.

  • Serial Amnioreduction
An amnioreduction is the removal of the excessive fluid from around the recipient twin using a needle directed by ultrasound imaging.  The purpose of this procedure is to remove excess amniotic fluid from the recipient's sac in order to prevent premature birth or miscarriage.  This procedure can be done in the Maternal Fetal Medicine office and should be readily available in most sites.  Because this approach does not treat the underlying cause of TTTS, the excessive fluid may return, resulting in the need for multiple amnioreductions, or serial amniocentesis (the act of withdrawing amniotic fluid).  This technique may be useful for milder cases of TTTS occuring later in pregnancy, and is often recommended in these cases.  It is generally not effective in severe, or early (prior to 20 weeks) cases.  Generally, the need for multiple procedures has been shown to result in a 40-60% survival rate of at least one of the twins, with approximately 25% of the surviviors mentally handicapped.

 

  • Selective Cord Coagulation

Umbilical cord coagulation is an endoscopic technique that involves using energy to interrupt the flow of blood through the umbilical cord of one of the babies.  By stopping the blood flow to one of the twins, the communication between the babies is severed.  The advantage of this procedure is that the communication between the babies is definite; thereby eliminating the chance of survival for one of the twins.  The remains of this baby stay inside the uterus for the duration of the pregnancy.  Generally this option is most suitable for pregnancies in which there are other issues with one twin beyond the scope of TTTS.

     

 

Laser Photocoagulation | Alternative Treatments for TTTS | RadioFrequency Ablation (RFA) | Cord Coagulation/Transection
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