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*SPECIAL GUEST* - Dr. Saul Snowise – Part 1 of 2
This week we continue our discussion with Dr. Saul Snowise talking about the role of selective reduction, specifically in the setting of monochorionic twins. This week we'll be covering the following:
Dr. Snowise’s preferred tool/method for selective reduction Selective reduction in the setting of monoamniotic twins with discordant anomalies & cord entanglement Various instruments & equipment used for the different methods of selective reduction How instrument/trocar size affects complication rates Discordant anomalies in monochorionic/identical twins Twin reversed arterial perfusion (TRAP) sequence Rate of occurrence Pathophysiology/disease process Optimal timing for fetal intervention/surgery Selective reduction for sIUGR Patient counseling and informed consent Laser ablation as treatment for sIUGR Effects of legislation and the overturning of Roe v. Wade on selective reduction as a treatment option in pregnancy -
*SPECIAL GUEST* - Dr. Saul Snowise – Part 1 of 2
This week and next week we have a two-part series with Dr. Saul Snowise as we discuss the role of selective reduction, specifically in the setting of monochorionic twins. Join us as we discuss the following this week:
How selective reduction differs in monochorionic vs. dichorionic twins Most common method of selective reduction Potassium chloride (KCl) injection contraindicated in monochorionic twins Method for monochorionic pregnancy Cord occlusion Indications for selective reduction in monochorionic twins Selective fetal growth restriction (sIUGR) Discordant anomalies Twin-twin transfusion syndrome (TTTS) Twin reverse arterial perfusion (TRAP) sequence Failed laser Various methods for performing a cord occlusion selective reduction Microwave Interstitial laser Radiofrequency ablation (RFA) Bipolar cautery Sizes of operative instruments, energy levels used and the treatment protocols Gestational age thresholds for performing a selective reduction procedure Risks associated with a selective reduction procedure Membrane complications (i.e. PPROM) Preterm delivery Bleeding, infection Loss of co-twin -
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Welcome back "What they didn't teach you in laser school" – now onto Part 2! This week we’re going to continue talking about all our laser tips & tricks while discussing the following:
Anterior placenta challenges Future of steerable operative scopes Current 30 degree operative Storz scope Using external pressure to aid in flattening the uterus Intraoperative amnioinfusion Intraoperative complications Concurrent fetal bradycardia in both fetuses What to do when the laser won’t stop firing Intra-operative bleeding Post-operative complications Bleeding Placental abruption -
Welcome to "What they didn't teach you in laser school"! This two-parter is going to be filled with Dr. Moise's tips and tricks (and some of Erin's too) as we share the following topics:
Pre-operative evaluation tips Identifying cord insertions via ultrasound Following the lie of the donor twin to find the inter-twin anastomotic plane Not true for “cocoon” sign Re-evaluate and confirm cord insertions and anticipated cannula insertion site in the OR Confirming renal blood flow in the donor twin Renal agenesis Intraoperative tips -
This week we’re going to be using the most recent episodes as building blocks to discuss atypical presentations of twin-twin transfusion syndrome or TTTS. Dr, Moise takes us through the following ‘unicorn’ presentations by covering the following:
Review of the classic Quintero staging system for TTTS Stage I, II, III, IIID, IIIR, IIIDR, IV, V Alternative TTTS staging systems that have been proposed Cincinnati CHOP Case scenario of an atypical TTTS IIID TTTS with sIUGR Review definition of sIUGR Cardiac dysfunction in the setting of monochorionic twins Which combination of twin complications in monochorionic twins would be candidates for laser surgery -
*SPECIAL GUEST* - Dr. Ramesha Papanna – Part 2 of 2
Join us as we continue our discussions on Twin Anemia Polycythemia (TAPS).
This week Dr. Papanna walks us through the following topics on TAPS:
Society of Maternal Fetal Medicine (SMFM) and International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) guidelines and recommendations for monitoring MCA Dopplers in monochorionic twins Laser ablation of placental anastomoses as treatment for TAPS Transabdominal approach Role of Solomon technique / solomonization in TAPS Disease severity and clinical indications for laser as treatment for TAPS Intrauterine Transfusion (IUT) or exchange transfusion as treatment options for TAPS -
*SPECIAL GUEST* - Dr. Ramesha Papanna – Part 1 of 2
Join us as we head down another aisle of Twins R’ Us but this time with a very special guest who is joining us for this two-part series on Twin Anemia Polycythemia Sequence (TAPS)!
This week Dr. Papanna walks us through the following topics on TAPS:
Defining TAPS Pathophysiology of TAPS Difference between spontaneous TAPS and TAPS after a laser for TTTS How TAPS is detected Rate of occurrence of TAPS in monochorionic twin pregnancies The original definition and staging of TAPS from the Leiden group in 2007 -
We know many of you tuned in eager to hear a big clinical research update that we've been so excited to share! That episode will be coming down the pipeline soon but unfortunately will not be released today.
Stay tuned for an episode later today as we travel down the TAPS aisle of Twins R' Us with Dr. Ramesh Papanna!
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We're heading down the Taco Aisle at Twins R' Us this week as we dive into sIUGR also known as selective intrauterine growth restriction. Join us this week as we discuss the following:
Defining sIUGR in monochorionic twins Must meet at least two of the following four criteria Smaller twin must be less than 10th percentile for EFW by ultrasound And/Or the smaller twin’s AC must be less than 10th percentile for gestational age More than 25% difference of smaller twin and the bigger twin EFW UA Doppler of the smaller twin has a pulsatility index greater than 95th percentile for gestational age Doppler measurements and why we do them UA Doppler – surrogate marker for placental resistance & placental territory or how much placenta each baby has Pulsatility index = (systolic velocity – diastolic velocity) / mean AEDF – high resistance in the placenta REDF – if the blood ‘bounces’ off the placenta from the UA Defining sIUGR in dichorionic twins Must meet at least two of the following three criteria Smaller twin must be less than 10th percentile for EFW by ultrasound More than 25% difference of smaller twin and the bigger twin EFW UA Doppler of the smaller twin has a pulsatility index grea ter than 95th percentile for How often sIUGR occurs in monochorionic twins The three subtypes of sIUGR described by Dr. Eduard Gratacos & their rate of occurrence Type 1 – positive EDF in smaller twin 29% of sIUGR cases Type 2 – Absent or reversed EDF in smaller twin 22% of sIUGR cases Type 3 – Absent or reversed EDF in smaller twin alternating with positive diastolic flow 49% of sIUGR cases The placental vessel anastomoses types & their frequency in each subtype of sIUGR Arterial to arterial (AA) Arterial to venous (AV) Venous to arterial (VA) Venous to venous (VV) ‘Spiders’ Umbilical artery cord Doppler physiology differences between singleton pregnancies and monochorionic twin pregnancies Ductus venosus Doppler as surrogate marker for fetal cardiac function Defining a cotyledon Outcomes based on sIUGR subtypes Typical gestational age at delivery for each subtype Management, possible complications & outcomes for each subtype of sIUGRGlossary of Abbreviations
sIUGR – selective intrauterine growth restriction FGR – fetal growth restriction SGA – small for gestation -
Introducing our newest segment - Great Syndromes! Modeled after Erin's PA school course developed to prepare healthcare students for clinical rotations, this segment utilizes real case scenarios to help guide diagnostic and treatment guidelines for patients in the setting of fetal medicine.
This week our case is a 34-year-old G10 P7 who presents at 23 weeks and 4 days with a referring diagnosis of monochorionic diamniotic twin gestation with Stage II twin-twin transfusion syndrome (TTTS). Her placenta is posterior and the maximum vertical pocket (MVP) of the 'recipient' twin sac is 22.0 cm. In this episode we'll discuss some of the following points:
Differential diagnoses for polyhydramnios in pregnancy Maternal gestational diabetes Anatomical fetal anomalies Upper GI tract obstructions Esophageal atresia Duodenal atresia Tracheoesophageal fistula (TEF) Arthrogryposis multiplex Twin-twin transfusion syndrome causes hypervolemia in the recipient twin and therefore increase urine output Post-procedure tocolytic options nifedipine vs. indomethacin How placental location affects surgical approach in TTTS -
*SPECIAL GUEST* - Dr. Yves Ville – Part 2 of 2
This is an episode we recorded at the 2023 SMFM Conference back in February. Our special guest, Dr. Yves Ville, returns this week to continue our discussion about his role and contributions to the field of fetal surgery and specifically twin-twin transfusion syndrome. In part 2 we go through the following:
Outcomes on survivors of both fetuses, one fetus or loss of both fetuses Laser surgery becomes accepted as evidence-based treatment as a result of the randomized controlled trial Intraoperative techniques: Selective vs. Nonselective Solomon Complications of a failed laser surgery Dr. Ville’s describes his contributions in research on offering laser surgery for Stage I TTTS and how he counsels these patients Dr. Ville’s research in short cervix and treatment options in the setting of TTTS -
*SPECIAL GUEST* - Dr. Yves Ville – Part 1 of 2
This is an episode we recorded at the 2023 SMFM Conference back in February. Our special guest this week, Dr. Yves Ville, sat down with us to talk about his role and contributions to the field of fetal surgery and specifically twin-twin transfusion syndrome. In part 1 we go through the following:
Dr. Ville’s training and the events that led up to him entering the field of fetal medicine Dr. Ville’s experience with laser surgery for twin-twin transfusion syndrome (TTTS) The 2004 randomized trail study comparing laser surgery to amnioreduction for TTTS Why the trial was stopped earlyTune in next week when we continue our conversation with Dr. Ville on the outcome studies and editorials that were published after his 2004 study.
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*SPECIAL GUEST* - Dr. Michael Bebbington.
This week Dr. Bebbington joins us to talk about the background of twin-twin transfusion syndrome (TTTS) as he covers the following topics:
Pathophysiology of twin-twin transfusion syndrome (TTTS) ‘Donor’ twin vs. ‘Recipient’ twin Types of vessel anastomoses involved in TTTS AA – artery to artery VV – vein to vein AV – artery to vein VA – vein to artery Pathophysiology of the polyhydramnios and oligohydramnios seen in TTTS Assessing Dopplers in-utero using ultrasound and the different fetal vessels Doppler is used on Defining the Quintero stages of TTTS (I through V) Stage I – “Poly” & “Oli” Donor DVP <2.0 cm Recipient MVP >8.0 cm Stage II – No visible bladder in donor twin Stage III – Doppler abnormalities in one or both twins (Stage IIID, IIIR, IIIDR, and ‘Atypical Stage III) Absent/reversed end diastolic flow in umbilical artery (UA) Absent/reversed ‘a’ wave in ductus venosus (DV) Umbilical vein (UV) pulsations Stage IV – Hydrops in one or both twins Stage V – Demise of one or both twins Risk of demise of both fetuses and physiological changes in the surviving twin should one twin die in-utero Atypical presentations of TTTS Why we use maximum vertical pocket (MVP) or deepest vertical pocket (DVP) to quantify fluid in twins over an amniotic fluid index (AFI) Adjuvant TTTS staging systems Frequency and rate of occurrence of TTTS in monochorionic pregnancies Prognosis, survival and outcomes of TTTS with and without treatment Frequency of surveillance for TTTS in monochorionic pregnancies How a laser surgery is performed for treatment of TTTS Solomon technique Recurrent TTTS and TAPS are complications of incomplete laser surgeries Amnioreduction at the end of the procedure to remove extra fluid from the recipient twin amniotic sac Pre-operative counseling for the patient and common complications that can occur during or after a laser procedure Gestational age at which a laser ablation of placental anastomoses typically occurs Follow-up after a laser surgery Factors associated with poorer prognosis or poorer survival rates Average gestational age of delivery after a laser surgery Training programs for learning to do laser surgery for TTTS The role of selective reduction in TTTS Implications laser surgery can have on future pregnancies for patients Risk of developing TTTS in a subsequent pregnancy -
We’re talking through the season six premiere of The Resident, where they take on a twin-twin transfusion case. We debunk and verify all myths and truths depicted in this episode surrounding the counseling, diagnosis, management, and even laser surgery itself from this episode.
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This episode is dedicated to the late Dr. Julian De Lia whom we lost in November 2022. Dr. De Lia was truly one of the greatest fetal surgery pioneers, particularly in the TTTS.
Welcome back to Twins R Us! This week we’re going to talk about the history of twin-twin transfusion syndrome (TTTS) and the history of treatment for the disease.
Dr. Moise will take us through the following topics in this episode:
The discovery of pathophysiology of TTTS Idea of the ‘Third Circulation’ Berniske’s proposed phenotype Placental injection studies The fetal loss rate of TTTS without treatment Early treatment attempts Weekly amnioreductions Septostomy trial The early use of laser therapy to treat TTTS in-utero during the early 1908s by DeVore and De Lia Laser technique variation and development by country The development of the Quintero Staging system Initial trials and implementation of evidence-based laser therapy for TTTS Karl Storz endoscopy develops fetoscopes for laser surgery under HDE in the US Discussions and support from national & international societies Major changes in laser techniques since its initial introduction into fetal surgery -
We’re back on scheduled wombmates! This week we’re talking about management of twin pregnancies as Dr. Moise takes us through the following topics:
The role of ultrasound in twin pregnancies CRL = Crown Rump Length for dating Chorionicity determination Transvaginal cervical length measurement Importance of the 18-20 week anatomy scan and fetal echocardiogram Ultrasound monitoring based on chorionicity Dichorionic pregnancies should be followed every 3 to 4 weeks with a growth scan ultrasound Monochorionic pregnancies should begin regular ultrasound monitoring at 16 weeks gestation Every 2 weeks – measurements of fluid levels and fetal bladders Then at 20 weeks ISUOG says to start monitoring umbilical artery (UA) and middle cerebral artery (MCA) Dopplers during regular growth scans Discordant anomalies and their rate of occurrence in twin pregnancies Screening for chromosomal problems Cell free DNA (cffDNA) – consider vanishing twin as source of abnormal result Nuchal translucency with analytes Maternal complications in twin pregnancies & how they are managed prenatally Timings & method of delivery for twin pregnancies Treatment options for short cervix in twin pregnancies Antenatal testing in twin pregnancies and when to start Management of monoamniotic twin pregnancies -
We're kicking off a new series on all things twins! Welcome to Twin 'R' Us where we will introduce the following in this episode: Prevalence & rate of occurrence of twins in general and the different types The different types in twins in terms of zygosity Identical – monozygotic Fraternal – dizygotic Rare fraternal twin occurrences: Superfetation Heteropaternal superfecundation Factors that affect a women’s risk of twinning Monozygotic – chance of nature Dizygotic Genetics Diet IVF Ethnicity Zygosity vs. Chorionicity and why the difference is important Monochorionic vs. dichorionic and why chorionicity matters How embryologic age affects chorionicity Importance of ultrasound in twin pregnancies Determining chorionicity: ‘Lambda’ sign ‘T’ sign Dating t
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No new episode today wombmates! We've had a busy clinic the last couple of weeks and Erin is heading out on vacation, but stay tuned for new content to drop later in the week!
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Before we enter our next series on twins, we wanted to go give some background on fetal centers and what they are. In this episode we’ll discuss some basic background on fetal centers, fetal therapies, and fetal medicine by covering the following:
Types of cases seen at a fetal center: 70% anomalies with coordination of care 20% fetal surgery or fetal intervention 10% life-limiting anomalies As of early 2023 there are currently about 37 fetal centers in the United States Of which about 14 are about to provide full fetal center services How national organizations have defined fetal centers The development of NAFNET – North American Fetal Treatment Network Full list of fetal interventions IUTs – Intrauterine Transfusion Lasers for twin-twin transfusion syndrome In-utero myelomeningocele / spina bifida repair Tracheal occlusion for congenital diaphragmatic hernia Which physician specialty specialties typically serve as director or head of fetal centers How the MOMS trial influenced the development and definition of fetal centers OB center & NICU center level designations (I, II, III, IV) Fetal center level designations (I, II, III) Legislature and committees that have formed to help create guidelines for fetal centers Areas the -
*SPECIAL GUEST* - Dr. Jacqueline Vidosh
In honor of Edwards Syndrome Awareness Day, March 18th, we're dropping Part 2 of our interview with Dr. Vidosh a little bit early.
Dr. Vidosh is a practicing OBGYN and proud Mother of a baby boy, Noah, diagnosed with Edwards Syndrome. This week she talks a bit more about Noah's early life and childhood as she continues her story.
Resources:
Support Organization For Trisomy (SOFT)
Trisomy 18 Foundation
- Visa fler
