MANAGEMENT OF A CASE OF TWIN-TO-TWIN TRANSFUSION SYNDROME BY A COMBINED SURGICAL APPROACH

Objective: The management of a case of severe twin-to-twin transfusion syndrome at 24 weeks of gestation is presented, using a combined surg ical and medical approach. Methods: Operative fetoscopy was used to co agulate placental vessels crossing the intertwin membranes. Repeated i ntrauterine transfusions were used to correct recurrent anemia in the donor twin. Selective three-dimensional placental angiography and dire cted histological analysis were used to study the placenta after deliv ery, Results: Resolution of twin-to-twin transfusion syndrome was obta ined by coagulation of placental anastomoses, but was followed by recu rrent anemia in the donor twin. This was successfully treated by seria l intrauterine blood transfusions, and 2 healthy twins were delivered at 31 weeks of gestation. One artery-to-vein anastomosis was demonstra ted to be the only communication left between the two circulations. Co nclusions: This case illustrates the limitations of placental surgery in twin-to-twin transfusion syndrome and highlights the need for ultra sound and Doppler follow-up of these high-risk fetuses to indicate fur ther treatment, Placental anastomoses can be overlooked by macroscopic examination and injection technique, but can be demonstrated by place ntal angiography.