Race Against Time: Innovative Treatment Saves Girls with Twin-to-Twin Transfusion Syndrome

Chelsea Donley was at a sixteen-week prenatal appointment when she learned from her physician at University of Florida (UF) Health Jacksonville that the twins she was carrying suffered from twin-to-twin transfusion syndrome (TTTS).

TTTS is a rare but serious complication that occurs in about 15% of monochorionic multiple pregnancies. It is characterized by an imbalance of blood flow between the donor and recipient twin, causing one to become hypervolemic and the other hypovolemic. TTTS is associated with very high perinatal morbidity and mortality rates and requires immediate intervention to increase the chances of survival.

That intervention is a highly specialized procedure — fetoscopic laser photocoagulation (FLP). Few centers have the expertise and experience performing the surgery. Donley’s physician referred her to the state-of-the-art Tampa General Hospital (TGH) and USF Heath Fetal Care Center. Sarah Običan, MD, division director of Maternal-Fetal Medicine at TGH and an associate professor in the Department of Obstetrics and Gynecology at USF Health, and center co-director Alejandro Rodriguez, MD, have handled numerous TTTS cases and are highly skilled at FLP.

The complex, delicate surgery is intended to selectively and sequentially ablate the placental connective vessel to equalize the flow of blood and nutrients to each fetus. The operation increases the chances of survival for both twins to roughly 60%, and one of the twins to 80%-85%. However, not performing the surgery increases the likelihood that one or both twins would die to 90%.

Dr. Običan, Dr. Rodriguez and their team prepared meticulously, doing scan after scan, before determining the precise spot to make the incision. Given how difficult it can be to find the vessels and how many there may be, there is little time to waste once they insert the scope and laser.

“Once you’re in, you go into the sac of the recipient twin — the one that has a lot of fluid, because that’s the amniotic sac you’re breaching with the scope,” Dr. Običan said. “And you’re looking for a membrane separation, the demarcation line and vascular equator of the shared vessels between the twins.

“After you identify that, you can see the vessels that are crossing on top of the placenta and you’re looking for the vessels that are crossing from one side to the other. Then you must see how many there are and laser them at the correct location where they are merging. And after you do that, you know each baby is getting the maximum amount from the placenta it can.”

Donley underwent a successful FLP at 19 weeks and went on to deliver twin girls at 31 weeks. Both girls are now thriving toddlers. Donley has grown accustomed to comments from strangers when she takes her adorable twins, Madison and Michelle, to the store or for walks in the stroller.

“People always say, ‘Oh you have twins, God bless you,’” she said. “And the first thing I say is, ‘He already did. If I told you my story, you’d understand.’”