Advanced Procedure Helps Bring Healthy Twins into the World

Advanced Procedure Helps Bring Healthy Twins into the World

Froedtert Today August 2014: IMPOSSIBLE

As seen in: Froedtert Today August 2014: IMPOSSIBLE
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Pregnancy can be an exciting and also challenging time. Heather and Adam Hanson of Appleton were surprised but thrilled when they learned they were pregnant with identical twin boys.

“We were so excited to be having two more boys,” said Heather, who also has an older son, Eli.

But after an 18-week ultrasound, the couple’s outlook shifted.
“We went from happy to confused and scared,” she said, upon learning that one of the babies was significantly smaller than the other, and it was likely because of a rare and fetal life-threatening condition known as twin-to-twin transfusion syndrome.

Rare Condition

“TTTS is a disease of the placenta, the organ through which a fetus receives nourishment,” explained Erika Peterson, MD, a maternal fetal medicine specialist. During the development of identical twins who share one placenta, which is about two-thirds of pregnancies with multiples, there are blood vessels that connect their blood circulations. If TTTS develops, the blood flows unevenly, with one fetal twin receiving too much blood and one receiving too little. The smaller twin is denied the nutrients he or she needs to grow, and it causes a strain on the larger twin’s heart to the point that it may develop heart failure. “The events in pregnancy that lead to TTTS can happen any time during the pregnancy,” Dr. Peterson said. “It’s not genetic nor caused by anything the parents did or did not do.”

Specialty Care

TTTS was unusual enough that Heather turned to the Fetal Concerns Center of Wisconsin, a joint effort of Children’s Hospital of Wisconsin and Froedtert & the Medical College of Wisconsin. Heather learned that not only was treatment available at the center, but the first surgical treatment in the nation for TTTS was performed there. Today, the surgery is available at fewer than 25 centers in the United States.

The Fetal Concerns Center of Wisconsin offers mothers and their fetuses a comprehensive team approach to care for complex conditions like TTTS and can involve numerous specialties all working together. The center’s team of experts partners with families and referring providers to develop comprehensive, personalized, maternal and fetal plans of care. They care for mothers and fetuses that are critically ill, have birth defects and those requiring lifesaving surgery or treatment during or after pregnancy. All care is coordinated through a specially trained nurse coordinator who arranges services and provides ongoing information before and after the birth.

Regular Ultrasound

Heather’s condition was found to be mild enough to forgo immediate treatment, but she was cautioned that things could change quickly. She was prescribed bed rest and twice-weekly ultrasounds with Randall Kuhlmann, MD, PhD, a maternal fetal medicine specialist and program director of the center, who also sees patients in Appleton. During her first visit with Dr. Kuhlmann, the ultrasound showed a change.

“The larger twin, or recipient baby, had too much fluid and the other ‘donor baby’ had decreased fluid,” Dr. Kuhlmann said. “I couldn’t see the donor baby’s bladder, which suggested he was not making enough urine, and there were some abnormal blood flow patterns in the placenta.” Dr. Kuhlmann immediately arranged for Heather to have TTTS surgery, with the fetuses at 21 weeks gestation.

“We didn’t want to look back on our decision and have regrets about not trying,” Heather said. “Even if we didn’t have a positive outcome, we at least did everything we could to help our children.”

TTTS Surgery

“The laser procedure is most often conducted between 16 and 26 weeks of pregnancy, and it seals off the shared blood vessels between twins,” said Amy Wagner, MD, Children’s Hospital of Wisconsin pediatric surgeon. “This is a critical time early in the pregnancy because babies are immature and cannot be delivered. Without treatment, most would not survive.” The surgery is offered through the Fetal Concerns Center, and care is coordinated between the center and the hospital where the mother plans to deliver.

“We were so relieved and so happy to have made it through that hurdle,” said Heather. After a few nights in the hospital, Heather returned home and followed up weekly in Dr. Kuhlmann’s office for ultrasounds and growth measurements. The hope was to get the twins to at least 26½ weeks gestation, with an ultimate goal of 32 weeks. All the while, Heather remained on bed rest.

Special Delivery

At 29½ weeks, Heather went into labor and spent a week on hospitalized bed rest in Appleton before giving birth to beautiful twin boys, Evan and Owen. The boys spent 9½ weeks in the neonatal intensive care unit before Heather and Adam were able to take them home. With Evan weighing 5 pounds, 15 ounces, and Owen at 8 pounds, 8 ounces, the babies faced remarkably few complications.

Today, like most toddlers, they happily climb, giggle and play with their big brother.

Importance of Ultrasounds

An ultrasound performed during the first three months of pregnancy can reveal if you are having multiples, and the number of placentas can be determined accurately as early as seven menstrual weeks. If the placenta is single, or monochorionic, your pregnancy is at risk for TTTS. “The key question is if the placenta is shared or not,” said Randall Kuhlmann, MD, PhD, maternal fetal medicine specialist. In those cases, your perinatologist will recommend ongoing ultrasounds:

  • From week 16 of pregnancy through delivery
  • Every two weeks to as frequently as twice weekly
  • Whether you are diagnosed with TTTS or not, because the condition can develop at any time during that period