Twinning Unicorns – Atypical Presentations of TTTS

The Role of Selective Reduction - Part 2

*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

The Role of Selective Reduction - Part 1

*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 *

What they didn't teach you in laser school - Part 2

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 *

What they didn't teach you in laser school - Part 1

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 *

Twinning Unicorns – Atypical Presentations of TTTS

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 *