Twins saved by surgery before birth

Jo with her twins Amy and Maddy.
Jo with her twins Amy and Maddy. Photo: Eddie Jim

Just 15 weeks into her first pregnancy and carrying twins, Jo and husband Troy were given a terrible choice: terminate the pregnancy, or have surgery on the twins in utero in an attempt to save their lives.

The problem, which had been discovered just a week earlier, was twin to twin transfusion syndrome, a potentially fatal condition in which one twin "donates" blood to the other, causing one to have insufficient blood for the proper functioning of organs, while the other becomes overloaded with blood, putting a dangerous strain on the heart.

In this case there was the added problem that the babies were not sharing the placenta equally, so one was much larger than the other.

Surgery on the twins was performed in utero in an attempt to save their lives.
Surgery on the twins was performed in utero in an attempt to save their lives. Photo: Eddie Jim

Jo had been referred to twin-specialist obstetrician Stephen Cole. He is one of six doctors at the Victorian Fetal Therapy Service, a collaboration between the state's three tertiary maternity hospitals: the Women's, Monash Medical Centre and the Mercy Hospital for Women.

Laser surgery for twin-to-twin transfusion has been performed in Victoria for only nine years, but the change in the prognosis for babies with the condition has been dramatic: prior to the surgery, there was an overall survival rate of 10 to 15 per cent.

Now, there is an overall survival rate of 65 to 70 per cent, and an 85  to 90 per cent chance that at least one twin will survive.

Twin-to-twin transfusion is still fairly rare: it occurs only in identical twin pregnancies, at a rate of about 10 to15 per cent. Of those, not all will require surgery, but sometimes it is the only way to save the babies' lives. The team performs about 20 procedures in Victoria every year.

To treat twin-to-twin transfusion, doctors insert a telescope through the mother's abdomen and her uterus to the placenta. On the surface of the placenta are blood vessels that send blood between the babies: the doctors identify which of those are flowing only one way and laser them, effectively sealing them over.

"So those communicating vessels are no longer functioning, and we essentially try to separate the circulations of the two babies," Dr Cole says. "Once we've done that, the body's normal regulatory systems take over."

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While twin-to-twin transfusion is the most common condition treated by fetal surgery, there are hopes it may soon be used to treat other conditions.

For example, surgery for diaphragmatic hernia, in which there is a hole in the baby's diaphragm that can cause the lungs to become compressed, is being trialled in Queensland and around the world, while Monash Medical Centre's team, headed by Mark Teoh, is working on new in-utero treatments for heart conditions.

Overseas, doctors have operated on babies with spina bifida during the pregnancy in an effort to improve the outcome for the child.

Sue Walker from the Mercy Hospital says any surgical intervention during pregnancy has to be carefully weighed against possible risks, not just to the baby but also to the mother, which is why advances in the field take a long time.

"I can see that sometimes it looks like progress is slow, but that is the way it needs to be," Professor Walker says.

For Jo and Troy, the surgery by Dr Teoh and Dr Cole on their twin girls was a success, and the circulatory systems of both babies soon rectified themselves. 

Jo needed an ultrasound each week to check everything was progressing as it should, and at 25 weeks Dr Cole gave them the thrilling news: "He said, 'well, you're in the game now'," she recalls.

But at 26 weeks Jo's membranes ruptured, and at 27 weeks she had been prescribed bed rest at the Women's. She went into labour at 28 weeks and her tiny, but remarkably healthy, twins were delivered: Amy was 1160 grams, and Maddy was just 680 grams.

The girls were cared for in neonatal intensive care, and later at the Freemasons, until they had reached the equivalent of 42 weeks: they are now healthy and strong, meeting all their developmental milestones.