Fetal Surgery-Twin-Twin Transfusion Syndrome

Fetal Surgery-Twin-Twin Transfusion Syndrome

  • Twin-twin transfusion syndrome occurs when twins share one placenta (monochorionic). Abnormal placental vascular connections allow one twin to pass blood from itself ("donor") to the other fetus ("recipient"), often resulting in growth retardation in the donor twin and oligohydramnios in the recipient twin. Without intervention, mortality is high.
  • In this procedure, the abnormal placental vasculature is coagulated with a laser on the end of a fetoscope. Current anesthetic practice for these patients includes:
  • Adequate counseling and preparation for the mother. Clearly defining plans and risks preoperatively reduces anxiety.
  • Rectal indomethacin is given preoperatively by nursing on 15 L to provide preoperative tocolysis
  • We generally place a spinal anesthetic, using 12mg of hyperbaric bupivicaine; no narcotic. Alternatively the surgeon can give local anesthetic.
  • We often begin a phenylepherine gtt with spinal placement at 35 mcg/min.
  • Following spinal placement, employ left uterine displacement
  • Minimal or conscious sedation may be delivered to ensure maternal comfort; however moderate to deep sedation should be avoided due to the risk of aspiration.
  • If the mother does not tolerate the procedure with minimal sedation, general anesthesia can be induced. A rapid sequence induction with propofol and succinylchlorine should be used.
  • In case of uterine contractions during/after the procedure, IV nitroglycerine 50-200mcg can be given to promote uterine relaxation. Phenylepherine infusion or ephedrine can be given to counteract nitroglycerine-induced hypotension as needed to maintain MAP within 10% of baseline or minimally >65mmHg and ensure adequate placental perfusion
  • Laser glasses worn whenever the laser is used
  • Patients recover on 15L; transport with a proPAC/pulse ox.
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This information is meant to serve as an educational resource. Clinicians should use their own professional judgment in the care of any individual patient as the guidance contained in this document may not be appropriate for all patients or all situations.