Doctors save baby in complex rare monoamniotic twin pregnancy

PUNE City doctors successfully performed “bipolar cord occlusion followed by in-utero cord transection” procedure to save a baby in a complex rare case of monoamniotic twins. This procedure is the third case in India involving such two staged interventions in monoamniotic twins, doctors said on Saturday.
A 21-week pregnant mother, a nurse from Satara district was diagnosed with monoamniotic twins.
Monoamniotic twins are identical twins that share an amniotic sac and placenta and is a rare type of twin pregnancy. Due to one placenta, these babies have a vascular connection called anastomosis and blood flows from one baby to another and vice-versa putting both babies at risk of fatality.
The team of doctors at KEM hospital comprised—Dr Manikandan K, fetal surgeon and fetal medicine consultant, fetal medicine expert, Dr Shweta Gugale and gynaecologist Dr Xerxes Coyaji. Also, Shreepad Karhade, head and associate consultant, fetal medicine, Dr Ashwini Jaybhaye and Dr Pooja Pable were part of the team.
Dr Gugale said, “One baby was extremely small while the other baby was developing normally. The small one had a depleting blood supply which would eventually stop. But due to the vascular connection, the normally developing baby would start giving its blood to the other one. This would ultimately lead to total pregnancy loss.”
As per the doctors, the normally developing baby was also at high risk and without a bipolar cord occlusion procedure on the small co-twin, the chances of survival of the normal twin become very low in such a situation.
The team performed a two-stage procedure. In the first step, bipolar forceps were used to coagulate the umbilical cord of the abnormal twin, stopping its blood supply. Later, with fetoscopy-guided laser technology, the doctors cut the cord to prevent further complications like cord entanglement. This results in a sacrifice of the abnormal twin hence increasing the chances of survival of co-twin, they said.
The clinical management of these pregnancies is challenging, there is a high risk of unexpected fetal death (up to 15–20%) and or a high risk of brain injury in the surviving co-twin.
“The first 24 hours are extremely crucial for the co-twin. A Doppler test post-24-hour observation was normal, and the mother’s follow-up scans indicated a healthy pregnancy,” added, Dr Gugale.
Dr Karhade, said, that addressing such rare and complicated cases requires a tertiary setup with a multidisciplinary approach. “With the available state-of-the-art facilities at Hospital for Reproductive Health we have successfully handled 25 high-risk fetal interventions, including this rare case,” he said.
Apart from the procedure itself, the most challenging part is counselling the family, they said.