title: Management of a case of twin-to-twin transfusion syndrome by a combined surgical approach.
abstract: OBJECTIVE
  The management of a case of severe twin-to-twin transfusion syndrome at 24 weeks of gestation is presented, using a combined surgical and medical approach.
  
  
  METHODS
  Operative fetoscopy was used to coagulate placental vessels crossing the intertwin membranes. Repeated intrauterine transfusions were used to correct recurrent anemia in the donor twin. Selective three-dimensional placental angiography and directed histological analysis were used to study the placenta after delivery.
  
  
  RESULTS
  Resolution of twin-to-twin transfusion syndrome was obtained by coagulation of placental anastomoses, but was followed by recurrent anemia in the donor twin. This was successfully treated by serial intrauterine blood transfusions, and 2 healthy twins were delivered at 31 weeks of gestation. One artery-to-vein anastomosis was demonstrated to be the only communication left between the two circulations.
  
  
  CONCLUSIONS
  This case illustrates the limitations of placental surgery in twin-to-twin transfusion syndrome and highlights the need for ultrasound and Doppler follow-up of these high-risk fetuses to indicate further treatment. Placental anastomoses can be overlooked by macroscopic examination and injection technique, but can be demonstrated by placental angiography.
authors.affiliation: Fetal Medicine Unit, Hôpital A. Beclère, Clamart, France.
authors.forename: P
authors.initials: P
authors.lastname: Van Peborgh
authors.forename: G
authors.initials: G
authors.lastname: Pelletier
authors.forename: B
authors.initials: B
authors.lastname: Suarez
authors.forename: Y
authors.initials: Y
authors.lastname: Ville
mesh_terms: D000328:Adult; D000740:Anemia / Q000209:etiology / Q000628:therapy; D000792:Angiography; D001805:Blood Transfusion, Intrauterine; D005260:Female; D005315:Fetal Diseases / Q000628:therapy; D005330:Fetofetal Transfusion / Q000601:surgery* / Q000628:therapy; D005332:Fetoscopy; D005865:Gestational Age; D006801:Humans; D010920:Placenta / Q000098:blood supply; D011247:Pregnancy; D011256:Pregnancy Outcome