title: Rapid initiation of fetal therapy services with a system of learner-centred training under proctorship: the National University Hospital (Singapore) experience.
abstract: BACKGROUND
  Management of complicated monochorionic twins and certain intrauterine structural anomalies is a pressing challenge in communities that still lack advanced fetal therapy. We describe our efforts to rapidly initiate selective feticide using radiofrequency ablation (RFA) and selective fetoscopic laser photocoagulation (SFLP) for twin-to-twin transfusion syndrome (TTTS), and present the latter as a potential model for aspiring fetal therapy units.
  
  
  METHODS
  Five pregnancies with fetal complications were identified for RFA. Three pregnancies with Stage II TTTS were selected for SFLP. While RFA techniques utilising ultrasonography skills were quickly mastered, SFLP required stepwise technical learning with an overseas-based proctor, who provided real-time hands-off supervision.
  
  
  RESULTS
  All co-twins were live-born following selective feticide; one singleton pregnancy was lost. Fetoscopy techniques were learned in a stepwise manner and procedures were performed by a novice team of surgeons under proctorship. Dichorionisation was completed in only one patient. Five of six twins were live-born near term. One pregnancy developed twin anaemia-polycythaemia sequence, while another was complicated by co-twin demise.
  
  
  CONCLUSIONS
  Proctor-supervised directed learning facilitated the rapid provision of basic fetal therapy services by our unit. While traditional apprenticeship is important for building individual expertise, this system is complementary and may benefit other small units committed to providing these services.
authors.affiliation: Department of Obstetrics and Gynaecology, National University Health System, Singapore.
authors.forename: Arundhati
authors.initials: A
authors.lastname: Gosavi
authors.affiliation: Department of Obstetrics and Gynaecology, National University Health System, Singapore.
authors.forename: Pradip D
authors.initials: PD
authors.lastname: Vijayakumar
authors.affiliation: Department of Anaesthesia, National University Health System, Singapore.
authors.forename: Bryan Sw
authors.initials: BS
authors.lastname: Ng
authors.affiliation: Department of Anaesthesia, National University Health System, Singapore.
authors.forename: May-Han
authors.initials: MH
authors.lastname: Loh
authors.affiliation: Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
authors.forename: Lay Geok
authors.initials: LG
authors.lastname: Tan
authors.affiliation: Department of Reproductive Medicine, KK Women's and Children's Hospital, Singapore.
authors.forename: Nuryanti
authors.initials: N
authors.lastname: Johana
authors.affiliation: Department of Reproductive Medicine, KK Women's and Children's Hospital, Singapore.
authors.forename: Yi Wan
authors.initials: YW
authors.lastname: Tan
authors.affiliation: Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
authors.forename: Dedy
authors.initials: D
authors.lastname: Sandikin
authors.affiliation: Department of Obstetrics and Gynaecology, National University Health System, Singapore.|Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
authors.forename: Lin Lin
authors.initials: LL
authors.lastname: Su
authors.affiliation: Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine, Siriraj Hospital, Bangkok, Thailand.
authors.forename: Tuangsit
authors.initials: T
authors.lastname: Wataganara
authors.affiliation: Department of Obstetrics and Gynaecology, National University Health System, Singapore.|Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
authors.forename: Arijit
authors.initials: A
authors.lastname: Biswas
authors.affiliation: Department of Obstetrics and Gynaecology, National University Health System, Singapore.|Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
authors.forename: Mahesh A
authors.initials: MA
authors.lastname: Choolani
authors.affiliation: Department of Obstetrics and Gynaecology, National University Health System, Singapore.|Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
authors.forename: Citra Nz
authors.initials: CN
authors.lastname: Mattar
mesh_terms: D017115:Catheter Ablation / Q000379:methods; D004502:Education, Medical, Continuing / Q000379:methods* / Q000458:organization & administration; D005260:Female; D046128:Fetal Therapies; D005330:Fetofetal Transfusion / Q000628:therapy; D005332:Fetoscopy / Q000193:education; D006785:Hospitals, University / Q000458:organization & administration; D006801:Humans; D053685:Laser Therapy / Q000379:methods; D011247:Pregnancy; D059285:Pregnancy, Twin; D012846:Singapore
keywords: fetoscopy; learner-centred training; proctorship; selective feticide; twin-twin transfusion syndrome