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Dear Editor, we present a case of twin twin transfusion syndrome (TTTS) with carbon
dioxide (CO2) insufflation enhancing visualization to complete fetoscopic laser ablation
(FLA). 19-year-old P0 presented at 24 weeks with symptomatic stage 1 TTTS, with regular
uterine contractions. Imaging revealed anterior placenta, maximum amniotic fluid (AF)
vertical pockets of 12 and 1 cm in the recipient and donor sacs. Doppler studies of
the umbilical artery, ductus venosus and middle cerebral arteries were normal. Twin
B, recipient, was noted to have an epignathus teratoma that was primarily external,
measuring 6.4 × 5.6 × 5.6 cm, with a small intraoral portion, 3.5 × 4.3 × 2.4 cm.
The tracheal position, esophageal diameter and stomach bubble appeared to be normal
in size on fetal magnetic resonance imaging, suggestive of a lack of airway or esophageal
obstruction. The patient was informed of the alternative options of selective reduction
of the anomalous fetus vs termination of pregnancy, which she declined. We were concerned
the AF would be cloudy and dark due to presence of the teratoma with a larger external
component. Approval was obtained by the Fetal Therapy board and patient was informed
of the experimental nature of the procedure. Uterine entry was by seldinger technique
using a 12 Fr cannula, AF was dark brown, limiting visualization (Fig. 1A). 200 mL of AF was drained, then 200 mL of heated, humidified CO2 was insufflated into the uterus, using a 60 mL syringe, minimizing concerns regarding
increased intrauterine pressure. CO2 gas rose to the anterior surface when in supine position, providing access to the
anterior placenta. The inter twin membrane and anastomosing vessels were identified
(Fig. 1B) and FLA was performed successfully. CO2 was then evacuated using 60 mL syringe under ultrasound guidance. Following surgery,
the Dopplers remained stable and the fluid normalized in both sacs by the end of the
first week. Fetal MRI was performed at 28 weeks which revealed a significant increase
in size, extra-oral measuring 8.7 × 8.6 × 10.2 cm, volume of 400 mL and intraoral
measuring 3.5 × 4.8 × 4.1 cm with concerns for airway compromise. Twin B was noted
to be growth restricted. Ex utero intrapartum treatment (EXIT) procedure was planned
and performed successfully at 29 weeks due to repetitive spontaneous decelerations
with minimal variability. Birth weight of twin A was 1460 g and her postnatal course
was uneventful. Twin B weighed 700 g, the teratoma was debulked using a GIATM stapler (Medtronic, Minnesota, USA) and the airway was secured by tracheostomy. However,
she remained critical and died on day of life 19. Placental pathology did not demonstrate
any residual anastomoses.
Fig. 1AFetoscopic image depicting cloudy fluid and limited visualization.
Successful release of pseudoamniotic bands after laser photocoagulation for twin-twin transfusion syndrome: utility of partial carbon dioxide insufflation of uterus.