*SPECIAL GUEST* - Dr. Saul Snowise – Part 1 of 2

This week we continue our discussion with Dr. Saul Snowise talking about the role of selective reduction, specifically in the setting of monochorionic twins. This week we'll be covering the following: 

• Dr. Snowise’s preferred tool/method for selective reduction
• Selective reduction in the setting of monoamniotic twins with discordant anomalies & cord entanglement
• Various instruments & equipment used for the different methods of selective reduction
  • How instrument/trocar size affects complication rates
• Discordant anomalies in monochorionic/identical twins
• Twin reversed arterial perfusion (TRAP) sequence
  • Rate of occurrence
  • Pathophysiology/disease process
  • Optimal timing for fetal intervention/surgery
• Selective reduction for sIUGR
  • Patient counseling and informed consent
  • Laser ablation as treatment for sIUGR
• Effects of legislation and the overturning of Roe v. Wade on selective reduction as a treatment option in pregnancy

*SPECIAL GUEST* - Dr. Saul Snowise – Part 1 of 2

This week and next week we have a two-part series with Dr. Saul Snowise as we discuss the role of selective reduction, specifically in the setting of monochorionic twins. Join us as we discuss the following this week:

• How selective reduction differs in monochorionic vs. dichorionic twins 
  • Most common method of selective reduction
    • Potassium chloride (KCl) injection contraindicated in monochorionic twins  
  • Method for monochorionic pregnancy
    • Cord occlusion
• Indications for selective reduction in monochorionic twins
  • Selective fetal growth restriction (sIUGR)
  • Discordant anomalies
  • Twin-twin transfusion syndrome (TTTS)
  • Twin reverse arterial perfusion (TRAP) sequence
  • Failed laser
• Various methods for performing a cord occlusion selective reduction
  • Microwave
  • Interstitial laser
  • Radiofrequency ablation (RFA)
  • Bipolar cautery
• Sizes of operative instruments, energy levels used and the treatment protocols
• Gestational age thresholds for performing a selective reduction procedure
• Risks associated with a selective reduction procedure
  • Membrane complications (i.e. PPROM)
  • Preterm delivery
  • Bleeding, infection 
  • Loss of co-twin
• Pre-operative counseling with patients
• Follow-up and surveillance for the remainder of the pregnancy

Tune in next week for part 2!

Welcome back "What they didn't teach you in laser school" – now onto Part 2! This week we’re going to continue talking about all our laser tips & tricks while discussing the following:  

• Anterior placenta challenges
  • Future of steerable operative scopes
    • Current 30 degree operative Storz scope
  • Using external pressure to aid in flattening the uterus
  • Intraoperative amnioinfusion
• Intraoperative complications
  • Concurrent fetal bradycardia in both fetuses
  • What to do when the laser won’t stop firing
  • Intra-operative bleeding
• Post-operative complications
  • Bleeding
    • Placental abruption
    • Intraperitoneal bleeding
  • Amniotic fluid leakage
    • PROM (premature rupture of membranes)
    • Intraperitoneal amniotic fluid leakage 

Welcome to "What they didn't teach you in laser school"! This two-parter is going to be filled with Dr. Moise's tips and tricks (and some of Erin's too) as we share the following topics: 

• Pre-operative evaluation tips
• • Identifying cord insertions via ultrasound
  • Following the lie of the donor twin to find the inter-twin anastomotic plane
  • • Not true for “cocoon” sign
  • Re-evaluate and confirm cord insertions and anticipated cannula insertion site in the OR
  • Confirming renal blood flow in the donor twin
  • • Renal agenesis
• Intraoperative tips
• • Anesthesia type
  • Maternal drugs we use & don’t use
  • Operative cannula placement
  • • Patients with a higher BMI or thick abdominal wall
    • • Using a ‘spike’ AKA ‘harpoon’ for entry
      • Spinal anesthesia for cut-down
    • Anterior placenta
    • • Patient positioning
      • Laparoscopic approach
    • Check uterine wall for vessels with color flow Doppler
    • Counterpressure
  • Intraoperative bleeding
  • • Amnioexchange / rapid infuser
    • Using humidified CO2 for anterior placenta
    • Pediatric foley
  • Intraoperative septostomy
  • • Inadvertent vs. purposeful septostomy
    • Complications
    • • Amniotic band syndrome
      • Tangled cords

Tune in next week for part 2!

This week we’re going to be using the most recent episodes as building blocks to discuss atypical presentations of twin-twin transfusion syndrome or TTTS. Dr, Moise takes us through the following ‘unicorn’ presentations by covering the following:

• Review of the classic Quintero staging system for TTTS
  • Stage I, II, III, IIID, IIIR, IIIDR, IV, V
• Alternative TTTS staging systems that have been proposed
  • Cincinnati
  • CHOP
• Case scenario of an atypical TTTS IIID
• TTTS with sIUGR
  • Review definition of sIUGR
• Cardiac dysfunction in the setting of monochorionic twins
• Which combination of twin complications in monochorionic twins would be candidates for laser surgery
• Monoamniotic twins with TTTS
  • Diagnosing TTTS with a spontaneous septostomy

*SPECIAL GUEST* - Dr. Ramesha Papanna – Part 2 of 2

Join us as we continue our discussions on Twin Anemia Polycythemia (TAPS). 

This week Dr. Papanna walks us through the following topics on TAPS:

• Society of Maternal Fetal Medicine (SMFM) and International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) guidelines and recommendations for monitoring MCA Dopplers in monochorionic twins
• Laser ablation of placental anastomoses as treatment for TAPS
• • Transabdominal approach
  • Role of Solomon technique / solomonization in TAPS
  • Disease severity and clinical indications for laser as treatment for TAPS
• Intrauterine Transfusion (IUT) or exchange transfusion as treatment options for TAPS
• How gestational age affects management of TAPS
• TAPS as a complication of an incomplete laser for TTTS
• Long-term outcomes and sequelae for a pregnancy affected by TAPS

Resources for patients:
www.tapssupport.com

*SPECIAL GUEST* - Dr. Ramesha Papanna – Part 1 of 2

 Join us as we head down another aisle of Twins R’ Us but this time with a very special guest who is joining us for this two-part series on Twin Anemia Polycythemia Sequence (TAPS)!

This week Dr. Papanna walks us through the following topics on TAPS: 

• Defining TAPS
• Pathophysiology of TAPS
• Difference between spontaneous TAPS and TAPS after a laser for TTTS
• How TAPS is detected
• • Rate of occurrence of TAPS in monochorionic twin pregnancies
• The original definition and staging of TAPS from the Leiden group in 2007
• • Fetal vs. neonatal criteria
  • • MCA Doppler discordance
  • Staging mirror TTTS staging
• The three stages of population-based disease
• • Screening – deploying a particular test on a large population to pick up on potential disease
  • Diagnosis – confirmatory test
  • Outcome –the effect of the diagnosis on
• Common ultrasound findings in TAPS
• • ‘Starry Liver’
  • Placental thickness
  • Discordant MCAs
• Placental vessel anastomosis types involved in TAPS

Tune in next week for Part 2!

We know many of you tuned in eager to hear a big clinical research update that we've been so excited to share! That episode will be coming down the pipeline soon but unfortunately will not be released today. 

Stay tuned for an episode later today as we travel down the TAPS aisle of Twins R' Us with Dr. Ramesh Papanna!