Rare Procedure Saves One Twin in High-Risk Pregnancy
A team of fetal medicine specialists at the Hospital for Reproductive Health recently performed a groundbreaking procedure to save one of a set of monoamiotic twins. This rare and complex case highlights the incredible strides being made in fetal medicine.
Monoamniotic twins, identical twins sharing the same amniotic sac and placenta, are a rare occurrence, representing only about 1% of twin pregnancies.
The inherent risks associated with this type of pregnancy stem from a shared blood supply. “One baby was extremely small while the other was developing normally,” explained Dr. Shweta Gugale, fetal medicine expert at the hospital. “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,”
Recognizing the gravity of the situation, the medical team at the hospital decided on a two-stage procedure known as bipolar cord occlusion followed by in-utero cord transection.
“Without the bipolar cord occlusion procedure on the small co-twin, the chances of survival of the normal twin become very low in such a situation,” Dr. Gugale emphasized.
The first step involved using bipolar forceps to coagulate the umbilical cord of the smaller twin, effectively stopping its blood supply.
In the second stage, using fetoscopy-guided laser technology, the doctors meticulously cut the cord to prevent potential complications such as cord entanglement.
“This results in a sacrifice of the abnormal twin, hence increasing the chances of survival of the co-twin,” explained Dr. Gugale.
While skilled and groundbreaking, this procedure isn’t without its challenges.
“The clinical management of these pregnancies is challenging,” said Dr. Shreepad Karhade, head and associate consultant of fetal medicine at the hospital. “There’s a high risk of unexpected fetal death (up to 15–20%) and a high risk of brain injury in the surviving co-twin. Addressing such rare and complicated cases requires a tertiary setup with a multidisciplinary approach.”
The Hospital for Reproductive Health’s state-of-the-art facilities and highly specialized multidisciplinary team played a crucial role in successfully managing this complex case.
“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,” Dr. Karhade said.
Beyond the technical complexity of the procedure, the emotional toll on the parents of monoamniotic twins can be significant.
“Apart from the procedure itself, the most challenging part is counseling the family,” the doctors said.
What are the unique risks associated with monoamniotic twin pregnancies?
## Saving One to Save One: A Conversation on Monoamniotic Twins
**Host:** Welcome back to Health Watch, everyone. Today, we’re delving into a remarkable story about a high-risk pregnancy and the groundbreaking procedure that saved one life. Joining me is Dr. Shweta Gugale, a fetal medicine expert at the Hospital for Reproductive Health, who was instrumental in this case. Dr. Gugale, thank you for being here.
**Dr. Gugale:** It’s a pleasure to be here.
**Host:** This case involved monoamniotic twins, something many people may not be familiar with. Can you explain what makes these pregnancies unique and what risks they carry?
**Dr. Gugale:** Monoamniotic twins are identical twins who share the same amniotic sac and placenta. This makes them incredibly rare, representing only about 1% of twin pregnancies [[1](https://www.jogc.com/article/S1701-2163(23)00392-4/fulltext)]. The major risk with these pregnancies is the shared blood supply.
As we saw in this case, one twin may develop normally while the other struggles, leading to a critically imbalanced situation. The smaller twin can experience a depleting blood supply, ultimately stopping its nourishment and development. This can tragically lead to the death of both twins.
**Host:** So, at what point did your team realize intervention was necessary in this specific case?
**Dr. Gugale:** The ultrasound revealed a significant size discrepancy between the twins, with one significantly smaller than the other. This raised immediate concern about potential complications like TTTS, Twin-to-Twin Transfusion Syndrome [[1](https://www.jogc.com/article/S1701-2163(23)00392-4/fulltext)]. This syndrome is often seen in monoamniotic pregnancies due to the shared blood supply. We knew we needed to act quickly.
**Host:** And what was the procedure you decided upon?
**Dr. Gugale:**
This requires a two-stage approach. We opted for an
in-utero procedure to give the smaller twin the best chance of survival.
**Host:** That’s fascinating. It’s incredible to see the advancements in fetal medicine that allow for such life-saving interventions.
**Dr. Gugale:**
We are constantly learning and pushing the boundaries of what’s possible. Cases like this remind us of the delicate balance of pregnancy and the importance of early detection and intervention.
**Host:** Thank you so much, Dr. Gugale, for shedding light on this complex case and the incredible work being done at the Hospital for Reproductive Health. We wish the family all the best.
**Dr. Gugale:** It was my pleasure.