Interstitial laser cauterization to placental anastomosis and intracardiac transfusion in monochorionic co-twin demise: baby born with bowel atresia

Abstract

A 36-year-old nulliparous woman was diagnosed with single fetal demise in a monochorionic twin pregnancy at 15 4/7 weeks. The co-twin was hydropic with ascites, tricuspid regurgitation and elevated CTR to 0.59. MCA PSV was increased to 2.18 MoM. The cord insertion was velamentous and an arterial anastomosis was identified running on the placental surface from surviving twin to placental cord insertion of the miscarried twin. This anastomotic artery was cauterised under ultrasound guidance using diode laser via a 18G spinal needle. Intracardiac transfusion was performed on the next day using a 22G needle directed to fetal right ventricle. Pre-transfusion hemoglobin was 4.2 g/dL and hematocrit was 10.5%. 4.5ml blood with hematocrit of 80% was transfused smoothly. Post-transfusion hemoglobin was 12.6 g/dL and hematocrit was 37.2%. MCA PSV was reduced to 0.9 MoM. Fetal hydrops resolved gradually and MCV PSV remained normal. Fetal echocardiogram and MRI were normal. A loop of prominent bowel was noticed since 23 weeks of gestation and this was progressively dilated to 1.72cm at 33 weeks of gestation. The patient went into preterm labour at 34 weeks and 2 days delivering a baby boy of 1960 gram vaginally. Laparotomy showed Type 4 intestinal atresia with resection of multiple atretic segments of small bowel and primary anastomosis was performed. A second laparotomy was required on day 34 for resection of rectal atresia. Bowel function returned to normal afterwards. This is the first reported case illustrating the combined role of interstitial laser in cauterisation of placental anastomosis and intrauterine intracardiac transfusion to rescue a fetus at 15 weeks of gestation suffering from fetal anemia secondary to demise of monochorionic co-twin. Bowel atresia may present early as fetal ascites and may not be preventable. Co-twin survivor requires detailed ultrasound assessment for placental anastomosis, fetal anemia, neurological and other hypoxic insults.