Twin to twin syndrome
Over the years, the controversies and challenges raised by twin–twin transfusion syndrome (TTTS) only contributed to my determination to tackle it. Testing the presumed pathophysiology, assessing the merits of a surgical approach to the disease combined with development of a specific surgical technique, overcoming technical obstacles such as bloody amniotic fluid discoloration and anterior placentas, and development of surgical instrumentation have all been part of a long-standing commitment to finding better ways to counsel and treat patients affected by TTTS.
A number of key developments in TTTS have taken place over the years. The definition of TTTS has gradually become standardized. Although previously used neonatal criteria of size discordance and hemoglobin differences still linger in the perinatal world, the sonographic definition of the disease in terms of specific amniotic fluid discordance has slowly gained wider acceptance. Indeed, acknowledgment of the ultrasound nature of the definition of the disease in-and-of itself constitutes a major achievement. The sonographic definition allowed distinction of TTTS from other conditions such as selective growth retardation. The sonographic nature of the definition, however, poses a serious epidemiological limitation, as the true incidence of the disease can only be known in countries with universal ultrasound screening. Comparison of outcomes between series (particularly with older series) is similarly limited, as not all investigators may have used the same diagnostic criteria.
No issue has been more controversial than the treatment of TTTS. Perhaps the only undisputed aspect in this regard was the early knowledge that expectant or medical management played no role. The debate then centered on which form of invasive therapy was more appropriate. Interpretation of outcomes undoubtedly were marred by lack of standard diagnostic criteria, poor understanding of the natural history of the disease, and a laser surgical technique in evolution. Though to this date, there continues to be resistance to the overwhelming evidence supporting laser therapy over symptomatic treatment, the tides are finally changing. Unfortunately, many patients still do not receive optimal care due to logistic, political, or other non-scientific reasons. Moreover, the therapeutic short cut represented by the development of the bipolar coagulator, has had the potential of creating more harm than good. Nonetheless, the increasing number of physicians becoming adept in the performance of the selective laser technique in centers worldwide attests to the success of laser over any other form of therapy.
While a number of myths and truly unresolved scientific questions about TTTS still remain, most queries have been adequately and successfully addressed. This book brings together such knowledge for the benefit of patients and physicians alike.
I wish to take this opportunity to thank my research team in Tampa, Ms Mary Allen RN, Ms Patricia Bornick RN, our sonographers Ms Karen Pomeroy, Ms Lynette Cole, our operating room staff Mr Francisco Espejo, Ms Linda Roper, Ms Jennifer Townsend, and Ms Jennifer Weatherilt, our nurse anesthetist Ms ‘Cookie’ Neuman, Ms Laura Kersey from the administrative staff, and the support of Richard Wolf.
My most sincere gratitude to all of the contributors, who kindly accepted the invitation to share their knowledge on twin–twin transfusion with us all. Special thanks to Diane Spicer, Mary Torretta, and Rhonda Mabry for their assistance with the figures and illustrations. Lastly, I would like to thank Ms Patricia Bornick and the editorial staff of Informa Healthcare for their assistance in the preparation of this material, and without whom this book would not have been possible.
Rubén A Quintero
xii PREFACE
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