Micah and Malachi Plumber just turned 1—a major milestone for any child. Watching the adorable twins crawl, giggle and play with their older sister, Kinsley, it’s hard to believe they had a medical condition that required surgery when they were still in their mother’s womb.
The boys had twin-to-twin transfusion syndrome (TTTS), a prenatal condition in which twins share unequal amounts of the placenta’s blood supply. This results in the two fetuses growing at different rates and can result in serious complications and even death if left untreated.
Understanding Twin-to-Twin Transfusion Syndrome
Most, but not all, identical twins share one placenta. This is called a monochorionic twin pregnancy. Usually, these babies are in separate amniotic sacs in the placenta, and blood vessels run from one twin to the other on the surface of the placenta. TTTS occurs when abnormal blood vessel connections form in this shared placenta. It is a rare condition affecting 15 to 20 percent of monochorionic pregnancies.
“When the blood vessel connections are present from one baby to the next, most of the time it’s balanced and doesn’t favor one twin over the other,” says UNC Health maternal-fetal medicine doctor William Goodnight, MD. “But in some cases, it results in an imbalance of blood and fluid volume from one twin to the next so that one twin becomes ‘fluid overloaded’ or has a massive amount of blood, while the other one becomes ‘fluid depleted’ and has less blood volume.”
When one twin receives more blood supply than the other, TTTS can occur. The baby who receives less blood supply can become dehydrated and cannot make much urine. The baby’s kidneys start to malfunction, and the amniotic fluid around the baby begins to decline.
“The baby actually becomes stuck in the amniotic sac because it has little or no amniotic fluid, and that can affect that baby’s lung development,” says UNC Health Fetal Care Nurse Coordinator Sacha Bryan, RN.
The baby with the excess blood flow grows faster and is larger than the other twin. The baby tries to urinate the excess fluid, so that baby has an enlarged bladder and too much amniotic fluid. The excess blood and fluid can put too much strain on the baby’s heart, Dr. Goodnight says.
“If that continues, the baby can develop heart failure,” Dr. Goodnight says. “If this condition is left untreated, the chance of survival for one or both twins is really small.”
Unbearable Pain Leads Pregnant Mother to Seek Answers
Brittany Fuller Plumber is used to carrying a heavy load. At age 26, she worked as a paramedic, phlebotomist and medical assistant while raising her daughter as a single parent and going to school. So when she started to feel run-down and experience pain toward the end of her first trimester of pregnancy with twins, she chalked it up to being overworked while she was pregnant.
Around the same time, her OB-GYN in her hometown of Fayetteville, North Carolina, also told her that it seemed that one of her twins was larger than the other but that this was normal in twin pregnancies. She continued to work and go to school, but her pain worsened.
“I had severe back pain, I was exhausted, and I had out-of-this-world swollen ankles,” Plumber says. “I was so swollen with extra fluid.”
Around 24 weeks into her pregnancy, her pain became unbearable, and her OB-GYN referred her to a maternal-fetal medicine specialist in Fayetteville who told her she would need surgery “to relieve fluid that was building up for one of my babies,” Plumber says.
The specialist in Fayetteville then referred her to Dr. Goodnight for the surgery.
Laser Used to Treat Twin-to-Twin Transfusion Syndrome
Dr. Goodnight and UNC Health maternal-fetal specialist Courtney Stephenson, DO, evaluated Plumber and determined she would benefit immediately from a procedure called fetoscopic laser photocoagulation (laser surgery). He explained that he would use a laser to cauterize the blood vessels that were causing the problems. He also let her know that one of the risks of fetal surgery is preterm labor.
“I’ve never had surgery before, and I was really scared, especially having surgery while pregnant—I didn’t want anything to happen to them,” Plumber says. “But I knew I needed the surgery to save my babies.”
On Feb. 4, 2021, Plumber had her surgery. First, an anesthesiologist administered an epidural. Then, Drs. Goodnight and Stephenson made a small incision in her abdomen and inserted a trocar, which is a small metal tube, into the uterus. They then passed a medical telescope called a fetoscope through the tube to see all the blood vessel connections on the surface of the placenta shared by the twins.
“You put a lighted camera into the amniotic fluid of the recipient baby—the one with extra amniotic fluid, and then you can identify the blood vessels on the surface of the placenta that are shared or going across one sac into the other twin’s sac,” Dr. Goodnight says. “Then, you use a laser to cauterize those blood vessels. Once you’ve blocked off those blood vessels, that treats the underlying problem of twin-twin transfusion. And the blood and fluid volumes will even out between the twins.”
Afterward, they also drained the extra amniotic fluid around the twin with the excess blood through the trocar. The day after surgery, Plumber was up and about.
“The surgery got all that unnecessary fluid and the next day I felt no pain—it was amazing,” she says. “I lost so much weight because all that extra fluid was gone. I couldn’t have asked for better doctors. They made me feel very comfortable the whole time.”
Over the remainder of the pregnancy, the babies were monitored closely with ultrasound to ensure resolution of the difference in amniotic fluid and follow the growth of each baby.
A few months later, Plumber delivered her full-term babies.
“They were born healthy and have been thriving ever since,” Plumber says. “They are the most handsome little boys, and they don’t have any health issues. I could have lost both of them, but this procedure saved my babies.”
Want to learn more about prenatal surgery for twin-to-twin transfusion syndrome? Talk to your doctor or contact UNC Maternal-Fetal Medicine at (984) 974-2131.