“Twin Twin Transfusion Syndrome Part 2: Treatment of TTTS. Yes, Lasers!” – with Dr. Nahla Khalek

Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. I’m back with Nahla Khalek, who is the wonderful physician, maternal-fetal medicine specialist, geneticist, expert at CHOP, which is the Children’s Hospital of Philadelphia. We’ve been talking about twin-twin transfusion, and we’re moving on to the treatment of twin-twin transfusion. So thank you for doing this again. Let’s just talk about, what are the treatment options? I know we’re gonna ultimately end up on definitive treatment, type of fetal surgery which is laser and whatnot, but let’s just go through what the options are that people might see online, or maybe used to be done before definitive treatment was available.
Dr. Khalek: A lot of this is gestational age dependent. Anyone in the obstetrics audience can appreciate that how you manage a patient ultimately depends on where the patient is in her pregnancy. And so when we have patients come to us and they have a diagnosis of twin-twin transfusion syndrome, there’s sort of a current range of options is, you can have what we call expected management, which means you just follow the pregnancy and the pregnancy just sort of follows its own natural history. It’s not something we recommend, but there are some families who feel this is the best choice for them.
Dr. Fox: I mean, that might be a choice if it develops in the third trimester, right?
Dr. Khalek: Yes. I’m talking about sort of the time window where you can do fetal therapy. The second option is to say, “Well, nope, we wanna try to go for two.” And we offer something called selective laser photocoagulation, which is the fetal surgery, which I’ll get into a little bit of detail later on. The third option is again, depending on the stage and how potentially sick the twins could be, you could do something called a selective cord occlusion, where you do a selective intentional disruption of blood flow to one baby to try to optimize and save the other baby. So what it translates into is one baby is alive and one baby is not alive. And then the fourth option is, some parents feel like the complications are too much. The diagnosis is too complex and they end up terminating the entire pregnancy. So it all kind of depends on gestational age.
So typically in the United States, the fetoscope or the instrument that we use to perform laser is approved by the FDA, Food and Drug Administration, for use starting at 16 weeks, all the way up to 26 weeks of gestation. So for example, if you have a diagnosis of twin-twin transfusion syndrome at 28 weeks, we’re not able to offer you laser therapy. You’re well beyond the gestational age for termination. And so one of the older methods of dealing with twin-twin transfusion syndrome is known as amnioreduction, is something that could potentially be offered. And what that involves is placing a needle under ultrasound guidance into the sac of the recipient that has an excess amount of fluid and to try to drain off some of that fluid, to buy more time for the pregnancy. It doesn’t address the issue of those blood vessel connections that are causing that distribution of blood flow or redistribution of blood flow, but it could potentially buy more time for the pregnancy
Dr. Fox: Why would it buy more time for the pregnancy? What would it do that would buy more time?
Dr. Khalek: The idea is that the polyhydramnios or the excess amniotic fluid can cause overdistension and potentially preterm contractions in preterm labor, which can result in a preterm delivery. And ideally, you’d like to buy as much time for the pregnancy as you can. And so sometimes amnioreduction can be used as a way to buy time, to get antenatal corticosteroids on board, to get a course of magnesium sulfate for neuroprotection on board, or to just prolong the pregnancy by even a week. A week is a lifetime for a twin pregnancy.
Dr. Fox: Sure. And this was a primary treatment before the laser therapy was developed and, you know, proven to be effective?
Dr. Khalek: It was one of, yeah. So the whole idea behind laser, so this was… You know, the really neat thing about twin-twin transfusion syndrome, it’s one of the few examples where a randomized controlled trial was performed on a pregnant population for a fetal surgery approach. So the reason laser has become the mainstay is that prior to laser, amnioreduction was one of the primary modalities used to treat twin-twin transfusion syndrome and the Euro-fetus trial, which was a randomized trial in the late 1990s, early 2000s, basically compared amnioreduction to laser. And the bottom line is that with laser, you get further along into pregnancy, which then translates into better neurodevelopmental or brain outcomes for kids. And so that’s how laser replaced amnioreduction, but amnioreduction does have its place for later gestation diagnoses. The idea is that, you know, you don’t make the later diagnosis because you’re screening earlier.
So, you know, everything sort of folds into itself. A much older technique which is actually no longer utilized is something called septostomy where you go in and intentionally create a hole between the two sacs, it’s called the inter-twin membrane. And the idea is then the fluid, the polyhydramnios that’s in the recipient’s sac, there’s fluid that kind of moves through that hole into the donor sac. But again, you’re not addressing the issue and you run a real risk of that hole sort of opening up and then both babies are in the same sac and then they become monochorionic monoamniotic. So, two fetuses in one sac, and the main risk of that is something called cord entanglement. So each baby’s umbilical cord can sort of twist around the other and that can cause a spontaneous death or a significant neurologic morbidity in the long-term. So septostomy, making that hole in between the membranes is no longer an approach that is endorsed.
Dr. Fox: So if septostomy is not really gonna be used, and amnioreduction is sort of limited to very specific instances where laser is not available, and the patient chooses not to terminate the pregnancy or not to do the selective termination and they’re going for the therapy, which is the laser therapy, explain what that is because it sounds like, you know, science fiction that we’re using a laser and what’s going on, because I think this is really an interesting point and a lot of people just don’t understand what’s going on here.
Dr. Khalek: It’s amazing that it works.
Dr. Fox: It’s always amazing when anything works, when we try, you know? It’s just amazing.
Dr. Khalek: The idea behind twin-twin transfusion syndrome, so in terms of the pathology, right? So it’s the anastomosis or these blood vessel communications that actually occur on the fetal side, on the surface of the placenta, so it’s not the deeper blood vessels within the body of the placenta, and what we’ve been able to do…I mean, this was pioneered in the late ’80s by Julian DeLia and it was refined by Ruben Quintero and then it’s [inaudible 00:06:49] with multiple iterations, subsequently Mark Johnson, Anthony Johnson. There’s like a million people that have really invested a significant amount of time and energy into refining the instruments. So we’ve gotten it down to where we use a 4 millimeter scope. We have mom under IV sedation and use some local anesthetic on their skin. So this is a far, far cry from when the therapy was first introduced where patients were under general anesthetic and a mini-laparotomy or an incision was made in the skin to access the uterus was performed. This is now considered one of the most minimally invasive procedures.
Dr. Fox: Right. So it’s conceptually like an amniocentesis, but instead of a very skinny needle, that’s maybe a millimeter wide, it’s like four times that, yeah?
Dr. Khalek: Yeah, exactly.
Dr. Fox: Okay.
Dr. Khalek: The way I describe it to patients is sort of, you want to envision yourself in a room with a door. And so you’ve got the room with the four walls, you’ve got a ceiling, you’ve got a floor, you’ve got a door. And if you think of that room as the uterus, your placenta could either be up on the ceiling or it can be on the floor or on the wall. And we would go in through the recipient’s sac. And so the procedure is done under ultrasound guidance, primarily, where we use a needle to introduce something called a trocar, which is like a plastic tube that goes through the skin, through the fatty tissue, through the uterine wall, and into the sac of the recipient. And the reason we choose the sac of the recipient is because that’s a much larger working space because there’s typically more fluid in that sac.
And so we were coming in through the door and either looking up at the ceiling or looking down at the floor, the floor and the ceiling being where the placenta is. And we can actually identify where the umbilical cord insert into the placenta for each fetus. And so if you imagine sort of, if you look at the palm of your hand and you put one point sort of by your wrists, and one point by the tip of your fingers, those are the insertion points for where the placenta cord is, you draw a line going across horizontal, and then imagine a perpendicular against that horizontal, that is where you’ll find the majority of your blood vessel communications or your anastomosis.
Dr. Fox: You mean midway between where one baby and the other baby’s cord attaches?
Dr. Khalek: Ideally.
Dr. Fox: Right.
Dr. Khalek: Ideally. Yeah.
Dr. Fox: I mean, you could see it.
Dr. Khalek: Yeah. We can see it.
Dr. Fox: And are you seeing this under an ultrasound picture? Are you seeing it, like, with a camera as if you were, like, in there yourself with, you know, with a pair of goggles on looking through the water?
Dr. Khalek: It’s a little bit of both, right? So the point where we enter with the fetoscope is ultimately determined by how we map where the cord inserts with ultrasound. So we use ultrasound to sort of identify where the placental cord insertions are and then kind of draw that perpendicular, and that’s our point of entry for the camera and the fetoscope. And then once we enter with a fetoscope…there’s a camera at the end of it, it’s all one instrument. There aren’t multiple incisions or multiple ports that we use. It’s just one instrument. And we can actually go in with the camera and then under direct visualization, it’s as though we were inside that amniotic sac, we can identify where the cord insertions are, confirm them in terms of what we saw with ultrasound. And then we can start mapping each individual artery and vein and finding the ones that are not paired. We wanna look for the ones that are crossing over to the other baby, and those are the ones that we use a laser fiber to ablate. It’s almost as though we were spot welding down the placenta. We’re not separating the placenta physically, but what we’re doing is we’re creating two separate circulations. So it’s still one placental mass, but now instead of having a shared circulation, each fetus has their own circulation.
Dr. Fox: So you’re basically using a laser to sort of burn or coagulate any blood vessel that you think is crossing over to the wrong side.
Dr. Khalek: Yeah. And you know, I mentioned that earlier, is the artery to vein communications that are primarily responsible, but what we ultimately do is we ablate all the communication. So if there’s an artery to artery or a vein to vein, anything that is not paired, we use a laser to ablate, to basically close off that connection.
Dr. Fox: So even though you’re not actually lasering the placenta in half or in two, at least the fetal surface of it, you’re functionally ablating anything that might connect one side to the other side or one baby to the other baby. And the thought is that when you’re done, either there’s no more connection between them or it’s much, much, much less of a communication between them and it should stop the process from happening.
Dr. Khalek: Yeah. Ideally, you want no connection between the two of them. If you leave a vessel open, it can cause a different competition post-laser, but ideally what you want to do is find every single communication, ablate it so that you now have two separate circulations for each baby. And the remarkable thing is that they’ll readjust. Just as much as they readjusted to the sort of maladaptations, they also adapt positively. It’s really quite remarkable. Within a week, you can start to see changes where you have normalization of blood flow, normalization of fluid. If there were heart changes in the recipient, those are starting to reverse. It’s very satisfying, and it’s very amazing at the same time.
Dr. Fox: Right. I have a lot of follow-up questions on that as I’m sure our listeners do, the first is, let’s start from the patient’s side. So she’s a little bit sedated and she has this procedure. How long does it take on her end? And when she’s either going through it or when she’s done, how much pain might she be in, assuming all goes well?
Dr. Khalek: Yeah. So the length of the procedure ultimately depends on how many anastomoses we have. So right now we don’t have a way of knowing the number of anastomoses prior to actually doing the procedure. The average number is somewhere between 12 and 13. So the length of the procedure on average can go anywhere from 20 to 45 minutes. We also spend a small amount of time, it doesn’t really add to the length of the procedure, by draining or reducing the excess fluid in that recipient sac that helps mitigate a risk of preterm labor and preterm delivery. So the patient is on the table. Typically in our operating room, we offer them music. You know, they can listen to music. A lot of times they’re just sort of dozing off. I don’t drink alcohol, but a lot of patients are telling me it’s like they had a couple of glasses of wine so they’re a little tipsy.
Sometimes there’ll be singing. Sometimes there’ll be talking. We always reassure them, you know, what happens in the OR stays in the OR, but it’s very minimal discomfort to the patient. Honestly, we’re very generous with the lidocaine that we use locally. And sometimes they feel a sensation of pressure, but there isn’t anything painful per se. Once the procedure is completed, anesthetic clears their system pretty rapidly within an hour or so. They’re in their room. They’re eating, we wanna make sure that they’re able to urinate, tolerate food and they usually spend the night with us. So we give them post-operative antibiotics. We don’t use any tocolytics, we’re using medications for contractions after the surgery, where you go with one dose of medication prior to the surgery. And then typically, the next morning we repeat an ultrasound. What we want to make sure, is that both babies are still alive.
We don’t anticipate seeing any major changes and then they get discharged. And this is kind of voodoo, I’ll own it, but we ask them to be on bed rest for a week. So kind of letting common sense be their guide, and then we see them the following week. And that’s when we start to appreciate whether or not the therapy was effective. But the mom herself is at minimal anesthetic risk, does not experience a significant amount of pain. There’s no, like, pain medication that they get discharged with or anything like that. And the incision is so small, we close it with basically glue.
Dr. Fox: And a Band-Aid. Yeah. And what do you tell people is the likelihood that it’s gonna be successful? And you can define success in different ways, obviously, but let’s just say the likelihood that they’re gonna have two healthy babies if you do this procedure?
Dr. Khalek: If we’re gonna define success by, like, intact neurologic outcome at the time of discharge, so basically your kid’s brain is normal by the time they go home from the hospital, and if we took all stages, it would be about 86 to 88%.
Dr. Fox: Wow. Which is the exact opposite of the likelihood of a horrible outcome if you don’t treat.
Dr. Khalek: Yeah. Totally.
Dr. Fox: Yeah. It just flips everything on its head which is amazing.
Dr. Khalek: Hundred percent. Yeah. It would be hard-pressed for anyone to be like, “No, I’m not going to do the laser,” but I mean, we’ve had families who’ve elected for just expecting that [inaudible 00:14:53]. So I think that patient autonomy is key, but that’s why spending so much time on informed consent is just crucial. And then if you took it stage-by-stage, the earlier stages, obviously, you have a much higher rate that you can go as high as 90%, 92% if it’s a stage 1, stage 2. And then as you get into more advanced stages, at least, you know, from the data coming out of CHOP, you have about a 72%, 75% chance. And part of that is because you’re taking kids to the OR that are much sicker, and so they tend to respond to the therapy differently.
Dr. Fox: Right. So the range is in the 70%s to 90%s, obviously, with the midpoint, the 80%s.
Dr. Khalek: Yeah. Overall about 86%, 88%. Yeah.
Dr. Fox: Yeah. Like I say about, and then give a very precise number. It’s great.
Dr. Khalek: Yeah.
Dr. Fox: It’s about 86% to 88%.
Dr. Khalek: Yeah. Exactly.
Dr. Fox: And then, what are the possible complications that could happen? How could this totally go wrong, you know, from the procedure that you warn people about? It is rare, but it’s a possibility.
Dr. Khalek: Again, thinking about obstetrics, there’s always a maternal-fetal dyad. So you always have two patients that you’re thinking about simultaneously. And thankfully, there’s really minimal, minimal maternal risks. So because we’ve moved away from heavy anesthetic, you know, the biggest risk to any mom during pregnancy and having surgery is anesthesia. So anesthesia risk is minimal. Risk of transfusion, abruption, which is premature separation of the placenta, all of these things are minimal to mom. And then in terms of the babies or the pregnancy, you know, the sort of so-called Achilles’ heel of all fetal surgery is that you could have rupture of membranes or your water could break. And depending on gestational age, that could translate into a complete loss of pregnancy or a very premature delivery.
Another complication is that you could have something called a membrane separation. So when you think about pregnancy, each baby or each fetus is in their own amniotic sac, within that sac is within a bigger sac called the chorion. And typically, those are fused by the time you’re about 16 weeks pregnant, but we’re going in with an instrument through all the different layers. And so sometimes we can separate those membranes. And if it’s a small separation, it typically doesn’t have an impact on the pregnancy. But if it’s a large separation, it then predisposes the patient to, again, breaking her water earlier, going into labor early. And depending on the age at delivery, that’ll have an impact on how the kids do.
Dr. Fox: I think what a lot of people might be thinking is, if you’re sticking a 4 millimeter trocar, an instrument through the uterus, through the membranes, into the water bag, how does someone’s water not break when you do that? I mean, you’re saying it’s a possible complication, but why does it not normally happen if you’re…you know, if you had a balloon filled with water and you took a 4 millimeter thing and poked it through, of course, the balloon would pop. So why does that not happen?
Ddr. Khalek: There’s a couple of reasons. One, we use a pretty atraumatic approach. So, you know, even though we use a needle, it’s about an 18 gauge needle, it’s a tiny needle, a little bit bigger rather than an amniocentesis needle to get in. And then we use a blunt approach. So the trocar that we use or that tube that we use to guide the fetoscope in is, it has a soft plastic tip. It’s not sharp, so there’s less trauma that occurs. And then the other thing is that what happens with the membrane is it typically just kind of scars over. It’s not terribly vascular, so it doesn’t have a super-rich blood supply. So what it does, is it basically scars over, almost like a scab. And then it’s really just a miracle that it doesn’t happen more often.
Dr. Fox: And what is the likelihood that someone, you know, they have the procedure and within a week let’s say their water’s gonna break and they’re gonna either, like you said, lose the entire pregnancy or if they’re…later that they’ll have a very premature birth.
Dr. Khalek: So when we look at the data coming out of our center, and we look at data coming out of other fetal therapy centers that risk can be anywhere from 10% to 18%.
Dr. Fox: So, it’s not insignificant. I mean, you’re taking that risk in order, again, to flip the risk for the babies from likely not surviving to likely surviving.
Dr. Khalek: Yeah. I mean, having surgery while you are pregnant is a high-risk situation, no matter how you look at it. And again, grateful that the evolution of this particular therapy had become so minimally invasive, but you’re still having some type of surgery while you’re pregnant.
Dr. Fox: And then, is that basically the reason why it wouldn’t be closer to 100% of two healthy babies afterwards because of this risk?
Dr. Khalek: Yeah, part of it is that, and part of it is that you could also lose one baby in the process. So, you know, twin-twin transfusion syndrome is not sort of a pure diagnosis. It can sometimes be blended with other complications of having one placenta and sometimes your donor baby can be quite small or growth restricted. And that’s because that baby not only has those connections, but also has a very small share of the placenta. And once you’ve sort of disconnected it from its co-twin, when there’s just not enough placenta to sustain ongoing growth and development, and that baby may die. So that also accounts for why you don’t always go home with two kids.
Dr. Fox: How does one learn how to do this procedure? Like, what’s the training in order to do this because it’s not done in a typical MFM fellowship. This is advanced, beyond advanced, beyond advanced.
Dr. Khalek: Yeah. So I mean, ideally, you would want to be trained…you know, ultimately, you know, you have to have your basics, right? So you wanna be trained in ultrasound imaging techniques, but you also want to be trained in ultrasound-guided procedures. So ideally, you want to be able to sort of have that hand-eye coordination that’s required for putting a needle into a sac, for putting a needle into an umbilical vessel. And then what most folks end up doing, initially was sort of like an apprenticeship, right? You would basically get hired in a fetal therapy center and, you know, sort of, as you grew professionally, you would get more cases under your belt. Right now there’s sort of a general consensus that you should have at least 35 to 40 cases in order to ensure that there’s like an 80% dual survival. And that would only occur if you worked diligently and regularly at a fetal therapy center. Right now in the country, there are six fetal therapy fellowships distributed throughout the United States. And so the idea is you’ve completed, you know, your training in maternal-fetal medicine, you want to do additional training in fetal medicine. And so you could do an additional two years specifically focused on fetal therapy techniques.
Dr. Fox: And is this a procedure that you do yourself or you evaluate people and then you have colleagues who do it at CHOP?
Dr. Khalek: Nope, we do it ourselves. So here at CHOP, the maternal-fetal…
Dr. Fox: I mean, you personally?
Dr. Khalek: Yeah. So, the maternal-fetal medicine docs. So I, and my four other partners do these procedures.
Dr. Fox: Right. And how many of these are you combined doing a week, a month, a year, however you wanna let people know?
Dr. Khalek: So a year we do about 50.
Dr. Fox: So, one a week?
Dr. Khalek: It’s a pretty decent number. Yeah. Ebbs and flows. So, you know, for example, last week we did four, this week, so far, we’ve done two. So it kinda depends on… It’s interesting, we joke that it’s a bit seasonal. We tend to do more of them during the spring and summer. And then it kind of dies down a bit and then it picks up again.
Dr. Fox: After someone has this procedure. And like I said, everything went well and they went home the next day, they come back in a week, what is the follow-up like afterwards, in terms of ultrasound? What are the things you’re looking for, and, you know, potential pluses, potential minuses that might happen moving forward?
Dr. Khalek: Yeah. This is one of also the super fun things about working in a center like this, is that we actually get to collaborate with a lot of referring physicians. And so typically what happens is patients will go back to their referring maternal-fetal medicine physician and have an ultrasound performed on a weekly basis for about three weeks. And what we’re looking for in those three weeks is sort of that redistribution and normalization of blood flow as manifested in ultrasound. So you start to see that each fetus or each baby now has a normal amount of amniotic fluid, both bladders are filling and emptying or cycling. If there was abnormal blood flow patterns in the umbilical cord, those have become normal. We also look to see that the heart muscle, if it was thickened and the recipient is less thick.
And then we’re also screening for a complication after laser called TAPS, which is another abbreviation called twin anemia polycythemia sequence, which roughly translates into one baby being very anemic, does not have enough red blood cells, and the other baby being very polycythemic, has too many red blood cells. That is a complication after laser that again has been quoted up to potentially, you know, somewhere between 13% and 15%. And you screen for that by looking at the blood cell patterns in the brain, specifically, a blood vessel called the middle cerebral artery. When you see significant discordance or difference then you are suspicious that you may have missed a vessel. And because of that, you now have this sort of reversal where the recipient starts acting like a donor and the donor starts acting like a recipient.
Dr. Fox: Right. And that’s something we actually screen for on all monochorionic twin pregnancies to some degree, but it’s more common after someone has this procedure versus not having the procedure.
Dr. Khalek: Yeah. Spontaneously, it happens about 3% of the time, but post-laser is when you would have it happen most often.
Dr. Fox: Yeah. And I can just say from my own experience for our listeners, I mean, we screen people for twin-twin all the time and we see a bunch of monochorionic twins and, you know, about again, 10% to 15% of the time, there is a concern for twin-twin. And usually what follows in our end is a call to you. Nahla, you need to see this person ASAP. And typically, it does work very, very well. I mean, you guys are awesome. Typically, the patient’s seeing you the next day or in two days, I mean, you know, essentially, they’ve to get to Philadelphia and then that’s how they’re done, and then you’re usually doing the procedure, if it’s warranted right away. And if it’s not, maybe follow up in a week or so. And then afterwards, like you said, after they see you in a week, and then they follow up with us the rest of the pregnancy, and the vast majority of the time, everything goes really, really well. And it’s, you know, crisis averted for most people, which is a big, big deal for them because it literally changes the entire outcome for the pregnancy just having that procedure available.
Dr. Khalek: Yeah. Yeah. I agree with you 100%. It’s why it’s so crucial to make that diagnosis as early as possible and then make the referral to maternal-fetal medicine as early as possible.
Dr. Fox: Yeah. And you guys have a really, I don’t wanna say intricate, like, it’s complicated, but you have a really well-developed system in place for accepting referrals because that’s what you do. I mean, this isn’t just people who happen to coincidentally live in Philadelphia, you see people from all over the place who have to come in to see you, they fly in, they drive in, they train in, whatever it is. And so you have a really good system to onboard these patients into your practice very quickly.
Dr. Khalek: Yeah. I mean, part of that is because this is all we do, right? So we eat, breathe, and drink fetal therapy, and unlike maternal-fetal medicine units or obstetric units, we’re not seeing the routine OB imaging studies, right? So we have that sort of luxury in that we can invest all of our resources specifically into helping families get what they need. And sometimes it’ll even extend to like if a family, for whatever reason, can’t come here, and then we’ll try to facilitate them getting to fetal therapy center. We’ve got grants in place for transportation and lodging. We have an incredible crew of social workers. Our fetal therapy coordinators are extraordinary. Basically, you have access to the center 24/7. And then, you know, in this day and age, I think everyone in the country has all of our cell phone numbers, so we get texts and emails. Obviously, we’re happy to support.
We know how emergent it is. We also know the emotional toll that it takes. I mean, imagine the sort of like having this amazing sense of joy that you’re pregnant and you have twins and you’re telling everyone, and everyone’s, like, posting on Facebook and Instagram and having all these gender reveal parties. And then you go to your ultrasound and, you know, the sonographer is scanning and it’s very quiet. And then they step out, and they’ll have to get the doctor. And the doctor’s, like, giving you this horrendous news. You go to like 180 degrees and it’s such an emotional roller coaster that we feel, you know, getting here should be the least of your concerns.
Dr. Fox: Yeah. And just for patients, you also have a really cool 1-800 number, 1-800-IN-UTERO.
Dr. Khalek: Yeah. You can credit that to our marketing people.
Dr. Fox: Listen, it’s great because I never forget it, right? If I have to tell people what’s their…like, “What’s their phone number?” I’m like, “I don’t know what it is, but it’s 1-800-IN-UTERO, whatever those numbers come out to, that’s what it is.” And that’s easy for, you know, simple people like me to remember. I’m so appreciative of your time to talk about this, both the diagnosis, as well as the management and also of course for what you do because you’re available to, you know, all patients, but certainly, you know, selfishly, to my patients. And I think that one of the messages that’s really important for, you know, women out there who are carrying twin pregnancies is number one, like we said before, it’s so important that we know immediately, what kind of twins are we dealing with here.
If, you know, you’re a woman and you’re pregnant with twins and you don’t know, or your doctor doesn’t know, or you don’t know if they know, ask, like, just say, “Do you know if I have one placenta or two?” And if the answer is, “Uhh, no,” then you need to have that figured out ASAP. And if the answer is, “Yes, I do. It’s two placentas and we’re gonna do A, B, C, and D because of that”, or, “Yes I do. It’s one placenta and we’re going to do, you know, whatever, A, B, C, and D because of that,” okay, you know that they know what they’re doing and things should go…either go perfectly okay, or if this complication does arise, they’re gonna be screening for it, they’re gonna know about it, and they’re gonna send you to the right people if it’s happening.
Dr. Khalek: Yeah. I mean, and I also would just add that it’s so, so important to be screened by someone in maternal-fetal medicine, only because they have that skillset to start looking for those nuances and subtleties that can indicate sort of progression or stability.
Dr. Fox: Nahla, thank you so much for coming on the podcast. I really do appreciate it. I mean that sincerely. It’s time out of your busy schedule and more importantly for what you do and what your colleagues do at CHOP. We just love you guys, think you’re awesome. And we just wish you all the best in continuing to do what you do to help women throughout the country for these really, as you said, complex issues that are beyond medicine. It’s very difficult for people, and to have you guys available and so caring at the same time, and so competent is just invaluable.
Dr. Khalek: Well, all of that right back at you. I mean, your group is also wonderful. We love working with you and we’re happy to support and be available in any way that’s helpful. Thank you so much.
Dr. Fox: Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at hw@healthfulwoman.com. Have a great day. The information discussed in “Health Woman” is intended for educational uses only. It does not replace medical care from your physician. “Healthful Woman” is meant to expand your knowledge of women’s health and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.