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Timeliness, a Critical Factor in Treating TTTS

It's one of the biggest controversies in fetal surgery and the cause of heated debate among surgeons and maternal-fetal medicine physicians// around the world: What's the best way to treat twin-twin transfusion syndrome (TTTS), one of the most common conditions requiring fetal surgery and the leading cause of mortality in twins?

The benchmark, NIH-funded study on TTTS, conducted at 17 centers in the United States, will be presented February 9 at the annual meeting of the Society for Maternal-Fetal Medicine in San Francisco, and it won't likely resolve the question of which is the best procedure.

The study, led by Timothy Crombleholme, M.D., director of the Fetal Care Center of Cincinnati, shows that the question isn't which surgical procedure is better, it's when the procedure is done.

Dr. Crombleholme issued a clarion call to fetal care specialists around the world. "The earlier in gestation TTTS is diagnosed, the more severe the syndrome tends to be," says Dr. Crombleholme, who is also a pediatric surgeon at Cincinnati Children's Hospital Medical Center.

"We have to shift attention to diagnosing this earlier in the progression of the syndrome and being more aggressive about intervention. We can't conclude that one therapy is better than another, but it's apparent that we're going to compromise survival if treatment isn't initiated before it gets to be severe."

In TTTS, the way in which blood flows through the connecting blood vessels on a shared placenta is unequal. As a result, the donor twin has slowed growth and decreased amniotic fluid, while the recipient has too much amniotic fluid and develops a form of heart failure. Without treatment, TTTS is fatal for at least 90 percent of twins, and both twins are at risk for severe complications.

There are two main treatment modalities: amnioreduction, in which excess amniotic fluid is removed from the recipient twin, or a fetoscopic laser proce
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