Today, the survival rate of identical twins who share a placenta and are affected by twin-to-twin transfusion syndrome has improved greatly. This is largely due to the recent advances in maternal fetal medicine, a well-established subspecialty in obstetrics and gynaecology. More than 70 per cent of identical twin pregnancies are monochorionic – i.e. the twins share a placenta. And twin-to-twin transfusion syndrome though rare is an important complication of such pregnancies, which without expert care can lead to the loss of both twins. However, with prompt diagnosis, monitoring and treatment including skilled keyhole laser surgeries with the babies still in the womb, their chance of survival is greatly enhanced. All of this is possible while under the care of a maternal fetal medicine specialist.
“Fetoscopic laser ablation treatment for twin pregnancies complicated by twin-to-twin transfusion syndrome is one of the biggest success stories of my time,” says Dr Samina Dornan, Consultant in Maternal Fetal Medicine leading the prestigious Fetal and Maternal Medicine and Obstetric Ultrasound Services, or FAMOUS, at Al Zahra Hospital, Dubai. “This intervention alone has increased the chances of taking both babies home, alive and well, from 25 per cent to over 70 per cent, and a single baby alive and well from 25 per cent to more than 90 per cent.”
However, Dr Dornan is quick to note that such success stories depend on exactly who is providing the pregnancy care and the level of their expertise. This includes immediate access to an extended multidisciplinary team of healthcare professionals who can offer the best care 24/7 to expectant parents where the pregnancy has complications.
If an experienced maternal fetal medicine specialist is the lead healthcare provider for your pregnancy, it goes without saying that you are in extremely safe hands. They will have undergone at least four additional years of specialised training in dealing with high-risk pregnancies on top of five to six years of general OB-GYN education.
"Such lengthy and intense training exposes us to the vast majority of high-risk conditions that can affect expectant mothers and their babies,” explains Dr Dornan. “It allows us to better understand, promptly diagnose, monitor and treat both new and existing health problems in the mother, as well as manage any problems that develop in the growing baby."
She believes that all pregnant women should consult a maternal fetal medicine specialist, preferably before they become pregnant, as these specialists approach preconception care from both the maternal and fetal perspectives, devising a plan to ensure a healthy pregnancy, birth and postnatal care. Not only do they provide standard preconception care such as medication reviews and modifications, the prescription of supplements and recommendations for dietary changes but also specialised advanced care to women with pre-existing medical conditions or a history of complications in a previous pregnancy. From invasive and non-invasive prenatal tests to treatments and surgeries, maternal fetal medicine specialists conduct preventative, diagnostic and therapeutic procedures such as ultrasound for fetal anomalies and growth, treatment of placental problems, and insertion of cervical stitches to prevent premature birth.
"Some of us are further trained in the fields of fetal diagnosis and prenatal therapy, developing competencies in advanced procedures such as targeted fetal assessment using ultrasound and Doppler techniques, fetal blood sampling and transfusion, fetoscopy and open fetal surgery,” she adds. “Open fetal or fetoscopic surgery for the correction of birth defects such as spina bifida (where a baby's spine and spinal cord do not develop properly) is now a realistic option that we discuss with couples.”
With such a range of specialisation and training available, it’s prudent to choose a maternal fetal medicine consultant who specialises in your particular condition or pregnancy risk factor, be it diabetes, cardiovascular disease or autoimmune disorders in the mother, fetal developmental problems or multiple pregnancy such as twins, and/or unexpected pregnancy-related conditions such as pre-eclampsia and preterm birth that are more likely in a high-risk pregnancy.
"Patients achieve better outcomes when they choose a maternal fetal medicine specialist who sees a high number of patients with the same or similar complicated condition, compared to an OB-GYN who would see such a patient maybe once a year, for example, a case of twins or triplets,” she explains.
Maternal risk factors such as diabetes, hypertension, older age, assisted reproduction and chronic medical conditions may cause complications in the developing fetus and therefore closer fetal evaluation using ultrasound throughout the pregnancy is needed. There can also be fetal complications that are independent of maternal conditions such as twins and triplets, babies that develop with structural anomalies like tumours, renal anomalies, diaphragmatic hernias, and fetal growth problems including babies that are bigger or smaller than the normal range.
“The idea of such close monitoring is to identify the right time, place and mode to deliver these high-risk mothers and their babies,” says Dr Dornan.
At Al Zahra Hospital Dubai’s Maternal Fetal Medicine department, FAMOUS, Dr Dornan and her team tackle all maternal conditions including asthma, diabetes, and gastrointestinal, hepatic and neurologic problems as well as fetal conditions with the help of a multidisciplinary team. “We have experience in nearly every medical condition that can co-exist with pregnancy. If something comes up that is a risk factor during pregnancy, we've almost certainly seen it and have managed it before."
The advantage of choosing a specialist who practises within a large hospital such as Al Zahra Hospital Dubai is that they can immediately refer patients with pre-existing conditions or complications that arise during a pregnancy to other specialists who can help evaluate, treat and monitor them, she says. "When you choose a maternal fetal medicine provider, you also choose their connections within an extensive multidisciplinary team that is working to ensure the best possible outcomes for babies and their families."
This applies to postnatal care too. “If, for example, a baby has a heart condition, is severely growth restricted, or needs to be delivered prematurely, a newborn intensive care unit (NICU) neonatologist can work closely with a patient's maternal fetal medicine physician to ensure the health of the baby after birth,” emphasizes Dr Dornan.
With a collaborative relationship with Al Zahra’s NICU, one of the largest in Dubai that provides newborn care for nearly 200 premature and seriously ill babies every year, FAMOUS is able to provide top-class postnatal care as well.
Although pregnancy and birth is an important part of a women’s health journey, it’s not the only part of her life, adds Dr Dornan. “A woman, on average, spends only 20-25 years in a reproductive period, but the rest of her life is outside this period. The relationship between the OBGY and a woman is lifelong. I am always on hand to see my patients and their families for any gynaecological issues before pregnancy, in between pregnancies or after their families are complete. Continuity of obstetric and gynaecological medical care for women throughout their lives is extremely important and one of the most rewarding and enjoyable aspects of my job.”
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