Imagine an aeroplane full of small children that’s careening out of control. The airline – let’s call it HSEAir – doesn’t have a brilliant reputation and the plane is expected to crash, with huge loss of life.
But then the crew perform a manoeuvre they’re never made before. At the last moment, they impose order on the path of the plane. It still has to make an emergency landing, and there are some fatalities and injuries, but most of the children’s lives are saved.
It’s a fair bet the pilot and crew would be feted as heroes for pulling off such a daring manoeuvre. Banner headlines would celebrate their achievement in rescuing so many children.
This scenario is imaginary, of course, yet something similar is going on in an area of our otherwise maligned health service, with little fanfare or celebration.
Over the past nine years, more than 100 babies' lives have been saved because they underwent groundbreaking surgery at the Rotunda Hospital in Dublin while they were still in their mothers' wombs.
In the past, the majority of the babies who were diagnosed as having Twin-to-Twin Transfusion Syndrome (TTTS) died, but thanks to the use of a new technique using keyhole surgery, microscopic cameras and laser therapy, most now survive.
The vast improvement in survival rates is confirmed in a new review of the first 106 cases of TTTS treated in the Rotunda since 2006. In almost half of these cases, both twins survived the treatment, while in 75 per cent of cases at least one twin survived. This compares with a mortality rate of more than 90 per cent in the absence of treatment.
"It's a good news story. These are big numbers and they show Ireland is punching above its weight and can look in the eye the big international centres that are doing this work," says Prof Fergal Malone, consultant obstetrician at the Rotunda and the Royal College of Surgeons in Ireland. "It also shows good things are happening in the health service. It isn't all 'Angola'."
Struggle for resources
There’s something primal about the Cain-and-Abel-like struggle for resources that is the root of the syndrome, which affects only identical twins who share the same placenta. “What you have are two fundamentally healthy babies, but there is an imbalance in their blood connections,” Malone explains.
There are no winners in this battle, as one baby ends up being starved of nutrition while the other’s system becomes overloaded. “They both get sick. One gets the life sucked out of it and dies from growth restriction, while the other suffers heart failure.”
Previously, treatment involved draining off excess amniotic fluid but this didn’t deal with the source of the problem, which often returned later in the pregnancy. It wasn’t until technology allowed for the miniaturisation of medical cameras that it became possible to use surgery to address the problem.
The technique, fetoscopic laser ablation, involves putting a camera just 2mm wide through a keyhole incision in the mother’s abdomen and into the uterus.
The camera is used to examine the blood vessels, which are labelled “good” or “bad” before the bad ones are sealed, Malone says. “Effectively, you’re making the twins separate so there’s no more blood exchanged between them. Small baby gets to keep their blood and other baby stops getting overloaded.”
Quite apart from the impressive survival figures, the project is a model of good medical practice. When Malone returned to Ireland in 2005 with the necessary skills picked up while training in New York, he realised it wasn’t feasible to “send women off on planes” for a procedure that had to be done as quickly as possible after diagnosis. But rather than venture into the unknown, the Rotunda partnered with King’s College Hospital in London for the first few cases, and these were performed in the UK.
Then, when the Irish programme was ready to begin in 2006, it was designed as a collaboration between the Rotunda and the National Maternity Hospital in Holles Street. The creation of a single team ensured that experience was pooled in a bigger group of doctors. "It also meant that if I'm on my holidays people won't be asking 'What's going to happen now?' "
Pioneering treatment is all very well, but it has to work. Once a sufficient number of women had been treated, it was time to audit the results.
The figures, published recently in the European Journal of Obstetrics & Gynaecology, show that in the first 105 cases, 128 out of 210 foetuses lived, a survival rate of 61 per cent. Of those babies who survived, 86 per cent have a normal neurological outcome.
The review raises a number of concerns, notably the fact that not all of Ireland’s 19 maternity units offer access to early scans. Malone says there are still a lot of patients who aren’t getting the scans they need, though the situation is improving.
“Early diagnosis is crucial. This laser surgery works bests if we see the patient early. If a woman is pregnant with twins, she needs a scan early to tell her whether they are identical. If they are, she’s at risk. She then needs scans every two weeks as the situation can change rapidly with the build-up of excess fluid.”
With the number of treatments performed increasing every year, Malone hopes to offer the service on an all-Ireland basis in future. He also enthuses about the potential opened up by in-uterus surgery to save babies’ lives or correct impairments, such as operations to fix diaphragmatic hernia, spina bifida or cleft lip.
Healing happens faster in the womb than in life, it turns out. “Think of the foetus as a patient,” Malone suggests. “Rather than waiting for it to be delivered, you can do these things to save life or change outcomes while it’s in the womb.”
Some of this is still "Star Wars territory", he admits, and yet "the sky's the limit" for the potential for medical intervention in this area.
‘The twins still sleep beside each other, holding hands’
When Michelle Corrigan found out at her seven-week scan she was pregnant with twins, it was “a childhood dream come true”.
“That was my first thought. I had no worries about anything and I had never heard of Twin-to-Twin Transfusion Syndrome.”
Already the mother of one-year-old Daryl, Michelle’s thoughts in 2012 centred on whether she would get a night’s sleep in the foreseeable future in the family home in Swords, Co Dublin.
Another scan was fine but at 20 weeks she came in to the Rotunda hospital in Dublin with her husband, Eamonn, for what she thought would be another routine examination, but TTTS was diagnosed.
“I had noticed my bump was big. It felt tight and uncomfortable, but I put it down to having twins. I thought it was normal.”
The couple were told there was fluid around the babies and they should see Prof Fergal Malone after lunch. He recommended she undergo fetoscopic laser ablation that very evening. “We were devastated,” Michelle recalls, “but we agreed to it straight away after being told that, with the operation, it was one in three that two babies would make it, one in three that one would make it, and one in three that neither would survive. And that, without the procedure, we had no chance.”
The operation, carried out under local anaesthetic, lasted 40 minutes. Michelle, her hand gripping a nurse’s hand throughout, couldn’t bring herself to look at the monitor.
The scan performed afterwards showed both babies had survived the procedure. “That was a first step, but we weren’t out of the woods yet,” Michelle says. She had three litres of fluid removed and her bump went down, but by 26 weeks, her regular scan showed the babies were getting sick again.
Michelle was kept in and managed to get to 31 weeks before the decision was taken to deliver. On birth, Eric and Sean were whisked away to intensive care and she didn’t see them until the next morning. “It was overwhelming. They were so small and I couldn’t hold them yet.”
Sean, who had been anaemic in the womb, was given blood transfusions, while Eric’s heart was closely monitored. Overall, though, it was “normal premature baby stuff”, says Michelle, and by six weeks they were both allowed home.
The boys continued to attend the Rotunda until they were two years old and judged to have caught up developmentally. “They’re three now, and doing great. Each of them loves his brother, loves playing outdoors, doing all the things boys love.”
They have different personalities. “Sean, the donor in the womb, is the smaller of the two, and he’s feisty and loud, with a bit of a temper. “Eric is laid-back, quiet, the big softy. They’re very close, and still sleep beside each other, holding hands.”
Michelle knows now her situation was “days away from being too late” and that her boys owe their lives to the work of the medical team in the Rotunda. Her advice to other women who find themselves pregnant with identical twins is to “inform yourself, but the right way. Don’t do what I did and just Google information.”
As well as using only reliable sources of information, she recommends seeking help from support groups such as the Irish Multiple Births Association, imba.ie
To watch interviews with Prof Malone and Michelle Corrigan, and footage of this unique surgery, see irishtimes.com