When the Womb Becomes the Recovery Room

Two Helping Two: Anthony Johnson, D.O., (left) and Kenneth Moise, M.D., work together to saves lives, two babies at a time. While still in the womb, they use laser technology to seal off blood vessels shared by identical twins.

Anayele Martinez gently rubs her finger against the down soft cheek of her son Jonathan. The peace of the Level II nursery at Ben Taub General Hospital transmits serenity as this 23-year-old mother prepares to take home the second of her twins born approximately two weeks earlier.

The peace is welcome after nearly two months of turmoil as the young mother and physicians at Baylor College of Medicine fought to save the lives of the babies while they were still in the uterus. Christopher and Jonathan were born March 5, 2007, small but healthy. It was a tribute to a new technology that has only recently become available in Houston and the midsection of the United States.

"The whole center of the country was lacking a fetal therapy center until this one opened," said Kenneth Moise, M.D., Professor of Obstetrics and Gynecology at BCM and Director of the Division of Maternal-Fetal Medicine. His procedure, which uses tiny scopes, cameras and laser, is minimally invasive, reducing risk to both babies and mothers.

To date, he and his colleague, Anthony Johnson, D.O., Associate Professor in the Department of Obstetrics and Gynecology, have concentrated their efforts on a relatively rare condition called twin-twin transfusion syndrome. The problem occurs only in identical twins who share a placenta or afterbirth—occurring in approximately one in 360 pregnancies and in one in 60 sets of twins.

In 15 to 20 percent of these fetuses, the twin-twin blood vessel connections turn deadly. One twin (the recipient) receives too much blood. The other (the donor) receives too little. To deal with the influx of fluid, the recipient twin's bladder grows large and excretes large amounts of urine, increasing the volume of fluid surrounding the fetus. The second twin's bladder is unusually small and that fetus suffers from a lack of fluid. Without treatment, the donor twin can become "stuck" in its part of the uterus. The other twin, overloaded with fluid, may develop heart failure.

When this problem occurs before the 26th week of a pregnancy, the result is disastrous. Without treatment, approximately 90 percent of such pregnancies result in the death of one or both babies. Even if one survives, that infant has a significant risk of brain damage.

There are different treatment options available. One common method is to simply remove the excess fluid. However, doing this can require repeat invasion of the uterus, with a risk each time it is done.

Anayele Martinez holding her twin babies

Anayele Martinez has healthy twin boys, Christopher and Jonathan, thanks to an innovative procedure performed by BCM specialists when she was 18 to 20 weeks pregnant.

A study in the New England Journal of Medicine in 2004 found that using a laser to seal off the blood vessels that connect the babies on the surface of the placenta they share is preferable in most cases and in skilled hands.

"It's not an easy procedure," said Moise. "It is a very bad disease, and even in the best hands, the chance of taking two babies home is 50 percent. Taking one baby home is 70 percent. But do nothing, and the chance of taking two babies home is 10 percent—and there are a lot of consequences."

The actual chances vary with the stage of the disease and when the woman is referred for treatment, he said. Most of the pregnancies are between 18 and 28 weeks when the women are referred for treatment, he said. (The normal length of a pregnancy is 40 weeks.)

When they perform the procedure, Moise and Johnson first map out the blood vessels, identifying those that connect the fetuses. The duration of the procedure varies with the number of connections and the location of the placenta in the uterus.

"Some we can do as rapidly as 20 minutes," said Moise. "Others take two hours, although the average is one hour." During this time, the mother receives a local anesthesia to numb the area where the procedure is done and intravenous sedation that makes her drowsy.

A tiny fetal scope—no bigger than a small drinking straw—serves as the doctors' "telescope" into the uterus. The laser is standard but can be shot down a rod of quartz or a cable, enabling the physicians to pinpoint the exact spot where they are working. Working back and forth, they coagulate the blood vessels that connect the fetuses on a placenta that may be as big as two feet across.

"The tough part is identifying the good vessels that we want to keep intact," said Moise. "Basically, we are making the placentas separate from one another."

It was the opportunity to save young lives that brought Moise back to BCM late last year. He left BCM for the University of North Carolina at Chapel Hill School of Medicine in 1998. There he honed his fetal intervention program. Then, hearing about a new maternal-newborn program at BCM and Texas Children's Hospital, he came back to Texas.

In the future, he hopes to extend fetal intervention to other diseases. Some obstetricians in his field are already working on fetal hearts. A study is ongoing in how best to repair a myelomeningocele (a condition where the spine and backbone do not close before birth, leading to a type of spina bifida).

Some day soon, stem cell therapies for certain neurological diseases might be possible. Robotics may someday play a role in repairing defects in utero with fewer possibilities for injury. As technology progresses, Moise and Johnson see the field expanding.

"The aim is to come out with a healthier newborn," said Moise. That aim is already a reality for Anayele Martinez's sons. But their story would have been much different if the young mother had not voiced her suspicion that something was wrong during a visit to the doctor at Ben Taub when she was 18 to 20 weeks pregnant.

The resident doctor did an ultrasound after Martinez complained that her belly had suddenly swollen large during the past weekend. The results prompted the resident to call Moise, who confirmed the diagnosis of twin-twin transfusion syndrome. By the next morning, she was at Baylor Clinic, where Moise advised her to have laser surgery the next day.

She stayed in the hospital a day and then went home. She appreciated the concern by Moise who checked on her frequently throughout the pregnancy. Her pregnancy was considered high risk, and she had to quit working early. Two weeks after the procedure, she had premature contractions that required hospitalization. Luckily the doctors were able to stop them, and her pregnancy continued until the 34th week. The babies were born at 4 and 5 pounds, and they stayed in the hospital to gain weight. Taking them home was both a relief and a landslide of work for Martinez and her family.

Caring for twins is a time-consuming task, but Martinez knows that she beat the odds when she took her babies home.

The Long Road to Parenthood

Twins Bo and Yuri Melnyk are miracle babies according to mother Roberta, who conceived through in vitro fertilization and then almost lost one or both of them due to a condition called twin-twin transfusion syndrome.

When Roberta and Walter Melnyk cradle month-old twins Bo and Yuri, the Clear Lake couple seem little different from others who have adapted their lives to an influx of children.

Roberta is a competent mom who handles the two babies with aplomb while monitoring active 8-year-old Olek.

The journey from childlessness to parenthood, however, was a perilous one. After years of infertility, the Melnyks adopted Olek from abroad when he was three. Then, a change in insurance gave them a chance for biological children through in vitro fertilization.

It worked, and the couple seemed well on the way to parenthood. Then at 13 weeks into the pregnancy, Roberta knew something was wrong.

"I had been vomiting daily for two weeks," she said. "The first trimester was over. I was walking two miles a day and eating right."

One day, the vomiting got worse and she started to bleed. She told her husband to take her to the hospital immediately. Finally, at the hospital, an ultrasound revealed the problem—twin-twin transfusion syndrome. It was a blow.

After the emotional roller coaster of in vitro fertilization, they faced this new threat. Her Clear Lake physician sent her to Moise and Johnson. They explained the situation, and put her on bed rest. It would be best, they said, if they could do the procedure at 20 weeks of pregnancy. However, at 19-and-one-half weeks, they put her in the hospital and scheduled the procedure for the next day.

She was awake, and they asked her to hold her breath when they used the laser to sever the six or seven major blood vessels that connected the infants. She stayed in the hospital for 24 hours.

After the procedure, the babies equalized in size and stayed that way. At birth, their weights and head sizes were nearly identical.

As Roberta considers the future, she knows one thing: She is lucky that technology advanced at the right time to save the lives of the two youngsters she and Walter had wanted for so long.

The Long Road to Parenthood

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Volume 3, Issue 2, Summer 2007


	When the Womb Becomes the Recovery Room by Ruth SoRelle, M.P.H. Two Helping Two: Anthony Johnson, D.O., (left) and Kenneth Moise, M.D., work together to saves lives, two babies at a time. While still in the womb, they use laser technology to seal off blood vessels shared by identical twins. Anayele Martinez gently rubs her finger against the down soft cheek of her son Jonathan. The peace of the Level II nursery at Ben Taub General Hospital transmits serenity as this 23-year-old mother prepares to take home the second of her twins born approximately two weeks earlier. The peace is welcome after nearly two months of turmoil as the young mother and physicians at Baylor College of Medicine fought to save the lives of the babies while they were still in the uterus. Christopher and Jonathan were born March 5, 2007, small but healthy. It was a tribute to a new technology that has only recently become available in Houston and the midsection of the United States. "The whole center of the country was lacking a fetal therapy center until this one opened," said Kenneth Moise, M.D., Professor of Obstetrics and Gynecology at BCM and Director of the Division of Maternal-Fetal Medicine. His procedure, which uses tiny scopes, cameras and laser, is minimally invasive, reducing risk to both babies and mothers. To date, he and his colleague, Anthony Johnson, D.O., Associate Professor in the Department of Obstetrics and Gynecology, have concentrated their efforts on a relatively rare condition called twin-twin transfusion syndrome. The problem occurs only in identical twins who share a placenta or afterbirth—occurring in approximately one in 360 pregnancies and in one in 60 sets of twins. In 15 to 20 percent of these fetuses, the twin-twin blood vessel connections turn deadly. One twin (the recipient) receives too much blood. The other (the donor) receives too little. To deal with the influx of fluid, the recipient twin's bladder grows large and excretes large amounts of urine, increasing the volume of fluid surrounding the fetus. The second twin's bladder is unusually small and that fetus suffers from a lack of fluid. Without treatment, the donor twin can become "stuck" in its part of the uterus. The other twin, overloaded with fluid, may develop heart failure. When this problem occurs before the 26th week of a pregnancy, the result is disastrous. Without treatment, approximately 90 percent of such pregnancies result in the death of one or both babies. Even if one survives, that infant has a significant risk of brain damage. There are different treatment options available. One common method is to simply remove the excess fluid. However, doing this can require repeat invasion of the uterus, with a risk each time it is done. Anayele Martinez has healthy twin boys, Christopher and Jonathan, thanks to an innovative procedure performed by BCM specialists when she was 18 to 20 weeks pregnant. A study in the New England Journal of Medicine in 2004 found that using a laser to seal off the blood vessels that connect the babies on the surface of the placenta they share is preferable in most cases and in skilled hands. "It's not an easy procedure," said Moise. "It is a very bad disease, and even in the best hands, the chance of taking two babies home is 50 percent. Taking one baby home is 70 percent. But do nothing, and the chance of taking two babies home is 10 percent—and there are a lot of consequences." The actual chances vary with the stage of the disease and when the woman is referred for treatment, he said. Most of the pregnancies are between 18 and 28 weeks when the women are referred for treatment, he said. (The normal length of a pregnancy is 40 weeks.) When they perform the procedure, Moise and Johnson first map out the blood vessels, identifying those that connect the fetuses. The duration of the procedure varies with the number of connections and the location of the placenta in the uterus. "Some we can do as rapidly as 20 minutes," said Moise. "Others take two hours, although the average is one hour." During this time, the mother receives a local anesthesia to numb the area where the procedure is done and intravenous sedation that makes her drowsy. A tiny fetal scope—no bigger than a small drinking straw—serves as the doctors' "telescope" into the uterus. The laser is standard but can be shot down a rod of quartz or a cable, enabling the physicians to pinpoint the exact spot where they are working. Working back and forth, they coagulate the blood vessels that connect the fetuses on a placenta that may be as big as two feet across. "The tough part is identifying the good vessels that we want to keep intact," said Moise. "Basically, we are making the placentas separate from one another." It was the opportunity to save young lives that brought Moise back to BCM late last year. He left BCM for the University of North Carolina at Chapel Hill School of Medicine in 1998. There he honed his fetal intervention program. Then, hearing about a new maternal-newborn program at BCM and Texas Children's Hospital, he came back to Texas. In the future, he hopes to extend fetal intervention to other diseases. Some obstetricians in his field are already working on fetal hearts. A study is ongoing in how best to repair a myelomeningocele (a condition where the spine and backbone do not close before birth, leading to a type of spina bifida). Some day soon, stem cell therapies for certain neurological diseases might be possible. Robotics may someday play a role in repairing defects in utero with fewer possibilities for injury. As technology progresses, Moise and Johnson see the field expanding. "The aim is to come out with a healthier newborn," said Moise. That aim is already a reality for Anayele Martinez's sons. But their story would have been much different if the young mother had not voiced her suspicion that something was wrong during a visit to the doctor at Ben Taub when she was 18 to 20 weeks pregnant. The resident doctor did an ultrasound after Martinez complained that her belly had suddenly swollen large during the past weekend. The results prompted the resident to call Moise, who confirmed the diagnosis of twin-twin transfusion syndrome. By the next morning, she was at Baylor Clinic, where Moise advised her to have laser surgery the next day. She stayed in the hospital a day and then went home. She appreciated the concern by Moise who checked on her frequently throughout the pregnancy. Her pregnancy was considered high risk, and she had to quit working early. Two weeks after the procedure, she had premature contractions that required hospitalization. Luckily the doctors were able to stop them, and her pregnancy continued until the 34th week. The babies were born at 4 and 5 pounds, and they stayed in the hospital to gain weight. Taking them home was both a relief and a landslide of work for Martinez and her family. Caring for twins is a time-consuming task, but Martinez knows that she beat the odds when she took her babies home. The Long Road to Parenthood Twins Bo and Yuri Melnyk are miracle babies according to mother Roberta, who conceived through in vitro fertilization and then almost lost one or both of them due to a condition called twin-twin transfusion syndrome. When Roberta and Walter Melnyk cradle month-old twins Bo and Yuri, the Clear Lake couple seem little different from others who have adapted their lives to an influx of children. Roberta is a competent mom who handles the two babies with aplomb while monitoring active 8-year-old Olek. The journey from childlessness to parenthood, however, was a perilous one. After years of infertility, the Melnyks adopted Olek from abroad when he was three. Then, a change in insurance gave them a chance for biological children through in vitro fertilization. It worked, and the couple seemed well on the way to parenthood. Then at 13 weeks into the pregnancy, Roberta knew something was wrong. "I had been vomiting daily for two weeks," she said. "The first trimester was over. I was walking two miles a day and eating right." One day, the vomiting got worse and she started to bleed. She told her husband to take her to the hospital immediately. Finally, at the hospital, an ultrasound revealed the problem—twin-twin transfusion syndrome. It was a blow. "I felt so ill," she said. "We had been trying to have a baby for so long." After the emotional roller coaster of in vitro fertilization, they faced this new threat. Her Clear Lake physician sent her to Moise and Johnson. They explained the situation, and put her on bed rest. It would be best, they said, if they could do the procedure at 20 weeks of pregnancy. However, at 19-and-one-half weeks, they put her in the hospital and scheduled the procedure for the next day. She was awake, and they asked her to hold her breath when they used the laser to sever the six or seven major blood vessels that connected the infants. She stayed in the hospital for 24 hours. After the procedure, the babies equalized in size and stayed that way. At birth, their weights and head sizes were nearly identical. As Roberta considers the future, she knows one thing: She is lucky that technology advanced at the right time to save the lives of the two youngsters she and Walter had wanted for so long.		Search all issues: Features Saving Twins Before Birth Blessing to Botswana Preserving Brains Cocaine Vaccine Shows Promise News Building, Bucks & BBQ DNA Discoverer Gets His Own BCM Cancer Center One of Select Few Spotlight Bert O'Malley: A Pioneer in Molecular Endocrinology Making Sense of the Sense of Touch Tissue Samples Go Digital Severe Skin Conditions Take a Back Seat at Camp Dermadillo Health Economist Must Put Price Tag on the Priceless Doctor Creates Cartoon that "Bugs" Kids About the Risks of Tobacco Briefs Living Longer is Smelly Business Clinical Trials for Cancer Southward Bound Green Tea Component Blocks HIV Cell Entry Genetics Technique Takes Bite out of Research Barriers Sports Legends Lend Helping Hands, Arms to College Development & Alumni News Mitchell Gift Furthers Brain Research Lambert Receives Lifetime Achievement Award Kleberg Foundation Gift Establishes RNAi Screening Core Facility Alumnus Named White House Fellow New Trustees Announced Tailoring Technology to Benefit You, the Patient Anayele Martinez has healthy twin boys, Christopher and Jonathan, thanks to an innovative procedure performed by BCM specialists when she was 18 to 20 weeks pregnant.

	Volume 3, Issue 2, Summer 2007



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