frowned. ‘Which were?’
‘The recent floods prevented her from making the nineteen-week scan. They live three hours west in a small farming community that was flooded in for two weeks and the last week they’ve been cleaning up and trying to get back on their feet. Yesterday was the first chance she had to get to the medical centre for the ultrasound, which is, by the way, an hour’s drive.
‘The GP was concerned she was large for dates, which Kathy had put down to carrying twins and the breathlessness and exhaustion she was feeling down to the stress and hard work of mopping up. But the ultrasound…’
Callie handed over the images that Kathy had brought with her.
‘It shows a larger twin with evidence of polyhydramnios and enlarged bladder and the smaller twin with next to no amniotic fluid or discernible bladder.’
Cade looked at the dramatic images. The larger twin, or the recipient twin as it was medically known, was sitting pretty in its over-filled sac while his brother, the donor twin, was practically shrink-wrapped inside his.
‘They were referred here immediately and travelled up last night.’ Callie turned to her computer and retrieved the data she was looking for. She swivelled the monitor round for Cade to see. ‘These are the images I took just now,’ she said.
Cade shifted forward but the angle and the light in the room made it difficult to see properly so he perched on the edge of her desk, letting his leg swing a little as he leaned in towards the screen.
As he watched he was thankful he worked in, and had had exposure to, the more advanced technology of a large modern hospital. Still images were fine but to be able to see the babies in action, so to speak, was much more helpful. Callie had been thorough with all her measurements and the colour Doppler flow study was particularly helpful.
Callie looked up at him. ‘I think she’s a good candidate for FPLT.’
‘Well, they’re obviously too young to deliver. Certainly fetoscopic placental laser therapy is an option but reduction amniocentesis would be a more conservative approach.’
Callie smiled. Cade Coleman was not known for his conservative approach to medicine or else he wouldn’t be blazing a trail in prenatal surgery, but it was good to know he wasn’t a cowboy, either.
‘Yes. But I think Kathy and Ray’s personal circumstances lend themselves much better to a one-off therapy like FPLT. You and I both know that removing the excess amniotic fluid from the recipient twin is a procedure that often needs to be done multiple times with associated risk of premature birth each time. Not to mention the need for stringent follow-up.
‘They don’t live close to a treatment centre, which would cause a lot of undue stress both physically and, I suspect, financially for them. And she’d need to be on bed rest for the remaining pregnancy. Kathy is not a bed rest kind of woman—she has three little kids and a farm that she helps run. We’d have to admit her for the rest of her pregnancy to ensure that.’
‘She’ll still need to rest after laser therapy.’
‘I know,’ Callie agreed, tapping her pen absently against the wooden desktop. ‘But if she’s non-compliant or poorly compliant, at least the basic cause has been dealt with.’
Callie had grown up around women like Kathy—they worked hard from sun-up to sundown. Rest was something people in the city did.
‘I think she’d be much happier having weekly follow-up ultrasounds locally than stuck in a city hospital, worrying about how her hubby is coping with the kids and the farm.’
She put down her pen and stared at him for a moment. She didn’t think she’d have to work this hard to convince Cade Coleman, of all people!
‘It has the best outcomes for both twins over any other treatment,’ she said. ‘Prior to your arrival, Kathy and Ray would have to have travelled to Sydney for this.’
He grinned. ‘You know you’re preaching to the converted, right?’
Callie shot him an exasperated glare. ‘Well, what are we waiting for?’ she said, standing up. ‘Let’s go and talk to them.’
He followed her through an interconnecting door to the next room, where a couple sat quietly holding hands. After the introductions were over, Callie gave them a reassuring smile.
‘You’ve both had a lot to take in this morning,’ she said. ‘Before I get on to treatment options, have you got any questions about the actual condition?’
Kathy’s husband, Ray, nodded. ‘Yes. I’m sorry, it’s all a little overwhelming. Did you say that the twins are sharing the same blood supply through the placenta?’
Callie smiled again encouragingly. ‘Kind of,’ she said. It was often hard for laypeople to understand complex medical conditions and part of Callie’s job was helping them to understand. If that meant she had to go over and over the information again, that’s what she did.
‘Your twins share the same placenta—that’s common for identical twins. Usually in this scenario each twin has its own separate connection to the placenta via its umbilical cord, but in TTTS the placenta contains abnormal blood vessels, which connect the umbilical cords and circulations of the twins.’
Callie paused to check that Kathy and Ray were following. She glanced at Cade, indicating for him to jump in. ‘So essentially,’ Cade said, ‘blood from one twin is transfused into the other twin.’
‘That’s the donor twin, right?’ Kathy said. ‘The recipient is the twin who gets the transfusion?’
Callie nodded. ‘That’s right. The recipient twin has a lot of extra stress put on its heart because of the extra fluid. Also the kidneys produce a lot of urine to try and remove some of the excess fluid, which leads to a build-up of amniotic fluid. That’s what I showed you on the scan earlier.’
‘That’s why I’m so big,’ Kathy stated.
‘Yes,’ Cade confirmed. ‘It’s called polyhydramnios. But the donor baby has hardly any amniotic fluid because it’s donating all its blood to its sibling and therefore producing hardly any urine. The donor twin also becomes quite anaemic.’
Cade paused, too, for a moment, glancing at Callie. Ray and Kathy seemed to have grasped the basics. They looked shaken but, from what he’d gleaned already about people from ‘the bush’, as they called it here, also stoic. Something that was confirmed a moment later when Ray cut straight to the chase.
‘Okay. So how do we fix it?’
Callie ran down the rather short list of options from doing nothing, which would almost certainly lead to the death of one if not both twins, to bed rest and nutrition to treating the symptoms with serial reduction amniocentesis and stringent monitoring.
‘There is one more option,’ she said. ‘I’ve asked Dr Coleman here because he offers a one-off treatment that is curative.’
Ray frowned. ‘So let’s do that.’
Cade looked at Callie and she nodded for him to continue. ‘Well, it is a little out there for a lot of people. It’s called fetoscopic placental laser therapy and involves me operating on the
