In-Utero Surgery Leads to Twin Births

Cutting-edge surgery at 20 weeks gestation saved two healthy boys born at the CHLA-USC Institute.
By Monika Guttman
Ramen Chmait performed Operative Fetoscopic Laser Therapy last March when the mother was 20 weeks pregnant to treat Twin-Twin Transfusion Syndrome.

Two healthy twin boys born via C-section were saved by state-of-the art surgery performed in utero by Ramen Chmait, director of fetal therapy within the Childrens Hospital Los Angeles-USC Institute for Maternal-Fetal Health.

The babies and their mother were the first in-utero surgery patients at the institute, one of only a few facilities nationwide and the only one in Los Angeles offering in-utero surgeries.

Chmait performed Operative Fetoscopic Laser Therapy last March when the mother was 20 weeks pregnant to treat Twin-Twin Transfusion Syndrome (TTTS), a life-threatening condition in which identical twins who share a placenta do not share the blood supply evenly.

The shared placenta contains abnormal blood vessels that connect the umbilical cords and circulations of the twins. Unequal blood flow between the twins via the communicating blood vessels, with one twin receiving unnecessary blood from the other, leads to TTTS.

“When we did the surgery, the recipient twin was already in heart failure,” said Chmait, assistant professor of clinical obstetrics and gynecology at the Keck School of Medicine of USC. “If the recipient twin dies, the donor twin has a 30 percent chance of death or brain damage.”

Operative Fetoscopic Laser Therapy uses laser energy to remove the connecting blood vessels on the surface of the placenta so that the babies’ blood is no longer shared.

Using local anesthesia, the scope is placed into the uterus through a tiny hole in the skin. The small connecting blood vessels can then be visualized and closed using laser energy from a small fiber optic passed inside of the scope.

After the surgery in March, “all the previous blood flow pattern abnormalities [were] resolved,” Chmait said. “The babies were able to grow normally, and the problems caused by TTTS [were] resolved.”

Lizbeth Erazo, 30, delivered the identical twins at 36 weeks at Hollywood Presbyterian Medical Center. The first boy was born at 8:51 a.m. July 6, weighing 4 lbs. 15.6 oz, and the second was born at 8:52 a.m., weighing 5 lbs. 13.2 oz.

The twins were delivered by Dr. Arus Zograbyan and assisted by Chmait. The babies are in the NICU for observation, and Erazo is in recovery. All are doing well, according to hospital representatives.

“I am grateful to Dr. Chmait, the nurses and the hospital,” Enzo said. “If it wasn’t for this program, there would be no hope for my babies.”

Chmait performed more than 200 surgeries in utero during his tenure at the Fetal Surgery Program at St. Joseph’s Women’s Hospital in Tampa, Fla. Since the March surgery on the twins, he has performed more than 13 operations in Los Angeles as part of the CHLA-USC Institute for Maternal-Fetal Health (IMFH).

“It has been a long-term goal of ours to expand services at the IMFH into minimally invasive fetal surgery, and we were fortunate to be able to attract one of the few perinatologists in the world with Dr. Chmait’s skills,” said T. Murphy Goodwin, chief of Maternal-Fetal Medicine at the Keck School of Medicine and co-director of the IMFH.

Goodwin worked closely with David Miller, medical director of the IMFH, to recruit Chmait to join the faculty at USC and expand the services of the IMFH into minimally invasive fetal surgery.

“The IMFH is now capable of providing the full spectrum of cutting-edge prenatal diagnostic and therapeutic options through one tightly coordinated team, a service unique in the Los Angeles area,” Goodwin said.

The IMFH, based at Childrens Hospital Los Angeles, is a cooperative program between CHLA and the Keck School of Medicine of USC. The institute’s Diagnostic Perinatal Program and its Minimally Invasive Fetal Surgical Program are based at Hollywood Presbyterian Medical Center, located next to CHLA. The institute is now entering its fourth year of operation.