EP21.01: Maternal changes in monochorionic pregnancy complicated by Twin–twin transfusion syndrome after laser ablation of placental anastomosis

Abstract

Fetal aortic valvuloplasty may be considered in critical aortic stenosis (AS), to prevent progression of AS to hypoplastic left heart syndrome (HLHS), which can be followed by fetal hydrops or death in utero. A multigravid woman was transferred at 29 +4 weeks of gestation, due to fetal cardiomegaly. The fetus was diagnosed with severe AS, cardiomegaly, a dilated LV with poor contractility, and mitral regurgitation. She was admitted to the hospital for fetal cardiac function monitoring. At 31weeks of gestation, fetal echocardiography revealed a thickened and dysplastic aortic valve with severe stenosis, accompanied by severe LV dilatation and dysfunction, as well as RV dilatation and dysfunction. A retrograde flow in the hypoplastic aortic arch, a left-to-right shunt across foramen ovale, and prominent a-wave reversal in the pulmonary vein Doppler were also found, suggesting evolving physiology of HLHS. Under ultrasound-guided approach, the fetal aortic balloon valvuloplasty was performed using biopsy needle through maternal abdominal wall, placenta, and fetal LV free wall, a guide wire, and a coronary balloon. After procedure complete, severe fetal bradycardia was developed. After intra-ventricular injection of epinephrine and atropine, the fetal heart rate was recovered. Fetal movement with biophysical profile was recovered within 12 hours after the procedure. At 35+3 weeks of gestation, fetal echocardiography showed a slightly improved cardiac function. A 3070 g female neonate was delivered vaginally at 38weeks of gestation with Apgar score 6/7 at 1/5 minutes. The neonate underwent operation including RV-PA conduit implantation for recurrent AS and LV dysfunction at 11months after birth. She is alive with tolerable condition.