*SPECIAL GUEST* - Dr. Saul Snowise – Part 1 of 2 This week we continue our discussion with Dr. Saul Snowise talking about the role of selective reduction, specifically in the setting of monochorionic twins. This week we'll be covering the following:  Dr. Snowise’s preferred tool/method for selective reduction Selective reduction in the setting of monoamniotic twins with discordant anomalies & cord entanglement Various instruments & equipment used for the different methods of selective reduction How instrument/trocar size affects complication rates Discordant anomalies in monochorionic/identical twins Twin reversed arterial perfusion (TRAP) sequence Rate of occurrence Pathophysiology/disease process Optimal timing for fetal intervention/surgery Selective reduction for sIUGR Patient counseling and informed consent Laser ablation as treatment for sIUGR Effects of legislation and the overturning of Roe v. Wade on selective reduction as a treatment option in pregnancy

*SPECIAL GUEST* - Dr. Saul Snowise – Part 1 of 2 This week and next week we have a two-part series with Dr. Saul Snowise as we discuss the role of selective reduction, specifically in the setting of monochorionic twins. Join us as we discuss the following this week: How selective reduction differs in monochorionic vs. dichorionic twins  Most common method of selective reduction Potassium chloride (KCl) injection contraindicated in monochorionic twins   Method for monochorionic pregnancy Cord occlusion Indications for selective reduction in monochorionic twins Selective fetal growth restriction (sIUGR) Discordant anomalies Twin-twin transfusion syndrome (TTTS) Twin reverse arterial perfusion (TRAP) sequence Failed laser Various methods for performing a cord occlusion selective reduction Microwave Interstitial laser Radiofrequency ablation (RFA) Bipolar cautery Sizes of operative instruments, energy levels used and the treatment protocols Gestational age thresholds for performing a selective reduction procedure Risks associated with a selective reduction procedure Membrane complications (i.e. PPROM) Preterm delivery Bleeding, infection  Loss of co-twin Pre-operative counseling with patients Follow-up and surveillance for the remainder of the pregnancy Tune in next week for part 2!

Welcome back "What they didn't teach you in laser school" – now onto Part 2! This week we’re going to continue talking about all our laser tips & tricks while discussing the following:   Anterior placenta challenges Future of steerable operative scopes Current 30 degree operative Storz scope Using external pressure to aid in flattening the uterus Intraoperative amnioinfusion Intraoperative complications Concurrent fetal bradycardia in both fetuses What to do when the laser won’t stop firing Intra-operative bleeding Post-operative complications Bleeding Placental abruption Intraperitoneal bleeding Amniotic fluid leakage PROM (premature rupture of membranes) Intraperitoneal amniotic fluid leakage 

Welcome to "What they didn't teach you in laser school"! This two-parter is going to be filled with Dr. Moise's tips and tricks (and some of Erin's too) as we share the following topics:  Pre-operative evaluation tips Identifying cord insertions via ultrasound Following the lie of the donor twin to find the inter-twin anastomotic plane Not true for “cocoon” sign Re-evaluate and confirm cord insertions and anticipated cannula insertion site in the OR Confirming renal blood flow in the donor twin Renal agenesis Intraoperative tips Anesthesia type Maternal drugs we use & don’t use Operative cannula placement Patients with a higher BMI or thick abdominal wall Using a ‘spike’ AKA ‘harpoon’ for entry Spinal anesthesia for cut-down Anterior placenta Patient positioning Laparoscopic approach Check uterine wall for vessels with color flow Doppler Counterpressure Intraoperative bleeding Amnioexchange / rapid infuser Using humidified CO2 for anterior placenta Pediatric foley Intraoperative septostomy Inadvertent vs. purposeful septostomy Complications Amniotic band syndrome Tangled cords Tune in next week for part 2!

This week we’re going to be using the most recent episodes as building blocks to discuss atypical presentations of twin-twin transfusion syndrome or TTTS. Dr, Moise takes us through the following ‘unicorn’ presentations by covering the following: Review of the classic Quintero staging system for TTTS Stage I, II, III, IIID, IIIR, IIIDR, IV, V Alternative TTTS staging systems that have been proposed Cincinnati CHOP Case scenario of an atypical TTTS IIID TTTS with sIUGR Review definition of sIUGR Cardiac dysfunction in the setting of monochorionic twins Which combination of twin complications in monochorionic twins would be candidates for laser surgery Monoamniotic twins with TTTS Diagnosing TTTS with a spontaneous septostomy

*SPECIAL GUEST* - Dr. Ramesha Papanna – Part 2 of 2 Join us as we continue our discussions on Twin Anemia Polycythemia (TAPS).  This week Dr. Papanna walks us through the following topics on TAPS: Society of Maternal Fetal Medicine (SMFM) and International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) guidelines and recommendations for monitoring MCA Dopplers in monochorionic twins Laser ablation of placental anastomoses as treatment for TAPS Transabdominal approach Role of Solomon technique / solomonization in TAPS Disease severity and clinical indications for laser as treatment for TAPS Intrauterine Transfusion (IUT) or exchange transfusion as treatment options for TAPS How gestational age affects management of TAPS TAPS as a complication of an incomplete laser for TTTS Long-term outcomes and sequelae for a pregnancy affected by TAPS Resources for patients: www.tapssupport.com

*SPECIAL GUEST* - Dr. Ramesha Papanna – Part 1 of 2  Join us as we head down another aisle of Twins R’ Us but this time with a very special guest who is joining us for this two-part series on Twin Anemia Polycythemia Sequence (TAPS)! This week Dr. Papanna walks us through the following topics on TAPS:  Defining TAPS Pathophysiology of TAPS Difference between spontaneous TAPS and TAPS after a laser for TTTS How TAPS is detected Rate of occurrence of TAPS in monochorionic twin pregnancies The original definition and staging of TAPS from the Leiden group in 2007 Fetal vs. neonatal criteria MCA Doppler discordance Staging mirror TTTS staging The three stages of population-based disease Screening – deploying a particular test on a large population to pick up on potential disease Diagnosis – confirmatory test Outcome –the effect of the diagnosis on Common ultrasound findings in TAPS ‘Starry Liver’ Placental thickness Discordant MCAs Placental vessel anastomosis types involved in TAPS Tune in next week for Part 2!

We know many of you tuned in eager to hear a big clinical research update that we've been so excited to share! That episode will be coming down the pipeline soon but unfortunately will not be released today.  Stay tuned for an episode later today as we travel down the TAPS aisle of Twins R' Us with Dr. Ramesh Papanna!

We're heading down the Taco Aisle at Twins R' Us this week as we dive into sIUGR also known as selective intrauterine growth restriction. Join us this week as we discuss the following:  Defining sIUGR in monochorionic twins Must meet at least two of the following four criteria Smaller twin must be less than 10th percentile for EFW by ultrasound And/Or the smaller twin’s AC must be less than 10th percentile for gestational age More than 25% difference of smaller twin and the bigger twin EFW UA Doppler of the smaller twin has a pulsatility index greater than 95th percentile for gestational age Doppler measurements and why we do them UA Doppler – surrogate marker for placental resistance & placental territory or how much placenta each baby has Pulsatility index = (systolic velocity – diastolic velocity) / mean AEDF – high resistance in the placenta REDF – if the blood ‘bounces’ off the placenta from the UA Defining sIUGR in dichorionic twins Must meet at least two of the following three criteria Smaller twin must be less than 10th percentile for EFW by ultrasound More than 25% difference of smaller twin and the bigger twin EFW UA Doppler of the smaller twin has a pulsatility index grea ter than 95th percentile for How often sIUGR occurs in monochorionic twins The three subtypes of sIUGR described by Dr. Eduard Gratacos & their rate of occurrence Type 1 – positive EDF in smaller twin 29% of sIUGR cases Type 2 – Absent or reversed EDF in smaller twin 22% of sIUGR cases Type 3 – Absent or reversed EDF in smaller twin alternating with positive diastolic flow 49% of sIUGR cases The placental vessel anastomoses types & their frequency in each subtype of sIUGR Arterial to arterial (AA) Arterial to venous (AV) Venous to arterial (VA) Venous to venous (VV) ‘Spiders’ Umbilical artery cord Doppler physiology differences between singleton pregnancies and monochorionic twin pregnancies Ductus venosus Doppler as surrogate marker for fetal cardiac function Defining a cotyledon Outcomes based on sIUGR subtypes Typical gestational age at delivery for each subtype Management, possible complications & outcomes for each subtype of sIUGR   Glossary of Abbreviations  sIUGR – selective intrauterine growth restriction FGR – fetal growth restriction SGA – small for gestational age Defined as below 10th percentile EFW – estimated fetal weight AC – abdominal circumference UA – umbilical artery PI – pulsatility index EDF – end diastolic flow AEDF – absent end diastolic flow REDF – reversed end diastolic flow AA – arterial to arterial AV – arterial to venous VA – venous to arterial   VV – venous to venous DV – Ductus venosus

Introducing our newest segment - Great Syndromes! Modeled after Erin's PA school course developed to prepare healthcare students for clinical rotations, this segment utilizes real case scenarios to help guide diagnostic and treatment guidelines for patients in the setting of fetal medicine. This week our case is a 34-year-old G10 P7 who presents at 23 weeks and 4 days with a referring diagnosis of monochorionic diamniotic twin gestation with Stage II twin-twin transfusion syndrome (TTTS). Her placenta is posterior and the maximum vertical pocket (MVP) of the 'recipient' twin sac is 22.0 cm. In this episode we'll discuss some of the following points:  Differential diagnoses for polyhydramnios in pregnancy Maternal gestational diabetes Anatomical fetal anomalies Upper GI tract obstructions Esophageal atresia Duodenal atresia Tracheoesophageal fistula (TEF) Arthrogryposis multiplex Twin-twin transfusion syndrome causes hypervolemia in the recipient twin and therefore increase urine output Post-procedure tocolytic options nifedipine vs. indomethacin How placental location affects surgical approach in TTTS