FLA is a minimally invasive fetoscopic surgery used in fetal medicine to treat conditions during pregnancy especially multiple gestations. It is done with the help of a small camera (fetoscope) and laser to act on the specific blood vessels in the placenta to correct the abnormal blood flow or any other disturbances in the placenta. FLA is a specialized prenatal procedure done under ultrasound and fetoscopy. The aim is to treat those diseases that are associated with abnormal functioning of placenta or when placenta functions are abnormal to the developing fetus thus improving to better results for both the baby or babies and the mother.
Indications
Twin-to-Twin Transfusion Syndrome (TTTS)
TTTS occurs when one of both the twins that sharing a placenta has lesser blood supply and therefore becomes anemic, while the other one has more blood supply and becomes polycythemic. This laser only removes the anastomoses between the two placentas to provide an optimal blood flow rate.
Selective intrauterine growth restriction
A condition where one twin gets fewer blood supplies and nutrients because the placenta was not equally divided among the two fetuses causing stunted growth. It is done where there are complications (Type 2 or Type 3 sIUGR with repeated doppler abnormalities) to save the life of the larger twin.
Twin Anemia-Polycynthiaemia Sequence (TAPS)
TAPS is a chronic form of blood disease originating from monochorionic twins in which it exhibits doppler studies of discordant MCA peak systolic velocity. It addresses the zones of pathological anastomoses which are the source of this paradoxical blood.
Twin reversed arterial perfusion sequence (TRAP)
A condition in which a pump twin supports an acardiac or nonviable twin through placental vascular connections.
Used to obliterate the blood supply of the acardiac twin thus decreasing the workload on the pump twin.
Congenital Diaphragmatic Hernia (CDH)
It is a birth defect characterised by the presence of a hole in the diaphragm through which several abdominal organs migrate into the chest cavity, and this is compounded if associated with tracheal occlusion.
However, FLA is not usually the initial examination, but it may help situations to guide processes such as balloon tracheal occlusion in CDH.
Contraindications
Severe Fetal Malformations: If the fetuses have severe, life-limiting malformations that are incompatible with life, FLA is not appropriate.
Severe Fetal Growth Restriction: In cases where one or both fetuses are severely growth-restricted, FLA might not be successful or beneficial.
 Intrauterine Infection: If there is evidence of an infection in the uterus (e.g., chorioamnionitis), performing a fetoscopic procedure is contraindicated due to the risk of spreading infection.
Placental Anomalies: If there is an abnormal placental location or structure (e.g., placental previa or an abnormally placed placenta), it may increase the risk of complications during FLA.
Non-Twin Pregnancies: FLA is only used for twin pregnancies where TTTS is diagnosed. It is not applicable to single or higher-order multiple pregnancies.
Severe Polyhydramnios (Excessive Amniotic Fluid): Severe polyhydramnios can increase the risk of complications during the procedure, and may affect the success rate of FLA.
Outcomes
Equipment’s
Fetoscope
Laser Fiber
Laser System
Trocars and Cannulas
Electrocautery or Coagulation Device
Ultrasound Equipment
Fetal Monitoring Equipment
Surgical Instruments
Patient Preparation
Pre-Procedural Evaluation
Confirm Diagnosis: The patient will need FLA; the diagnosis of TTTS or another condition requiring FLA will be confirmed by imaging typically ultrasound or MRI.
Fetal Monitoring: Ultrasound studies will be done on the fetus to observe formation and growth of organs, fetal growth and amniotic fluid. This is to assess the effect of the condition on both fetuses and the placenta when present.
Maternal Health Evaluation: Patient details, medical history of the patient and pregnancy related disorders like hypertension or diabetes.
Procedure Information and Counselling
Explanation of the Procedure: The patient and her family will be educated on fetoscopic laser ablation purpose, risks for the patient, benefit and the baby.
Informed Consent: The patient will agree to undergo this procedure following a discussion of the treatment plan and its risks, which include provocation of preterm labor, miscarriage, injury to the fetus, or fetal demise.
Pre-Procedure Preparations
Fasting: The patient may be instructed to fast (usually for 8-12 hours) before the procedure to reduce the risk of aspiration during anesthesia.
Anesthesia Assessment: To determine if a particular patient is fit for anesthesia, an anesthesiologist is going to evaluate the patient. Either GA or RA (epidural or spinal or both) may be employed depending on the details of the surgery.
Patient Positioning
Lithotomy Position: The patient is commonly positioned on the operative table with the legs drawn up in stirrups.
This position enables the head of the womb, that is the cervix, to be free from obstruction so that the uterus can be accessed.
Step 1-Preoperative Preparation:
Assessment and Diagnosis: The mother is examined and usually undergoes an ultrasound to ensure a diagnosis of TTTS or some other pathology, for example, vascular disorders (trapped twin syndrome). Anesthesia: The mother is usually given local anesthesia. Only where necessary general anesthesia be given.
Positioning: The management involves the patient lying supine on the operating table with her back exposed to the surgeon. To facilitate the operation, it is common to use a urinary catheter to help the bladder to keep free of content for the duration of the procedure.
Step 2-Fetoscopic Insertion:
Incision: Using ultrasound as the guide, a small incision (about 1-2 cm) is made on the abdomen and the uterus.
Insertion of Fetoscope: A fetoscope is a thin tube which has a camera put through this incision.
The camera helps the surgeon visualize the uterus and the placental structures.
Step 3-Visualization of the Placenta:
Identifying the Placenta: Fetoscope is utilised to determine the position of the placenta and to identify the vessels linking the two twins.
The surgeon identifies the abnormal blood vessels leading to the transfusion problem.
Assessment of Vascular Connections: The surgeon searches for connections between two circulatory systems in the placenta known as arterio-venous anastomoses.
This results in the abnormal connections that give rise to the unequal blood flow as well.
Step 4-Laser Ablation:
Laser Fiber Insertion: A laser fiber is then inserted through the fetoscope, this will be placed at a close range to the desired blood vessels.
Laser Treatment: The laser is employed to cauterize or close up the vessels that allow the transfusion to occur. The aim is to cut several malformed vascular connections between the twins to allow each to have more equal blood supply.
Precision and Caution: The surgeon carefully navigates the laser to avoid harming the developing fetuses. The laser’s energy is delivered directly to the vessels to obliterate the anastomoses.
Step 5-Monitoring and Verification: Evaluation of Outcomes: The surgeon checks for the confirmation that the vascular connections are appropriately treated to have no further flow of blood between the twins following laser ablation. Re-evaluation: Further scans may be performed to confirm the appropriate correction of the imbalance in blood flow by the laser treatment. Step 6-Completion of the procedure:
After the procedure, the fetoscope and laser fiber are withdrawn from the uterus carefully. Closure: The small incision on the uterus is sealed with a stitch, and the abdominal incision is sealed with sutures. Step 7-Postoperative Care: Follow-up monitoring: The mother is followed up closely post-procedure for complications of preterm labour, infection, or fetal distress.
The status of the twins can be monitored through ultrasound.
Follow-up care: Ultrasound check-ups are regularly conducted to monitor growth and health of the twin.
Complications
Premature Rupture of Membranes (PROM): This is possible when the amniotic sac rupture early, a condition that results to preterm labor or infection. The risk is however higher if there is damage to the membranes during the procedure.
Preterm Labor and Delivery: FLA is undertaken when pregnancy is threatened by TTTS and therefore likely to result in preterm birth. There is always a possibility of provoking preterm labour which in turn can cause delivery of the fetuses before they are mature.
Infection: Like with most surgical procedures, there is a potential of infections; these may be within the uterus or the amniotic sac. This could lead to complications like chorioamnionitis or sepsis.
Fetal Injury: Although the procedure is minimally invasive, there is still a risk of injury to the fetuses. This can occur during the laser ablation of blood vessels or due to the introduction of the fetoscope.
Hemorrhage (Bleeding): Suspected adverse effects of the procedure include bleeding due to coagulation of placental vessels and bleeding from the uterus.
Increased Risk of Neonatal Morbidity and Mortality: FLA is designed to improve outcomes of TTTS pregnancies, risks are always associated with TTTS; the fetuses may be at risk of developing neurological damage, developmental delays, or even death based on the severity of TTTS and the time in which the FLA will be conducted.
Placental or Umbilical Cord Abnormalities: This procedure can lead to alterations on the placenta that may cause dysfunction of the placenta, which adds on complications of pregnancy.
FLA is a minimally invasive fetoscopic surgery used in fetal medicine to treat conditions during pregnancy especially multiple gestations. It is done with the help of a small camera (fetoscope) and laser to act on the specific blood vessels in the placenta to correct the abnormal blood flow or any other disturbances in the placenta. FLA is a specialized prenatal procedure done under ultrasound and fetoscopy. The aim is to treat those diseases that are associated with abnormal functioning of placenta or when placenta functions are abnormal to the developing fetus thus improving to better results for both the baby or babies and the mother.
Twin-to-Twin Transfusion Syndrome (TTTS)
TTTS occurs when one of both the twins that sharing a placenta has lesser blood supply and therefore becomes anemic, while the other one has more blood supply and becomes polycythemic. This laser only removes the anastomoses between the two placentas to provide an optimal blood flow rate.
Selective intrauterine growth restriction
A condition where one twin gets fewer blood supplies and nutrients because the placenta was not equally divided among the two fetuses causing stunted growth. It is done where there are complications (Type 2 or Type 3 sIUGR with repeated doppler abnormalities) to save the life of the larger twin.
Twin Anemia-Polycynthiaemia Sequence (TAPS)
TAPS is a chronic form of blood disease originating from monochorionic twins in which it exhibits doppler studies of discordant MCA peak systolic velocity. It addresses the zones of pathological anastomoses which are the source of this paradoxical blood.
Twin reversed arterial perfusion sequence (TRAP)
A condition in which a pump twin supports an acardiac or nonviable twin through placental vascular connections.
Used to obliterate the blood supply of the acardiac twin thus decreasing the workload on the pump twin.
Congenital Diaphragmatic Hernia (CDH)
It is a birth defect characterised by the presence of a hole in the diaphragm through which several abdominal organs migrate into the chest cavity, and this is compounded if associated with tracheal occlusion.
However, FLA is not usually the initial examination, but it may help situations to guide processes such as balloon tracheal occlusion in CDH.
Severe Fetal Malformations: If the fetuses have severe, life-limiting malformations that are incompatible with life, FLA is not appropriate.
Severe Fetal Growth Restriction: In cases where one or both fetuses are severely growth-restricted, FLA might not be successful or beneficial.
 Intrauterine Infection: If there is evidence of an infection in the uterus (e.g., chorioamnionitis), performing a fetoscopic procedure is contraindicated due to the risk of spreading infection.
Placental Anomalies: If there is an abnormal placental location or structure (e.g., placental previa or an abnormally placed placenta), it may increase the risk of complications during FLA.
Non-Twin Pregnancies: FLA is only used for twin pregnancies where TTTS is diagnosed. It is not applicable to single or higher-order multiple pregnancies.
Severe Polyhydramnios (Excessive Amniotic Fluid): Severe polyhydramnios can increase the risk of complications during the procedure, and may affect the success rate of FLA.
Equipment’s
Fetoscope
Laser Fiber
Laser System
Trocars and Cannulas
Electrocautery or Coagulation Device
Ultrasound Equipment
Fetal Monitoring Equipment
Surgical Instruments
Patient Preparation
Pre-Procedural Evaluation
Confirm Diagnosis: The patient will need FLA; the diagnosis of TTTS or another condition requiring FLA will be confirmed by imaging typically ultrasound or MRI.
Fetal Monitoring: Ultrasound studies will be done on the fetus to observe formation and growth of organs, fetal growth and amniotic fluid. This is to assess the effect of the condition on both fetuses and the placenta when present.
Maternal Health Evaluation: Patient details, medical history of the patient and pregnancy related disorders like hypertension or diabetes.
Procedure Information and Counselling
Explanation of the Procedure: The patient and her family will be educated on fetoscopic laser ablation purpose, risks for the patient, benefit and the baby.
Informed Consent: The patient will agree to undergo this procedure following a discussion of the treatment plan and its risks, which include provocation of preterm labor, miscarriage, injury to the fetus, or fetal demise.
Pre-Procedure Preparations
Fasting: The patient may be instructed to fast (usually for 8-12 hours) before the procedure to reduce the risk of aspiration during anesthesia.
Anesthesia Assessment: To determine if a particular patient is fit for anesthesia, an anesthesiologist is going to evaluate the patient. Either GA or RA (epidural or spinal or both) may be employed depending on the details of the surgery.
Patient Positioning
Lithotomy Position: The patient is commonly positioned on the operative table with the legs drawn up in stirrups.
This position enables the head of the womb, that is the cervix, to be free from obstruction so that the uterus can be accessed.
Step 1-Preoperative Preparation:
Assessment and Diagnosis: The mother is examined and usually undergoes an ultrasound to ensure a diagnosis of TTTS or some other pathology, for example, vascular disorders (trapped twin syndrome). Anesthesia: The mother is usually given local anesthesia. Only where necessary general anesthesia be given.
Positioning: The management involves the patient lying supine on the operating table with her back exposed to the surgeon. To facilitate the operation, it is common to use a urinary catheter to help the bladder to keep free of content for the duration of the procedure.
Step 2-Fetoscopic Insertion:
Incision: Using ultrasound as the guide, a small incision (about 1-2 cm) is made on the abdomen and the uterus.
Insertion of Fetoscope: A fetoscope is a thin tube which has a camera put through this incision.
The camera helps the surgeon visualize the uterus and the placental structures.
Step 3-Visualization of the Placenta:
Identifying the Placenta: Fetoscope is utilised to determine the position of the placenta and to identify the vessels linking the two twins.
The surgeon identifies the abnormal blood vessels leading to the transfusion problem.
Assessment of Vascular Connections: The surgeon searches for connections between two circulatory systems in the placenta known as arterio-venous anastomoses.
This results in the abnormal connections that give rise to the unequal blood flow as well.
Step 4-Laser Ablation:
Laser Fiber Insertion: A laser fiber is then inserted through the fetoscope, this will be placed at a close range to the desired blood vessels.
Laser Treatment: The laser is employed to cauterize or close up the vessels that allow the transfusion to occur. The aim is to cut several malformed vascular connections between the twins to allow each to have more equal blood supply.
Precision and Caution: The surgeon carefully navigates the laser to avoid harming the developing fetuses. The laser’s energy is delivered directly to the vessels to obliterate the anastomoses.
Step 5-Monitoring and Verification: Evaluation of Outcomes: The surgeon checks for the confirmation that the vascular connections are appropriately treated to have no further flow of blood between the twins following laser ablation. Re-evaluation: Further scans may be performed to confirm the appropriate correction of the imbalance in blood flow by the laser treatment. Step 6-Completion of the procedure:
After the procedure, the fetoscope and laser fiber are withdrawn from the uterus carefully. Closure: The small incision on the uterus is sealed with a stitch, and the abdominal incision is sealed with sutures. Step 7-Postoperative Care: Follow-up monitoring: The mother is followed up closely post-procedure for complications of preterm labour, infection, or fetal distress.
The status of the twins can be monitored through ultrasound.
Follow-up care: Ultrasound check-ups are regularly conducted to monitor growth and health of the twin.
Complications
Premature Rupture of Membranes (PROM): This is possible when the amniotic sac rupture early, a condition that results to preterm labor or infection. The risk is however higher if there is damage to the membranes during the procedure.
Preterm Labor and Delivery: FLA is undertaken when pregnancy is threatened by TTTS and therefore likely to result in preterm birth. There is always a possibility of provoking preterm labour which in turn can cause delivery of the fetuses before they are mature.
Infection: Like with most surgical procedures, there is a potential of infections; these may be within the uterus or the amniotic sac. This could lead to complications like chorioamnionitis or sepsis.
Fetal Injury: Although the procedure is minimally invasive, there is still a risk of injury to the fetuses. This can occur during the laser ablation of blood vessels or due to the introduction of the fetoscope.
Hemorrhage (Bleeding): Suspected adverse effects of the procedure include bleeding due to coagulation of placental vessels and bleeding from the uterus.
Increased Risk of Neonatal Morbidity and Mortality: FLA is designed to improve outcomes of TTTS pregnancies, risks are always associated with TTTS; the fetuses may be at risk of developing neurological damage, developmental delays, or even death based on the severity of TTTS and the time in which the FLA will be conducted.
Placental or Umbilical Cord Abnormalities: This procedure can lead to alterations on the placenta that may cause dysfunction of the placenta, which adds on complications of pregnancy.
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