‘GEORGIE, LEO…’ CHARLIE BEGAN as Juliet entered the room carrying some handwritten notes on a clipboard along with the printed obs. ‘This is Dr Juliet Turner. She is the in-utero surgeon who has travelled from Australia to consult on your pregnancy. She will be providing another option with regards to the condition the boys have developed. I must say upfront that I’m not supportive of this option for reasons I have already explained. However, Dr Turner has flown a long way to explain the procedure and answer your questions so I will hand over to her.’ He paused and turned his attention to a very stunned Juliet. ‘Dr Turner, let me introduce Leo and Georgina Abbiati.’
Juliet couldn’t believe that he had just put doubt in the Abbiatis’ minds before she opened her mouth. Despite his apology and consideration in ensuring she made it to the consult, he was not giving her any other professional courtesies. She stepped forward with her hand outstretched. ‘Very pleased to meet you.’
Juliet knew she was up against his bias. He was stubbornly conservative and not open to accepting proven progressive procedures just as her father had suggested. It was not what she would expect at face value from the motorcycle-riding doctor. The two seemed miles apart. She drew a deep breath hoping Charlie would leave any further opinions until they were alone in his office and show a mutual professional respect and, as he said, hand over to her. She was not about to back away from her belief that the in-utero surgery was the best and most logical option for the patient. In the limited time Charlie had given her, Juliet had read the last few days’ patient notes and it was exactly as she had first thought: an open and shut case in favour of laser surgery. The twin-to-twin transfusion needed to be halted immediately.
‘It’s a long way to come just for our babies,’ Leo said as he tenderly stroked his wife’s arm. ‘And we appreciate it. This is a huge decision for us to make. It’s our babies’ lives we’re talking about.’
‘Of course it is and I was more than happy to travel here so that you and your children have options to ensure for the best possible outcome,’ she replied empathetically. ‘The hospital board and the Assistant Head of Obstetrics believed it necessary for me to come and discuss the next management strategy that can be employed. Can you please tell me what you know about your babies’ condition, so that I don’t repeat anything that either Dr Warren or Mr Darrington have already covered?’
‘We know that the two girls are okay and the two boys are sharing an artery or something so one of our boys is getting lots of blood and the other one not enough. Georgie’s been having a special diet hoping to get all of them big enough in case they came early anyway. She’s twenty-nine weeks tomorrow.’
‘You certainly have an overall picture of what’s happening. Twin-to-twin transfusion syndrome, or TTTS for short, is a condition of the placenta that affects identical twin pregnancies. The placenta itself is shared unequally by the twins so that one of your sons is receiving too little blood to provide the necessary nutrients to grow normally and the other too much and so his heart is being overworked. Your TTTS was diagnosed at stage three, which is already advanced, and unfortunately has progressed to stage four.’ Juliet paused. She knew that she needed to be honest but what she had to say would be hard for the parents-to-be. ‘I am not telling you this to add to your concerns but I need to tell it how it truly is and, while the recipient baby is coping at the moment, if we do not surgically intervene that can change quickly and he can suffer heart failure. If that happened, it would immediately cross to stage five and we cannot save him and you will only have three babies. And even then their survival will be compromised.’
The expressions on Leo’s and Georgie’s faces fell further. ‘What do you think, Charlie?’
‘I agree with Dr Turner that the boys’ condition is serious but I feel the high-protein diet has assisted with the babies’ gaining weight and if we continue on that path we may be able to deliver within the next two weeks if necessary.’
Juliet felt as if she were playing a polite game of medical ping-pong but she had to keep serving. ‘I would like to commend Dr Warren for the exceptional care he has provided to you and your babies up to now, but unfortunately your boys’ condition has worsened. I’m not convinced that without surgical intervention you’ll be able to carry four healthy babies for long enough for a good outcome,’ Juliet countered.
‘But I don’t understand why it happened,’ Leo said, oblivious to the battle of medical opinion that was being waged very politely in his wife’s room. ‘We’ve asked everyone and everyone has told us we did nothing wrong, but you’re the specialist. Be honest, was it something we did?’
‘Not at all,’ Juliet answered. ‘It’s something that the medical experts can’t predict. The events in pregnancy that lead to TTTS are quite random events. The condition is not hereditary or genetic, nor is it caused by anything either of you did or didn’t do. TTTS can literally happen to anyone having multiple births at any stage up until about thirty weeks.’
‘So it’s definitely not our fault?’
‘Absolutely not,’ Juliet responded again honestly and without hesitation.
‘Charlie and Mr Darrington told us that but it’s nice to hear it from you.’
Georgina’s expression, on hearing confirmation about the cause of her babies’ condition, was subdued but Juliet was happy that at least unwarranted guilt would not be another struggle for the quads’ mother.
‘We know the boys are in trouble but are there any risks to Georgie from the TTTS?’ her husband asked as he looked at his wife with loving concern.
‘That is something we have to consider, and another reason your wife is in Teddy’s on bed rest,’ Juliet continued. ‘Carrying quads is in itself quite taxing on a woman’s body and that stress has been increased by the TTTS. Her uterus is being stretched past what is normal for pregnancy—’
‘Should you just wait then and take the babies in two weeks as Charlie says and not put Georgie at any risk?’ Leo cut in.
Without giving Charlie time to interrupt, Juliet answered quickly. ‘Actually no. That could’ve been a consideration if, since the diagnosis two days ago, the condition had not progressed, but it has and, for want of a better word, aggressively. I’m not convinced that the recipient baby would survive until thirty-one weeks. If the pregnancy was just twins, we could deliver at twenty-nine weeks. However, with quads the babies are still very small so if we can prolong the pregnancy another few weeks by having the laser surgery, the babies will be bigger when they’re born and that will make their lives easier. At the moment they are all less than three pounds and we no longer have time on our side to observe their growth.’
‘Like you said, Dr Turner,’ Georgina responded, ‘we agree that Charlie has taken such good care of me up until now we’re really struggling to think about ignoring his advice. Perhaps we should have the needle and stay with bed rest.’
Charlie drew in a deep breath, plumped out his chest, and in Juliet’s opinion looked like a pigeon about to mate. His polite interruptions made her believe their professional battle would lean towards a gentleman’s sword fight, but a fight nonetheless, and she was right. But for the good of the mother and her babies, she would not hold back. There would be a level of professional courtesy, but she would not cower to him. Juliet was prepared to argue on the evidence-based merit of surgery and then leave the decision where it should lie. With the well-informed parents.
‘While the needle you spoke of, an amniotic reduction, can work well in stage one patients, you have moved past this option very quickly. Teddy’s brought me here to discuss laser surgery and the benefits and they would not have flown me halfway around the world if there was any doubt that surgery was a viable and preferable choice for you.’ Juliet paused for a moment, then continued with a serious timbre in her voice. ‘But I won’t lie to you, there are risks in the surgical route as there are with any surgery, but the benefit far outweighs the risks. I also must let you know that if