Six Characters In Search of a Plot

Twin-Twin Transfusion Syndrome (TTTS) is a rare disorder that sometimes occurs when women are pregnant with identical (monozygotic) twins. It is a rare disease of the placenta, the organ that joins the mother to her offspring and provides nourishment to the developing fetuses. During the development of identical twins, there are often blood vessels in the fetuses' shared placenta that connect their blood circulations (placental anastomoses). In most cases, the blood flows properly through these vessels. However, in Twin-Twin Transfusion Syndrome, the blood begins to flow unevenly, with one fetal twin receiving too much blood (recipient) and one receiving too little (donor). The recipient twin may experience heart failure due to continual strain on its heart and blood vessels (cardiovascular system). The donor twin, on the other hand, may experience life-threatening anemia due to its inadequate supply of blood. Such an imbalance in blood flow (i.e., twin-twin transfusion) can occur at any time during the pregnancy, including during delivery.

The recipient twin (often larger) becomes effectively overloaded with the extra blood supply. His or her heart has to work harder to pump the enriched blood around, which can result in heart failure. The recipient also produces far too much amniotic fluid - termed "polyhydramnios", which causes the mother to appear far further on in the pregnancy than she actually is. This excess fluid is not only extremely uncomfortable for the mother, but can often bring about an early delivery due to cervical pressure and ruptured membranes, and by directly stretching and stimulating the uterine muscles to contract. The recipient twin may also develop hydrops or edema (retained fluid) within his or her body, which in turn can lead to respiratory, digestive, heart, or brain defects.

The donor twin (often smaller) becomes anaemic due to not having enough blood supply, and usually has a small amniotic sac (the bag of fluid in which the baby lives). This lack of amniotic fluid is termed "oligohydramnios". The sac is often very close to the developing baby's body, and the baby appears to be almost shrinkwrapped and "stuck" up against the wall of the uterus. When donor babies survive birth, however, they are often the baby that is stronger as their hearts have not had to work so intensely during pregnancy.

If left untreated, TTTS has a mortality rate of over 80% and can be the root cause of severe handicaps for the few survivors..

It is possible to seal off some or all of the blood vessels the twins share using a laser. This would separate the circulation of the fetuses and end twin-to-twin transfusion. However, this requires operating while the fetuses are still in the womb, and it may cause serious complications.

There are other procedures which can be done, such as repeated drainage of excess amniotic fluid from the recipient twin by amniocentesis. A hole can be punched between the twins' two amniotic sacs to equalize the fluid between the sacs. However, neither of these procedures stops the twin-to-twin transfusion.

If one twin is dead or dying, that part of the umbilical cord can be blocked so that blood no longer goes to that twin. The pregnancy can also be voluntarily terminated.

The most conservative treatment is to simply watch and wait. The pregnancy would be followed closely with frequent ultrasound examinations, with the option of delivering the twins by cesarean section if medically necessary.

Amniocentesis with Septostomy was recommended, and within 1 hour of the scan Jackie had 2.6 liters of fluid removed. The immediate results were that Jackie's back pain and swelling disappeared. Jackie & Chris stayed overnight at St. Mary's and the following day's scan showed that the larger baby's heart rate had reduced, and that the "stuck" twin appeared no longer stuck and was moving much more freely. The only apparent problem was that the smaller twin's bladder could not be seen. Jackie was also examined by Dr. Ratko Matijevic, who was performing research into placental abnormalities.

Twin-to-twin transfusion syndrome occurs specifically in identical twins sharing the same placenta. It is estimated to occur in 5-10% of identical twin pregnancies. In twin-to-twin transfusion syndrome, the twins share not only the same placenta but some of the same circulation. This allows the transfusion of blood from one twin (the donor) to the other (the recipient). The donor twin becomes small and anemic, and the recipient twin becomes large and overloaded with blood.

Because the recipient twin has more blood, he/she also urinates more and has more amniotic fluid. The donor twin has less amniotic fluid; sometimes there is so little fluid that the fetus appears on ultrasound to be stuck in place on the wall of the uterus (known as "stuck twin phenomenon").

It can occur at any point during the pregnancy, even at birth (once one umbilical cord has been clamped after delivery, the other twin may get a rush of extra blood).

• Pregnant mother - a rapidly enlarging abdomen over 2-3 weeks, as the amniotic fluid of the recipient twin builds up; premature labor, and premature rupture of membranes (water breaks early)

• Donor twin - Small for gestational age, 10-20% smaller than recipient twin, pallor (due to anemia), poor circulation

• Recipient twin - Large for gestation age, 10-20% larger than donor twin, ruddy (red) skin and jaundice (due to extra blood).

An additional complication known as hydrops fetalis may develop in either twin. In this condition, fluid accumulates in some part of the fetus, such as in the scalp, abdomen, lungs, or heart.

Twin-to-twin transfusion syndrome may be suspected if a pregnant woman carrying twins finds her abdomen enlarging rapidly. The syndrome can also be detected on ultrasound examination of the uterus. If the syndrome is mild, or not detected on ultrasound, the appearance of the twins at birth may identify the syndrome. Also, a complete blood cell count done after birth will show anemia in the donor twin and excess red blood cells in the recipient twin.

Medical care of the twins after birth is focused on problems related to premature birth (the more premature, the more problems are likely to develop). Newborns with twin-to-twin transfusion syndrome may be critically ill at birth and require treatment in a neonatal intensive care unit. The donor twin is treated for anemia and the recipient twin for excess red blood cells and jaundice. Any complications that developed during the pregnancy, such as hydrops fetalis, are also treated.

Peace Child Israel - Background

Established in 1988, Peace Child Israel is the veteran organization utilizing theatre and the arts as a tool for cross-cultural dialogue in Israel. Committed to addressing minority-majority relations and co-citizenship issues. the goals of Peace Child Israel are: education for democracy, pluralism and tolerance in the Israeli society. Through the medium of theatre and the arts, the pedagogical objectives of compassionate listening, critical thinking and non-violent communication are applied whiling workshop participants address issues of identity, stereotypes, mutual respect, equality in a democratic society, cultural similarities and differences. Role playing, reverse role-playing, collage, movement and improvisation are among the numerous tools used to facilitate experiential learning. cooperation in the creative process reSULTS in the writing and performance of original play by each group of teens from neighboring schools that participate in the project. programs for parents and teachers were added to the organization’s agenda in 2001. The Peace Child Israel program is recognized in the Ministry of Education “Community service program”

Twin-Twin Transfusion Syndrome (TTTS)

Background Information for Six Characters in Search of a Plot

Twin-Twin Transfusion Syndrome (TTTS)

Peace Child Israel: Making Conflict Resolution and Dialogue Work in the Middle East