Maternal Fetal Intervention and Surgery Program

• Drs. Bettina Paek and Martin Walker have done more than 1,000 fetal procedures over nearly 20 years. This includes more than 575 laser ablation procedures for twin-to-twin transfusion syndrome (TTTS) with 96.5% of procedures resulting in 1 or more twins surviving and over 75% dual survival.
• Our fetal therapy nurse coordinator, Melissa Dorn, MN, RN, has worked closely with both doctors for many years caring for families with a wide range of conditions and needs.
• Our specially trained sonographers are experienced in getting the images the doctors need to care for babies while they are still in the womb.
• More team members, like genetic counselors, social workers and others, are here to offer services and support based on your needs.
• This team provides highly specialized care with compassion. We understand the challenges your family is facing and create the most caring, seamless experience possible. We are here not only to provide technical expertise but also to help support you emotionally.

• Many of our families are carrying twins (or more babies) and have complicated pregnancies. Whether you are carrying triplets, twins or 1 baby, we thoughtfully assess what they need to be healthy.
• Each baby is unique, even if your baby has a condition we have treated hundreds of times before. We make an individual care plan just for them and you. You can feel confident we are always looking after your interests and your baby’s interests.
• When a baby has health concerns serious enough to consider treatment before birth, families often need to make hard choices about what to do. We understand how difficult this can be. Our approach is to listen carefully to your values and needs, inform you about every option and answer your questions. We guide you so you can choose the right path for your family — and we support you, whatever you decide.
• Based on your baby’s health, we work with the rest of your pregnancy care team to make special plans for delivery if needed. If your baby is likely to need complex care or surgery soon after birth, we have a highly skilled neonatal transport team to transfer your newborn from your birth hospital to Seattle Children’s.
• After birth, specialists from across Seattle Children’s are here to provide any care your child may need, from their first hours and days through young adulthood. U.S. News & World Report has recognized Seattle Children’s as a top children’s hospital every year since it began ranking medical facilities more than 25 years ago, which means your child will be cared for by the very best.

• We are available 24 hours a day, 7 days a week, every week of the year, for conditions that need care right away. For urgent health concerns that might need intervention or surgery, we typically speak with you by telephone the same day you or your referring doctor contacts us. Often, we see families in person within 1 day and do intervention or surgery the same day or the next day.
• We make it easy for you and your referring doctor to reach us. Usually, a referring doctor calls us, describes the health concern and sends us your details, like your imaging, test results and contact information. We review everything right away and call you, typically the same day, to talk about next steps.
• The process is designed to be simple, seamless and hassle-free for you so you can stay focused on yourself and your family.
• Families come to us from around the Northwest and beyond. Our social workers and Guest Services staff have a great deal of experience providing support with housing and transportation in the Seattle area, financial counseling, interpreter services, spiritual care and more. Read about our services for patients and families.

• In 2021, Seattle Children’s remodeled and expanded our Fetal Care and Treatment Center in the Springbrook Professional Center, a block from our main Seattle hospital campus. Families come here for appointments with our Maternal Fetal Intervention and Surgery team. Many procedures take place in this clinic setting.
• In the Fetal Care and Treatment Center, we have the advanced technology to provide the best care for you and your baby. At the same time, we have made the space comfortable, calming and warm.
• New consultation rooms mean you can stay in 1 place for your consultation. We also added exam rooms so we can help more families.
• For some procedures, an operating room is the safest place to provide care. Seattle Children’s specialists do these procedures in operating rooms at UW Medical Center–Montlake, less than 1 mile from Springbrook. In general, these include fetoscopic surgery, laser procedures, bipolar cord coagulation and any procedure for a baby over 22 to 24 weeks of pregnancy.
• Your care team will explain where your procedure will take place and why. We will make sure you have all the details you need so your care goes as smoothly as possible — before, during and after your procedure.

• Drs. Bettina Paek and Martin Walker are founding members of the North American Fetal Therapy Network. This group brings doctors and scientists together to collaborate on research and education to improve care for babies before birth.
• They have led or taken part in many research projects to learn more about the best ways to detect and treat a wide range of fetal conditions, like twin-to-twin transfusion syndrome (TTTS), tumors, anemia and others. Their work includes studies that formed the basis for prenatal treatment of spina bifida and congenital diaphragmatic hernia.
• Paek has also published articles to teach other doctors about listening to patients and families, taking their values into account and helping them through difficult decisions and outcomes.

Some developing babies do not need any intervention. But they do need to be checked closely on a regular basis. Regular exams and tests, like ultrasound, let us see if your baby’s condition is changing in ways that need active treatment. Seeing Seattle Children’s experts, along with your pregnancy care provider, lets your family plan and prepare for care your child might need after they are born. Expectant management is sometimes an option for a twin with TAPS, SIUGR or discordance for anomalies and for babies with LUTO.

Medicines given to you during pregnancy can help control some conditions that may affect your baby. If your baby has a solid CPAM that is large enough to cause problems before birth, you might get corticosteroids to keep the CPAM from growing further. If your immune system is harming your baby’s red blood cells or platelets, the corticosteroid prednisone and the medicine IVIG  (intravenous immunoglobulin) may help.

Our doctors have several methods to stop the flow of blood through a blood vessel. This is an important option for conditions that affect twins who share 1 placenta, where blood may not be flowing the way it should to both twins. It is also an option for some babies with a chorioangioma. The methods we use include:

• Laser treatments (laser ablation/laser photocoagulation and interstitial laser therapy) — To stop blood flow from 1 twin to the other in TTTS, to separate the twins’ blood circulation in SIUGR, to stop blood flow that is feeding the growth of a chorioangioma and to release amniotic bands.
• Radiofrequency ablation — To stop blood flow from the healthy twin whose heart is pumping to the nonpumping (acardiac) twin in TRAP sequence. We may also use this procedure in other conditions, like to stop blood flow to a twin with severe anomalies and help preserve the life of the other twin.
• Bipolar cord coagulation and transection — To stop blood flow through the umbilical cord to the less healthy twin in cases of severe discordant anomalies, TRAP sequence, TTTS or SIUGR and to cut (transect) this twin’s cord. (Cutting the cord lowers the risk that it may tangle around and harm the healthy twin in the rare case where they share the same amniotic sac, called monoamniotic twins.)

Draining or moving amniotic fluid, lymph, urine or other fluid can help manage some conditions that may affect your developing baby. The procedures we offer are:

• Amnioreduction — To take out amniotic fluid using a needle if there is too much around 1 of your twins with TTTS or around your baby with a chorioangioma. Often, fluid builds up again over time, and we need to take out more. This is called serial amnioreduction.
• Aspiration of a cyst — To take out fluid using a needle if your baby has a large CPAM that may keep their lungs from developing well.
• Thoracentesis — To take out extra fluid around your baby’s lungs using a needle if your baby has pleural effusion and chylothorax that may harm their lungs, heart or blood vessels.
• Thoracoamniotic shunting — To place a shunt that will drain fluid into your womb from around your baby’s lung if they have pleural effusion or from inside a large cyst if they have a CPAM.
• Vesicoamniotic shunting — To place a shunt that will drain urine from your baby’s bladder into your womb if your baby has a LUTO.

For each of these procedures, we use ultrasound to guide the needle or shunt to the right place.

For some of the procedures described above (to stop blood flow or drain or move fluid), we need to make a small puncture in your belly. Through this hole, we can pass thin tube-like tools, such as tools for radiofrequency ablation or placing a shunt. These methods let us treat your baby’s condition with only a tiny cut (incision) that requires a simple bandage to cover. Some of these procedures are done in the clinic, and some are done in an operating room.

For other procedures, we use minimally invasive surgery. This involves making a small incision in your belly (3 millimeters, or about the thickness of 2 pennies). Through this hole we can insert a thin tube with a camera (fetoscope) as well as surgical tools. For example, we use this method to do laser ablation and bipolar cord coagulation and to release amniotic bands that pose a high risk of serious harm to your baby. Surgery like this is done in an operating room.

We can help manage several conditions by adding red blood cells or platelets into your baby’s bloodstream through a needle. These conditions include TAPS, alloimmune thrombocytopenia, alloimmunization and fetal anemia, fetal anemia secondary to parvovirus and anemia or low platelets due to a chorioangioma.

• Ask your pregnancy care provider to fax us records about your pregnancy, including lab results, ultrasound reports and your health history. Our fax number is 206-985-3274. Often, medical offices can also send us ultrasound images electronically. Your appointment will never be delayed by records requests.
• Before your first visit, a dedicated fetal coordinator will review your referral to understand your health and the health of your baby or babies. Then we will design your first visit to match your unique needs.
• Follow any instructions we have given you about whether to stop eating or drinking before your visit and whether to stop taking any medicines you are on.
• You do not need a full bladder for this appointment.
• Arrive 15 minutes early to register.
• Learn more about what to do before your appointment.

We see patients whose pregnancy is complicated by:

• Alloimmune thrombocytopenia
• Alloimmunization and fetal anemia
• Amniotic band syndrome
• Chorioangioma
• Conditions that can affect monochorionic twins
  • Twin-to-twin transfusion syndrome (TTTS), including twin anemia polycythemia syndrome (TAPS) 
  • Twin reversed arterial perfusion (TRAP)
  • Selective intrauterine growth restriction (SIUGR)
  • Discordance for anomalies
• Congenital pulmonary airway malformation (CPAM)
• Fetal anemia
• Lower urinary tract obstruction (LUTO)
• Pleural effusion and chylothorax

The specialists you see at your first visit depend on the medical concern. A fetal coordinator will review your referral before we schedule your visit so we can choose the team that best matches your family’s needs.

You may meet with:

• A medical assistant, who takes you to the exam room and checks your vital signs, like blood pressure
• A nurse care coordinator, who talks with you about the medical history for your developing baby and for you during your pregnancy
• A sonographer, who does an ultrasound
• A maternal-fetal intervention and surgery doctor

Based on the needs of your baby or babies, you may meet with other pediatric medical or surgical specialists from Seattle Children’s.

Learn more about the Fetal Care and Treatment Center team.

1. During your first visit, we will take a detailed heath history and review the medical records sent to us.
2. You will have imaging studies to help diagnose or check your baby’s condition (usually an ultrasound, sometimes a fetal echocardiogram).
3. You will meet with your care team to discuss your goals and values for this pregnancy and the findings from your tests and what they mean.
4. We will work to clarify or to rule out certain medical conditions. We will give you as much information as we can about the condition and your treatment options.
5. We will try to answer all your questions. Please ask if anything is not clear. We are available to answer questions that come to mind after your visit as well.
6. By the end of your first visit, our goal is to give you a complete understanding of the diagnosis and possible options so you can make informed choices that are right for your family.
7. We will work with you and your providers to make a plan for the next steps in your pregnancy care. A nurse care coordinator helps you move from one step to the next. We also connect you with other support and services you and your family may need.
8. If surgery is an option and you choose to have surgery, we will schedule it for as soon as is reasonably appropriate. Usually, this means the same day or the next day.

Plan to be at the clinic for 2 to 5 hours, depending on how many diagnostic exams you will have and how many specialists you will see.

• Your appointment reminder notice.
• Your insurance cards/Medicaid medical coupon.
• Your medicines or a list of them. Include nonprescription items like vitamins and herbs. Include the name, dose and instructions.
• Any forms that might need to be signed by our providers.
• Snacks and drinks for yourself.
• An overnight bag with toiletries, comfortable clothes and something to read or keep you busy in case you decide to stay overnight for a procedure.

Due to COVID-19, pregnant patients can bring only 1 healthy adult to their appointment at the Fetal Care and Treatment Center. Children are not allowed at these visits right now.

Most of the time the team will be able to give you a diagnosis at your first visit. For some complex conditions, it might take longer. We will always share with you the full extent of what we know.

• Some patients come to our clinic only once. Others return for more appointments. Before you leave, we will give you detailed instructions about any future appointments. We will give recommendations for what will happen next.
• Each provider who sees you will write notes for your medical chart. After the visit, we will send a copy to your pregnancy care provider. Our nurses also write notes for you to go home with so you do not have to memorize everything during your visit.
• Between clinic visits, you can call 206-987-4137 if you have questions for our team.
• See Common Questions After Your Prenatal Visit (PDF) (Spanish).

• For an ultrasound or fetal echocardiogram, we will review the results with you soon after the exam, before you leave the clinic.

Call 206-987-4137 as soon as possible.

• Find your location in our map and directions section.
• Arrive 15 minutes before your appointment to allow time for registration.