At 13 weeks, Dana Salmonese joyfully announced to everyone that she was pregnant with twins. Just a few weeks later, she was in the operating room, having emergency surgery to save their lives. The goal of any pregnancy is to be routine. But when it's not, fetal surgeons like NYU Langone Health's Dr. Martin Chavez are there to help the smallest of patients find their way.
At 13 weeks, Dana Salmonese joyfully announced to everyone that she was pregnant with twins. Just a few weeks later, she was in the operating room, having emergency surgery to save their lives. The goal of any pregnancy is to be routine. But when it's not, fetal surgeons like NYU Langone Health's Dr. Martin Chavez are there to help the smallest of patients find their way.
Sirius XM and NYU Langone Health present:
Vital Signs - Season 2 Episode 8
Title:
Description:
Participants:
Dr. Martin Chavez, guest
Dana Salmonese, guest
Rose Reid, Narrator
TRANSCRIPT:
Dana Salmonese: I found out I was pregnant. I was so excited. We weren't thinking about another baby, but it happened and we were so excited. I went to the doctor the day after New Year's Day, and that's when we saw a beautiful heartbeat. And, um, my doctor said, well, you have a beautiful baby in there. I said, can I have another picture? So she went back to do the sonogram and she was like, wait a second. And she's like just staring at it and I can't see it cause it's behind me, but my husband can see it. And he goes, “Wait, doc, am I seeing double?” And she was like, yeah, there's two in there. [laughs] I freaked out. I was so excited. I couldn't wait to call my mom. And, uh, and it was, it was two. It was crazy. Two heartbeats. My name is Dana Salmonese and I'm the mother of three of the most beautiful children. And two of them were not supposed to be here.
Narrator: In early 2020, Dana Salmonese and her husband, Joe, had their world rocked… in the best way possible: they were expecting twins. The news was shocking, but welcome, and amazing. Their small family of three - Dana, Joe, and their one year-old daughter Gianna - was about to grow.
Dana Salmonese: I was 13 weeks and I felt comfortable enough to announce on Facebook that I was pregnant. And that night I woke up, five o'clock in the morning, to a pool of blood. We go to the hospital… they're checking everything out... babies still have a heartbeat. They told me to go on modified bedrest. And they had a 50/50 chance of surviving. And I remember going to the doctor that week, around week 18. That's when my maternal fetal medicine said, something was happening.
Narrator: From SiriusXM and NYU Langone Health, this is Vital Signs, where medicine is made personal. I’m your host, Rose Reid. A lot of what physicians do focuses on preventing bad things from happening, or treating and trying to fix them when they do. It can be uplifting, but in general, when people go to the doctor, it’s because they have a problem that needs attention. They go to the hospital for surgery, or an acute emergency, or to recover from these events. Obstetrics is a little different. The specialists who work in this field have the profound - and often joyful - responsibility of keeping pregnant women and their developing fetuses safe and healthy until delivery. Of course, they also try to prevent, treat, and fix bad things along the way: pregnancy is rife with complications, risks, and bumps in the road. But eventually, in the great majority of cases: a baby is born. It’s a unique happiness within medicine. New life begins…and everything changes.
Dr. Chavez: It's one of those rare moments that we come to a hospital, where we want to be there, where we know it's the next generation, it's the next family member. It's the next individual that we are going to love so much. My name is Dr. Martin Chavez. I am the director of maternal fetal medicine and the fetal surgery program at NYU Langone Hospital Long Island. There is nothing more incredible than watching a mother hold that baby for the first time. It's such an incredible moment because at that moment you realize that you're part of something special. You're part of that, that family history, that family legacy.
Narrator: Dr. Martin Chavez is a maternal fetal medicine specialist, which means he takes care of high-risk pregnancies. His path into medicine was circuitous; for a while after attending a technical vocational high school in New York City, he worked as an electrician. College wasn’t an obvious destination for him, but once he enrolled, he was hooked on higher education.
Dr. Chavez: I was able to get into Queens college. And that opened up an entire new world for me, because now I realize that not only could I work with my hands and be happy and make a great living, but now I could also start flexing the muscle of my brain. And I was able to pursue a degree in biology. And then that was the gateway to going into medical school. I grew up surrounded by wonderful and powerful women. My mother, my grandmother, my aunt, and to me, this, that was the norm. I would not imagine being in any other environment where I would not want to be. So women's healthcare was just a natural progression. So if I had to give credit to anyone, it was probably going to be my mother, because to me, she was the one that set the bar high and made me realize that it would be a privilege and an honor to make sure that I could help as many people as I could.
Narrator: Many of the people Dr. Chavez has helped - aren’t even born yet. He not only looks after pregnant women, but also the fetus, or fetuses, developing inside.
Dr. Chavez: In our world, we have two patients in one, or at least two patients in one, right? And we balanced the care of both of them. Pregnancy in itself is a normal, healthy, wonderful part of life. But there are situations where it can be more complicated and it can be more complicated, not only for the mother, but also for the unborn child, the fetus. In particular, what drew me into the fetal surgery aspect of it, was having that ability to try to help that patient within that had not even been born. I remember one of the first procedures I did when I was being trained and I was actually giving a transfusion to a fetus that was anemic because it had an infection. And then, making sure that I had the appropriate blood type to give to that fetus. And I remember talking to the lab and then they're asking, what's the patient's name? I said, I don't know yet. What's the date of birth - to be determined. And I smiled at that moment, because it made me realize that I was doing something that very few people have the honor of doing… being able to help a patient that has even arrived in our world yet.
Narrator: Maternal fetal medicine is layered: Patients inside of patients can lead to problems on top of problems. Dr. Chavez and his colleagues manage pregnant women with certain pre-existing issues, like hypertension or diabetes, or women who develop these conditions during pregnancy. In some cases, mom’s medical concerns can affect the developing baby. Other times, the fetus has complications all its own.
Dr. Chavez: Some of the concerns can range from pretty minor ones that can be just monitored, and after the baby's born, be evaluated. A perfect example of that is what we call pyelectasis, where there might be a little enlargement of the area where the urine is collected in the fetus. Most of the time it's mild, and it resolves. That in itself is an example of something that we would just… monitor it very closely without much intervention, other than observation through ultrasound. We also have conditions where if we do not intervene, either the fetus will not make it… meaning that it would die in utero or there the baby might be delivered early, and the consequences of that prematurity.
Narrator: Not all maternal fetal medicine doctors are surgeons, but Dr. Chavez is. His team consists of specially trained fetal surgeons who perform procedures on one or more fetuses while they are still inside the uterus. The situations that necessitate these surgeries are rare - and when they do happen, they’re risky. They can also be kinda cool.
Dr. Chavez: So the first time we did a fetal surgery, or fetoscopy, one of the things that was absolutely amazing to me was that the fetus reached out and grabbed the scope. And you can see in very exquisite details, all the fingers and the fingernails. And for a while, we patiently waited. And then we realized that this fetus was very curious as to our scope. Did it know who we were or what we're doing? Probably not. It was probably just simple stimulus, but at the same time, it absolutely amazed me in an entire team. So we gently move the fetus over to one side and said, okay, little guy we'll be back, but let's focus on what we need to do in here. And it patiently waited inside of the uterus and allowed us to do what we needed to do. Could I have planned that? Absolutely not. Was it one of those incredible moments that you'll always remember from your professional career as a fetal surgeon? Absolutely. The way I look at it is that I'm visiting their world temporarily and by doing so and them, um, uh, tolerating me while I'm in there, they actually, um, get benefit from it. But yes, absolutely, I feel like we're very fortunate and extremely blessed and having this skillset and as well as these resources to allow us to help these babies. It's, it's an amazing feeling because it's almost like getting to meet this baby for the first time twice: Once when I'm in there and I actually get to see their faces and I see them moving around. And then the second time when I actually get to see them getting delivered, whether through our team or another obstetrical team. It's, it's an incredible feeling.
Narrator: Even when an adorable hand reaches out to say hello, the surgeries Dr. Chavez performs are extremely serious, and delicate. They are done to preserve and prolong pregnancies, to ensure the baby or babies inside will survive. Fetal surgery can address problems with a fetus’s lungs, urinary tract, or spine. It can also treat a condition called twin-to-twin transfusion syndrome.
Dr. Chavez: And that condition is basically where you have a set of twins that are sharing a placenta and they have their own separate sacs, but the circulation that comes out of their heart and through umbilical cord and through the placenta is shared by both of them. So imagine living in a duplex, I'm living on the first floor, you might be living on the second floor, but the heating system is not balanced out. One might get too much heat. The other one might not get enough, but instead of heat, we worry about blood circulation. So one fetus might get too much blood, that is the recipient, and the other fetus might not get enough blood. That is the donor. That's giving blood to the it's sibling in utero. We actually take a very small scope, usually the size of a pen, not much larger. And we go inside the uterine environment. It's almost like having a window for us to look inside. We get in there by ultrasound guidance, but once we're in there, we have the scope. And that scope allows us to look at the fetus floating around…the one that's getting too much. And we also get to see the fetus that's giving too much of its blood because it's usually draped very tightly with its, um, amniotic SAC, um, membrane. And then we map out… It's almost like if you had a very complex trip to go to and you wanted to know exactly what road you needed to take. So what we do is we map out every single vessel and these vessels allow us to figure out where their imbalances are occurring. And once we've identified these, we then introduce a laser fiber made out of glass. And that allows us to direct energy using a diode laser to seal these abnormal connections. And this process allows the balance to naturally reoccur. So this way both babies can get the appropriate amounts of blood and nourishment through the placenta.
Narrator: Twin-to-twin transfusion syndrome, or TTTS, has been around as long as humans have. Surgery to address it has only existed for a few decades. Before these procedures, developing fetuses with twin-to-twin transfusion syndrome had only a 10 to 15 percent chance of surviving. Now, proper management and care typically means there is a 65 to 70 percent chance that both twins will survive, and go on to live normal, healthy lives. When Dr. Chavez identifies TTTS, he helps shepherd the expectant family through a process that is unexpected, scary, and overwhelming. It is an essential element of his job, as much as performing a surgery or delivering a baby.
Dr. Chavez: Every single patient who goes through to the fetal surgery program at NYU Langone has my personal cell phone number. I want the patient to have full access to me, not only before the procedure, but after the procedure. And in fact, they keep in touch with me throughout the entire pregnancy. In addition to that, it really allows us to stay connected with the patients and gives me insight as to how the babies are doing afterwards. One of the most important things for me, especially when I'm counseling patients, is being able to give the patients the likelihood of success and what type of success and how success looks for that particular clinical scenario.
We really do take a personal approach for the pretty straightforward high risk patients. We make sure that we spend time with them and we address all their questions. In addition to that, we try to follow up with them afterwards, just to give them a couple of hours or a couple of days just to absorb everything. The other thing specific to the fetal surgery program, which, um, I'm I take great pride in is that, when a clinician reaches out about a patient that they want to refer to us, one of the first things our team does is actually call the patient even before they get to us. The reason we do that is because we know how anxious the patient is.
Narrator: The goal of any pregnancy is to be boring. Painfully, delightfully boring. Doctors appointments are quick and easy, tests are routine. In between, there are no events worthy of calling the physician, nothing outside the range of normal for an average pregnancy. And yet, for the woman going through it, even the most boring pregnancy can be riddled with anxiety. Dana’s pregnancy was anything but boring.
Dana Salmonese: I found out I was pregnant. I was so excited. We weren't thinking about another baby, but it happened and we were so excited. I went to the doctor the day after new year's day and that's when we saw a beautiful heartbeat. And, um, my doctor said, well, you have a beautiful baby in there. I said, um, can I have another picture? So she went back to do the sonogram and she was like, wait a second. And she's like just staring out and I can't see it cause it's behind me, but my husband can see it. And he goes, “Wait, doc, am I seeing double?” And she was like, yeah, there's two in there. I freaked out. I was so excited. I couldn't wait to call my mom. And, uh, and it was, it was two. It was crazy. two heartbeats.
Narrator: After a relatively straightforward first trimester, Dana finally shared with friends and family that she and her husband Joe were expecting twin boys.
Dana Salmonese: I felt comfortable enough to announce on Facebook that I was pregnant. And that night I woke up, five o'clock in the morning to a pool of blood. And I was like, I'm miscarrying… I'm miscarrying… I woke my husband up, I'm miscarrying. I have to go to the hospital, I'm miscarrying. And you know, he is the most positive person in the world. So he's like, you're not miscarrying, something's just going on, we're going to get it checked out. Don't worry. Um, meanwhile, I'm in like the bathroom passing clots… and like, I was scared to look. We go to the hospital, they're checking everything out. Babies still have a heartbeat. And they diagnosed me with a sub chorionic hematoma hemorrhage. They had a 50, 50 chance of surviving. They told me to go on modified bedrest. And I bled from week 13 to week 17.
Narrator: In pregnancy, modified bedrest means it’s generally okay to sit, stand, or walk around for short periods of time, but otherwise, women on bedrest should take it really easy. One of the hardest parts of bedrest for Dana was not being able to pick up her then 14-month old toddler, Gianna.
Dana Salmonese: I remember going to the doctor that week… around week 18 and I said, oh, I'm so excited to pick up my daughter again.And then I went in and uh, that's when my maternal fetal medicine said, something was happening.She said, do you remember that rare disorder I was talking to you about when you first came in here with twins. And I was like, yeah, I try not to look it up because I have anxiety disorder. But I remember the name TTS and she was like, I think you have it. I think you need to see a doctor today. She called Dr. Chavez's office for me. And that's when I said to myself, this is serious.
Dr. Chavez: So the concern was, there were early signs of twin to twin transfusion syndrome.
We quickly started evaluating Dana and pregnancy, her twin pregnancy, through ultrasound. We realized that it had gotten to the stage that we needed to offer intervention. She was very early in the pregnancy. So delivery was not even a remote option because delivery at that point would have meant death to both of those babies. And we also knew that if we did not intervene, she would have a 70 to 80% chance of losing one or both of those babies.
Dana Salmonese: So Dr. Chavez had said to me, you're in stage two, borderline stage three TTTS and I need to do surgery on you tomorrow.
Dr. Chavez: So after careful discussions and detailed and lengthy discussions in consultation with her and her partner, we felt that the best option was to offer her fetal surgery or fetoscope where we would go in there, evaluate the circulation on the placental surface, map out all of these vessels in detail, and with the laser, create the balance that would allow the pregnancy to continue.
Dana Salmonese: Dr. Chavez is an amazing man and he knows how to talk to his patients, being upfront and honest, but also compassionate. He has a gift for that. So he made it clear to me what was going on, but at the same time, he didn't want to alarm me... and I don't know how he did that because I said, well, I'm going in for surgery tomorrow. You know, both my twins might die one, both might die. I might have my whole uterus taken out because of complications during surgery. And that night I'm just thinking to myself, well, at least I got one. At least I have my daughter. And uh, and I remember going to sleep that night. Well, if you could call it sleep, I remember just praying, praying, praying, praying. Cause I'm just thinking like the worst… that was my night.
Narrator: It was the night of March 10, 2020. The next day, Dana and Joe got up early, and went in for the surgery. The world was starting to change - dramatically - as a novel coronavirus began spreading throughout and beyond New York City.
[News Clip: “New York City remains the national epicenter of the pandemic, it has more than a quarter of those sickened so far, and this is overwhelming the city’s hospitals and first-responders.”]
Narrator: They watched mass on television while they waited.
[Mass clip: “In the name of the father, and of the son and of the holy spirit. Amen. Peace be with you. And also with you.”]
Dana Salmonese: I do remember just waiting for the ER to open up. And, they did the epidural, Dr. Chavez just reassuring me “I'm gonna do the best I can. I'm going to do the best I can for your boys.” And that's what gave me such calmness.
Narrator: The procedure took longer than expected. Because of the bleeding earlier in the pregnancy, Dana’s amniotic fluid was extremely murky, which meant Dr. Chavez had to work even more slowly and carefully.
Dana Salmonese: I'm laying there and I'm awake for the most nerve-wracking thing of my life, I'm awake. I kept asking him, “are we there yet?” Like a kid. “Did you start lasering yet?” And, and he goes, “No, we're still draining your fluid.” I just feel like it took forever.
Narrator: Once he finished draining the fluid, Dr. Chavez was able to replace it with clear saline, and begin lasering the abnormal blood vessel connections in her uterus, to restore the balance of circulation between the twins. At some point, Dana’s epidural started to wear off, and she could feel strange, but not painful, electrical zaps. Finally, after what felt like an eternity, it was over.
Dana Salmonese: So then, when he wrapped up, he said something really reassuring to me because some women have to go back for the surgery two times. But he said, “There's no way that the vessels can grow back. I soldered everything.” So I was like, that's why I was like, “You're the best Doctor Chavez.” …He really is the best doctor.
Narrator: Dana’s surgery was a success, but pregnancy is long. Her twins still had many weeks to go before they could safely survive outside the womb. And then two weeks after the surgery, at 20 weeks pregnant, Dana’s water broke.
Dana Salmonese: This was the height of COVID in New York and especially Long Island. And I remember being you know… terrified. So you think, you know, oh God, my water broke. This is it. And I'm thinking to myself, I'm just trying to soothe myself saying I did everything I possibly could for these boys. I did everything. I did everything. And Dr. Chavez was like, I'm here you come straight to labor and delivery. And we're going to check it out. Don't worry. And I just remember I was losing so much fluid. I was like, this is, it's not even like a small leak. Like my water broke. It was a gush. I said, this is it. This is where the journey ends. So I get to Labor and Delivery. Dr. Chavez is there. He said, “Don't worry, Dana, don't worry. We're going to check out these boys.” And he goes, “They're strong, they're strong. They're like their mom and dad.” I go, okay, Dr. Chavez, you know,
Narrator: Under normal circumstances, Dr. Chavez would have kept Dana in the hospital for observation. When a woman’s water breaks, it sharply increases the risk she’ll develop an infection, and possibly go into sepsis, which is a life-threatening condition. But because of COVID, Dr. Chavez couldn’t admit her to the hospital.
Dana Salmonese: He said, “I cannot keep you here. The threat of being in this hospital is too high. The whole wing is COVID, it's becoming COVID tomorrow. This whole wing.” And I see people, I see people running in the hallways, you know, trying to get stuff ready. It was surreal because it's like, I should be here, you know, but this thing is happening. It's totally out of my control. It's totally out of everyone's control… you know, how quickly everything is collapsing.. You know?. And uh, I just remember. Yeah. Like, yeah, I have to get out of here. I can't, I can't be here. Right. It's like, I have to be here, but I can't be here.
Narrator: Dana went home with strict instructions to check her temperature every hour. If it went above 100.4, she had to call Dr. Chavez immediately, because it could be a sign of infection. She had one scare - a 24-hour virus that caused a fever spike - but otherwise she was okay. Dr. Chavez monitored Dana through a combination of telemedicine and in-person visits. It was May of 2020, and while the first COVID wave in New York had subsided a bit, Dana’s pre-term labor contractions had not. She was admitted to the hospital, where she stayed for 3 weeks. Eventually, at 31 weeks pregnant, they decided it was time.
Dana Salmonese: During one of my scans, one of my big scans, the weekly big scans, um, they noticed that my donor twin wasn't getting enough oxygen, blood flow. Um, his umbilical cord was like failing… that's when they decided to do a C-section the next day. I was like, okay. Like, it doesn't matter anymore. They're coming out. They were born 3:26 in the afternoon. Vince Joseph, weighing four pounds, one ounce and Paul Nicholas, weighing two pounds, nine ounces. It was so good. It was just so good to see them. Welcome to the world. It's going to be better now.
Narrator: Vince Joseph spent 85 days in the neonatal intensive care unit at NYU Langone Hospital - Long Island; his brother Paul Nicholas was there for 105 days. They experienced breathing problems, received blood transfusions, and underwent spinal taps. They had other issues too, like infections and water in the brain. It wasn’t an easy road. But those two tough little boys made it home, thanks to Dr. Chavez and the incredible neonatal specialists at NYU Langone. And also, because of their parents.
Dana Salmonese: It was 105 days. I went in every single day, cause you have, you have to have to see how they're doing, you know, give them that mother's touch. I think this was my ultimate calling, being the mother of those babies. I was going to see this through and I knew they were going to be okay. The outcome that happened, wasn't supposed to happen. It's too rare. Like my boys are perfectly healthy. I mean, they get a lot of services… They get physical therapy, they get, um, speech therapy, they get feeding therapy. Uh, they get special ed, um, you know, all these early interventions, but they're thriving and none of it would have been possible without the surgery I got.
[Baby sounds: Dana off-mic: “Tickle Tickle Tickle… Say Momma” Baby Coos]
Dr. Chavez: I've done this for a long time and Dana's energy, positivity is infectious, but infectious in such a way you cannot help, but wanting to be positive and have nothing but the best possible outlook. So I have total confidence that Dana and her partner will have nothing but the best outcome because of who they are and because of who their children are.
Narrator: Vinny and Paulie are now nearly two years old. The surgery that gave them a chance to survive continues to save other fetuses with twin-to-twin transfusion syndrome. Surgeons like Dr. Chavez are looking at how to make these procedures even better.
Dr. Chavez: I think we're just starting to look at opportunities. We are looking for other ways, for all our campuses; here at Tisch in Long Island, to look at ways we can provide other, um, treatment options in utero. It's interesting because the uterine environment actually serves two purposes. And it not only serves the purpose of letting that fetus develop in utero, but believe it or not, a lot of the things that occur in utero will determine the health of that individual later on in life. So if that fetus is too small, that might determine if certain aspects of heart disease would develop later on, if that fetus is too big, that individual might develop diabetes later on in life. And everything in between. So, by maximizing that environment in utero will not only get the best possible outcome for that newborn, but also maximize the outcome for that individual, for the rest of its life. So that's what excites me the most about our field.
Narrator: Dr. Chavez likes to imagine a bright future for these babies that he gets to meet for the first time, inside and outside the womb. He can’t help himself.
Dr. Chavez: It's the beginning, right? Every, every baby that we help take care of, every fetus, I think to myself, is that going to be the next president? Is that going to be the next person who develops a cure, whether it's for COVID-19 or for cancer, or is that the next person who is going to bring peace to our world? It's limitless. You don't necessarily know what they're going to do, but you're part of the very beginnings of the future. And very few fields can say they're part of the future.
[Baby Sounds off-mic]:
Dana: [Laughs]
Jim: Hi!
Dana: This is Vince.
Jim: Hi Vince!
Dana: “Say “Hi I’m Vinny” [Laughs]
Jim: Hi! Thanks Paulie, good to meet you, buddy.
Dana: Say “Nice meeting you.”
[Baby Coos]
Jim: A couple miracle babies right here.
Dana: “You’re gonna listen to this podcast when you’re older and you’re gonna be like “That was me… that was me…”
Narrator:Vital Signs is a co-production of NYU Langone Health and SiriusXM. The podcast is produced by Jim Bilodeau, Julie Kanfer, and Keith King, with sound design by Jim Bilodeau and writing from Julie Kanfer. SiriusXM’s executive producer is Beth Ameen, in partnership with Allison Clair and Jim Mandler of NYU Langone Health. Don’t miss a single episode of Vital Signs and subscribe for free wherever you listen to podcasts. To hear more from the world-renowned doctors at NYU Langone Health, tune to Doctor Radio on SiriusXM channel 110, or listen anytime on the SXM app. To get in touch with our production team, email VitalSigns@siriusxm.com. For the Vital Signs podcast, I’m Rose Reid. Join us next time as we bring you the stories of medicine made personal.