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Twin-to-Twin Transfusion Syndrome Clinical Presentation

  • Author: Terence Zach, MD; Chief Editor: Ronald M Ramus, MD  more...
Updated: Dec 30, 2015


Women with twin pregnancies who develop twin-to-twin transfusion syndrome (TTTS) frequently complain of a rapidly enlarging abdomen over 2-3 weeks as polyhydramnios develops in the amniotic sac of the recipient twin.

Other complaints include preterm labor and premature rupture of membranes.



TTTS should be considered in a pregnant woman carrying monochorionic twins if she develops a rapidly increasing fundal height. After birth, TTTS can be considered if the twins are monozygotic, and significant differences occur in the size or appearance of the twins.

Donor twin features include the following:

  • Small for gestational age - More than 20% smaller than recipient twin
  • Pallor
  • Poor peripheral perfusion

Recipient twin features include the following:

  • Large for gestational age - More than 20% larger than donor twin
  • Plethoric and ruddy
  • Jaundice

Hydrops fetalis can be present in either twin in TTTS. These infants have subcutaneous edema, a distended abdomen, and respiratory distress.



TTTS occurs in monozygotic, monochorionic twin pregnancies when an anastomosis between placental vasculature exists.

Contributor Information and Disclosures

Terence Zach, MD Department Chair, Professor, Department of Pediatrics, Section of Newborn Medicine, Creighton University School of Medicine

Terence Zach, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.


Michael J Barsoom, MD, FACOG Director, Division of Maternal-Fetal Medicine, Alegent Health at Bergan Mercy Medical Center

Michael J Barsoom, MD, FACOG is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, Society for Maternal-Fetal Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Ronald M Ramus, MD Professor of Obstetrics and Gynecology, Director, Division of Maternal-Fetal Medicine, Virginia Commonwealth University School of Medicine

Ronald M Ramus, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, Medical Society of Virginia, Society for Maternal-Fetal Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Robert K Zurawin, MD Associate Professor, Chief, Section of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine

Robert K Zurawin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine, Association of Professors of Gynecology and Obstetrics, Central Association of Obstetricians and Gynecologists, Society of Laparoendoscopic Surgeons, Texas Medical Association, AAGL, Harris County Medical Society, North American Society for Pediatric and Adolescent Gynecology

Disclosure: Received consulting fee from Ethicon for consulting; Received consulting fee from Bayer for consulting; Received consulting fee from Hologic for consulting.

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Monozygotic twins with monochorionic, diamniotic placentation.
Monozygotic twins with monochorionic, monoamniotic placentation.
Table. TTTS Staging System


Absent Urine in Donor BladderAbnormal Doppler Blood FlowsHydrops FetalisFetal Demise
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