eMedicine Specialties > Obstetrics and Gynecology > Obstetrical Complications

Twin-to-Twin Transfusion Syndrome: Differential Diagnoses & Workup

Author: Terence Zach, MD, Department Vice-Chair, Professor, Department of Pediatrics, Section of Newborn Medicine, Creighton University
Coauthor(s): Michael J Barsoom, MD, Assistant Professor of Obstetrics and Gynecology, Director of Perinatal Ultrasound, Creighton University Medical Center
Contributor Information and Disclosures

Updated: Aug 24, 2007

Differential Diagnoses

Other Problems to Be Considered

Hydrops fetalis
Polycythemia
Polycythemia of the newborn
Polyhydramnios
Oligohydramnios
Anemia of the newborn

Workup

Laboratory Studies

  • Amniocentesis should be considered to test for aneuploidy and intrauterine infection.
  • CBC count: The donor twin is frequently anemic at birth, whereas the recipient twin is frequently polycythemic at birth.
  • Calcium: Hypocalcemia is frequently present in the donor twin.
  • Glucose: Hypoglycemia may be present in either twin.
  • Creatinine: Either twin may have evidence of renal dysfunction.
  • Platelet count: Thrombocytopenia can occur in either twin.
  • Bilirubin: Hyperbilirubinemia may develop in the polycythemic recipient twin.

Imaging Studies

  • Sonographic findings of TTTS include the following:
    • Significant discrepancy in size of same-sex fetuses
    • Significant disparity in the amount of amniotic fluid between the fetuses with the smaller twin having oligohydramnios
    • Single placenta
  • Neonatal brain ultrasonography: Because ischemia of the brain can occur during fetal development in either the donor or recipient twin, brain ultrasonography should be considered in both twins born with TTTS. Twins born prematurely are susceptible to intraventricular hemorrhage and periventricular leukomalacia.
  • Neonatal echocardiography: Myocardial dysfunction, myocardial hypertrophy, valvular insufficiency, and pericardial effusions can be detected in either twin.
  • Neonatal renal ultrasonography: Abnormal renal echogenicity may be present in either twin and indicates hypoxic-ischemic cortical necrosis.
  • Neonatal abdominal ultrasonography: Ascites may be present if hydrops fetalis occurs.
  • Neonatal chest radiography: Pleural effusions and cardiomegaly may be present if hydrops fetalis occurs.

Staging

The most useful staging system for TTTS was developed by Quintero:1

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Table
Stage
Oligohydramnios/
Polyhydramnios
Absent Urine in Donor Bladder
Abnormal Doppler Blood Flows
Hydrops Fetalis
Fetal Demise
I
+
-
-
-
-
II
+
+
-
-
-
III
+
+
+
-
-
IV
+
+
+
+
-
V
+
+
+
+
+
Stage
Oligohydramnios/
Polyhydramnios
Absent Urine in Donor Bladder
Abnormal Doppler Blood Flows
Hydrops Fetalis
Fetal Demise
I
+
-
-
-
-
II
+
+
-
-
-
III
+
+
+
-
-
IV
+
+
+
+
-
V
+
+
+
+
+
 

More on Twin-to-Twin Transfusion Syndrome

Overview: Twin-to-Twin Transfusion Syndrome
Differential Diagnoses & Workup: Twin-to-Twin Transfusion Syndrome
Treatment & Medication: Twin-to-Twin Transfusion Syndrome
Follow-up: Twin-to-Twin Transfusion Syndrome
Multimedia: Twin-to-Twin Transfusion Syndrome
References
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References

  1. Quintero RA, Morales WJ, Allen MH, Bornick PW, Johnson PK, Kruger M. Staging of twin-twin transfusion syndrome. J Perinatol. Dec 1999;19(8 Pt 1):550-5. [Medline].

  2. Brackley KJ, Kilby MD. Twin-twin transfusion syndrome. Hosp Med. Jun 1999;60(6):419-24. [Medline].

  3. Denbow ML, Battin MR, Cowan F, et al. Neonatal cranial ultrasonographic findings in preterm twins complicated bysevere fetofetal transfusion syndrome. Am J Obstet Gynecol. Mar 1998;178(3):479-83. [Medline].

  4. Duncan KR. Twin-to-twin transfusion: update on management options and outcomes. Curr Opin Obstet Gynecol. Dec 2005;17(6):618-22. [Medline].

  5. Elliot JP. Amniocentesis for twin-twin transfusion syndrome. Contemp Ob Gyn. 1992;37:30-47.

  6. [Best Evidence] Fox C, Kilby MD, Khan KS. Contemporary treatments for twin-twin transfusion syndrome. Obstet Gynecol. Jun 2005;105(6):1469-77. [Medline].

  7. Huber A, Diehl W, Bregenzer T, Hackelöer BJ, Hecher K. Stage-related outcome in twin-twin transfusion syndrome treated by fetoscopic laser coagulation. Obstet Gynecol. Aug 2006;108(2):333-7. [Medline].

  8. Machin GA, Keith LG. Can twin-to-twin transfusion syndrome be explained, and how is it treated?. Clin Obstet Gynecol. Mar 1998;41(1):104-13. [Medline].

  9. Milner R, Crombleholme TM. Troubles with twins: fetoscopic therapy. Semin Perinatol. Dec 1999;23(6):474-83. [Medline].

  10. Sueters M, Middeldorp JM, Lopriore E, Oepkes D, Kanhai HH, Vandenbussche FP. Timely diagnosis of twin-to-twin transfusion syndrome in monochorionic twin pregnancies by biweekly sonography combined with patient instruction to report onset of symptoms. Ultrasound Obstet Gynecol. Oct 2006;28(5):659-64. [Medline].

  11. Taylor MJ, Govender L, Jolly M, Wee L, Fisk NM. Validation of the Quintero staging system for twin-twin transfusion syndrome. Obstet Gynecol. Dec 2002;100(6):1257-65. [Medline].

  12. Yamamoto M, Ville Y. Recent findings on laser treatment of twin-to-twin transfusion syndrome. Curr Opin Obstet Gynecol. Apr 2006;18(2):87-92. [Medline].

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Further Reading

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Keywords

twin-to-twin transfusion syndrome, TTTS, stuck twin syndrome, stuck twin phenomenon, feto-fetal transfusion syndrome, interfetal transfusion syndrome, polyhydramnios, oligohydramnios, hydrops fetalis, thoracocentesis, pericardiocentesis, paracentesis, placental vascular anastomoses, anemia, plethora, polycythemia, hypocalcemia, renal dysfunction, thrombocytopenia, hyperbilirubinemia, intraventricular hemorrhage, periventricular leukomalacia, myocardial dysfunction, myocardial hypertrophy, valvular insufficiency, pericardial effusion, abnormal renal echogenicity, hypoxic-ischemic cortical necrosis, ascites, pleural effusions, cardiomegaly

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Contributor Information and Disclosures

Author

Terence Zach, MD, Department Vice-Chair, Professor, Department of Pediatrics, Section of Newborn Medicine, Creighton University
Terence Zach, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, and Nebraska Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Michael J Barsoom, MD, Assistant Professor of Obstetrics and Gynecology, Director of Perinatal Ultrasound, Creighton University Medical Center
Michael J Barsoom, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, and Society for Maternal-Fetal Medicine
Disclosure: Nothing to disclose.

Medical Editor

Robert K Zurawin, MD, Associate Professor, Director of Fellowship Programs, Minimally Invasive Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine; Chief of Gynecology, Texas Children's Hospital
Robert K Zurawin, MD is a member of the following medical societies: American Association of Gynecologic Laparoscopists, American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine, Association of Professors of Gynecology and Obstetrics, Central Association of Obstetricians and Gynecologists, Harris County Medical Society, North American Society for Pediatric and Adolescent Gynecology, and Texas Medical Association
Disclosure: Johnson and Johnson Honoraria Speaking and teaching; Conceptus Honoraria Speaking and teaching

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

CME Editor

Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Assumption Community Hospital
Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians
Disclosure: Nothing to disclose.

Chief Editor

David Chelmow, MD, Professor of Obstetrics and Gynecology, Tufts University School of Medicine; Program Director, Tufts University Affiliated Hospitals OB/GYN Residency Program; Chair, Tufts University Health Sciences Campus Institutional Review Board
David Chelmow, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Association of Professors of Gynecology and Obstetrics, Massachusetts Medical Society, Phi Beta Kappa, Sigma Xi, Society for Gynecologic Investigation, and Society for Medical Decision Making
Disclosure: Nothing to disclose.

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