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Twin-to-Twin Transfusion Syndrome Treatment & Management

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

Medical Care

The most common procedure to treat TTTS is reduction amniocentesis. This procedure involves draining the amniotic fluid from around the recipient twin. This procedure may improve circulation in the donor twin especially if the anastomosis are superficial in the placenta and the TTTS is a lower stage. This procedure may need to be performed multiple times during the pregnancy.

Fetoscopic laser photocoagulation of chorionic plate vessels is a highly specialized procedure performed in a few centers around the world. This is mostly reserved for more severe cases, especially those that do not respond to amnioreduction. In pregnancies treated with fetoscopic procedures, the overall survival is 75% with 85% having at least 1 fetus survive.[8] The fetal death rate for the donor is higher that the recipient following this procedure.[9]

Timing of delivery depends on multiple factors. The ideal would be for delivery at term; however, evidence of lack of fetal growth or nonreassuring antepartum testing or preterm labor may result in a premature delivery.

Medical care of twins after birth is directed toward problems related to prematurity, anemia, polycythemia, and hydrops fetalis.

  • Severely anemic donor twins may require packed RBC transfusions or partial exchange transfusions.
  • Polycythemic recipient twins may require partial exchange transfusion to lower serum hematocrit levels.
  • Newborns with hydrops fetalis may require mechanical ventilation, thoracocentesis, pericardiocentesis, and paracentesis.


Nutritional supplementation with commercially available dietary supplements during pregnancies has been reported to reduce the severity and incidence of TTTS. In addition, patients who took dietary supplements required fewer invasive procedures.[10]

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
Stage Oligohydramnios/


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