Twin-to-Twin Transfusion Syndrome Treatment & Management
- Author: Terence Zach, MD; Chief Editor: Ronald M Ramus, MD more...
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. The fetal death rate for the donor is higher that the recipient following this procedure.
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.
De Paepe ME, Luks FI. What-and why-the pathologist should know about twin-to-twin transfusion syndrome. Pediatr Dev Pathol. 2013 Jul-Aug. 16(4):237-51. [Medline].
Fujioka K, Sakai H, Tanaka S, Iwatani S, Wada K, Mizobuchi M, et al. N-terminal Pro-brain Natriuretic Peptide Levels in Monochorionic Diamniotic Twins with Twin-to-twin Transfusion Syndrome Treated by Fetoscopic Laser Photocoagulation. Kobe J Med Sci. 2013 Apr 17. 59(1):E28-35. [Medline].
O'Donoghue K, Rutherford MA, Engineer N, Wimalasundera RC, Cowan FM, Fisk NM. Transfusional fetal complications after single intrauterine death in monochorionic multiple pregnancy are reduced but not prevented by vascular occlusion. BJOG. 2009 May. 116(6):804-12. [Medline].
Robyr R, Boulvain M, Lewi L, Huber A, Hecher K, Deprest J, et al. Cervical length as a prognostic factor for preterm delivery in twin-to-twin transfusion syndrome treated by fetoscopic laser coagulation of chorionic plate anastomoses. Ultrasound Obstet Gynecol. 2005 Jan. 25(1):37-41. [Medline].
O'Brien BM. MFM/geneticist view on prenatal management of twins. Am J Med Genet C Semin Med Genet. 2009 May 15. 151C(2):155-61. [Medline].
Rossi AC, Vanderbilt D, Chmait RH. Neurodevelopmental outcomes after laser therapy for twin-twin transfusion syndrome: a systematic review and meta-analysis. Obstet Gynecol. 2011 Nov. 118(5):1145-50. [Medline].
Quintero RA, Morales WJ, Allen MH, Bornick PW, Johnson PK, Kruger M. Staging of twin-twin transfusion syndrome. J Perinatol. 1999 Dec. 19(8 Pt 1):550-5. [Medline].
Cincotta RB, Gray PH, Gardener G, Soong B, Chan FY. Selective fetoscopic laser ablation in 100 consecutive pregnancies with severe twin-twin transfusion syndrome. Aust N Z J Obstet Gynaecol. 2009 Feb. 49(1):22-7. [Medline].
Baschat AA, Barber J, Pedersen N, Turan OM, Harman CR. Outcome after fetoscopic selective laser ablation of placental anastomoses vs equatorial laser dichorionization for the treatment of twin-to-twin transfusion syndrome. Am J Obstet Gynecol. 2013 May 22. [Medline].
Chiossi G, Quigley MR, Esaka EJ, Novic K, Celebrezze JU, Golde SH, et al. Nutritional supplementation in monochorionic diamniotic twin pregnancies: impact on twin-twin transfusion syndrome. Am J Perinatol. 2008 Nov. 25(10):667-72. [Medline].
Brackley KJ, Kilby MD. Twin-twin transfusion syndrome. Hosp Med. 1999 Jun. 60(6):419-24. [Medline].
Denbow ML, Battin MR, Cowan F, et al. Neonatal cranial ultrasonographic findings in preterm twins complicated bysevere fetofetal transfusion syndrome. Am J Obstet Gynecol. 1998 Mar. 178(3):479-83. [Medline].
Duncan KR. Twin-to-twin transfusion: update on management options and outcomes. Curr Opin Obstet Gynecol. 2005 Dec. 17(6):618-22. [Medline].
Elliot JP. Amniocentesis for twin-twin transfusion syndrome. Contemp Ob Gyn. 1992. 37:30-47.
Fox C, Kilby MD, Khan KS. Contemporary treatments for twin-twin transfusion syndrome. Obstet Gynecol. 2005 Jun. 105(6):1469-77. [Medline].
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. 2006 Aug. 108(2):333-7. [Medline].
Machin GA, Keith LG. Can twin-to-twin transfusion syndrome be explained, and how is it treated?. Clin Obstet Gynecol. 1998 Mar. 41(1):104-13. [Medline].
Milner R, Crombleholme TM. Troubles with twins: fetoscopic therapy. Semin Perinatol. 1999 Dec. 23(6):474-83. [Medline].
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. 2006 Oct. 28(5):659-64. [Medline].
Taylor MJ, Govender L, Jolly M, Wee L, Fisk NM. Validation of the Quintero staging system for twin-twin transfusion syndrome. Obstet Gynecol. 2002 Dec. 100(6):1257-65. [Medline].
Yamamoto M, Ville Y. Recent findings on laser treatment of twin-to-twin transfusion syndrome. Curr Opin Obstet Gynecol. 2006 Apr. 18(2):87-92. [Medline].
Degenhardt J, Reinold M, Enzensberger C, et al. Short-time impact of laser ablation of placental anastomoses on myocardial function in monochorionic twins with Twin-to-Twin Transfusion Syndrome. Ultraschall Med. 2015 Sep 2. [Medline].
Peeters SH, Akkermans J, Bustraan J, et al. Operative competence in fetoscopic laser surgery for TTTS: a procedure-specific evaluation. Ultrasound Obstet Gynecol. 2015 Aug 26. [Medline].
van Klink JM, Slaghekke F, Balestriero MA, et al. Neurodevelopmental outcome at 2 years in twin-twin transfusion syndrome survivors randomized for the Solomon trial. Am J Obstet Gynecol. 2015 Aug 20. [Medline].