Twin-to-Twin Transfusion Syndrome Treatment & Management

  • Author: Terence Zach, MD; Chief Editor: Ronald M Ramus, MD   more...
 
Updated: Nov 16, 2011
 

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.[6] 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.
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Diet

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.[7]

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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, FACOG  Director, Division of Maternal-Fetal Medicine for Alegent Health at Bergan Mercy Medical Center, Omaha, NE

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, and Society for Maternal-Fetal Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Robert K Zurawin, MD  Associate Professor, Director of Baylor College of Medicine Program for Minimally Invasive Gynecology, Director of Fellowship Program, Minimally Invasive Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine

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; ConMed Consulting fee Consulting

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

Disclosure: Medscape Salary Employment

Frederick B Gaupp, MD  Consulting Staff, Department of Family Practice, Hancock Medical Center

Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians

Disclosure: Nothing to disclose.

Chief Editor

Ronald M Ramus, MD  Practice of Maternal-Fetal Medicine, Director of Perinatal Services, Bon Secours Perinatal Center, Richmond Health System

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, and Society for Maternal-Fetal Medicine

Disclosure: Nothing to disclose.

References

  1. [Best Evidence] 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. May 2009;116(6):804-12. [Medline].

  2. 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. Jan 2005;25(1):37-41. [Medline].

  3. O'Brien BM. MFM/geneticist view on prenatal management of twins. Am J Med Genet C Semin Med Genet. May 15 2009;151C(2):155-61. [Medline].

  4. Rossi AC, Vanderbilt D, Chmait RH. Neurodevelopmental outcomes after laser therapy for twin-twin transfusion syndrome: a systematic review and meta-analysis. Obstet Gynecol. Nov 2011;118(5):1145-50. [Medline].

  5. 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].

  6. 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. Feb 2009;49(1):22-7. [Medline].

  7. 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. Nov 2008;25(10):667-72. [Medline].

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

  9. 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].

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

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

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

  13. 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].

  14. 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].

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

  16. 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].

  17. 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].

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



Polyhydramnios



Absent Urine in Donor BladderAbnormal Doppler Blood FlowsHydrops FetalisFetal Demise
I+----
II++---
III+++--
IV++++-
V+++++
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