Twin-to-Twin Transfusion Syndrome scenarios - the making of a decision

Abstract

Introduction: Twin-to-Twin Transfusion Syndrome (TTTS) is a prenatal condition affecting 10-20% of monochorionic – diamniotic (identical) twins and is defined by unbalanced blood flow from one twin to the co-twin. TTTS is staged using the Quintero Staging System (I-V) based on ultrasound and Doppler findings. Even with the staging, TTTS does not have a linear course of progression and lacks predictably in the outcome of the pregnancy. If it does progress and is left untreated, TTTS has a 100% mortality of both twins. There are various treatments for TTTS including septostomy and serial amnioreductions, but the optimal treatment for TTTS is laser ablation of the communicating placental vessels between both twins. These anastomoses are the pathophysiological cause of the syndrome and LASER treatment allows the twins to recover in utero. LASER treatment is associated with risks, including preterm rupture of membranes and preterm labor in 4% of pregnancies and short-and long-term morbidities in 13% of the twin, with the main cause of all morbidity in TTTS infants being prematurity. Twin-to-Twin Transfusion Syndrome’s associated unpredictability, lack of linear progression, and various risks and outcomes cause decision-making in TTTS to be problematic for both physicians and parents. Methods: A six-month observational period from July 2012 through January 2013, a cohort of women pregnant with monochorionic – diamniotic twins were referred to the Fetal Treatment Program of New England for assessment of TTTS in their twins by ultrasonography. If diagnosed with TTTS, the twins were staged (I-IV) and treatment recommendations were discussed. At Stage I, patients were recommended for observational, conservative management of weekly ultrasounds. If the patient's ultrasound findings were consistent with Stage II, III, or IV, they underwent LASER treatment. During LASER treatment, communicating anastomoses between both twins were ablated using a diode laser. The women were discharged 2 days post-op and were recommended to have at least weekly ultrasounds for the first two weeks after surgery and then every other week ultrasounds thereafter, to monitor each twin’s health. [TRUNCATED]