Your Pregnancy After 35 : More Than One Baby (part 3) - Twin-to-Twin Transfusion Syndrome

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6. Twin-to-Twin Transfusion Syndrome (TTTS)

Twin-to-twin transfusion syndrome (TTTS), also called chronic intertwin transfusion syndrome, occurs only in identical twins who share the same placenta. The condition can range from mild to severe and can occur at any point during pregnancy, even at birth.

TTTS cannot be prevented; it’s not a genetic disorder nor a hereditary condition. We believe it occurs in 5 to 10% of all identical-twin pregnancies. These problems do not occur in twins who each have a placenta.

In TTTS, twins also share some of the same blood circulation. This allows the transfusion of blood from one twin to the other. One twin becomes small and anemic. Its body responds by partially shutting down blood supply to many of its organs, especially the kidneys, which results in reduced urine output and a small volume of amniotic fluid.

The other twin grows large, overloaded with blood. It produces excessive amounts of urine so it is surrounded by a large volume of amniotic fluid. Its blood becomes thick and difficult to pump through its body; this can result in heart failure, generalized soft-tissue swelling and death.

When a Multiple Pregnancy Isn’t a Multiple Pregnancy

Some women are told early in pregnancy they are carrying twins, only to discover later they are carrying only one baby. Early ultrasound exams reveal two babies; later ultrasounds of the same woman show one baby disappeared, but the other baby is OK. We believe one of the pregnancies dies and is absorbed by the mother’s body. This is one reason many healthcare providers prefer not to predict a twin birth before 10 weeks of pregnancy.

Twins are often very different in size. There can also be a large difference in their weights. TTTS is a progressive disorder, so early treatment may help prevent complications.

Symptoms of TTTS

There are symptoms of the syndrome your healthcare provider looks for. If your abdomen enlarges quite rapidly over a 2- to 3-week period, it may be caused by the buildup of amniotic fluid in the recipient twin. The result can be premature labor and/or premature rupture of membranes. If one twin is small for its gestational age or one is big for its gestational age, it may indicate TTTS. In addition, your healthcare provider may suspect TTTS if any of the following is seen during an ultrasound:

large difference in the size of fetuses of the same gender

difference in size between the two amniotic sacs

difference in size of the umbilical cords

one placenta

evidence of fluid buildup in the skin of either fetus

indications of congestive heart failure in the recipient twin

An additional problem may develop in either twin. With this condition, fluid accumulates in some part of the fetus, such as in the scalp, abdomen, lungs or heart.

Diagnosing and Treating TTTS

Report any of the following to your healthcare provider, especially if you know you’re expecting twins:

rapid growth of your uterus

abdominal pain, tightness or contractions

sudden increase in body weight

swelling in the hands and legs in early pregnancy

The syndrome may also be detected with ultrasound examination of the uterus. It’s important to find out whether twins share the same placenta. It’s preferable to learn this in the first trimester because in the second trimester it can be harder to discover whether they share a placenta.

If the syndrome is mild or undetected on ultrasound, the appearance of the babies at birth may identify it. A complete blood cell count done after birth will show anemia in one twin and excess red blood cells (polycythemia) in the other.

If diagnosed, the Twin to Twin Transfusion Syndrome Foundation recommends weekly ultrasounds after 16 weeks until the end of the pregnancy to monitor the condition. They recommend this be done even if the warning signs of TTTS have decreased.

The most common treatment for TTTS is amnioreduction, in which large volumes of amniotic fluid are drained from the sac of the larger twin. A needle is placed through the mother’s abdomen, and fluid is drained. The procedure is repeated, as necessary.

In another procedure, a hole punched between the two amniotic sacs can help equalize the fluid between the sacs. However, neither of these procedures stops the twin-to-twin transfusion.

Some cases of TTTS do not respond to amnioreduction. A small-scope laser procedure may be done to seal off some or all of the blood vessels the twins share. Usually only one procedure is necessary during the pregnancy. Survival rates are also about 60% with this procedure. This treatment is most successful if done before 26 weeks of pregnancy.

With laser treatment, a detailed ultrasound exam is done first to help locate the abnormal connection. Then a thin fiber-optic scope is placed through the mother’s abdomen, through the wall of the uterus and into the amniotic cavity of the larger twin. By looking directly at the placenta, blood connections can be found and sealed with a laser beam. This separates the circulation of the fetuses and ends twin-to-twin transfusion. However, this requires doing the procedure while the babies are still in the womb and may cause complications.

The most conservative treatment is to watch and wait. The pregnancy is followed closely with frequent ultrasound exams, with the choice of delivering the twins by Cesarean delivery if medically necessary.

Newborns with twin-to-twin transfusion syndrome may be critically ill at birth and require treatment in a neonatal intensive care unit (NICU). The smaller twin is treated for anemia, and the larger twin is treated for excess red blood cells and jaundice.

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