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Twin-twin transfusion syndrome: Management and outcome

Authors
Anthony Johnson, DO
Ramesha Papanna, MD, MPH
Section Editors
Deborah Levine, MD
Louise Wilkins-Haug, MD, PhD
Deputy Editor
Vanessa A Barss, MD, FACOG

INTRODUCTION

Monochorionic twin pregnancies are monitored for development of twin-twin transfusion syndrome (TTTS) with ultrasound examination every two weeks, beginning at 16 weeks of gestation and continuing until the mid-third trimester, although most cases present in the early second trimester. Severity of disease is staged according to the Quintero system (table 1). The stage may remain stable, regress, or progress over time, and progression can occur rapidly. (See "Twin-twin transfusion syndrome and twin anemia polycythemia sequence: Pathogenesis and diagnosis", section on 'Monitoring for TTTS'.)

The three primary approaches to management of TTTS are expectant management, fetoscopic laser ablation of anastomotic vessels, and amnioreduction. Selective reduction is another option, but is rarely performed in the absence of discordant malformations or severe selective fetal growth restriction. The choice of approach depends on the Quintero stage, maternal symptoms and signs, gestational age, and availability of requisite technical expertise.

This topic will review the management and outcome of TTTS. The pathogenesis, clinical manifestations, diagnosis, and monitoring for TTTS are discussed separately. (See "Twin-twin transfusion syndrome and twin anemia polycythemia sequence: Pathogenesis and diagnosis".)

MANAGEMENT OF QUINTERO STAGE I

The choice of therapy for Quintero stage I TTTS is based primarily on severity of maternal discomfort from uterine distention and on cervical length. No randomized trials have compared treatment approaches for stage I TTTS. A systematic review concluded that the optimal initial management of stage I TTTS "remains in equipoise" [1]. In this review, the pooled incidence of progression in stage I TTTS was 27 percent (95% CI 16-39).

Women with no or tolerable symptoms and a normal cervical length

Choice of therapy — For women with Quintero stage I (table 1) TTTS and no maternal symptoms or tolerable symptoms and transvaginal cervical length >25 mm, we avoid intervention and monitor TTTS status with weekly ultrasound examinations to detect progression to more severe disease. In addition to the morbidity associated with any intervention, unnecessary intervention can affect therapeutic options later in pregnancy if intervention becomes indicated because of progressive disease. For example, amnioreduction performed as a first-line treatment of minimally symptomatic stage I disease can result in an inadvertent septostomy or bloody amniotic fluid, which would make subsequent laser treatment difficult to undertake when indicated because of worsening TTTS.

                                         

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Literature review current through: Nov 2016. | This topic last updated: Mon Oct 24 00:00:00 GMT+00:00 2016.
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