The Fetal Treatment Program
HASBRO CHILDREN'S HOSPITAL - WOMEN & INFANTS' HOSPITAL OF RHODE ISLAND
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HOW COMMON IS TWIN-TO-TWIN TRANSFUSION SYNDROME? It happens in 5 to 15% of all identical twins, and puts about 6,000 babies at risk in the United States each year.* It can happen anytime during the pregnancy. It can also affect triplet and higher order pregnancies. WHAT IS THE RISK TO THE TWINS? If twin-to-twin transfusion syndrome occurs late in gestation, the risks are usually minimal; if one fetus is threatening to develop hydrops or failure, delivery of the babies might be the best option. If this occurs earlier, before the babies are mature enough to survive out of the womb, the options are fewer and the risks greater. Preterm, premature rupture of the membranes (PPROM) and premature labor are often a threat to the twin pregnancy, possibly due to increased pressure and increased amounts of amniotic fluid (polyhydramnios in the 'recipient' fetus). If the babies are born prematurely, they may be at a higher risk of suffering serious complications, or even dying in infancy. One or the other twin is at a high risk of suffering severe heart- or brain problems (due to insufficient or inappropriate blood flow caused by the transfusion). The donor twin is usually the sickest; he will often be anemic (not enough red blood cells), and is the one at highest risk of dying in utero. The recipient twin may suffer as well, and develop hydrops (heart failure) due to fluid and blood overload. In addition, chronic transfusion may make the recipient's blood thicker (more viscous). This, in combination with somewhat sluggish blood flow because of heart failure, may place the recipient at risk for "vascular accidents" whereby a blood vessel becomes blocked. This may theoretically affect any organ, or an entire limb, causing necrosis. As a result, the organ may be damaged or even absent. Examples of this are an absent kidney, an interruption in the intestinal tract or a severely abnormal leg. Once a fetus dies, the remaining twin is at a very high risk of dying within days. If he survives, he is very likely to develop very severe heart or brain damage. If twin-to-twin transfusion syndrome develops early in pregnancy (before 20 weeks) and nothing is done, there is a very high likelihood that both twins will die. ARE ALL CASES OF TTTS THE SAME? No, some cases of TTTS are extremely severe and rapid in onset, while others have a less aggressive course. There are several ways doctors can describe and classify the severity of the syndrome, but the most commonly used is the one devised by Dr. Ruben Quintero. The Quintero classification (or its modifications) uses ultrasound findings to estimate the severity of TTTS: In stage I, there is severe polyhydramnios around the recipient and severe oligohydramnios around the donor, but the donor is still able to produce enough urine to fill his bladder (which is visible on ultrasound). In stage II, the degree of transfusion and dehydration of the donor is such, that he is no longer able to fill his bladder - the bladder is now no longer visible on ultrasound. In stage III, additional signs of fetal stress are seen: there may be pulsatile (rather than uniform) flow through the umbilical vein (usually of the recipient), absent or even reversed end-diastolic flow in the umbilical artery (usually of the donor) or other signs of cardiovascular stress, such as a leaky heart valve (tricuspid regurgitation, or TR). As a group, these signs are called "critical dopplers," because they are usually diagnosed by using doppler ultrasound (a feature of the ultrasound machine). In stage IV, there are now overt signs of heart failure in one or both twins: fluid starts to accumulate around the heart (pericardial effusion), around the lungs (pleural effusions), in the abdomen (ascites) or under the skin (edema, or thickened nuchal fold). Clearly, stages III and IV are more severe than stages I and II. In general, surgical intervention (such as laser) is not recommended in lesser stages, and most centers will only offer aggressive treatment for stages II, III or IV. The main reason for this is that the prognosis is better for stage I than for higher stages (provided that the twins remain in stage I and do not progress to a higher stage). Unfortunately, it is very difficult, at this time, to predict how a particular case will progress: some twins have been seen to remain in stage I for many weeks, or even improve on their own; while others have progressed very rapidly to a higher stage, sometimes even skipping one or more stage. Much of the current research in TTTS is now directed at understanding why some twins develop the syndrome and others don't, and why some progress more rapidly than others. WHAT ARE THE TREATMENT OPTIONS? 1. Observation and bedrest. If twin-to-twin transfusion syndrome occurs after 25 to 28 weeks, conservative measures (bedrest, single amnioreduction) and early delivery are usually recommended. Amnioreduction means the removal, through a fine needle, of the excess amniotic fluid from the recipient twin with polyhydramnios (see below). As the pregnancy comes closer to term, it may be best to 'wait and see,' and to plan early delivery if either twin shows signs of distress. In this situation, the risks associated with (mild to moderate) prematurity may be smaller than the risk of an intervention in the womb (such as the ones described below). 2. Amnioreduction. Removal of excess amniotic fluid from the recipient twin has been, until recently, the best available treatment for twin-to-twin transfusion syndrome. The reason for its effectiveness is not completely clear, but removing the excess amniotic fluid may help decrease the risk of rupture of the membranes (PPROM) and premature labor. It may also be beneficial by relieving the pressure on the umbilical cord of the twin with excess fluid, and thus improve blood flow between the fetus and the placenta. Amnioreduction does not, however, treat the cause of twin-to-twin transfusion syndrome, only one of its effects. Since the fluid is likely to accumulate again (usually within a few days to a week or two), the procedure will have to be repeated. With each amnioreduction, the risk of bleeding or infection increases, as does the risk of injury to the membranes. The results of repeated amnioreduction depend on how often this has to be done, and how rapidly fluid accumulates again. In general, the earlier in gestation the syndrome develops and the quicker polyhydramnios recurs after amnioreduction, the worse the outcome. Whereas survival of either twin in twin-to-twin transfusion syndrome is very low if the condition develops early (before 20 weeks of gestation), repeated amnioreduction can improve survival of at least one twin to 50-60%. Unfortunately, the risks of severe complications in the surviving twins may be as high as 20 to 35%, and includes severe heart or brain anomalies. 3. Laser coagulation of the communicating placental vessels. This technique, a form of fetal surgery, was originally described in 1995 by Dr. Julian DeLia, and is now being performed in several centers world-wide, including our own. This is the only known form of treatment for twin-to-twin transfusion syndrome where the likely cause of the condition is addressed. In essence, a laser fiber is used, through a very small endoscope (a long telescopic lens) inserted into the uterus, to block all vessels that run from one twin to the other (see figure 3) 
Fetal surgery is done under epidural or general anesthesia. A small incision is made on the mother's abdomen and, under ultrasound guidance, a long and thin instrument (less than 1/8 " in diameter) is introduced into the amniotic cavity. This instrument contains an endoscope, which allows the surgeon to directly look into the uterus; and a laser fiber to coagulate, or block, the blood vessels that are seen to cross from one twin to the other. All other blood vessels, that connect the fetus to its own side of the placenta, are left alone. The procedure has been performed hundreds of times since it was first described. It was initially developed in the United States, but the majority of cases have been performed in Europe. Today, several centers in the U.S. are offering this technique. The results of laser fetal surgery appear to be better than those of other techniques, when patients are properly selected. Survival of at least one twin has been reported to be 70-80%, and survival of both twins is seen in 30-40% of the pregnancies. Also, the complication rate appears to be much lower. There are much fewer cases of severe heart and brain damage, and the overall complication rate (including a few instances of infection and damage to the membranes) is less than 10%, not including PPROM. Preterm, premature rupture of the membranes (PPROM) usually leads to premature delivery; it is common in twin gestations (5-15%), particularly if TTTS is present. While decreasing the polyhydramnios (see under Amnioreduction) reduces that risk, it may still occur as a result of the invasive procedure itself. After laser coagulation, the incidence of PPROM may be as high as 15%, particularly if multiple procedures (such as repeated amnioreductions) preceded the endoscopic operation. Since its first description, the technique has undergone many improvements. For example, the use of special endoscopes that can be custom-curved now allows the treatment of patients with an anterior placenta. The use of magnetic resonance imaging (MRI) and computerized three-dimensional reconstruction allows the surgeons to plan the procedures on a virtual reality model, before the uterus is even entered (figure 5).
4. Amniotic septostomy. A few centers have, in the past, offered an alternative procedure ,whereby one or more small holes are created between the two amniotic cavities, in the hope that fluid from the recipient twin (with polyhydramnios) will flow toward the donor twin (who has oligohydramnios). The reasoning is that this way, both twins will have a normal amount of amniotic fluid. Some early results appeared promising, but this technique has since been abandoned. SUMMARY: OUTCOME OF SEVERE TTTS WITH AND WITHOUT TREATMENT
[1] Risk increases with increasing number of amnioreductions |
