{"id":3800,"date":"2018-01-14T22:06:38","date_gmt":"2018-01-15T03:06:38","guid":{"rendered":"https:\/\/mindonmed.com\/?p=3800"},"modified":"2018-02-09T12:47:10","modified_gmt":"2018-02-09T17:47:10","slug":"twin-twin-transfusion-syndrome","status":"publish","type":"post","link":"https:\/\/old.mindonmed.com\/2018\/01\/twin-twin-transfusion-syndrome.html","title":{"rendered":"Twin-Twin Transfusion Syndrome"},"content":{"rendered":"<p>I want to start sharing a bit more educationally-focused information here. However, in\u00a0line with my long history of utilizing social media to connect with patients and\u00a0understand the human side\u00a0of the story, I hope to employ\u00a0my non-medical, digital-friends to inspire these topics.<\/p>\n<figure id=\"attachment_3808\" aria-describedby=\"caption-attachment-3808\" style=\"width: 314px\" class=\"wp-caption alignright\"><img decoding=\"async\" class=\" wp-image-3808\" src=\"https:\/\/mindonmed.com\/wp-content\/uploads\/2018\/01\/twin-twin-transfusion-syndrome-fetal-mri.jpg\" alt=\"Case courtesy of Dr Alexandra Stanislavsky, Radiopaedia.org. From the case rID: 51114\" width=\"314\" height=\"294\" srcset=\"https:\/\/old.mindonmed.com\/wp-content\/uploads\/2018\/01\/twin-twin-transfusion-syndrome-fetal-mri.jpg 1024w, https:\/\/old.mindonmed.com\/wp-content\/uploads\/2018\/01\/twin-twin-transfusion-syndrome-fetal-mri-300x281.jpg 300w, https:\/\/old.mindonmed.com\/wp-content\/uploads\/2018\/01\/twin-twin-transfusion-syndrome-fetal-mri-768x720.jpg 768w\" sizes=\"(max-width: 314px) 100vw, 314px\" \/><figcaption id=\"caption-attachment-3808\" class=\"wp-caption-text\">Fetal MRI of Stage III Twin-to-Twin Transfusion &#8211; Case courtesy of Dr Alexandra Stanislavsky, <a onclick=\"javascript:pageTracker._trackPageview('\/outgoing\/radiopaedia.org\/');\"  href=\"https:\/\/radiopaedia.org\/\">Radiopaedia.org<\/a>.\u00a0Case:\u00a0<a onclick=\"javascript:pageTracker._trackPageview('\/outgoing\/radiopaedia.org\/cases\/51114');\"  href=\"https:\/\/radiopaedia.org\/cases\/51114\">rID: 51114<\/a><\/figcaption><\/figure>\n<p>Hannah from <a onclick=\"javascript:pageTracker._trackPageview('\/outgoing\/daytripsanddiapers.com\/category\/twins\/');\"  href=\"http:\/\/daytripsanddiapers.com\/category\/twins\/\">Daytrips &amp; Diapers<\/a> has graciously given me permission to discuss\/link her in this post. She is pregnant with monochorionic &#8211; diamniotic twins and was diagnosed with twin-twin transfusion syndrome (TTTS) at 16 weeks. She recently traveled to the nearest fetal surgery center, &gt;8 hours from her home, and underwent\u00a0a procedure\u00a0aimed\u00a0at decreasing\u00a0placental\u00a0connections and improving\u00a0blood flow (and hopefully, outcomes) for both babies.<\/p>\n<p>She then experienced a known complication of the surgery,\u00a0however at the time of my writing is still joyfully pregnant with both of her twins. Hop over to her blog or <a onclick=\"javascript:pageTracker._trackPageview('\/outgoing\/www.instagram.com\/daytripsanddiapers');\"  href=\"htttp:\/\/www.instagram.com\/daytripsanddiapers\">Instagram<\/a> and follow her story for the human side of medicine. Read on below if you&#8217;re interested in the medical side &#8211; I&#8217;ll discuss diagnosis, pathophysiology, and treatment of TTTS below.<\/p>\n<p>&nbsp;<\/p>\n<p><strong>What is Twin-Twin-Transfusion Syndrome?<\/strong><\/p>\n<ul>\n<li>A complication\u00a0isolated to monochorionic (one placenta) twin pregnancies where vascular connections on the shared placenta develop pressure\/flow gradients. This allows one twin (&#8220;donor&#8221;) to become anemic and the other (&#8220;recipient&#8221;) to become plethoric and begins a cascade of physiologic changes which can become catastrophic.<\/li>\n<\/ul>\n<p><strong>How Often Does This Occur?<\/strong><\/p>\n<ul>\n<li>The incidence in mo\/di pregnancies is about\u00a010-15%\u00a0and bout 6% in mo\/mo twins develop TTTS. Dichorionic twins cannot develop twin-twin transfusion syndrome, as they have two placentas.<\/li>\n<\/ul>\n<p><strong>How Is Twin Twin Transfusion Syndrome Diagnosed?<\/strong><\/p>\n<ul>\n<li>The diagnosis is made clinically by ultrasound. It is classically\u00a0identified by &#8220;Poly-Oli Sequence&#8221;\n<ul>\n<li><strong>!! This will be how it&#8217;s presented on USMLE-type exams. !!<\/strong>\n<ul>\n<li>Refers to polyhydramnios of recipient twin and oligohydramnios of donor twin.<\/li>\n<\/ul>\n<\/li>\n<li>Occasionally, there will be such severe oligo in the donor twin that it develops &#8220;Stuck Twin,&#8221; which is essentially the ultrasound appearance of a donor twin\u00a0being stuck to the placenta. Anatomically, this results from such severe oligohydramnios that the amniotic sac is lying directly against the fetus.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><strong>What&#8217;s The Pathophysiology?<\/strong><\/p>\n<figure id=\"attachment_3805\" aria-describedby=\"caption-attachment-3805\" style=\"width: 231px\" class=\"wp-caption alignright\"><a onclick=\"javascript:pageTracker._trackPageview('\/downloads\/wp-content\/uploads\/2018\/01\/IMG_0062-e1515981568974.png');\"  href=\"https:\/\/mindonmed.com\/wp-content\/uploads\/2018\/01\/IMG_0062-e1515981568974.png\"><img decoding=\"async\" class=\"wp-image-3805\" src=\"https:\/\/mindonmed.com\/wp-content\/uploads\/2018\/01\/IMG_0062-e1515981568974.png\" alt=\"Basic overview of donor and recipient pathophysiology in TTTS.\" width=\"231\" height=\"235\" srcset=\"https:\/\/old.mindonmed.com\/wp-content\/uploads\/2018\/01\/IMG_0062-e1515981568974.png 1579w, https:\/\/old.mindonmed.com\/wp-content\/uploads\/2018\/01\/IMG_0062-e1515981568974-295x300.png 295w, https:\/\/old.mindonmed.com\/wp-content\/uploads\/2018\/01\/IMG_0062-e1515981568974-768x781.png 768w, https:\/\/old.mindonmed.com\/wp-content\/uploads\/2018\/01\/IMG_0062-e1515981568974-1007x1024.png 1007w\" sizes=\"(max-width: 231px) 100vw, 231px\" \/><\/a><figcaption id=\"caption-attachment-3805\" class=\"wp-caption-text\">Basic TTTS Pathophysiology<\/figcaption><\/figure>\n<ul>\n<li><span style=\"text-decoration: underline;\">DONOR<\/span>: Relative Hypovolemia &#8211;&gt; Kidney Injury &#8211;&gt; Hypertension<\/li>\n<li><span style=\"text-decoration: underline;\">RECIPIENT<\/span>: Relative Hypervolemia &#8211;&gt; Vasodilation\/Diuresis &#8211;&gt;\u00a0Polyhydramnios &#8211;&gt; Hypertension<\/li>\n<li><span style=\"text-decoration: underline;\">BOTH<\/span>: Hypertension &#8211;&gt; Cardiac Dysfunction\u00a0&#8211;&gt; Hydrops Fetalis<\/li>\n<li>Click\u00a0Flow Chart to <a onclick=\"javascript:pageTracker._trackPageview('\/downloads\/wp-content\/uploads\/2018\/01\/IMG_0062-e1515981568974.png');\"  href=\"https:\/\/mindonmed.com\/wp-content\/uploads\/2018\/01\/IMG_0062-e1515981568974.png\">enlarge for more detail<\/a><\/li>\n<\/ul>\n<p><strong>How Bad Is It?<\/strong><\/p>\n<ul>\n<li>It depends on the stage.<\/li>\n<li>Quintero Staging\n<ul>\n<li>I: Poly-Oli Sequence\u00a0(Visible Donor Bladder + Normal Doppler Flow)<\/li>\n<li>II: Poly-Oli Sequence + Collapsed Donor Bladder (Normal Doppler Flow)<\/li>\n<li>III: Poly-Oli Sequence + Non-Visualized Bladder + Abnormal Doppler Flow<\/li>\n<li>IV: Hydrops Fetalis in one or both twins<\/li>\n<li>V: Fetal Death in One or Both Twins<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><strong>How Is It Treated?<\/strong><\/p>\n<ul>\n<li>The treatment course depends on gestational age at diagnosis and severity\/stage, however there are basically 3 options:\n<ul>\n<li>Expectant Management (i.e. No intervention, just watch)<\/li>\n<li>Fetoscopic Laser Ablation<\/li>\n<li>Amnioreduction (removing the &#8220;Poly&#8221; of the poly-oli sequence)<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<figure style=\"width: 320px\" class=\"wp-caption alignright\"><a onclick=\"javascript:pageTracker._trackPageview('\/downloads\/wp-content\/uploads\/2018\/01\/IMG_0061-1.png');\"  href=\"https:\/\/mindonmed.com\/wp-content\/uploads\/2018\/01\/IMG_0061-1.png\" rel=\"attachment wp-att-3824\"><img decoding=\"async\" class=\" wp-image-3824\" src=\"https:\/\/mindonmed.com\/wp-content\/uploads\/2018\/01\/IMG_0061-1-1024x939.png\" alt=\"Fetoscopic Laser Ablation - Edited by me, click for original source from Japan Fetal Therapy Group\" width=\"320\" height=\"294\" srcset=\"https:\/\/old.mindonmed.com\/wp-content\/uploads\/2018\/01\/IMG_0061-1-1024x939.png 1024w, https:\/\/old.mindonmed.com\/wp-content\/uploads\/2018\/01\/IMG_0061-1-300x275.png 300w, https:\/\/old.mindonmed.com\/wp-content\/uploads\/2018\/01\/IMG_0061-1-768x704.png 768w, https:\/\/old.mindonmed.com\/wp-content\/uploads\/2018\/01\/IMG_0061-1.png 1442w\" sizes=\"(max-width: 320px) 100vw, 320px\" \/><\/a><figcaption class=\"wp-caption-text\">Fetoscopic Laser Ablation &#8211; Edited by me, click image for\u00a0detail. For\u00a0original source &#8211; <a onclick=\"javascript:pageTracker._trackPageview('\/outgoing\/en.fetusjapan.jp\/method\/fetal_conditions');\"  href=\"https:\/\/en.fetusjapan.jp\/method\/fetal_conditions\">Japan Fetal Therapy Group<\/a><\/figcaption><\/figure>\n<p><strong> What is Fetoscopic Laser Ablation?<\/strong><\/p>\n<ul>\n<li>This is a surgical procedure which is performed by fetal surgeons. It involved laser cauterization of superficial anastomotic placental connections through minimally invasive fetoscopes.<\/li>\n<li>Maternal preparation includes complete ob ultrasound (including placental location, distance between umbilical cord insertions, and fetal locations\/presentation\/sizes) and medications (antibiotic + tocolytic +\/- steroid for fetal lung maturity depending on gestational age). The procedure is enerally performed with local or regional anesthesia + sedation<\/li>\n<\/ul>\n<p><strong>Fetoscopic Laser Ablation Procedure Steps<\/strong><\/p>\n<ul>\n<li>Skin incision\u00a0with scalpel (site determined by placental and fetal locations)<\/li>\n<li>Entry Options\n<ul>\n<li>18g hollow-needle introduced through maternal abdominal wall and placenta\n<ul>\n<li>J-Wire guide placed &#8211;&gt; Needle removed &#8211;&gt; Catheter placed over guidewire with US guidance<\/li>\n<li>Metal trocar placed through cannula to allow for uterine entry<\/li>\n<\/ul>\n<\/li>\n<li>2-3mm Fetoscope (with or without angled scope, depending on entry-technique and surgeon preference) inserted<\/li>\n<\/ul>\n<\/li>\n<li>Identify all fetal extremities to avoid injury<\/li>\n<li>Identify vascular equator\n<ul>\n<li>Typically in recipient amniotic sac (parallel to &#8220;stuck twin&#8221; if present)<\/li>\n<\/ul>\n<\/li>\n<li>Anastomoses are mapped out and typed\n<ul>\n<li>Types include arterial-venous\u00a0(AV), venous-arterial (VA), arterial-arterial (AA), and venous-venous (VV)<\/li>\n<\/ul>\n<\/li>\n<li>Visible connections are coagulated using laser ablation\n<ul>\n<li>Sequential selective ablation (AV &#8211;&gt; VA &#8211;&gt; AA &#8211;&gt; VV) reduces intrauterine fetal death rates<\/li>\n<\/ul>\n<\/li>\n<li>Vascular equator re-identified and coagulated<\/li>\n<\/ul>\n<p><strong>What are the Complications and Outcome?<\/strong><\/p>\n<ul>\n<li>Complications of the Procedure\n<ul>\n<li>Preterm Labor<\/li>\n<li>Preterm Delivery (Avg. gestational age is 31-33w)<\/li>\n<li>Preterm Premature Rupture of Membranes (PPROM)<\/li>\n<li>Intertwin Membrane Rupture\n<ul>\n<li>Essentially bringing all the risks of monoamniotic twins into play (like cord-entanglement)<\/li>\n<\/ul>\n<\/li>\n<li>Pseudo-Amniotic Band Syndrome<\/li>\n<li>Fetal Demise\n<ul>\n<li>Perinatal Survival Rates: 65%\n<ul>\n<li>Still with long-term neurodevelopmental, cardiac, &amp; renal morbidities associated with survival.<\/li>\n<\/ul>\n<\/li>\n<li>OVERALL AFTER LASER\n<ul>\n<li>50% both survive<\/li>\n<li>33% one survivor\/one fetal demise<\/li>\n<li>33% both with fetal demise<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><strong>Wow, Those Odds Look Bad&#8230;<\/strong><\/p>\n<ul>\n<li>They are daunting, for sure. However, TTTS severe enough to warrant laser-intervention which is left completely un-treated will result in fetal death of\u00a0one twin in nearly 100% cases and both twins in &gt;90%. These outcomes, when appropriate candidates are selected, are far superior to no treatment.<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p>That&#8217;s a brief overview of TTTS and fetoscopic laser ablation. I&#8217;ve done a few LIVE Q&amp;As on Twins, I&#8217;ll try to round those up to get on YouTube for a more thorough discussion of the pathophysiology and also the different types of twins.<\/p>\n<p>It&#8217;s so important when learning about things like this that we don&#8217;t forget there&#8217;s a human (or, in this case 3) on the other side of our text books. Hop over to the blog and\/or IG linked in the intro paragraph for a view into how this looks from a patient perspective.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>I want to start sharing a bit more educationally-focused information here. However, in\u00a0line with my long history of utilizing social media to connect with patients and\u00a0understand the human side\u00a0of the story, I hope to employ\u00a0my non-medical, digital-friends to inspire these topics. Hannah from Daytrips &amp; Diapers has graciously given me permission to discuss\/link her in [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":3803,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":[],"categories":[579,38],"tags":[138,567,566,569,565,255,206,564,570,571,572,568,453],"jetpack_featured_media_url":"https:\/\/old.mindonmed.com\/wp-content\/uploads\/2018\/01\/cp_ttts_02.png","_links":{"self":[{"href":"https:\/\/old.mindonmed.com\/wp-json\/wp\/v2\/posts\/3800"}],"collection":[{"href":"https:\/\/old.mindonmed.com\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/old.mindonmed.com\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/old.mindonmed.com\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/old.mindonmed.com\/wp-json\/wp\/v2\/comments?post=3800"}],"version-history":[{"count":5,"href":"https:\/\/old.mindonmed.com\/wp-json\/wp\/v2\/posts\/3800\/revisions"}],"predecessor-version":[{"id":3904,"href":"https:\/\/old.mindonmed.com\/wp-json\/wp\/v2\/posts\/3800\/revisions\/3904"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/old.mindonmed.com\/wp-json\/wp\/v2\/media\/3803"}],"wp:attachment":[{"href":"https:\/\/old.mindonmed.com\/wp-json\/wp\/v2\/media?parent=3800"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/old.mindonmed.com\/wp-json\/wp\/v2\/categories?post=3800"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/old.mindonmed.com\/wp-json\/wp\/v2\/tags?post=3800"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}