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GYNAECOLOGY AND OBSTETRICS IMAGING Table of Contents   
Year : 2006  |  Volume : 16  |  Issue : 4  |  Page : 797-799
Twin-Twin transfusion syndrome: - A case report


Nijjar Scan and Diagnostic Centre, Amritsar, India

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Date of Submission29-Aug-2005
Date of Acceptance30-Aug-2006
 

   Abstract 

Twin-Twin transfusion syndrome leads to high rates of perinatal morbidity and mortality due to its poorly understood etiology and difficulty in diagnosing and treatment. Early diagnosis during foetal ultrasound is, therefore, important in reducing the morbidity and mortality rates. We report a case of twin-twin transfusion syndrome diagnosed on foetal ultrasound at 26 weeks of gestation.

Keywords: Twin transfusion Syndrome; foetal ultrasound

How to cite this article:
Arora V, Nijjar I S, Abrol R, Chopra R, Roopa. Twin-Twin transfusion syndrome: - A case report. Indian J Radiol Imaging 2006;16:797-9

How to cite this URL:
Arora V, Nijjar I S, Abrol R, Chopra R, Roopa. Twin-Twin transfusion syndrome: - A case report. Indian J Radiol Imaging [serial online] 2006 [cited 2019 Aug 24];16:797-9. Available from: http://www.ijri.org/text.asp?2006/16/4/797/32351

   Case report Top


A twenty-seven years old woman was referred for foetal ultrasound in the second trimester of pregnancy. The ultrasound examination revealed intrauterine monochorionic diamniotic twins, both in cephalic presentation. Both were live and placenta was found to be single. It was lying in the upper segment anteriorly. The maturity of placenta was grade II. No peak sign was identified.

Twin A

Maturity 26 weeks, 4 days + 2 weeks. Effective Foetal Wt. -700gm + 200gm.

It appeared to stick to the anterior wall of uterus (Fig.1). There was marked oligohydramnios. The foetal bladder could not be visualised over forty-five minutes of examination. At least one foetal kidney was normal.

Twin B

Maturity 26 weeks,4 days + 2 weeks. Effective Fetal Wt. -1900gm + 300gm.

Twin B had ascites, pericardial effusion, pleural effusion and marked degree of generalized subcutaneous oedema (Fig.2). The umbilical cord also showed oedema. Polyhydramnios was seen. Foetal kidneys were normal. Urinary bladder was full.

The diagnosis of Twin-Twin Transfusion Syndrome was made with twin A as donor twin and twin B as recipient twin.

The pregnancy was terminated on patient's request and the ultrasound findings were confirmed. The donor twin appeared hypovolemic and anaemic. It was smaller in size as compared to the recipient, which was oedematous, hypertensive and polycythemic (Fig.3).


   Discussion Top


Twin-Twin transfusion syndrome occurs in multiple gestations and involves the chronic flow of blood from one twin to its co-twin. The syndrome usually occurs in monochorionic twins, who themselves have a very high rate of complications including severely preterm delivery, fetal growth restriction, fetal death, and twin-twin transfusion syndrome [1]. The mortality rate of twin-twin transfusion syndrome is high, ranging from 40% to 70% [2].

Vascular connections in the placenta between both twins are necessary for twin-twin transfusion syndrome to develop [3]. Vascular anastomoses are present in virtually 100% of monochorionic twin pregnancies, whereas twin-twin transfusion occurs (with rare exception) in 5-10% of monochorionic pregnancies [4],[5]. The progressive nature of twin-twin transfusion in utero is thought to be due to one twin (the donor) who slowly pumps blood to the other (the recipient) through the placental vascular anastomoses. The reason for the occurrence of twin-twin transfusion syndrome in only a small proportion of the monochorionic twin pregnancies with vascular anastomoses is unknown. The intraplacental anastomosis is usually situated in a single, shared cotyledon of the common placenta [6], and is usually arteriovenous but maybe arterial-arterial [7].

Twin-Twin Transfusion Syndrome is a diagnosis made prenatally by ultrasound and great advances have been made in its identification. The hallmarks of the diagnosis are:

  1. Monochorionic gestation.
  2. The combination of the polyhydramnios in one sac and oligohydramnios in the other, and
  3. The persistent finding of a small or non-visualized bladder in the donor and a large bladder in the recipient (Table 1) [8].


In addition to the above second trimester diagnostic criteria, ultrasound findings in the first trimester also are associated with the subsequent development of twin-twin transfusion syndrome [11]. According to Sebire and co-workers [12], these include the presence of monochorionicity, an increased nuchal translucency measurement >3mm between 10 and 14 weeks of gestation, poor crown-rump length growth of one fetus, and membrane folding at 10-13 weeks of gestation.

Treatment Options:

Careful antenatal assessment by ultrasound and tocolysis for preterm labor are the cornerstones of conservative management and generally used as adjuncts to other invasive treatments. Frequent antenatal assessment may form the basis of an iatrogenic decision for delivery, and is often associated with prevention of death in utero. The various options available are amnioreduction, foetoscopic laser occlusion of chorioangiopagus placental vessels, septostomy, removal of one twin at hysterotomy and percutaneous ultrasound guided umbilical cord ligation (1).

 
   References Top

1.Skupski DW. Twin-twin transfusion syndrome: An update. Croatian Medical Journal 2000; 41(3):228-234.   Back to cited text no. 1    
2.Brown DL, Benson CB, Driscoll SG, et al: Twin-twin transfusion syndrome: Sonographic findings. Radiology 1989;170:61-63.  Back to cited text no. 2    
3.Rausen AR, Seki M, Strauss L. Twin transfusion syndrome. J Pediatr 1965;66:613-28.   Back to cited text no. 3  [PUBMED]  
4.Blickstein I. The twin-twin transfusion syndrome. Obstet Gynecol 1990;76:714-21.   Back to cited text no. 4  [PUBMED]  
5.King AD, Soothill PW, Montemagno R, Young MP, Sams V, Rodeck CH. Twin-to-twin blood transfusion in a dichorionic pregnancy with out the olighydramnious-polyhydraminous sequence. Br J Obstet gynaecol 1995;102:334-5.   Back to cited text no. 5  [PUBMED]  
6.Filly RA, Goldstrein RB, Callen PW: Monochorionic twinning: Sonographic assessment. AJR 1990;154:459-469.   Back to cited text no. 6    
7.Pretorius DH, Mahony BS: Twin gestations. In Nyberg DA, Mahony BS, Pretorius DH, (eds): Diagnostic ultrasound of fetal anomalies: Text and Atlas. Chicago, Year Book Medical Publishers, 1990. Pp 592-622.   Back to cited text no. 7    
8.Skupski DW. Current perspectives on twin-to-twin transfusion syndrome. In: Chervenak FA, Kurjak A, editors. Fetal medicine: the clinical care of the fetus as a patient. Carnforth, Lancaster, UK: Parthenon Publishing Group Ltd; 1999. P. 205-10.   Back to cited text no. 8    
9.Hecher K, Ville Y, Snijders R, et al: Doppler studies of the fetal circulation in twin-twin transfusion syndrome. Ultrasound Obstet Gynecol 1995;5:318-324.   Back to cited text no. 9    
10.Pretorius DH, Manchester D, Barkin S, et al: Doppler ultrasound of twin transfusion syndrome. J Ultrasound Med 1988;7:117-124.   Back to cited text no. 10    
11.Sebire NJ, D' Ercole C, Hughes K, Carvalho M, Nicolaides KH. Increased nuchal translucency thickness at 10-14 weeks of gestation as a predictor of severe twin-to-twin transfusion syndrome. Ultrasound Obstet Gynecol 1997;10:86-9.   Back to cited text no. 11    
12.Sebire NJ, D' Ercole C, Carbelho M, Sepulveda W. Nicolaides KH. Inter-twin membrane folding in monochorionic pregnancies. Ultrasound Obstet Gynecol 1998;11:324-7.  Back to cited text no. 12    

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Correspondence Address:
V Arora
Nijjar Scan and Diagnostic Centre, 51/1, Court Road, Amritsar - 143001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-3026.32351

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