Diagnosis of twin to twin transfusion syndrome at 18 weeks of gestation

Twin-to-Twin Transfusion Syndrome: Definition, Staging, and Ultrasound Assessment

Objective: The purpose of this article is to review the definition of twin-to-twin transfusion syndrome (TTTS) and the sonographic diagnostic assessment of these cases prior to therapy.

Materials and Methods: The article addresses the terminology used to refer to the condition and describes the systematic ultrasound assessment of the condition, including the ultrasound diagnosis, the staging of the disease, cervical assessment and pre-operative mapping.

Results: From an etymologic and medical point of view, the term ‘fetofetal transfusion’ is more appropriate than ‘TTTS’. However, as the latter, and its attendant acronym TTTS, have been widely adopted in the English language, it is impractical to change at this point. TTTS is defined sonographically in the combined presence of a maximum vertical pocket (MVP) of 8 cm or greater in one sac and 2 cm or less in the other sac, regardless of the gestational age at diagnosis. Staging of the condition using the Quintero staging system is practical, reproducible, and accepted. Transvaginal cervical length assessment should be an integral part of the ultrasound evaluation. Pre-operative mapping to anticipate the location of the placental vascular anastomoses and avoid injuring the dividing membrane is also discussed.

Conclusions: The term ‘TTTS’ can continue to be used in the English medical literature. The condition can be diagnosed and assessed following a systematic ultrasound methodology. The use of such ultrasound methodology breaks the examination into a distinct set of components, assuring a comprehensive examination and proper communication among caregivers.

Natural History of 11 Cases of Twin-twin Transfusion Syndrome Without Intervention

The natural history of 11 cases of twin–twin transfusion syndrome (TTTS) in monochorionic diamniotic (MCDA) twin pregnancies has been reviewed. Seven cases before 28 weeks and four pregnancies after 28 weeks had been followed up without intervention. Eight cases had premature uterine contractions. All seven pregnancies before 28 weeks aborted, leading to a 100% mortality rate. After 28 weeks all mothers delivered live births. The diagnosis of TTTS before 28 weeks, and with premature uterine contraction, seems to be a poor prognostic sign.

Prenatal diagnosis of twin-twin transfusion syndrome complicated with hydrops fetalis at 14 weeks of gestation

Twin-twin transfusion syndrome (TTTS) may complicate multiple pregnancy. Monochorionic discordant twins with oligohydramnios and polyhydramnios may be diagnostic. Hydrops fetalis is particularly ominous. All the signs can appear independently at any stage of gestation. However, TTTS with hydrops fetalis in early pregnancy is rare. We report here a case of TTTS complicated with hydrops fetalis diagnosed at 14 weeks of gestation. Our case may be one of the earliest cases of the prenatal diagnosis of TTTS complicated with hydrops fetalis in the literature.

Hydrops fetalis: recent advances

Hydrops fetalis is a morbid condition caused by a wide variety of fetal, placental, and maternal diseases. Mortality is high and depends on the gestational age at the time of occurrence and underlying etiology. Although the condition was described more than 300 years ago, recent advances in obstetric ultrasound, prenatal diagnostics have made it possible to differentiate various etiologies involved. It is also possible to treat some of these fetuses prenatally. In utero medical and surgical therapy is presently done in some centers. However, the majority of cases diagnosed remain untreatable. Early diagnosis of untreatable cases allows parents to make informed choices about subsequent management. Recent advances are covered in this review.

Hydrops revisited: literature review of 1,414 cases published in the 1980s

This paper reviews 47 series of hydrops fetalis (804 cases) and 610 individual cases published since 1980. From this large number of cases, guidelines are derived for prenatal diagnosis and management.

Acute polyhydramnios

A case of acute polyhydramnios successfully managed via therapeutic amniocentesis is reported. A discussion and review of this rare entity is presented.

The prenatal growth of the human body determined by the measurement of bones and organs by ultrasonography

This paper presents the ultrasonographic analysis of the growth of two groups of human fetuses, one longitudinal and the other cross-sectional. Measurements of all the long bones were taken, as well as measurements of the following diameters: Biparietal, occipitofrontal, thoracic and abdominal anterior/posterior and transverse, spinal canal width, arm, forearm, thigh and leg transverse. The bladder and the stomach were also measured. The pregnancies analyzed covered the period between the 8th and 38th week of gestation. Centiles (3rd-97th) were calculated for each structure and week. All pregnancies known or suspected to be abnormal were removed from the study. The values obtained were tested in 102 pregnancies (test group); the expected values (from the graphs) did not deviate from the values obtained from this group of fetuses, demonstrating the reliability of the values presented in these graphs. All structures measured showed linear growth. There was no significant difference between the longitudinal and cross-sectional groups.

Twin pregnancy: case reports illustrating variations in transfusion syndrome

The twin transfusion syndrome is diagnosed in 5.5% to 14.6% of monochorionic twins and the classical picture reveals a small anemic donor and a large plethoric recipient. Many other clinical discrepancies have been described. Today, by ultrasound it is possible to diagnose the syndrome in (early) pregnancy. In these case reports different clinical pictures and the importance of ultrasound are described. In twin pregnancies repeated ultrasound examinations should be considered with the consequences of vascular anastomoses.

Monozygotic twin aborted fetuses discordant for holoprosencephaly/synotia

A pair of monozygotic twin fetuses aborted at 15 weeks were found to be discordant for holoprosencephaly and synotia. They were studied grossly, radiologically, and histologically. Features of first brancial arch dysplasia (synotia, agnathia, and astomia) and holoprosencephaly (absent ethmoid bone and Rathke's pouch) observed in one twin were contrasted with minimal dysmorphology in the co-twin. Some evidence of the twin transfusion syndrome was also apparent, perhaps contributing to the twins' spontaneous abortion.