complications-of-monochronic-twins-audio

Twin-twin transfusion syndrome(TTTS) – It is a clinicopathological state, exclusively met with in monozygotic twins, where one twin appears to bleed into the other through some kind of placental vascular anastomosis. Clinical manifestations of twin transfusion syndrome occur when there is hemodynamic imbalance due to unidirectional deep arteriovenous anastomoses. As a result the receptor twin becomes larger with hydramnios , polycythemic, hypertensive and hypervolemic, at the expense of the donor twin which becomes smaller with oligohydramnios, anemic, hypotensive and hypovolemic. The donor twin may appear “stuck” due to severe oligohydramnios. Difference of hemoglobin concentration between the two, usually exceeds 5 gm% and estimated fetal weight discrepancy is 25% or more.

Management: Antenatal diagnosis is made by ultrasound with doppler blood flow study in the placental vascular bed. (a) Repeated amniocentesis to control polyhydramnios in the recipient twin is done. (b) Septostomy (making a hole in the dividing amniotic membrane). (c) Laser photocoagulation to interrupt the anastomotic vessels on the fetuses is at risk. The smaller twin generally has got better outcome. The plethoric twin runs the risk of congestive cardiac failure and hydrops. Congenital abnormalities (neural tube defects, holopresencephaly) are high (2 -3 times). Perinatal mortality in TTTS is about 70%.

(ii) Dead fetus syndrome – death of one twin (2 -7%) is associated with poor outcome of the cotwin (25%) specially in monochronic placenta. The surviving twin runs the risk of cerebral palsy, microcephaly, renal cortical necrosis and DIC. This is due to thromboplastin liberated from the dead twin that crosses via placental anastomosis to the living twin .

(iii) Twin reversed arterial perfusion (TRAP) is characterized by an acardiac perfused twin having blood supply from a normal cotwin via large arterio-arterial or vein to vein anastomosis . In majority the cotwin dies(in the perinatal period) due to high output cardiac failure. The arterial pressure of the donor twin being high, the recipient twin receives the used blood from the donor. The perfused twin is often chromosomally abnormal. The anomalous twin may appear as an amorphous mass. Management of TRAP is controversial . Ligation of the umbilical cord of the acardiac twin under fetoscopic guidance has been done.

(iv) Monoamniocity (2% of all twins) in monochorionic twins leads to high perinatal mortality due to cord problems(entanglement). Sulindac, a prostaglandin synthase inhibitor has been used to reduce fetal urine output, creating borderline oligohydramnios and to reduce the excessive movements.

(v) Conjoined twin is rare (1.3 per 100,000 births). Perinatal survival depends upon the type of joint. Major cardiovascular connection leads to high mortality.

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