If you are a mother-to-be expecting twins, first of all, congratulations! However, it is also important to be aware of the special conditions that can sometimes occur in twin pregnancies. One such condition that is a bit unexpected but worth knowing about is Twin-to-Twin Transfusion Syndrome , also known as TTTS for short. Don’t worry, let’s talk about it simply.
What is Twin-to-Twin Transfusion Syndrome (TTTS)? Simply put...
Imagine that the two twins in your womb share the same placenta . We call these twins (monochorionic twins) . Normally, both babies receive the same blood and nutrients from this placenta. However, in this case (TTTS), that division does not happen properly.
Simply put, one baby (let's call him the 'donor twin' ) doesn't get enough blood from the placenta. The other baby (let's call him the 'recipient twin' ) gets too much. This imbalance in blood flow is what causes TTTS. This is a rare but potentially serious condition. Close monitoring by a Maternal-Fetal Medicine (MFM) specialist is essential. Early detection, monitoring, and treatment can lead to better outcomes for both babies.
What happens to the 'donor twin'?
The baby is getting less blood from the placenta. So, the amount of blood in his body is also reduced. This can cause the baby to grow slowly, and the amount of amniotic fluid around him may also decrease. This is because the baby is urinating less. This is because amniotic fluid is made up mostly of the baby's urine. When the amniotic fluid decreases, the sac that holds the baby can shrink, or even disappear. This is dangerous, because the baby cannot move properly, and the umbilical cord may become compressed.
What happens to the 'recipient twin'?
This baby is receiving more blood than it should. This extra blood puts a lot of strain on the baby's heart, and can even lead to heart failure . When the donor baby's body is malnourished, the recipient baby's body has to work harder. Because this baby has to process more blood, he urinates more than usual. As a result, his amniotic sac becomes much larger.
Who does this (TTTS) condition affect?
TTTS only affects pregnancies in which twins share a single placenta (monochorionic) , and look the same (identical twins). Most often, these twins with TTTS have two separate amniotic sacs (diamniotic). We call these twins (monochorionic diamniotic twins) .
However, very rarely, there are cases where two babies share the same placenta and amniotic sac (monoamniotic). In such cases, TTTS can also occur. However, such twins are very rare.
How late in pregnancy can TTTS occur?
This condition can usually start to develop as early as 16 weeks, but it can occur at any time during pregnancy.
How common is (TTTS)?
TTTS occurs in about 15% of monochorionic twin pregnancies.
What are the symptoms of TTTS?
Most mothers with TTTS do not experience any specific symptoms. However, some may experience:
- Feeling like the uterus is growing faster than expected.
- Feeling of pain or tightness in the stomach.
- Sudden weight gain.
If you have these symptoms, you should see your doctor immediately.
What causes TTTS?
Normally, in a twin pregnancy with a single placenta, both babies share the same amount of blood from the placenta. However, in TTTS, the way the blood vessels in the placenta are connected causes the blood to be divided unequally. One baby (the recipient baby) gets more blood, and the other baby (the donor baby) gets less.
You can't control how the placenta develops. (TTTS) is a random event. It's not something you did or didn't do. So don't blame yourself. (TTTS) is not preventable.
Who is at risk for (TTTS)?
This has no genetic or hereditary link. It is a random occurrence. However, this can only happen in twin pregnancies that share a single placenta (monochorionic) .
What are the possible complications of TTTS?
If left untreated, or if the condition develops very early in pregnancy, TTTS can cause serious health problems for the baby, and can even be fatal. Therefore, it is essential to seek treatment or close monitoring from a specialist maternal-fetal medicine (MFM specialist) or a fetal care center. Even with prompt treatment, there is a risk of miscarriage.
Other complications that can commonly occur with TTTS include:
- Complications from premature birth (such as breathing difficulties, nervous system problems).
- The recipient twin may develop heart failure or other heart problems due to the extra fluid.
- The donor twin may have growth retardation or kidney problems.
How is TTTS diagnosed?
Your prenatal care provider will diagnose TTTS with an ultrasound scan . The first thing the doctor will see on the scan is that there are two identical twins sharing the same placenta.
If TTTS is suspected, your doctor will refer you to a maternal-fetal medicine specialist (MFM specialist) for further testing. There, the specialist will look for one or more of the following on an ultrasound scan:
- The difference in size between the two babies.
- One baby has too much amniotic fluid around it, while the other baby has too little amniotic fluid around it.
- Blood flow abnormalities in babies (this can be seen with a Doppler ultrasound test).
In some cases, a fetal MRI (magnetic resonance imaging) test and a fetal echocardiography (echo) may also be necessary.
Your prenatal care team will monitor you closely throughout your pregnancy. You may need to have frequent ultrasound scans to assess the baby's health.
The doctor will also check your health. Sometimes, the increased amniotic fluid on the recipient's side can cause your uterus to enlarge and your cervix to weaken. These changes can also lead to premature birth.
What are the stages of (TTTS)?
An ultrasound scan assesses the severity of the condition (TTTS), that is, the stage it is in. This allows the doctor to see how the condition is progressing and recommend the best treatment options.
There are five stages of TTTS:
- Stage 1: There is very little or no amniotic fluid around the donor baby. There is often too much amniotic fluid around the recipient baby.
- Stage 2: The donor baby's bladder is not visible on ultrasound. This means that the donor baby has stopped urinating normally.
- Stage 3: There is a significant imbalance in blood flow between the babies. This may affect the heart function of one baby.
- Stage 4: One or both babies show signs of skin or body swelling.
- Stage 5: One or both babies have died.
In stage 1 (TTTS), observation alone may be sufficient. However, if the condition worsens, it can happen very quickly. After stage 2 (TTTS), if your pregnancy is less than 26 weeks, fetal surgery is usually recommended.
What are the treatments for (TTTS)?
Treatment depends on how far along you are in your pregnancy and what stage of TTTS you are in.
- Observation and monitoring: Your doctor will closely monitor your pregnancy with ultrasound scans. This is an option if you have stage 1 (TTTS) or if there are reasons why surgery or other treatments are not possible.
- Septostomy: This involves making a small hole in the membrane between the two babies' amniotic sacs. This can equalize the pressure in both amniotic sacs. This is less risky, but it does not cure the underlying cause of TTTS.
- Amnioreduction: In this procedure, the doctor uses a small, hollow needle to remove excess amniotic fluid from the recipient baby's amniotic sac. The doctor may recommend this in stage 1 (TTTS) or in severe cases of TTTS later in the pregnancy. This procedure does not treat the underlying cause of TTTS, so it may need to be repeated if the amniotic fluid continues to build up.
- Fetoscopic laser ablation: This procedure involves passing a small camera (fetoscope) into the uterus and using a laser beam to close off the blood vessels on the surface of the placenta that are causing unequal blood flow between the babies. The goal of this procedure is to change the blood flow from one baby to the other, so that each baby has separate blood volumes. This is an option for stage 2 or higher (TTTS) and pregnancies between 16 and 26 weeks.
- Umbilical cord occlusion: This is a last resort procedure that your doctor may recommend when both babies cannot be saved, or when one baby is in life-threatening condition. This surgery stops the blood flow to one baby, giving the other baby the best chance of survival.
- Delivery: If the baby is past the viable gestational age, the doctor may recommend delivery.
Your healthcare team will help you choose the treatment that is best for you. They will answer all your questions and talk to you about the risks, benefits, and alternatives of each treatment option.
How is TTTS managed?
Your healthcare provider, along with a maternal-fetal medicine specialist (MFM specialist), will closely monitor your pregnancy. You will have regular ultrasound scans (perhaps once or twice a week), and you may also need to have a fetal echocardiogram during your pregnancy. Your care team will provide you with medical and emotional support throughout your pregnancy.
What should I expect if this is the case?
The outcome depends on how far along you are in your pregnancy when you are diagnosed and how serious the condition is (stage). With advances in medical science, close monitoring and early treatment can give both babies a better chance of survival. Talk to your doctor about the expectations and possible outcomes to understand how TTTS will affect your pregnancy and your baby. Many surviving twins need to stay in the NICU (Neonatal Intensive Care Unit) for a short time after birth to get the start they need.
(TTTS) can be a very emotional and stressful experience. Remember to take care of yourself and seek support from your healthcare team, partner, and friends.
What is the survival rate in (TTTS)?
Survival rates depend on how severe the TTTS is, when you are diagnosed, and whether you receive treatment. Getting the right treatment can make a big difference in your survival rate with TTTS:
- About 90% of twins diagnosed with severe TTTS early in pregnancy are at risk of dying before birth (if left untreated).
- Between 85% and 90% of treated (TTTS) pregnancies result in at least one baby surviving.
- In between 50% and 65% of treated (TTTS) pregnancies, both babies survive.
Because many factors affect survival, talk to your care team about your baby's prognosis.
What questions should I ask my healthcare team?
Some questions you can ask:
- How is my pregnancy different from a twin pregnancy without TTTS?
- Will I need to see a specialist? Who is on my care team?
- How often will I need to have scans or other tests?
- How will (TTTS) affect my delivery plans?
- Will I feel any changes in my body due to TTTS? If so, what should I expect?
- What treatment do you recommend for my condition? Why?
- What lifestyle habits (such as diet, exercise, rest, therapy) do you recommend to support my health?
What is this 'Daisy Baby'?
'Daisy baby' is another name for a baby with TTTS. The Twin-to-Twin Transfusion Syndrome (TTTS) Foundation first used the name. The name came about after its founder planted daisy seeds in their garden with her surviving twin sons. The daisy garden is a symbol of hope that every baby suffering from TTTS will survive.
Finally, the most important thing! (Take-Home Message)
Receiving a diagnosis of Twin-to-Twin Transfusion Syndrome (TTTS) can be a scary experience. It's normal to feel scared and anxious about what's next for you and your twins. Talk to your doctor about the best treatment options for your situation. Seek support from friends and family as your pregnancy progresses. Joining a support group for families who have experienced TTTS can also be a great way to help you through this journey. Remember, you are not alone. With the right medical advice and support, you will be able to face this challenge head on!
` Twin-to-Twin Transfusion Syndrome, TTTS, twins, pregnancy, placenta, amniotic fluid, monochorionic
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