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To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ajog.2005.04.047 Byline: Jeroen P.H.M. van den Wijngaard (a), Michael G. Ross (b), Jos A.P. van der Sloot (c), Yves Ville (d), Martin J.C. van Gemert (a) Abstract: This study was undertaken to model the sequence of events that occurs after amnioreduction, laser therapy, and digoxin administration in twin-twin transfusion syndrome (TTTS) with and without a hydropic recipient twin. Author Affiliation: (a) Laser Center and Department of Obstetrics and Gynecology, Academic Medical Center-University of Amsterdam, Amsterdam, The Netherlands (b) Department of Obstetrics and Gynecology, Harbor-UCLA School of Medicine, Torrance, CA (c) Department of Cardiology and Intensive Care, Academic Medical Center-University of Amsterdam, Amsterdam, The Netherlands (d) Department of Obstetrics and Gynecology, University Paris Ouest Versailles St. Quentin, Centre Hospitalier Intercommunale Poissy St. Germain, Poissy, France Article History: Received 30 December 2004; Accepted 19 April 2005 Article Note: (footnote) Supported in part by the European Community Euro-twin-2-twin project (J.P.H.M.v.d.W.) and by the National Institutes of Health, grant HL40899 (M.G.R.).

A simulation of therapy in a model of a nonhydropic and hydropic recipient in twin-twin transfusion syndrome (TTTS) is presented. TTTS presenting with a hydropic recipient prior to fetal viability ( ~ 26 weeks) may be best treated with laser therapy whereas more advanced gestations may be offered digoxin administration plus aminoreduction, to delay progression of TTTS.

Abstract: We report a case of rapid onset of severe twin–twin transfusion syndrome (TTTS) at 25 weeks gestation in a monochorionic twin pregnancy that was uneventful before that time. Thrombosis of a main venous branch draining several arteriovenous (AV) anastomoses to the donor changed the previous hemodynamic balance that existed between multiple bidirectional AV anastomoses. The opposing AVs became hemodynamically uncompensated and, despite amnioreductions, severe TTTS developed. At 27 weeks a cesarean section was performed because of worsening cardiotocography parameters of both fetuses. Birth weights were 750 and 1840 g, and initial hemoglobin concentrations were 9.2 and 13.4 mmol/liter for donor and recipient, respectively. The recipient twin died 5 months later of an ischemic, necrotic, and perforated small intestine due to a thrombosed superior mesenteric artery. The donor is well at 2.5 years. No abnormalities in several factors associated with thrombophilia, including factor V Leiden mutations, were found in the parents.

AbstractTwin-twin transfusion syndrome in monochorionic twin pregnancies has a complex and variable clinical presentation. We present the first documented case where two unidirectional arteriovenous anastomoses connecting the donor twin’s larger with the recipient’s smaller placental part produce late onset of discordant growth and subsequent twin-twin transfusion syndrome. We conclude that the haemodynamic effects of the anastomoses caused the observed discordant fetal development and not the unequally shared placenta.Copyright © 2001 S. Karger AG, Basel