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Twin to Twin Transfusion Syndrome (TTTS) is a prenatal condition in which twins share unequal amounts of the placenta’s blood supply resulting in the two fetuses growing at different rates. Stage 2: The bladder of the donor twin is not visible or it does not fill with urine during an ultrasound exam. Stage 3: The imbalance of blood flow starts to affect the heart function in one or both babies. For Stage 1 cases, observation may be all that is necessary, but for Stage 2 or higher cases, fetal surgery may be the best option. A routine prenatal ultrasound will show whether there are twins in a pregnancy, and we can see if the twins are identical and sharing a placenta.
A highly specialized maternal-fetal medicine physician should monitor TTTS and determine if the stage is progressing.
Stage 1 cases may not require intervention, but it is important to monitor the twins’ progress frequently and closely, to rule out progression to stage 2 or beyond. In cases of TTTS of Stage 2 or higher, at approximately 16-26 weeks of gestation, surgeons use a laser to block the blood vessels that communicate between the two fetuses. Once these are all mapped, a tiny laser fiber is inserted and laser energy is used to stop the blood flow between the twins.
This procedure removes the excess fluid from around the larger twin, reducing amniotic pressure and reducing the risk of preterm labor. The staff at the Fetal Care Institute is here to support you, arming you with knowledge about all your options, and assisting you with your decision of what is right for you and your family. Twins with untreated advanced stages of TTTS during pregnancy usually do not do well after delivery—there is a 90% risk of fatality and, for those who do survive, a 15-50% risk of neurologic handicap.
The good news, however, is that there are many treatment options during pregnancy that can significantly improve survival and lower the risk of neurologic handicaps. Identical twins are monozygotic, meaning that they developed from the same fertilized egg, and so have nearly identical genetic code. Diochorionic-diamniotic twins either never divided (aka are fraternal twins) or divided within the first four days and have two separate amniotic sacs and placentas.
Monochorionic-monoamniotic twins share the same amniotic sac and appear when the embryo splits after 9 days.
Quite paradoxically, identical twins may not always look exactly alike even though they share the same genetic make up.
The survival rate of monoamniotic twins is between 50-60%, because of the risk that the umbilical cord will become tangled around the babies.


The chance of identical twins is the same all over the world: around 3 in every 1000 births. The chance of fraternal twins depends on many factors, include the country of birth (they form 6 out of every 1000 births in Japan, to 15 or more per 1000 births in parts of India). 70% of identical twins share a placenta, and 15-20% of these pregnancies are affected by TTTS.
This is a critical determination because if so, your babies are at risk for developing TTTS (15-20% risk). Louis Fetal Care Institute, we recommend that screening ultrasounds be performed every two weeks between 16 and 24 weeks of the pregnancy.
The surgeon inserts a pencil-tip-sized fiber-optic scope in the mother’s uterus and examines the entire placenta to find the crossing blood vessels. Separating the twin blood flow is like functionally separating the placenta, allowing each twin to develop independently. We will explain the risks and benefits of the various options, considering your specific case.
If your twins’ TTTS has been successfully managed and treated during pregnancy, there is a much better chance that they will be healthy babies.
The likelihood of identical twins is the same around the world — about 3 in 1,000, while the incidence of fraternal twins varies by geography and ranges from 6 to over 20 per 1,000 deliveries. Fraternal twins are dizygotic, meaning that they developed from two different eggs fertilized by two different sperms. They almost always have the same gender and many of the same physical characteristics (phenotypes).
This occurs when the embryo splits in 4-8 days and includes 60-70% of all identical twin pregnancies.
After birth, it can be deduced that twins are fraternal if they are of different genders (a boy and a girl) or if they have different blood types. Environmental factors may cause their appearance to evolve differently as early as inside the mother's womb.
This is because environmental factors in the womb affect the development of fingerprints, slightly altering them for each individual. This type of twin pregnancy is called monochorionic (one placenta) and di-amniotic (two sacs).
If signs of TTTS develop, such as different amniotic fluid levels or growth differences, then ultrasounds can be performed more frequently to determine if the TTTS is really progressing.


We examine each case closely, and our team of doctors and nurses explain the options for treatment of your specific case. Although untreated cases of TTTS can become severe, threatening the lives of both twins, fetoscopic laser photocoagulation can completely cure TTTS. However, they may develop some genetic differences after the zygote splits, due to mutations in the DNA.
However, the only way to reliably conclude that they are identical twins is through genetic testing (a twin zygosity DNA test). Women who have already had fraternal twins are four times more likely to have fraternal twins in their next pregnancy. Fingerprints are an example of phenotype, which can be different even if two individuals share the same genotype.
In monochronionic, di-amniotic twins (mo-di twins), there are shared blood vessels, which run from one twin to the other on the surface of the placenta. Louis Fetal Care Institute works to inform parents as part of twin to twin transfusion syndrome awareness month. Certain drugs like clomiphene increase the probability of fraternal twins to about 10% because they tend to bring about hyper-ovulation. Most often the net flow of blood between the twins is fairly even, but when there is an imbalance of blood flow across these blood vessels, such that one twin is getting more blood supply than the other, then TTTS can occur.
A fetal echocardiogram (echo) gives us much more information about the heart function and anatomy. The fetus with more blood flow is called the recipient twin, and the fetus with less is called the donor twin. The recipient baby tries to urinate the excess fluid from having more blood, so it has an enlarged bladder and too much amniotic fluid. Your treatment options depend on the stage of TTTS, and range from observation to placental laser surgery.



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