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Twin to Twin Transfusion Syndrome (TTTS)

If you're expecting twins or triplets, you'll be monitored to see if any of the babies share a single placenta. This is to screen for Twin to Twin Transfusion Syndrome (TTTS), a life threatening condition where one of your babies receives more blood and nutrients than the other baby does.

EvergreenHealth is a national leader in the evaluation and treatment of TTTS, and is one of only a handful of centers in the United States currently able to provide both nonsurgical and in utero surgical treatments for TTTS.

What is Twin to Twin Transfusion Syndrome?

Twin to Twin Transfusion Syndrome (TTTS) is a condition that occurs in identical twins or triplets who share a single placenta where one baby donates its blood and nutrients to his/her sibling(s).

This happens in approximately 10-15% of identical twins/triplets who share a placenta.

The baby who is donating his/her blood is at risk of dehydration and anemia. The baby who is receiving the extra blood is at risk for volume overload which can lead to congestive heart failure in severe cases.

TTTS is usually diagnosed by ultrasound between 16 and 26 weeks of pregnancy by a high-risk OB center.

Learn more about TTTS detection, staging

What will happen without treatment?

If not treated, TTTS will continue to worsen and both babies will likely pass away (80-100% of the time).

Babies that survive a pregnancy with severe TTTS and no treatment have a 1 in 4 risk of brain injury due to lack of oxygen, blood and other nutrients. This pregnancy may also be jeopardized by the excessive fluid, which rapidly enlarges the uterus, potentially causing preterm labor and delivery.

What are the treatment options for TTTS?

Serial amnioreduction

Serial amnioreduction is a less invasive approach in managing the symptoms of less severe cases of TTTS. It involves removing the excess fluid from around the recipient twin with a needle, similar to an amniocentesis.

It reduces the amount of fluid around the recipient twin and temporarily alleviates some associated pain and pressure, but it is not a cure. It will need to be repeated multiple times over the course of your pregnancy.

This technique is often recommended for milder cases of TTTS or cases occurring after 26 weeks of pregnancy, but it is generally not effective for severe TTTS.

Results for serial amnioreduction

  • At least one twin survives in 40-60% of the cases
  • Approximately 25% of surviving twins have some brain damage

Laser photocoagulation

Laser photocoagulation is an in utero surgical treatment for TTTS. The surgery is done in an operating room using spinal anesthesia, and typically takes 30-to-60 minutes.

The procedure involves placing a very thin camera, called a fetoscope, into the uterus through a tiny 2-3mm incision in the skin. The fetoscope allows our surgeon to identify the small connecting blood vessels on the surface of the placenta. There may be as few as one or two connections, or there may be as many as 19 or 20, depending on the specific case.

Our surgeon then closes the blood vessels using laser energy from a small laser fiber through a channel on the fetoscope.

Dr. Bettina Paek interviewed on New Day NorthwestDr. Bettina Paek discusses the in-utero surgical treatment available for Twin-to-Twin Transfusion Syndrome. (interview on New Day Northwest)

Results for laser photocoagulation

EvergreenHealth's Dr. Martin Walker and Dr. Bettina Paek are among the few physicians in the country trained in laser photocoagulation to treat TTTS. Together they have performed more than 460 laser photocoagulation procedures, with the following results:

  • One twin survives in 90% of the cases
  • Both twins survive in 60-70% of the cases
  • Less than 5% of surviving twins have brain damage

What are the possible risks?

  • Chorioamnionitis, rupture of membranes, premature labor and miscarriage
  • Maternal complications, such as abruption and infection, occur in less than 1% of cases
  • Premature labor occurs in up to 10% of cases

Who is a candidate for laser photocoagulation?

Pregnancies are considered appropriate for laser photocoagulation to treat TTTS when they have the following:

  • Single placenta with a thin dividing membrane
  • Excess fluid around the recipient twin (greater than 8-to-10 centimeters)
  • Low fluid around the donor twin (less than two centimeters)
  • Prominent bladder in the recipient and non-filling bladder in the donor

Patients with the following situations may not be suitable for laser photocoagulation in TTTS:

  • Pre-term labor with a short or open cervix
  • Prior septostomy procedure
  • Abnormal genetic studies
  • Ruptured membranes
  • Infection of the amniotic fluid

Follow-up care for laser photocoagulation

After the surgery, you can return to the care of your OB for the remainder of your pregnancy and delivery. You and your OB can always contact us if there are any questions or concerns.

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