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Diagnosis & Treatment Options.

PLEASE NOTE: This is information that we have gathered for education purposes only. If you wish to discuss any of this further please contact one of the medical professionals listed in our Medical Contacts section. Please also check and make sure that the treatment options are available where you are, if they aren't ask to be transferred somewhere they are.



TTTs Foundation's Important 15 Questions. Please read here.



How is TTTS diagnosed?



Signs and symptoms of TTTS usually develop mid-pregnancy, between 16 and 26 weeks. The mother may initially notice that her abdomen has become very large and uncomfortable with associated back pain. She may also experience uterine contractions and decreased fetal movements. An ultrasound scan is required to measure the reduced fluid around the donor twin and the increased fluid around the recipient twin for a diagnosis of TTTS.

If TTTS is suspected on an ultrasound scan the mother should be referred to a tertiary facility that is experienced in the accurate assessment and management of TTTS.

 



What are the stages of TTTS?


A staging system for TTTS based on the ultrasound findings has been developed to help counsel parents and to guide treatment options.

Stage one (I)

Reduced or no amniotic fluid seen around the donor twin and increased amniotic fluid around the recipient twin

Stage two (II)

An empty bladder in the donor twin

Stage three (III)

Abnormal blood flows in the umbilical cord of either twin

Stage four (IV)

Hydrops of the recipient twin

Stage five (V)

Death of either twin



In addition to confirming the diagnosis and stage of TTTS, a thorough ultrasound is undertaken which includes measuring the babies, looking for major malformations and assessing the placental location and cord insertions. A vaginal ultrasound assessment of the cervix is usually performed.





What are the treatment options for TTTS?

1. No treatment
Leaving severe TTTS untreated is associated with a high loss rate of both babies, of more than 80 per cent. This can result from prematurity due to the waters breaking and/or early delivery or loss can occur before birth from the direct effects of TTTS.

2. Expectant management or observation
Expectant management involves monitoring the pregnancy by regular ultrasound scans but without any specific treatment. Expectant management is usually recommended for Stage one TTTS, as in some cases it will remain stable or resolve without treatment.

3. Amnioreduction (amniodrainage or amniocentesis)
Amnioreduction is also called amniodrainage or amniocentesis. It is an ultrasound guided procedure that removes amniotic fluid from around the recipient twin with the aim to reduce the risk of the waters breaking and/or early birth. A needle is inserted into the amniotic sac of the recipient twin and one to four litres of amniotic fluid may be removed.

An amnioreduction may need to be repeated on more than one occasion during the pregnancy as the fluid can return within a week or two. There is a small risk of the waters breaking and/or early delivery associated with the procedure. Figures from Mater's Centre for Maternal Fetal Medicine have shown that repeated amnioreduction for TTTS results in a survival rate of 60 per cent of babies. Of the survivors, 20 to 25 per cent may have subsequent brain damage and disability.



4. Fetal laser surgery
Fetal laser surgery involves passing a small camera (called a fetoscope) into the amniotic sac of the recipient twin. A laser fibre is then used to block the connecting vessels on the surface of the placenta and stop the flow of blood from one twin to the other. Fetal laser surgery is performed in an operating theatre under local anaesthetic and sedation. An overnight hospital stay is required after fetal laser surgery.



The main advantage of laser therapy over repeated amnioreduction is that it treats the underlying cause of TTTS, and usually requires only one intervention. It also means that the co-twin is better protected if one twin dies.



This first fetal laser surgery for TTTS in Australia was performed at Mater Mothers' Hospital in 2002. Mater's Centre for Maternal Fetal Medicine continues today as one of the busiest fetal therapy centres in Australasia. The overall survival rate of one or both babies after fetal laser surgery is approximately 75 per cent. The incidence of cerebral palsy or significant developmental delay is up to 10 per cent. The long term outcomes following fetal laser surgery are recognised to be significantly better than those after amnioreduction. The risks of fetal laser surgery include the waters breaking and/or early delivery which occurs in around 15 per cent of cases before 28 weeks. Complications affecting the mother are uncommon, but include breathing problems, bleeding, blood clots forming in the legs and infection.



Cerebral palsy and brain damage may not be prevented by fetal laser surgery, as an injury may have occurred prior to treatment. Fetal death affecting one or both of the twins may occur within the first week following laser treatment. This may reflect an abrupt change in the shared fetal circulation.

Repeat fetal laser surgery is uncommon but may it be required if there is evidence of ongoing harmful blood vessel connections between the twins after an initial treatment.

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