Managing Twin-Twin Transfusion Syndrome | The Children's Hospital of Philadelphia

Center for Fetal Diagnosis and Treatment

Physician Tool Kit:

Managing Complicated Twin Pregnancies

Fetal complications in twin pregnancies are challenging to diagnose, can threaten the survival of one or both twins, and often result in secondary complications that put pregnancies at risk for early delivery. Successful diagnosis and treatment require an experienced multidisciplinary team that employs cutting-edge diagnostic techniques, advanced surgical skill and a comprehensive approach to care.

Complicated Twin Pregnancies: Referrals & Interventions Accessible Chart for Screen Readers

Based on data from the Center for Fetal Diagnosis and Treatment at The Children's Hospital of Philadelphia - 1995 through March 2014.

The multidisciplinary team at the Center for Fetal Diagnosis and Treatment at The Children’s Hospital of Philadelphia has more than 18 years of experience managing twin and triplet pregnancies — among the greatest collective experience in the world. The team evaluates more than 200 multiple gestation pregnancies a year using state-of-the-art imaging technology, including high-resolution ultrasound and detailed fetal echocardiography. On occasion, fetal MRI — a technique pioneered at CHOP in the 1990s — may be used.

Complications in twin pregnancies can include twin-twin transfusion syndrome (TTTS), selective (only one twin involved) severe placental insufficiency and growth restriction, in utero demise of one twin, one twin with a birth defect or genetic abnormality, twin reversed arterial perfusion (TRAP) sequence, both twins within one amniotic sac (monoamniotic) with entanglement of their umbilical cords, and conjoined twins.

Specialists at the Center will partner with you to provide a seamless continuum of care, discussing the diagnosis and treatment options, offering suggestions for follow-up if fetal surgery is required, and remaining available for consultation for the remainder of the pregnancy as part of the patient's ongoing prenatal management team.

A quick look at our patient volumes prove the Center is a nationally recognized resource for evaluation and treatment of complicated twin pregnancies — specifically those affected by twin-twin transfusion syndrome.

Selective Laser Photocoagulation for TTTS - Outcomes

Selective laser photocoagulation for TTTS - Outcomes at CHOP
Total: More than 200 twins/triplets, Stage 2 or greater, <26 weeks, treated at CHOP. Based on data from 2005-2011. ©CHOP

Resources for professionals

To better partner with you, the Center has created a number of professional-focused resources about TTTS (and other complicated twin pregnancies), as well as information you can share with your patients.

Twin-Twin Transfusion Syndrome: Making the Right Connections

This flipchart for healthcare professionals provides an overview of TTTS incidence, diagnosis, physiology and treatment options. Download the document.

The CHOP cardiac scoring system

CHOP’s unique cardiovascular scoring system, created in collaboration with the Fetal Heart Program, measures the existence and progression of adaptive cardiovascular changes, a common complication in twin anomalies, resulting in more informed treatment decisions for TTTS. When laser therapy is indicated, the team studies the patient's cardiac function scores before treatment, 24 hours after the procedure and at the patient's one-week follow-up appointment to determine the response to the intervention.

This chart outlines the scoring system. (See page 7).

In Utero Insights Newsletter

3-D Image of TTTS ©CHOP

The Summer 2010 issue of In Utero Insights, the Center's newsletter to healthcare professionals, focused on twin-twin transfusion syndrome.

It includes information on how the Center supports families with TTTS from evaluation through follow up, sonography of complicated monochorionic twin pregnancies, research updates and more.

Resources you can share with patients 

Condition content — English and Spanish

The Center has detailed diagnosis-specific information about TTTS and TRAP written for families. Easy-to-understand diagnosis pages are available in English and Spanish (Español). Feel free to print out and share Children's Hospital resources with your patients. To access the Spanish content, look for the "en Español" tab under the banner of each page.

TTTS video

Lives in the Balance: Understanding Twin-Twin Transfusion Syndrome - CHOP
Lives in the Balance video

Lives in the Balance: Understanding Twin-Twin Transfusion Syndrome, an educational DVD created by the Center for clinicians and patient families, is now available. The video provides updated information on treatment protocols and the exclusive CHOP Cardiac Scoring System.

You can watch the TTTS video online. To request a copy, call 1-800-IN-UTERO (1-800-468-8376) or complete our online contact form.   

Recent publications on CHOP's twin experiences

For an expanded list of publications about complex twin pregnancies authored by our team, visit our publication page. A selection of recent publications are highlighted below:

Bebbington M, Tiblad E, Huesler-Charles M, Wilson R, Mann S, Johnson M. Outcomes in a cohort of patients with stage 1 twin-to-twin transfusion syndrome (TTTS). Ultrasound Obstet Gynecol. 2010 July; 36(1): 48-51. [Epub ahead of print]

Bebbington M. Twin-to-twin transfusion syndrome: current understanding of pathophysiology, in-utero therapy and impact for future development. Semin Fetal Neonatal Med. 2009 Jun 16. [Epub ahead of print]

Wilson RD, Johnson A, Ryan G. Current controversies in prenatal diagnosis 2: Should laser ablation of placental anastomoses be used in all cases of twin to twin transfusion? Prenat Diagn. 2009 Jan; 29(1): 6-10.

Ilagan JG, Wilson RD, Bebbington M, Johnson MP, Hedrick HL, Liechty KW, Adzick NS. Pregnancy outcomes following bipolar umbilical cord cauterization for selective termination in complicated monochorionic multiple gestations. Fetal Diagn Ther. 2008; 23(2): 153-8. Epub 2007 Nov 26.

Crombleholme TM, Shera D, Lee H, Johnson MP, D'Alson M, Porter F, Chyu J, Silver R et al. A prospective, randomized, multicenter trial of amnioreduction vs selective fetoscopic laser photocoagulation for the treatment of severe twin-twin transfusion syndrome. Am J Obstet Gynecol. 2007; 197: 396.e1-369.e9.

Rychik J, Tian Z, Bebbington M, Xu F, McCann M, Mann S, Wilson RD, Johnson MP.  The twin-twin transfusion syndrome: Spectrum of cardiovascular abnormality and development of a cardiovascular score to assess severity of disease. Am J Obstet Gynecol. 2007: 197: 392f.e1-392.e8.

Szwast A, Tian Z, McCann M, Donaghue D, Bebbington M, Johnson M, Wilson RD, Rychik J. Impact of altered loading conditions on ventricular performance in fetuses with congenital cystic adenomatoid malformation and twin-twin transfusion syndrome. Ultrasound Obstet Gynecol. 2007 Jul; 30(1):40-6.

The following were presented at the 19th World Congress on Ultrasound in Obstetrics and Gynecology:

OC24.06: The CHOP cardiovascular score for TTTS: Analysis of post laser effects. Ultrasound in Obstetrics and Gynecology, Volume 34, Issue 0, Date: September 2009, Pages: 46-47.  M. Bebbington, J. Rychik, Z. Tian, S. Zhao, M. Johnson.

OP18.09: Cardiovascular changes in the donor twin after laser photocoagulation therapy for twin-twin transfusion syndrome (TTTS) Ultrasound in Obstetrics and Gynecology, Volume 34, Issue 0, Date: September 2009, Page: 120.  J. Rychik, M. Bebbington, Z. Tian, S. Zhao, M. Johnson.

Contact us

If you have any questions about The Center for Fetal Diagnosis and Treatment or our treatment for complicated twin pregnancies, please call 1-800-IN-UTERO (1-800-468-8376) or contact us online.

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