Physician Toolkit: 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 and interventions
The multidisciplinary team at the Center for Fetal Diagnosis and Treatment at The Children’s Hospital of Philadelphia has more than 20 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.
Based on data from the Center for Fetal Diagnosis and Treatment at Children's Hospital of Philadelphia - 1995 through January 2024.
Based on data from the Center for Fetal Diagnosis and Treatment at Children's Hospital of Philadelphia - 1995 through January 2024.
Find more information about our experience and outcomes treating complicated monochorionic twin pregnancies »
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 (Flip Chart)
This flip chart for healthcare professionals provides an overview of TTTS incidence, diagnosis, physiology and treatment options. Contact us to request a copy of this resource.
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.
In Utero Insights Newsletter
The twin-twin transfusion syndrome edition of In Utero Insights, the Center's newsletter to healthcare professionals, 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.
Case studies
The following case studies examine the implications and outcomes of specific diagnoses in complicated monochorionic pregnancies:
Resources you can share with patients
Condition content
The Center has detailed diagnosis-specific information about TTTS, sIUGR, and TRAP written for families.
TTTS video
Lives in the Balance: Understanding Twin-Twin Transfusion Syndrome, an educational DVD created by the Center for clinicians and patient families, provides updated information on treatment protocols and the exclusive CHOP Cardiac Scoring System.
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Dennis Hasson: That day in the ultrasound room when that technician looked at us like, "You two know you're having twins?"
Marie Hasson: On the ultrasound you could see, you know, a lot of detail because it was a level II ultrasound.
Mark P. Johnson, MD, MS: It's very uncommon. Only 10, 15% of monochorionic twins develop this type of a syndrome.
Marie Hasson: You could tell they were both girls.
Dennis Hasson: And for one moment it was exciting.
Nahal Khaled, MD, MPH: We still don't know the exact reason behind why certain monochorionic pregnancies are affected by twin-to-twin transfusion syndrome.
Marie Hasson: I could see the screen that something was wrong. There wasn't any fluid in the one sac at all.
Nahal Khaled, MD, MPH: It results from an imbalance in the flow between specific blood vessels that are in the placenta of monochorionic pregnancies.
Mark P. Johnson, MD, MS: They don't share the placenta equally.
Dennis Hasson: That doctor came in, took a look at these ultrasounds-
Marie Hasson: And he didn't say a word. He just was looking and kinda taking notes, and then he brought us into his office and shut the door and he said, "Man, this is gonna ... It's gonna be a very difficult pregnancy."
Mark P. Johnson, MD, MS: Twin-to-twin transfusion syndrome is a complicated disorder.
Joy N. MacDonald, RN, BSN: The serious complication of monochorionic or identical twin pregnancies.
Mark P. Johnson, MD, MS: Monochorionic meaning that they share a placenta.
Susan R. Miesnik, MSN, CRNP: In a monochorionic diamniotic pregnancy there is one chorion, which is the outer sac, and each twin is in its own amnion so that it's like a single balloon with two filled balloons inside it.
N. Scott Adzick, MD, MMM: One twin, the recipient twin, gets too much blood and the other twin, the donor twin, doesn't get enough blood.
Mark P. Johnson, MD, MS: Because the amount of oxygen and nutrition going to the donor baby is less than to the recipient baby, they grow at different rates.
Susan R. Miesnik, MSN, CRNP: One twin will end up being very large, having excessive amniotic fluid around it or polyhydramnios.
Mark P. Johnson, MD, MS: The opposite kind of occurs in the smaller baby or the donor baby.
Susan R. Miesnik, MSN, CRNP: The other twin on ultrasound will show itself as being very small for gestational age. It will have decreased amniotic fluid or actually no fluid.
Mark P. Johnson, MD, MS: Over time the amniotic fluid around the donor baby shrinks away until literally the baby becomes shrink-wrapped along the side of the uterine wall or placenta.
Susan R. Miesnik, MSN, CRNP: As this disease progresses you end up seeing cardiac changes in both of the babies.
Jack Rychik, MD: When we begin to see cardiac changes one can have significant complications as a consequence which can lead to, either residual issues that these fetuses face, or even death in either the recipient or the donor.
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
Our team members have written extensively about the management of pregnancies with complicated multiples. Find a full list of publications about complex twin pregnancies authored by our team.