Twin-to-twin transfusion syndrome

doi:10.1017/CBO9780511997778.018

Chapter 11.2 - Twin-to-twin transfusion syndrome

placental circulation

from Section 2 - Fetal disease

Published online by Cambridge University Press: 05 February 2013

Edited by

Anthony Johnson and

Mark D. Kilby: Affiliation:
Department of Fetal Medicine, University of Birmingham
Anthony Johnson: Affiliation:
Baylor College of Medicine, Texas
Dick Oepkes: Affiliation:
Department of Obstetrics, Leiden University Medical Center

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Summary

Introduction

Monochorionic (MC) twin and triplet pregnancies pose complex clinical problems and high risks of types that are not seen in dichorionic (DC) twin pregnancies. About 40% of MC twin pregnancies have major complications, and perinatal deaths are frequent. Fetal growth discordance (FGD) and twin-to-twin transfusion syndrome (TTTS) are the most common problems. The MC twin placenta is usually a truly single, not fused, placenta that is produced by a single zygote and intended for the metabolic support of a singleton fetus (but rare departures from this rule are noted in “Exceptions” below). When monozygotic (MZ) twinning occurs within 48 hours of conception, the whole zygote splits and the result is twinning of the embryos and their placentae (MZ, DC placentation). Thereafter, the inner cell mass (ICM) and trophoblast separate. If a twinning event is confined to the ICM after the ICM has physically separated from the trophoblast, the single structure and function of the MC twin placenta is retained as such. The single trophoblast resolutely declines to respond to the confined ICM twinning event, and does not “retrofit” to DC, although this would be much safer for the fetuses, and is close to the objective of laser occlusion in TTTS. There are three vascular consequences of the insertion of two or more umbilical cords into an MC placenta:

Cord insertions: asymmetric cord insertions, e.g., eccentric/velamentous combination, with unequal parenchymal sharing if the cord insertions are markedly asymmetric, result in significant FGD [1, 2]; many TTTS cases have FGD and also have asymmetric cord insertions; twin reversed arterial perfusion (TRAP) is a risk if cord insertions are close together.
Single umbilical artery: special considerations apply if one MC twin has a single umbilical artery. Acardiac TRAP fetuses all have a single umbilical artery.
Interfetal vascular connections: the presence of interfetal vascular connections on the chorionic plate and in the placental parenchyma is a major determinant of MC twin fetal outcomes, especially TTTS.

Keywords

twin-to-twin transfusion syndrome monochorionic twin placental circulation triplet pregnancy vascular structures fetus arteriovenous connections dichorionic twin pregnancy

Information

Type: Chapter
Information: Fetal Therapy
Scientific Basis and Critical Appraisal of Clinical Benefits
, pp. 156 - 165
DOI: https://doi.org/10.1017/CBO9780511997778.018 [Opens in a new window]
Publisher: Cambridge University Press
Print publication year: 2012

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References

Fick, AL, Feldstein, VA, Norton, ME, et al. Unequal placental sharing and birth weight discordance in monochorionic diamniotic twins. Am J Obstet Gynecol 2006;195:178–83.Google Scholar

De Paepe, ME, Shapiro, S, Young, L, et al. Placental characteristics of selective birth weight discordance in diamniotic-monochorionic twin gestations. Placenta 2010;31:380–6.Google Scholar

Baergen, RN. Manual of Pathology of the Human Placenta, 2nd edn. New York, Springer, 2011;262.

Baergen, RN. Manual of Pathology of the Human Placenta, 2nd edn. New York, Springer. 2011; 268.

Wee, LY, Taylor, M, Watkins, N, et al. Characterisation of deep arterio-venous anastomoses within monochorionic placentae by vascular casting. Placenta 2005;26:19–24.Google Scholar

van der Wijngaard, JPHM, Lopriore, E, van der Salm, SM, et al. Deep-hidden anastomoses in monochorionic twin placentae are harmless. Prenat Diagn 2007;27:233–9.Google Scholar

Machin, G, Still, K, Lalani, T. Correlations of placental vascular anatomy and clinical outcomes in 69 monochorionic twin pregnancies. Am J Med Genet 1996;61:229–36.Google Scholar

Machin, GA, Feldstein, VA, van Gemert, MJ, et al. Doppler sonographic demonstration of arterio-venous anastomosis in monochorionic twin gestation. Ultrasound Obstet Gynecol 2000;16:214–17.Google Scholar

Tan, TY, Taylor, MJ, Wee, L, et al. Doppler detection of arterio-arterial anastomoses predicts survival independent of stage in twin-twin transfusion syndrome. Obstet Gynecol 2004;103:1174–80.Google Scholar

De Paepe, ME, Shapiro, S, Greco, D, et al. Placental markers of the twin-to-twin transfusion syndrome in diamniotic-monochorionic twins: a morphometric analysis of deep artery-to-vein anastomoses. Placenta 2010;31:269–76.Google Scholar

Nikkels, PG, van Gemert, MJ, Sollie-Szarynska, KM, et al. Rapid onset of severe twin-twin transfusion syndrome caused by placental venous thrombosis. Pediatr Dev Pathol 2002;5:310–14.Google Scholar

Tan, TY, Denbow, M, Cox, P, et al. Arterio-arterial anastomosis occlusion manifesting as acute twin-twin transfusion syndrome. Placenta 2004;25:238–42.Google Scholar

Chmait, RH, Assaf, SA, Benirschke, K. Residual vascular communications in twin-twin transfusion syndrome treated with sequential laser surgery: frequency and clinical implications. Placenta 2010;31:611–14.Google Scholar

Machin, G. Non-identical monozygotic twins, intermediate twin types, zygosity testing, and the non-random nature of monozygotic twinning: a review. Am J Med Genet C Semin Med Genet 2009;151C:110–27.Google Scholar

Quintero, R, Kontopoulos, EV, Barness, E, et al. Twin-twin transfusion syndrome in a dichorionic-monozygotic twin pregnancy: the end of a paradigm? Fetal Pediatr Pathol 2010;29:81–8.Google Scholar

Baergen, RN. Manual of Pathology of the Human Placenta, 2nd edn. New York, Springer. 2011; 204.

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