American Journal of Obstetrics & Gynecology
Volume 203, Issue 1 , Pages 3-16 , July 2010

Twin-twin transfusion syndrome: an ethics-based and evidence-based argument for clinical research

  • David M. Stamilio, MD, MSCE

      Affiliations

    • Department of Obstetrics & Gynecology, Maternal Fetal Medicine Division, Washington University School of Medicine, St. Louis, MO
    • ,
  • William D. Fraser, MD, MSc

      Affiliations

    • Department of Obstetrics & Gynecology, University of Montreal, Montreal, Quebec, Canada
    • ,
  • Thomas R. Moore, MD

      Affiliations

    • Department of Reproductive Medicine, University of California San Diego, San Diego, CA

Received 28 August 2009 ,Revised 29 November 2009 ,Accepted 7 December 2009.

References 

  1. Fisk NM, Duncombe GJ, Sullivan MH. The basic and clinical science of twin-twin transfusion syndrome. Placenta. 2009;30:379–390
  2. Saunders NJ, Snijders RJ, Nicolaides KH. Twin-twin transfusion syndrome during the 2nd trimester is associated with small intertwin hemoglobin differences. Fetal Diagn Ther. 1991;6:34–36
  3. Urig MA, Clewell WH, Elliott JP. Twin-twin transfusion syndrome. Am J Obstet Gynecol. 1990;163:1522–1526
  4. Fusi L, Gordon H. Twin pregnancy complicated by single intrauterine death (Problems and outcome with conservative management). BJOG. 1990;97:511–516
  5. van Heteren CF, Nijhuis JG, Semmekrot BA, Mulders LG, van den Berg PP. Risk for surviving twin after fetal death of co-twin in twin-twin transfusion syndrome. Obstet Gynecol. 1998;92:215–219
  6. Ong SS, Zamora J, Khan KS, Kilby MD. Prognosis for the co-twin following single-twin death: a systematic review. BJOG. 2006;113:992–998
  7. Hack KE, Nikkels PG, Koopman-Esseboom C, et al. Placental characteristics of monochorionic diamniotic twin pregnancies in relation to perinatal outcome. Placenta. 2008;29:976–981
  8. Yamamoto M, Ville Y. Twin-to-twin transfusion syndrome: management options and outcomes. Clin Obstet Gynecol. 2005;48:973–980
  9. Dickinson JE, Evans SF. The progression of disease stage in twin-twin transfusion syndrome. J Matern Fetal Neonatal Med. 2004;16:95–101
  10. Detterbeck FC, Tanoue LT, Boffa DJ. Anatomy, biology and concepts, pertaining to lung cancer stage classification. J Thorac Oncol. 2009;4:437–443
  11. Madazli R, Sal V, Cift T, Guralp O, Goymen A. Pregnancy outcomes in women with heart disease. Arch Gynecol Obstet. 2009;Epub ahead of print
  12. Pecorelli S, Zigliani L, Odicino F. Revised FIGO staging for carcinoma of the cervix. Int J Gynaecol Obstet. 2009;105:107–108
  13. Quintero RA, Morales WJ, Allen MH, Bornick PW, Johnson PK, Kruger M. Staging of twin-twin transfusion syndrome. J Perinatol. 1999;19:550–555
  14. Brown DL, Benson CB, Driscoll SG, Doubilet PM. Twin-twin transfusion syndrome: sonographic findings. Radiology. 1989;170:61–63
  15. Moore TR. Superiority of the four-quadrant sum over the single-deepest-pocket technique in ultrasonographic identification of abnormal amniotic fluid volumes. Am J Obstet Gynecol. 1990;163:762–767
  16. Sunagawa S, Kikuchi A, Kurihara N, et al. Monochorionic twin fetuses showing a reversal of donor-recipient phenotypes in severe twin-twin transfusion syndrome without oligo-polyhydramnios sequence. Congenit Anom Kyoto. 2008;48:92–96
  17. Yamamoto M, Essaoui M, Nasr B, et al. Three-dimensional sonographic assessment of fetal urine production before and after laser surgery in twin-to-twin transfusion syndrome. Ultrasound Obstet Gynecol. 2007;30:972–976
  18. Quintero RA, Dickinson JE, Morales WJ, et al. Stage-based treatment of twin-twin transfusion syndrome. Am J Obstet Gynecol. 2003;188:1333–1340
  19. Rossi AC, D'Addario V. The efficacy of Quintero staging system to assess severity of twin-twin transfusion syndrome treated with laser therapy: a systematic review with meta-analysis. Am J Perinatol. 2009;26:537–544
  20. Dickinson JE, Duncombe GJ, Evans SF, French NP, Hagan R. The long term neurologic outcome of children from pregnancies complicated by twin-to-twin transfusion syndrome. BJOG. 2005;112:63–68
  21. Kagan KO, Gazzoni A, Sepulveda-Gonzalez G, Sotiriadis A, Nicolaides KH. Discordance in nuchal translucency thickness in the prediction of severe twin-to-twin transfusion syndrome. Ultrasound Obstet Gynecol. 2007;29:527–532
  22. Sebire NJ, Souka A, Skentou H, Geerts L, Nicolaides KH. Early prediction of severe twin-to-twin transfusion syndrome. Hum Reprod. 2000;15:2008–2010
  23. Kontopoulos EV, Quintero RA. Assessment of the peak systolic velocity of the middle cerebral artery in twin-twin transfusion syndrome: part I, preoperative assessment. Am J Obstet Gynecol. 2009;200:61.e1–61.e5
  24. Denbow ML, Cox P, Taylor M, Hammal DM, Fisk NM. Placental angioarchitecture in monochorionic twin pregnancies: relationship to fetal growth, fetofetal transfusion syndrome, and pregnancy outcome. Am J Obstet Gynecol. 2000;182:417–426
  25. Tan TY, Taylor MJ, Wee LY, Vanderheyden T, Wimalasundera R, Fisk NM. Doppler for artery-artery anastomosis and stage-independent survival in twin-twin transfusion. Obstet Gynecol. 2004;103:1174–1180
  26. Taylor MJ, Denbow ML, Duncan KR, Overton TG, Fisk NM. Antenatal factors at diagnosis that predict outcome in twin-twin transfusion syndrome. Am J Obstet Gynecol. 2000;183:1023–1028
  27. O'Donoghue K, Cartwright E, Galea P, Fisk NM. Stage I twin-twin transfusion syndrome: rates of progression and regression in relation to outcome. Ultrasound Obstet Gynecol. 2007;30:958–964
  28. Tei C. New non-invasive index for combined systolic and diastolic ventricular function. J Cardiol. 1995;26:135–136
  29. Michelfelder E, Gottliebson W, Border W, et al. Early manifestations and spectrum of recipient twin cardiomyopathy in twin-twin transfusion syndrome: relation to Quintero stage. Ultrasound Obstet Gynecol. 2007;30:965–971
  30. Rychik J, Tian Z, Bebbington M, et al. 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;197:392.e1–392.e8
  31. Murakoshi T, Ishii K, Nakata M, et al. Validation of Quintero stage III sub-classification for twin-twin transfusion syndrome based on visibility of donor bladder: characteristic differences in pathophysiology and prognosis. Ultrasound Obstet Gynecol. 2008;32:813–818
  32. Moise KJJ. Polyhydramnios: problems and treatment. Sem Perinatol. 1993;17:197–209
  33. Saade GR, Belfort MA, Berry DL, et al. Amniotic septostomy for the treatment of twin oligohydramnios-polyhydramnios sequence. Fetal Diagn Ther. 1998;13:86–93
  34. Steinberg LH, Hurley VA, Desmedt E, Beischer NA. Acute polyhydramnios in twin pregnancies. Aust N Z J Obstet Gynaecol. 1990;30:196–200
  35. Excellence NIfHaC (Intrauterine laser ablation of placental vessels for the treatment of twin-to-twin transfusion syndrome). London: National Institute for Health and Clinical Excellence; 2006;
  36. Roberts D, Gates S, Kilby M, Neilson JP. Interventions for twin-twin transfusion syndrome: a Cochrane review. Ultrasound Obstet Gynecol. 2008;31:701–711
  37. Robyr R, Quarello E, Ville Y. Management of fetofetal transfusion syndrome. Prenat Diagn. 2005;25:786–795
  38. Senat MV, Deprest J, Boulvain M, Paupe A, Winer N, Ville Y. Endoscopic laser surgery versus serial amnioreduction for severe twin-to-twin transfusion syndrome. N Engl J Med. 2004;351:136–144
  39. Bebbington MW, Tiblad E, Wilson RD, Mann SE, Huesler-Charles M, Johnson MP. Outcomes in a cohort of patients with stage 1 twin–twin transfusion syndrome. Ultrasound Obstet Gynecol. 2007;30:487
  40. Taylor MJ, Govender L, Jolly M, Wee L, Fisk NM. Validation of the Quintero staging system for twin-twin transfusion syndrome. Obstet Gynecol. 2002;100:1257–1265
  41. Quarello E, Molho M, Ville Y. Incidence, mechanisms, and patterns of fetal cerebral lesions in twin-to-twin transfusion syndrome. J Matern Fetal Neonatal Med. 2007;20:589–597
  42. Kline-Fath BM, Calvo-Garcia MA, O'Hara SM, Crombleholme TM, Racadio JM. Twin-twin transfusion syndrome: cerebral ischemia is not the only fetal MR imaging finding. Pediatr Radiol. 2007;37:47–56
  43. Lopriore E, Middeldorp JM, Sueters M, Oepkes D, Vandenbussche FP, Walther FJ. Long-term neurodevelopmental outcome in twin-to-twin transfusion syndrome treated with fetoscopic laser surgery. Am J Obstet Gynecol. 2007;196:231.e1–231.e4
  44. Lopriore E, Ortibus E, Acosta-Rojas R, et al. Risk factors for neurodevelopment impairment in twin-twin transfusion syndrome treated with fetoscopic laser surgery. Obstet Gynecol. 2009;113:361–366
  45. Graef C, Ellenrieder B, Hecher K, Hackeloer BJ, Huber A, Bartmann P. Long-term neurodevelopmental outcome of 167 children after intrauterine laser treatment for severe twin-twin transfusion syndrome. Am J Obstet Gynecol. 2006;194:303–308
  46. Wagner MM, Lopriore E, Klumper FJ, Oepkes D, Vandenbussche FP, Middeldorp JM. Short- and long-term outcome in stage 1 twin-to-twin transfusion syndrome treated with laser surgery compared with conservative management. Am J Obstet Gynecol. 2009;201:286.e1–286.e6
  47. Montori VM, Devereaux PJ, Adhikari NK, et al. Randomized trials stopped early for benefit: a systematic review. JAMA. 2005;294:2203–2209
  48. Middeldorp JM, Sueters M, Lopriore E, et al. Fetoscopic laser surgery in 100 pregnancies with severe twin-to-twin transfusion syndrome in the Netherlands. Fetal Diagn Ther. 2007;22:190–194
  49. Chervenak FA, McCullough LB. Perinatal ethics: a practical method of analysis of obligations to mother and fetus. Obstet Gynecol. 1985;66:442–446
  50. Chervenak FA, McCullough LB. A comprehensive ethical framework for fetal research and its application to fetal surgery for spina bifida. Am J Obstet Gynecol. 2002;187:10–14
  51. Chervenak FA, McCullough LB. Ethics of maternal-fetal surgery. Semin Fetal Neonatal Med. 2007;12:426–431
  52. Dennis LG, Winkler CL. Twin-to-twin transfusion syndrome: aggressive therapeutic amniocentesis. Am J Obstet Gynecol. 1997;177:342–349
  53. Trespidi L, Boschetto C, Caravelli E, Villa L, Kustermann A, Nicolini U. Serial amniocenteses in the management of twin-twin transfusion syndrome: when is it valuable?. Fetal Diagn Ther. 1997;12:15–20
  54. de Lia JE, Kuhlmann RS, Harstad TW, Cruikshank DP. Fetoscopic laser ablation of placental vessels in severe previable twin-twin transfusion syndrome. Am J Obstet Gynecol. 1995;172:1202–1211
  55. Ville Y, Hecher K, Gagnon A, Sebire N, Hyett J, Nicolaides K. Endoscopic laser coagulation in the management of severe twin-to-twin transfusion syndrome. BJOG. 1998;105:446–453
  56. Ville Y, Hyett J, Hecher K, Nicolaides K. Preliminary experience with endoscopic laser surgery for severe twin-twin transfusion syndrome. N Engl J Med. 1995;332:224–227
  57. Moise KJ, Dorman K, Lamvu G, et al. A randomized trial of amnioreduction versus septostomy in the treatment of twin-twin transfusion syndrome. Am J Obstet Gynecol. 2005;193:701–707
  58. Crombleholme TM, Shera D, Lee H, 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.e1–396.e9
  59. Huber A, Diehl W, Bregenzer T, Hackeloer BJ, Hecher K. Stage-related outcome in twin-twin transfusion syndrome treated by fetoscopic laser coagulation. Obstet Gynecol. 2006;108:333–337
  60. Harkness UF, Crombleholme TM. Twin-twin transfusion syndrome: where do we go from here?. Semin Perinatol. 2005;29:296–304
  61. Karatza AA, Wolfenden JL, Taylor MJ, Wee L, Fisk NM, Gardiner HM. Influence of twin-twin transfusion syndrome on fetal cardiovascular structure and function: prospective case-control study of 136 monochorionic twin pregnancies. Heart. 2002;88:271–277
  62. Shah AD, Border WL, Crombleholme TM, Michelfelder EC. Initial fetal cardiovascular profile score predicts recipient twin outcome in twin-twin transfusion syndrome. J Am Soc Echocardiogr. 2008;21:1105–1108
  63. Tei C, Ling LH, Hodge DO, et al. New index of combined systolic and diastolic myocardial performance: a simple and reproducible measure of cardiac function--a study in normals and dilated cardiomyopathy. J Cardiol. 1995;26:357–366
  64. Habli M, Livingston J, Harmon J, Lim FY, Plozin W, Crombleholme T. The outcome of twin-twin transfusion syndrome complicated with placental insufficiency. Am J Obstet Gynecol. 2008;199:424.e1–424.e6
  65. Huhta JC. Right ventricular function in the human fetus. J Perinat Med. 2001;29:381–389
  66. Ichizuka K, Matsuoka R, Hasegawa J, et al. The Tei index for evaluation of fetal myocardial performance in sick fetuses. Early Hum Dev. 2005;81:273–279
  67. Bajoria R, Ward S, Chatterjee R. Brain natriuretic peptide and endothelin-1 in the pathogenesis of polyhydramnios-oligohydramnios in monochorionic twins. Am J Obstet Gynecol. 2003;189:189–194
  68. Bajoria R, Ward S, Sooranna SR. Atrial natriuretic peptide mediated polyuria: pathogenesis of polyhydramnios in the recipient twin of twin-twin transfusion syndrome. Placenta. 2001;22:716–724
  69. Mahony BS, Petty CN, Nyberg DA, Luthy DA, Hickok DE, Hirsch JH. The “stuck twin” phenomenon: ultrasonographic findings, pregnancy outcome, and management with serial amniocenteses. Am J Obstet Gynecol. 1990;163:1513–1522
  70. Reisner DP, Mahony BS, Petty CN, et al. Stuck twin syndrome: outcome in thirty-seven consecutive cases. Am J Obstet Gynecol. 1993;169:991–995
  71. Roberts D, Neilson JP, Kilby M, Gates S. Interventions for the treatment of twin-twin transfusion syndrome. Cochrane Database Syst Rev. 2008;CD002073
  72. Gilbert WM, Davis SE, Kaplan C, Pretorius D, Merritt TA, Benirschke K. Morbidity associated with prenatal disruption of the dividing membrane in twin gestations. Obstet Gynecol. 1991;78:623–630
  73. Bussey JG, Luks F, Carr SR, Plevyak M, Tracy TF. Minimal-access fetal surgery for twin-to-twin transfusion syndrome. Surg Endosc. 2004;18:83–86
  74. Gratacos E, Deprest J. Current experience with fetoscopy and the Eurofoetus registry for fetoscopic procedures. Eur J Obstet Gynecol Reprod Biol. 2000;92:151–159
  75. Hering R, Hoeft A, Putensen C, et al. Maternal haemodynamics and lung water content during percutaneous fetoscopic interventions under general anaesthesia. Br J Anaesth. 2009;102:523–527
  76. Robinson MB, Crombleholme TM, Kurth CD. Maternal pulmonary edema during fetoscopic surgery. Anesth Analg. 2008;107:1978–1980
  77. Hecher K, Plath H, Bregenzer T, Hansmann M, Hackeloer BJ. Endoscopic laser surgery versus serial amniocenteses in the treatment of severe twin-twin transfusion syndrome. Am J Obstet Gynecol. 1999;180:717–724
  78. Lopriore E, Nagel HT, Vandenbussche FP, Walther FJ. Long-term neurodevelopmental outcome in twin-to-twin transfusion syndrome. Am J Obstet Gynecol. 2003;189:1314–1319
  79. Lopriore E, Sueters M, Middeldorp JM, Oepkes D, Vandenbussche FP, Walther FJ. Neonatal outcome in twin-to-twin transfusion syndrome treated with fetoscopic laser occlusion of vascular anastomoses. J Pediatr. 2005;147:597–602
  80. Skupski D, Chervenak FA, McCullough L. An ethically justified decision-making pathway for the management of pregnancies complicated by twin-to-twin transfusion syndrome. Fetal Diagn Ther. 2007;22:339–342
  81. Flather M, Delahunty N, Collinson J. Generalizing results of randomized trials to clinical practice: reliability and cautions. Clin Trials. 2006;3:508–512

 Reprints not available from the authors.

 Authorship and contribution to the article is limited to the 3 authors indicated. There was no outside funding or technical assistance with the production of this article.

PII: S0002-9378(09)02249-2

doi: 10.1016/j.ajog.2009.12.006

American Journal of Obstetrics & Gynecology
Volume 203, Issue 1 , Pages 3-16 , July 2010

Article Tools

* Image Usage & Resolution