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Symptoms and Treatment of Twin to Twin Transfusion Syndrome

Twin to twin transfusion syndrome is a serious complication that can occur in identical twin pregnancies. This condition causes an imbalance of blood flow in the twin fetuses, thus disrupting the supply of nutrients and oxygen they need.

Twin to twin transfusion syndrome occurs when the blood supply needed by the unborn fetus is unbalanced. As a result, one fetus gets an abundant supply of blood, while the other fetus is deficient.

Causes of Twin to Twin Transfusion Syndrome

The cause of twin to twin transfusion syndrome (TTTS) is not yet known with certainty. However, disruption of cell division after fertilization is claimed to be the cause of abnormalities of the placenta and blood vessels in TTTS.

TTTS is a condition that should not be underestimated. Imbalance of blood supply received by twins can interfere with growth and development and even cause death.

A fetus that receives a small amount of blood can experience growth retardation and anemia. While other twin fetuses who get too much blood supply and experience excess fluid can experience disorders of the respiratory system, digestive system, heart, and brain.

Signs and Symptoms of Twin to Twin Transfusion Syndrome

Twin to twin transfusion syndrome is estimated to occur in 15 percent of identical twin pregnancies. Therefore, mothers who are pregnant with twins need to know the symptoms of this condition.

Here are the signs and symptoms of twin to twin transfusion syndrome that can be experienced by pregnant women:

  • Rapid uterine growth.
  • The size of the uterus and stomach is greater than the gestational age in general.
  • Increase in excess body weight.
  • Abdominal pain, shortness of breath, and contractions.
  • Swelling of the feet and hands early in pregnancy.

If you are pregnant with twins and find these signs or symptoms, consult your obstetrician immediately. The doctor will conduct a series of examinations, including ultrasound, to ascertain the cause of the complaint you are experiencing. If caused by TTTS, the ultrasound results will show the following:

  • There is only one placenta.
  • The size and weight of the two fetuses are different, even though they have the same sex.
  • The difference in the size of the amniotic sac and umbilical cord.
  • Fluid buildup in one of the twin fetuses.
  • Excess amniotic fluid in one twin fetus, while the other twin fetuses have a small amniotic fluid.

In addition to an ultrasound examination, the obstetrician may recommend other tests, such as echocardiography, or MRI, to confirm the condition.

Five stages of Twin to Twin Transfusion Syndrome

  • Stage 1: There is an imbalance of amniotic fluid, where a small amount (<2cm) is around the donor twin and a large amount around the recipient twin (> 8cm).
  • The twins often have a size of more than 20%.
  • Stage 2: The bladder of the donor twin is invisible or does not fill with urine during an ultrasound examination.
  • Stage 3: Imbalance of blood flow begins to affect heart function in one or both babies.
  • This is seen in abnormal blood flow in the umbilical cord or hearts of the twins.
  • Stage 4: Imbalance of blood flow causes signs of heart failure in one of the twins.
  • Stage 5: One or both twins have died due to severe TTTS.

For Stage 1 cases, observation may be needed, but for Stage 2 or above, fetal surgery may be the best choice.

How to Overcome Twin to Twin Transfusion Syndrome

Pregnant women who are diagnosed with TTTS will be advised to regularly see a gynecologist. Treatment for TTTS depends on the severity. If TTTS is not severe, the doctor will monitor the condition of the fetus periodically. If the TTTS condition is suspected to inhibit and interfere with fetal growth and development, your doctor may recommend:


This action is done to reduce amniotic fluid in one fetus that has an excess supply of fluid. One of the most frequently used methods in amino reduction is amniocentesis. This action aims to make the amount of amniotic fluid to normal and improve blood circulation to the fetus.

Laser fetoscopy surgery

If amnioreduction is not effective, then a laser fetoscopy procedure can be an alternative. This action is done by blocking the blood vessels that have abnormalities so that the fetus can get a balanced blood supply.

Early or premature labor

In some cases, labor can also be an option to save the fetus. This action is usually recommended if the fetal lungs are mature.

Although including a rare condition, twin to twin transfusion syndrome should not be underestimated. This is because the condition of TTTS can adversely affect the fetus, ranging from stunted development, birth with a defect, to death. Therefore, pregnant women need to check themselves regularly to the obstetrician.



  1. American Pregnancy Association. Twin to Twin Transfusion Syndrome (TTTS).
  2. Boston Children's Hospital. Twin-Twin Transfusion Syndrome (TTTS) | Diagnosis & Treatment.

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Health and clinical interests include all aspects of infectious diseases

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