Twin-To-Twin Transfusion Syndrome (Ttts) Associated With Single Intrauterine Fetal Death: Report Of A Clinical Case

Case Report

Abstract

Approximately 20–25% of twin pregnancies are monochorionic, meaning that the twins share a single placenta.¹ Out of these monochorionic twin pregnancies, about 10–15% are complicated by twin-to-twin transfusion syndrome (TTTS), which arises from unequal sharing of the placental blood supply.  TTTS generally manifests during the second trimester of pregnancy, most commonly between 16 and 26 weeks. It occurs due to the net transfer of fluids and hormones from one twin to the other through vascular connections on the placenta. If left untreated, TTTS can have a very poor prognosis. While stage I of the condition may stabilize or even improve in up to 30% of cases managed with observation, there is a risk of progression, fetal demise, or previable birth.^2_12

The Quintero staging system, is widely accepted as the standard to communicate the severity of disease. However, these indicators are not always reliable for early detection, as TTTS can develop unpredictably.^2_5

• Twin-to-twin transfusion syndrome (TTTS) occurring in 8-10% of cases
• Selective fetal growth restriction (sFGR) in 10-15% of cases
• Single intrauterine fetal death (sIUFD) at a rate of 6%
• Twin anemia-polycythemia sequence (TAPS) in about 3-13% of cases
• Twin reversed arterial perfusion sequence (TRAP), which occurs in approximately 1% of cases.⁹

Most of these complications are primarily due to a single shared placenta with intertwined vascular connections. A subset of monochorionic diamniotic twin (MCDA) pregnancies may exhibit advanced TTTS without earlier stage indicators, a condition known as “atypical TTTS.”

Additionally, the atypical TTTS may include coexisting conditions such as TAPS, sFGR, or cardiac compromise. This group also encompasses cases complicated by spontaneous septostomy( a rare complication that occurs when the dividing membrane in a multiple pregnancy ruptures, resulting in a pseudomonoamniotic environment) or TTTS in monochorionic monoamniotic twins (MCMA).⁷

Outcomes and Prognosis for Twin-to-Twin Transfusion Syndrome (TTTS):  Contemporary outcome data after laser surgery suggests survival for both fetuses can be anticipated in up to 65% of cases and survival of a single fetus in up to 88% of cases.  Without treatment, FFTS carries a high risk of stillbirth or disability if undetected, with up to 90% fetal loss. ^1,2

However, preterm birth remains a significant contributor to postnatal morbidity and mortality. Long term outcomes of TTTS survivors indicate that up to 11% of children may show signs of neurologic impairment.²

A 37-year-old patient came to the unit experiencing abnormal uterine bleeding, and she was subsequently diagnosed with a monochorionic-biamniotic twin pregnancy. After being denied access to tertiary-level care, she received treatment within our unit, resulting in the delivery of one healthy newborn and a papyraceous fetus that weighed 60 grams.