Atypical twin-to-twin transfusion syndrome case managed in a single centre in Indonesia with fetoscopic laser photocoagulation and amniopatch: 'Case Report'

Abstract

Introduction and importance: The diagnostic criteria for Quintero staging in twin-to-twin transfusion syndrome (TTTS) are not applicable in all cases of TTTS, such as those in which the symptoms overlap with other monochorionic twin complications such as selective intrauterine growth restriction (sIUGR).

Case presentation: A 25-year-old woman, G1P0A0, at 22-24 weeks' gestational age was diagnosed with TTTS, with no outstanding history of medication use during pregnancy, and no family history of genetic disorder or twin pregnancy. In the donor twin, persistently absent end-diastolic flow in the umbilical artery was observed using Doppler velocimetry. Polyhydramnios was observed in the recipient twins. The fetal weight discordance between the twins was 39%. After 2 weeks of follow-up, the authors performed fetoscopic laser photocoagulation and successfully ablated five vascular anastomoses and amnioreduction by 2.5 l. Five days after the laser surgery, the patient developed amniotic fluid leakage, and an amniopatch was performed. The authors did the caesarean section at 34 weeks because of severe preeclampsia, the donor and recipient birth weights were 1,120 g and 1,837 g, respectively (weight discordance 39%). The APGAR scores were 3/4 and 6/8, respectively. The donor twin died 6 days after delivery due to respiratory failure, and the recipient twin survived. Neonatal echocardiography of the surviving twin showed no tricuspid regurgitation. No long-term follow-up was performed.

Clinical discussion: The traditional diagnostic criteria for TTTS stage 3 were not met and overlapped with the diagnostic criteria for sIUGR type 2. This is the first procedure reported in Indonesia for atypical TTTS with the outcome, one twin survived.

Conclusion: Some TTTS cases do not meet traditional diagnostic criteria and overlap with other monochorionic twin complications.

Keywords: amniopatch; amnioreduction; atypical TTTS; case report; fetoscopic laser photocoagulation.

Figure 1

A. Bladder filling in the donor twin was observed. B. Absent end-diastolic flow (AEDF) shown by Doppler umbilical artery velocimetry.

Figure 2

A. The Tei Index (TI) or Myocardial Performance Index (MPI) in the recipient’s left. Ventricle (LV) was 0.77. B. TI or MPI in the recipient’s right ventricle (RV) was 0.79. Both findings classified this TTTS as Cincinnati be sure to include a legend for each figure. Sure to note prominent features.

Figure 3

A. Fetoscopy images, before laser coagulation, the laser tip (right picture) about 1 cm, from the vessel surface. B. After laser coagulation; the macroscopic whitening of the coagulated vessel was observed if you use arrows, letters, or other indicators in your figures, be sure that they are permanently affixed in place, and referenced in the legend.

Figure 4

Timeline in the management of this patient.