Management of Twin-Twin Transfusion Syndrome: Staging and Treatment
Twin-to-twin transfusion syndrome (TTTS) is classified into 5 stages based on ultrasound findings and Doppler velocimetry. Management depends on the stage, maternal symptoms, and gestational age. Treatments range from expectant management to fetal interventions like fetoscopic laser ablation. Regular monitoring, Doppler studies, and delivery planning are crucial aspects of managing TTTS.
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Presentation Transcript
QUINTERO STAGING AND TTTS MANAGEMENT DR.MOUNIKA
QUINTERO STAGING BASED ON THE USG FINDINGS AND DOPPLER VELOCIMETRY OF UMBILICAL ARTERY, UMBILICAL VEIN AND DUCTUS VENOSUS TTTS IS CLASSIFIED INTO 5 STAGES STAGE I : 1. OLIGO AND POLYHYDRAMNIOS SEQUENCE 2. BLADDER OF DONOR TWIN IS VISIBLE 3. DOPPLER INDICES IN BOTH TWINS ARE NORMAL
STAGE II : 1. OLIGO POLYHYDRAMNIOS SEQUENCE 2. BLADDER OF DONOR NOT VISIBLE 3. DOPPLER INDICES IN BOTH TWINS ARE NORMAL STAGE III : 1. OLIGO POLYHYDRAMNIOS SEQUENCE 2. ABNORMAL DOPPLER INDICES : AT LEAST ONE OF THE FOLLOWING TO BE PRESENT IN EITHER TWIN i. ABSENT OR REVERSED END DIASTOLIC FLOW IN UMBILICAL ARTERY ii. REVERSED FLOW IN A WAVE OF DUCTUS VENOSUS iii. PULSATILE FLOW IN THE UMBILICAL VEIN
STAGE IV : 1. OLIGO POLYHYDRAMNIOS SEQUENCE 2. ONE OR BOTH FETUSES SHOW SIGNS OF HYDROPS STAGE V : 1. OLIGO POLYHYDRAMNIOS SEQUENCE 2. ONE OR BOTH FETUSES ARE DEAD OTHER CLASSIFICATION SYSTEMS CARDIOVASCUALR PROFILE SCORE : CARDIAC SIZE, CARDIAC FUNCTION AND DOPPLER INDICES CHOP SCORE CINCINNATI MODIFICATION : DIVIDES STAGE III INTO A,B,C
MANAGEMENT OF TTTS MANAGEMENT DEPENDS ON STAGE , MATERNAL SYMPTOMS & SIGNS AND GESTATIONAL AGE STAGE I TTTS : CHOICE OF TREATMENT IS BASED PRIMARILY ON SEVERITY OF MATERNAL DISCOMFORT FROM UTERINE DISTENSION , CX LENGTH AND RISK OF PROGRESSION I. NO / TOLERABLE SYMPTOMS & CX LENGTH > 25 MM : EXPECTANT MANAGEMENT 1. AT 16 WEEKS MCA DOPPLER 2. AMNIOTIC FLUID VOLUME WEEKLY 3. FETAL GROWTH MONITORING EVERY 3-4 WEEKS : IF GROWTH LAG PRESENT WEEKLY DOPPLER 4. FROM 30 WEEKS BPP WEEKLY DELIVER AT 34 37+6 WK
STAGE I WITH RESPIRATORY DISTRESS/ PRETERM CONTRACTION/ CX LENGTH < 25 MM AT 16- 26 WEEKS GA : FETOSCOPIC LASER ABLATION FOLLOW UP : 1. AMNIOTIC FLUID VOLUME IT TAKES 5 WEEKS IN DONOR & 8 WEEKS IN RECIPIENT TO BECOME NORMAL 2. FETAL MEMBRANES SIGNS OF MEMBRANE SEPARATION , MEMBRANE RUPTURE , INADVERTENT SEPTOSTOMY 3. MCA PSV MEASURED TO DETECT TAPS WHICH MAY OCCURS DUE TO RESIDUAL PLACENTAL ANASTOMOSIS , USUALLY AROUND 6 WEEKS AFTER LASER ABLATION 4. FETAL GROWTH EVERY 3-4 WEEKS 5. AFTER 30 WEEKS BPP WEEKLY WEEKLY FOLLOW UP IN 1ST2 WEEKS LATER EVERY 2 WEEKS UPTO 30 WEEKS DELIVERY AT 34 - 37+6 WEEKS ACCORDING TO ACOG
AFTER 26 WEEKS : AMNIO REDUCTION BECAUSE OF TECHNICAL LIMITATIONS IN LASER ABLATION LIMITATIONS ARE : VERNIX CASEOSA IN AF DECREASES OPTIMAL VISUALISATION PLACENTAL VESSELS INCREASES IN CALIBER FOLLOW UP : 1. WEEKLY USG : TO SEE PROGRESSION OF TTTS STAGE & RESPONSE TO THERAPY FETAL GROWTH EVERY 3-4 WEEKS IF GROWTH LAG PRESENT WEEKLY DOPPLER 2. 3. FROM 28 WEEKS : MCA PSV DOPPLER WEEKLY 4. FROM 30 WEEKS BPP WEEKLY
STAGE II TO IV TTTS : NO EXPECTANT MANAGEMENT 16-26 WEEKS : FETOSCOPIC LASER ABLATION > 26 WEEKS : AMNIOREDUCTION FOLLOW UP SAME AS STAGE I STAGE V TTTS: 1. IF 1 FETUS DIED : BECAUSE OF SHARED CIRCULATION THERE ARE CHANCES FOR CO-TWIN DEATH OR NEUROLOGICAL IMPAIRMENT 2. IN ACUTE FETAL CO-TWIN DEMISE : MCA DOPPLER TO BE DONE TO EXCLUDE FETAL ANEMIA ,IF ANEMIA IS PRESENT IN UTERO TRANSFUSION CAN BE DONE 3. IF CO-TWIN IS PRETERM : EXPECTANT OBSERVATION WITH USG EVERY 3-4 WEEKS FOR FETAL GROWTH & CNS DEVELOPMENT [ MRI CAN BE DONE EVERY 3-4 WEEKS TO DETECT INTRACRANIAL INJURY]
