Stage 5 twin to twin transfusion syndrome (TTTS)

Case contributed by Dennis Odhiambo Agolah

Presentation

Thirty five year old gravida three patient with a twin pregnancy, twin B intrauterine fetal demise (IUFD). Now 35 weeks gestation by dates.

Patient Data

Age: 35 Years
Gender: Female

There is twin intrauterine pregnancy with the leading twin in cephalic presentation and viable with a regular heart rate at 148 BPM, showing unremarkable gross somatic morphology. A double loose loop of the umbilical cord is noted rounding twin A fetal neck. Twin B shows no cardiac activity and is tethered/abutting the fundal anterior chorionic roof with crowded skeletal structures and a partially collapsed calvarium/ skull bone plus a positive spalding sign on twin B fetal head. The placenta is one, fundal-posterior and is intact. The dividing amniotic membrane partitioning envelopes Twin B with no measurable pocket depth within twin B sac. The liquor is optimally normal in twin A sac. The cervix is closed and measures 3.9 cm in length.

Biometrics (Twin A) BPD = 36w 6d. HC = 36w 6d. AC = 33w 1d. FL = 36w 2d. AUA = 35w 5d. EFW = 2512g.

BPP Score (Twin A) F. Movements =2/2. F. Breathing =2/2. F. Tone =2/2. AFI =2/2. Total =8/8. UMBIL RI = 0.47; RT MCA RI = 0.69. Cerebral-placental ratio = 1.47 (normal).

Biometrics (Twin B) BPD = 13w 1d. HC = 14w 0d. FL = 17w 2d. AUA = 14w 5d.

BPP Score (Twin B) F. Movements =0/2. F. Breathing =0/2. F. Tone =0/2. AFI =0/2. Total =0/8. UMBIL RI = 0; MCA RI = 0. Cerebral-placental ratio = 0.

Case Discussion

Monochorionic- Diamniotic twin intrauterine pregnancy with a viable leading (twin A) at 35 weeks 5 days in cephalic presentation while the trailing (twin B) demised and tethered fundal-anteriorly at the chorionic roof aspect at 14 weeks 2 days gestation features of which are highly suggestive of stage 5 Twin to Twin Transfusion Syndrome (TTTS) with the donor twin demised while the recipient twin viable.

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