The twin to twin transfusion syndrome (human intrauterine parabiotic syndrome) is a wellknown condition which is more commonly associated with intrauterine transfer of blood between uniovular twins. It apparently has been known in the medical literature for at least 300 years. Portal' described triplets whose birth he attended on 19 March 1683 in Paris, France. One was "perfect"; the other two were putrified, of discordant size, and both attached to a single placenta. We have made a similar observation on triplets in Milwaukee, Wisconsin in 1980.Naeye,2 Benirschke and Dri~coll,~ and Sekiya and Hafez4 have reviewed the syndrome. It is characterized by polyhydramnios in the polycythemic (recipient) twin which also exhibits enlarged heart, kidneys, and muscular mass. Usually it is bigger than the donor twin, which has a smaller heart and lacks amniotic fluid in its sac. It is the purpose of this report to describe the findings by ultrasound of twin to twin transfusion syndrome at 18 weeks of gestation. CASE PRESENTATIONThe first pregnancy of this 18-year-old woman was being followed by her obstetrician, and developed normally up to the beginning of the 16th week of gestation. At that time the obstetrician noticed that the uterus was larger than normal, probably corresponding to a pregnancy at the 18th week. Ten days later the patient was examined again and was found to have a uterus that corresponded to 28 weeks of gestation. The pa- 442tient had a sonographic examination that showed that she had a twin pregnancy with polyhydramnios. She was referred for genetic consultation and the following findings were obtained. Sonographic findings were documented by multiple still pictures and videotape of the entire session, as is customary in this center, using a Toshiba Realtime Instrument Model SAL-BOA with a 3MHz transducer.The uterus was enlarged, total intrauterine volume 2417 cc (50th percentile at 28 weeks);5 most of its volume was amniotic fluid. The uterine wall and the single placenta (anterior type I> were very thin (2 cm and 1 cm, respectively). The abdominal wall was severely distended and the patient experienced pain and distress when sitting and standing. Due to the acute dilatation of the abdominal cavity, there was mild respiratory impairment. The amniotic sac of the first twin contained all the fluid, allowing for extensive movement of the fetus. The sac of the second twin was tightly attached around the fetus and did not contain any detectable fluid, keeping the fetus positioned against the placenta and on the anterior wall of the uterus against gravity (Fig. 1). Anthropometric measurements were obtained from both fetuses (Table 1).The first twin was larger with head measurements corresponding to the 95th percentile and the diameter of the thorax being at the 75th percentile for 18 weeks of gestation. All bone lengths were at the 50th percentile. Tables of age-specific normal values of fetal growth have been developed in this center with sonographic examination of over 500 pregnancies.6 It exhibited compl...
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