Perimortem Demonstration and Treatment of Recipient-to-Donor Transfusion in Monochorionic-Diamniotic Twin Gestation

Abstract

Twin-twin transfusion syndrome is a complication of monochorionic-diamniotic placentation. Should one twin die, ≈30% of co-twins will also die, and if they survive, ≈30% experience severe morbidity rates, each believed secondary to hemorrhage of the co-twin into the deceased twin. We report apparently the first ultrasound-documented case of perimortem hemorrhage in twin-twin transfusion syndrome and its treatment by emergent ultrasound-guided percutaneous cord occlusion followed by percutaneous fetal intravascular transfusion. The case illustrates three important pathophysiologic events. First, it confirms acute twin-to-twin hemorrhage occurs and reveals it can begin before the first twin dies. Thus, delivery of the survivor after its dead co-twin is discovered is unlikely to protect the survivor. Second, the elevated fetal middle cerebral artery peak systolic velocity due to acute anemia requires hours to develop. And thirdly, intracardiac epinephrine can correct the acute fetal bradycardia associated with hemorrhage that is presumably due to fetal hypotension.

Twin‐twin transfusion syndrome with anemia‐polycythemia developed during the third trimester of pregnancy

“…The contraction might have caused a more rapid blood shift than that of TTTS via arterio‐venous anastomoses in the placenta. Otherwise, acute polyhydramnios may have resulted in rapid compression in the amniotic sac leading to fetal heart load and/or hypotension associated with rapid blood inflow 7,8 . They may have led to rapid intertwin transfer of blood the patent anastomoses.…”

Histopathological examination of the placenta in twin pregnancies

“…If one monochorionic twin dies, the pressure in its circulation falls and placental anastomoses may allow for hemorrhage or transfusion from the surviving twin into the deceased twin's fetoplacental circulation . This process will be more rapid and severe if A‐A connections are present.…”