Sudden Fetal Hematologic Changes as a Complication of Amnioreduction in Twin-Twin Transfusion Syndrome

Abstract

We present the first case of a monochorionic twin pregnancy in which sudden hematologic changes occurred as a complication of the amnioreduction procedure for twin-twin transfusion syndrome (TTTS). At 33 weeks of gestation, 4 days after the amnioreduction, the recipient developed severe anemia while the donor developed severe polycythemia. Postnatal placental examination revealed several arteriovenous and venoarterial anastomoses, a pale placental mass of the recipient and a congested and plethoric placental mass of the donor. We speculate on the pathophysiologic changes and potential deleterious effects provoked by the decompressive amnioreduction. Decompression of the placenta and anastomoses after the amnioreduction may have led to an acute blood shift from recipient to donor (thus also a reversal of feto-fetal transfusion), resulting in anemia in the recipient and polycythemia in the donor twin. In the past 15 years, 13 TTTS cases with late presentation were treated with amnioreduction. This is the first time we encountered this severe complication, yielding an incidence of 8%. Although the optimal treatment in TTTS with late presentation is not known, perinatologists should be aware that treatment with amnioreduction can lead to sudden hematologic changes.

Balancing Benefits and Risks of Indomethacin in the Management of Antenatal Bartter Syndrome: A Case Report

“…Unlike amniocentesis, indomethacin has a therapeutic value on the fetal original condition together with its effect on the reduction of polyhydramnios and its tocolytic effect on the overly distended uterus. In our opinion, combining amniocentesis with indomethacin could have increased maternal and fetal risks such as pre-term delivery, premature rupture of membranes, fetal injuries, and maternal sepsis (24)(25)(26).…”

Latrogenic twin anemia: polycythemia sequence post-amnioreduction in twin-twin transfusion syndrome

“…Recent study showed that the placental dichotomy, cardiomegaly in donors, starry-sky liver in recipients was present in 44%, 70% and 66% of the TAPS, respectively [9] and they are associated with the severity of TAPS stage. [10,11] Iatrogenic TAPS post-amnioreduction in TTTS was only reported once by Kosinska et al [12] in which TAPS suddenly occurred 4 day after 2000 mL amniotic fluid drained from recipient's sac. But their case is different from ours in that they had a reversal fetofetal transfusion, meaning that the ex-recipient became anemia and the ex-donor became polycythemia.…”

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.…”