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Pregnant with MCDA twins. Diagnosed with twin transfusion syndrome. Refering to fetoscopic laser surgery once reach stage II.

Dec 2012
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General & Family Physician
Practicing since : 2012
Answered : 1704 Questions
My wife is currently at 18 weeks of her pregnancy with MCDA twins.
In her last ultrasound scan at 17 weeks + 3days. She was diagnosed with "substage I" twin to twin transfusion syndrome (TTTS). The amniotic fluid discrepancy was 4.7cm for donor and 5.3cm for the recipient.
Our gynaecologist suggested to continue monitoring with weekly scan. His plan is to refer for a fetoscopic laser surgery once it reaches stage II or above.
I read some study which shows at stage I and stage III (classical, with no visible bladder), the chances of perinatal survival and non-neurological sequale was the greatest.
Some additional information is:
The nuchal transluency scan done at 11 weeks +3days showed discrepancy of 1.2mm (donor) and 2.3mm (recipient). Mother is 29 years old and is her first pregnancy. It was spontaneous conception.

My question is,
1. Does this mean, do we either push and get the surgery done once we are diagnosed with stage I or do we wait until it progresses to stage III (if diagnosed stage II)?
2. Statistically, what is the chance of progression for each stage of TTTS? (i.e from substage I to I and from I to II etc)
3. we currently live in Australia. She would prefer to have the surgery in her hometown, Japan. Would this be inappropriate for her to fly over 10 hours?
4. Why does our gynaecologist prefer to wait until it reaches stage II or more?
Posted Mon, 21 Oct 2013 in Pregnancy
Answered by Dr. Nsah Bernard 10 hours later
Brief Answer:
Amnioreduction can be started first

Detailed Answer:

Thanks for posting on XXXXXXX

Fetoscopic laser photocoagulation of chorionic plate vessels is a highly specialized procedure performed in a few centers around the world and is mostly reserved for more severe cases, especially those that do not respond to amnioreduction.
The most common procedure to treat twin-twin transmission syndrome (TTTS) is reduction amniocentensis which is should be started immediately ones the diagnosis of TTTS made. It does not require waiting for the condition to reach stage 2 or 3 before it is done. It involves draining the amniotic fluid from around the recipient twin.
To answer your questions:
- You do not have to push for surgery to be done earlier as the fetoscopic laser procedure is done only in severe cases. Your doctor(s) should be able to start with amnioreduction now.
- Well as pregnancy progresses, TTTS will gradually evolve from stage I to IV but that will depend on the degree of connection between the twin. I am not sure there is any statistical data as to the progress from one stage to another but what I am sure about is that TTTS will eventually move from I stage to another and if you are lucky the condition might not get worst until you she finally delivers.
- I do not think she is a flight risk given that she might be traveling for 10 hours, but that you should discuss with her gyneco-obstetrician first who is able to physically evaluate her and decide whether or not she can travel with this condition.
- Your gyneco-obstetrician probably has his/her own reasons why he/she prefers to wait given that the procedure is only done in severe cases but normally should have started amnioreduction.

Hope this helps and wish you both the best
Dr. Nsah
Above answer was peer-reviewed by
Follow-up: Pregnant with MCDA twins. Diagnosed with twin transfusion syndrome. Refering to fetoscopic laser surgery once reach stage II. 30 hours later
Thanks for your reply doctor.

Can you answer the following question please?

According to the study, the success rate of amnioreduction is around 60% and with feotolaser surgery, it goes above 80%.

My question is.

Why is laser surgery only performed stage II or above?

Why not in stage I? Is there any reason for this?

Thank you
Answered by Dr. Nsah Bernard 20 minutes later
Brief Answer:
Success for single twin to survive and not both

Detailed Answer:

Thanks for updating and your welcome.

Amnioreduction is the most common and less XXXXXXX procedures to use in early stage and chances of both twins surviving is great but if this procedure fails, then one of the twins need to be saved (the recipient twin). As I earlier stated, festoscopic laser ablation is a highly specialized procedure which is performed only in a few centers around the world (and you seem to be lucky enough to have one around you). But note that, it is a procedure reserved only for more severe cases. In pregnancies treated with fetoscopic procedures, the overall survival is 75% with 85% having at least 1 fetus survive.
Timing of delivery depends on multiple factors. The ideal would be for delivery at term.
Personally I am not very versed with the procedure and the best person you can talk to her gyneco-obstetrician who can throw more light on this issue.
I believe that you should trust in her doctor's decision on when to start the laser treatment especially as from stage 2.
For now, I am positive that this procedure has reservations because it is not fully understood and until there is a certainty with this laser ablation, it will be best to start with the most practical procedure and reserve the complex ones only if the amnioreducation fails.
I believe, all you need to do is exercise some little patience with her doctors as precipitating things can get things out of hand.

Hope this further answers your questions.
Dr. Nsah
Above answer was peer-reviewed by
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