Suspected twin-twin transfusion syndrome: how often is the diagnosis correct and referral timely?

The purpose of this study was to describe a single center's experience with referrals suspected to have twin-twin transfusion syndrome.

A retrospective review was performed for patients with suspected twin-twin transfusion syndrome referred to a fetal treatment center between November 1, 2006, and June 1, 2010. Data were collected regarding diagnosis, treatment, and follow-up.

Of the 324 patients referred for twin-twin transfusion syndrome, the diagnosis was confirmed in 249 (77%): Quintero stage I in 28 (11%), stage II in 50 (20%), stage III in 150 (60%), stage IV in 15 (6%), and stage V in 6 (2%). Ten patients presented too late for any intervention, including 6 cases of stage V disease with either single- or dual-twin death and 4 patients who imminently delivered. Of the 249 confirmed cases, 200 (84%) patients elected to undergo laser photocoagulation. The average gestational age ± SD for referral evaluation for laser-treated cases was 20.9 ± 5.7 weeks (median, 20.5 weeks). The other 75 patients who were referred for suspected twin-twin transfusion syndrome had a diagnosis of either a discordant amniotic fluid volume that did not meet the criteria for Quintero stage I twin-twin transfusion syndrome (56%) or selective intrauterine growth restriction (44%).

Our data suggest that patients with confirmed twin-twin transfusion syndrome are referred with advanced stages of disease (69% stages III-V), with 59% of referrals made after 20 weeks' gestation. Such a referral pattern calls into question the current frequency of sonographic surveillance used by many obstetricians. Revisions of current practice guidelines emphasizing the importance of more frequent examinations in monochorionic twin gestations beginning at 16 weeks' gestation should be considered.