Intervention or expectant management for stage I twin-twin transfusion syndrome

Selective fetoscopic laser photocoagulation of communicating vessels (SFPL) is well established as the first line of therapy for stage II-IV twin-twin transfusion syndrome (TTTS). The optimal management of stage I TTTS is less well-defined. While many stage I patients resolve spontaneously or remain stage I with good pregnancy outcomes, a majority progress to higher stages. Risk factors that differentiate those who will remain stable or regress vs. those who will progress are lacking. This has led some centers to offer SFLP to patients with stage I disease either immediately or after a period of close observation. The objective of this manuscript is to review the current evidence on the merits of laser treatment versus expectant management for stage I TTTS. A search of PubMed and Google Scholar using the keywords "stage I," "twin transfusion," and "management" was undertaken. The results of this review suggest that expectant management of stable, asymptomatic stage I TTTS is a reasonable first-line treatment, whereas selective fetoscopic laser photocoagulation is an appropriate first step in some circumstances. Treatment of stage I TTTS should remain an option in select patients.