Twin-to-twin transfusion syndrome

Twin-to twin transfusion syndrome (TTTS) may occur only in twins who shared placenta (monochorionic twins) since they are connected by some the blood vessels in the placenta they shared. It is normal for monochorionic twins to exchange some blood during gestation and this exchange is usually balanced, means that at one moment the 1st twin will act as the blood donor while the 2nd is the recipient, and at the next moment the 2nd twin will act as the donor while the 1st become recipient.

Twin-to twin transfusion syndrome (TTTS) occurs when the exchange is unbalanced, where one of the twins always donates blood to the other. Twin-to twin transfusion syndrome (TTTS) not only compromises the donor twin, but also the recipient twin. Because there is less blood goes to the donor and more blood goes to the recipient, the donor become volume depletion and the recipient become volume overload.

With lees volume, the donor unable to produce enough amniotic fluid thus develops oligohydramnios. He also doesn’t get enough nutrients to grow and shows signs of intrauterine growth restriction.

Meanwhile, the recipient, who receives excessive volume, will develop polyhydramnios due to the excessive fluid. The recipient also tends to swell and develop heart failure (hydrops), due to the volume overload.

The risk and severity of the condition vary, depends on when is the onset occurs. If it starts later in gestation, the risks are usually minimal, and if there is complication occurs there is an option to deliver the baby earlier when they are mature enough to survive outside the womb. However, if the condition occurs earlier, before the babies mature enough to survive outside the womb, then there are not many options left and the risk is greater. 

Twin – donor	Twin – recipient
Hypovolemia	Hypervolemia
Oliguria / anuria	Polyuria
Oligohydramnios	Polyhydramnios
May develops hydrops due to anemia and high-output heart failure	May develops hydrops due to hypervolemia
Hypotension	Hypertension, hypertrophic cardiomegaly, disseminated intravascular coagulation

Conjoined twins in triplets

Macey and Mackenzie was born in December 2002, along with their triplet sister Madeline who came out 5 minutes after her twin sister. They are one of the rare types of triplets, which is the second known case in the world of conjoined twins in a triplets.

Macey and Mackenzie were fused at the pelvis up to the rib cage. They shared some organs and had 3 legs. Meanwhile Madeline was born 100% normal and healthy.

The biological mother of the triplets, who had drug problem, could not provide sufficient care for them even during the pregnancy and never have proper antenatal check-up. The babies were abandoned after they were born and fortunately, within a week, a couple, Jeff and Darla Garrison, came and adopted these 3 adorable babies.

A risky 24-hours surgery was done in September 2003, when the twins were 9 months of age. Both of them were successfully separated and each one of them has 1 leg.

Besides having one leg and has to rely on prostheses, other comorbidities they suffered from include the need for colostomy, liver and renal condition, spine problems and etc. However, they are able to face all these hurdles and challenges and able to lead a healthy, beautiful and active childhood as any child should have, with their new family by their side, Jeff and Darla Garrison and their 3 biological boys.

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Multiple pregnancy

Multiple pregnancy occurs when there is more than 1 fetus develop in the uterus (womb) during a single pregnancy. Different names have been used to describe multiple pregnancy depending on the number of the fetuses. For example two fetuses is called twins, three fetuses is called triplets, four is called quadruplets, five has been called as quintuplets, and so on.

Multiple pregnancy can be classified into several types based on: 1) The initial number of embryo produced 2)The number of placenta 3)The number of amniotic sac. 

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1) The number of initial embryo produced.

Multiple pregnancy can be resulted from the fertilization between 1 ovum and 1 sperm result in 1 embryo, which then divided into two or more embryos. It also can be a result of the fertilization between two or more ova and two or more sperms result in two or more embryos. The first way of fertilization will result in monozygotic twins / triplets / so on. These offspring is called identical twins / triplets / so on, which mean they are genetically identical since they are the result of the same one ovum and sperm. Meanwhile, the other way of fertilization will result in dizygotic, for twins, or polyzygotic triplets / so on. These offspring are called nonidentical twins / triplets / so on, which mean they are genetically not identical since they resulted from different sets of ovum and sperm.

2) The number of placenta

Monozygotic fetuses may share placenta or each of them has their own placenta. Twins who shared placenta is called monochorionic twins. These fetuses who shared placenta are at risk of having twin-to-twin transfusion syndrome. Meanwhile monozygotic twins which each one has their own placenta, thus also has separate amniotic sac, is called dichorionic diamniotic twins (DCDA)

3) The number of amniotic sac

Monochorionic fetuses may also share the same amniotic sac, or each of them has their own amniotic sac. Twins who shared amniotic sac is called monochorionic monoamniotic twins (MCMA), while the monochorionic twins which each of them has their own amniotic sac is called monochorionic diamniotic twins (MCDA). Only monochorionic monoamniotic twins have the risk to become conjoined twins. 

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Specific types of twins

DCDA twins – dichorionic diamniotic
MCDA twins – monochorionic diamniotic
MCMA twins – monochorionic monoamniotic

Investigation / work up for miscarriage

Investigation
Anti-phospholipid  antibodies	Recurrent 1st trimester miscarriage At least 1 time 2nd trimester miscarriage
Karyotyping -cytogenetic analysis -parental peripheral blood karyotyping	Recurrent 1st trimester miscarriage
Pelvic ultrasound/ hysteroscopy/ laparoscopy	Recurrent 1st trimester miscarriage At least 1 time 2nd trimester miscarriage
Thrombophilia screening	At least 1 time 2nd trimester miscarriage

 

All women with recurrent 1^st trimester miscarriage and all women with 1 or more 2^nd trimester miscarriage should be investigated for the cause of the miscarriage.

These investigation include : 1)Antiphospholipid antibodies 2)Cytogenetic analysis 3)Parental peripheral blood karyotyping 4)Pelvic ultrasound 5)Hysteroscopy laparoscopy 6)Thrombophilia screening.

Since antiphospholipid syndrome is the most common treatable cause for recurrent miscarriage, thus antiphospholipid antibodies presence should be checked in both women with recurrent 1^st trimester miscarriage and women with 1 or more 2^nd trimester miscarriage.

Karyotyping is done to detect any chromosomal abnormalities in cases of recurrent miscarriage. These include cytogenetic analysis of the miscarried product of conception and parental peripheral blood karyotyping. Cytogenetic analysis should be done on the miscarried product of conception of the third recurrent miscarriage and subsequent consecutive miscarriage. When report for the cytogenetic analysis of the product of conception showed unbalanced chromosomal abnormalities, parental peripheral blood karyotyping is done to detect any chromosomal abnormalities of the parents.

Pelvic ultrasound and gynecological procedure such as hysteroscopy or laparoscopy is done for both cases of recurrent 1^st trimester miscarriage and cases of women with 1 or more 2^nd trimester miscarriage to investigate for any congenital anomalies of the female reproductive system. Different types of anomalies may tend to cause miscarriage at different time during pregnancy. For example, arcuate uterus tend to cause miscarriage during the 2^nd trimester of pregnancy, while septate uterus usually causes 1^st trimester miscarriage.

Other important test to be done is thrombophilia screening which usually is done for 2^nd trimester miscarriage.

Classification of congenital uterine anomalies

Uterine morphology	Fundal contour	External contour
Normal	Straight / convex	Uniformly convex with indentation <10mm
Arcuate	Concave fundal indentation with central point of indentation at obtuse angle	Uniformly convex with indentation <10mm
Subseptate	Presence of septum that does not extend to the cervix, with central point at acute angle	Uniformly convex with indentation <10mm
Bicornuate	2 well-formed uterine cornua with a convex fundal contour in each	Fundal indentation >10mm dividing the 2 cornua