Twin of neurodevelopmental impairment have been reported to be

Twin to twin transfusion
syndrome: a pediatric physical therapy case report


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to twin transfusion syndrome (TTTS) is a severe complication of monochorionic
twin pregnancies in which uneven blood transfer occurs through placental
vascular anastomoses and has a reported prevalence of 9-15%.1-3 The
placenta may also be shared unequally by the twins, leaving one twin with an
inadequate blood supply and insufficient nutrients to develop typically. The
condition is clinically characterized by polyhydraminos, bladder distension,
and cardiac disturbances in the recipient twin; and oligohydraminos and severe
growth retardation in the donor twin.4,5 Left untreated, the risk of
perinatal mortality is 80% or more and the risk of physical and neurological morbidity,
as a result of the condition and/or preterm birth, is high.5-7
Severe polyhydraminos and subsequent uterine distention is the main cause of
perinatal mortality or preterm delivery.7 TTTS can develop at
different gestational ages and encompasses a spectrum of severities, with some
cases developing precipitously and others having a more insidious progression.7

interventions with endoscopic laser coagulation therapy and/or serial
amnioreduction significantly reduce perinatal mortality rate and improve
neonatal outcome.8,9 Endoscopic laser coagulation therapy is now
considered the intervention of choice for TTTS and aims to stop the blood
exchange between fetuses.5 In comparison to laser surgery,
amnioreduction correlates with an increased risk of neurological morbidity,
necrotizing entercolitis, neonatal renal failure, and advanced myocardial
dysfunction.10  A meta
analysis and review of literature concluded that overall survival rates
following laser surgery and serial amnioreduction varies from 57% to 77%, and
38% to 81%, respectively.11

primary long-term morbidity of TTTS cases treated conservatively or with laser
therapy is neurodevelopmental impairment. Rates of neurodevelopmental
impairment have been reported to be between 14.3%-26%.12-15 with
conservative management, and up to 18% with laser therapy.8,11,16,17
Neurologic deficits in monochorionic twins may be a result of: unstable
placental hemodynamics or fluctuations in blood pressure or blood volume18;
nutritional insufficiency affecting brain myelination19; ischemic
brain injury after the death of a monochorionic fetus20; premature
birth21; atypical brain development during the embryonic period22;
anemia and hypotension of the donor twin and polycythemia and hyperviscosity of
the recipient twin in chronic TTTS23. The key prognostic factor for
neurodevelopmental impairment is gestational age, regardless of whether
treatment approach is conservative or by laser surgery, making prolongation of
gestation critical.8

majority of research performed to date on treatment and developmental outcomes of
TTTS cases has been during the prenatal and/or perinatal periods. This case
report aims to provide a concise description of the long-term developmental
outcome and physical therapy interventions of a 6-year, 10-month old male
diagnosed with TTTS.