Twin-Twin Transfusion Syndrome (TTTS · Quintero)

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] MCDA + TOPS + Quintero stage
   MCDA + TOPS + Quintero stage? (TTTS = a monochorionic diamniotic (MCDA) complication (~10–15%), unbalanced placental vascular anastomoses. Two diagnostic conditions: MCDA + donor oligohydramnios (MVP <2 cm) + recipient polyhydramnios (MVP >8 cm) = TOPS. MCDA: ultrasound every 2 weeks from 16 weeks + echocardiography to screen CHD. Exclude other causes of oligohydramnios (e.g. ruptured membranes) first.)
   • Stage I: fluid sequence, donor bladder visible, normal Dopplers → Stage I · expectant + close monitoring
   • Stage II: donor bladder not seen (>60 min) → Stage II–IV → fetoscopic laser
   • Stage III–IV: critical Dopplers (absent/reversed UA, reversed DV a-wave) or hydrops → Stage II–IV → fetoscopic laser
   • Stage V: one/both twin demise → Stage V (one twin demise)
2. [End] Stage I · expectant + close monitoring
   Quintero stage I (asymptomatic): expectant + at least weekly monitoring (~75% stable or regress); maternal polyhydramnios symptoms (dyspnea/contractions) or progression → consider fetoscopic laser; avoid over-intervention.
3. [End] Stage II–IV → fetoscopic laser
   Quintero stage II–IV (<26 weeks): fetoscopic laser coagulation of the anastomoses (Solomon technique) is first choice (better than amnioreduction); stage III critical Dopplers and stage IV hydrops indicate severity; perinatal mortality 30–50%, neurological injury 5–20% afterward; steroids at 24–34 weeks for lung maturity.
4. [End] Stage V (one twin demise)
   Quintero stage V (one twin demise): the survivor has ~10% death, 10–30% neurological injury risk (acute hemodynamic shift); MRI to assess survivor brain injury (after 4–6 weeks); decide expectant/delivery by gestation and survivor status; multidisciplinary counselling.

Source guidelines & references

• TTTS Quintero staging and management (SMFM Consult #72; fetoscopic laser Solomon)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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