Twin to Twin Transfusion Syndrome
TTTS Protocol
Here is the template for our initial US of a TTTS patient – blue underlined are the choices:
Type of Gestation: TWINS – Monochorionic, diamniotic, Monochorionic, monoamniotic.
TTTS evaluation
Twin A RECIPIENT (boy, female, girl, SECRET) in breech, cephalic, transverse, variable presentation on inferior, left, right.
Normal fetal cardiac activity and fetal movement was seen.
SIZE
Fetal size is appropriate, constitutionally small, decreased, increased, small for gestational age.
ANATOMY
The following fetal structures were observed and appeared normal: Lateral ventricles, choroid plexus, biparietal diameter level, cavum septum pellucidum, cerebellum and cisterna magna, thorax, diaphragm, nuchal skin thickness, orbits and lenses, upper lip and nostrils, profile, transverse and longitudinal spine, cord insertion, three vessel umbilical cord,diaphragm, stomach, kidneys, female, male, SECRET genitalia, all four extremities were examined in detail including long bones.
Bladder is empty, full, small but visible
Hydrops present, No evidence of hydrops
Cardiac Anatomy:
Rate and rhythm:
Normal cardiac rate and sinus rhythm were identified.
Structural anatomy:
A 4 chamber view of the heart confirmed normal situs and axis within the thorax. The ventricles are symmetric. The mitral and tricuspid valves are normally mobile and normally placed. The interventricular septum is a normal size, small septal defects cannot be completely ruled out. The interatrial septum is identified with a normally mobile foramen ovale. The inferior and superior vena cava enter appropriately into the right atrium. Aortic outflow in the long axis view is normal. The aortic valve is identified and appears normally placed. Aortic arch is aligned to the left ventricle and appears normal. Pulmonic outflow was visualized in a short axis view. The pulmonary valve was identified and appears normally placed. The three vessel view was normally visualized.
Lateral ventricles: XX mm
No evidence of ventriculomegaly.
Dopplers
Umbilical artery Dopplers:
S/D: XX PI: XX
AEDF: cyclical, intermittent, no, yes REDF: cyclical, no, yes
Middle cerebral artery:
PI: XX PSV MoM: XX
Ductus venosus:
Umbilical vein:
Non-pulsatile, Pulsatile umbilical vein flow.
Cardiac:
Mild, Moderate, No evidence of, Severe, Trivial tricuspid regurgitation
TEI Index:
Right: XX Abnormal, Borderline, Normal
Left: XX Abnormal, Borderline, Normal
Placental Position
Placental position is anterior, anterior fundal, left lateral, posterior, posterior fundal, right lateral.
Placental Umbilical Cord Insertion
The placental umbilical cord insertion is Central right, Eccentric Left, Left, left and appears velamentous. , marginal left, marginal right, Right, velamentous left, velamentous right
Amniotic fluid:
The amniotic fluid volume is decreased, high normal, increased, low normal , normal, largest single vertical pocket measures XXX cm.
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Twin B DONOR (boy, girl, SECRET) in breech, cephalic, transverse presentation on left, right, superior.
Normal fetal cardiac activity and fetal movement was seen.
SIZE
Fetal size is appropriate, constitutionally small, decreased, increased, large, small, small normal for gestational age.
ANATOMY
The following fetal structures were observed and appeared normal: Lateral ventricles, choroid plexus, biparietal diameter level, cavum septum pellucidum, cerebellum and cisterna magna, thorax, diaphragm, nuchal skin thickness, orbits and lenses, upper lip and nostrils, profile, transverse and longitudinal spine, cord insertion, three vessel umbilical cord,diaphragm, stomach, kidneys, female, male, SECRET genitalia, all four extremities were examined in detail including long bones.
Bladder is empty, full, small but visible
Hydrops present, No evidence of hydrops
Cardiac Anatomy:
Rate and rhythm:
Normal cardiac rate and sinus rhythm were identified.
Structural anatomy:
A 4 chamber view of the heart confirmed normal situs and axis within the thorax. The ventricles are symmetric. The mitral and tricuspid valves are normally mobile and normally placed. The interventricular septum is a normal size, small septal defects cannot be completely ruled out. The interatrial septum is identified with a normally mobile foramen ovale. The inferior and superior vena cava enter appropriately into the right atrium. Aortic outflow in the long axis view is normal. The aortic valve is identified and appears normally placed. Aortic arch is aligned to the left ventricle and appears normal. Pulmonic outflow was visualized in a short axis view. The pulmonary valve was identified and appears normally placed. The three vessel view was normally visualized.
Lateral ventricles: XX mm
No evidence of ventriculomegaly.
Dopplers
Umbilical artery Dopplers:
S/D: XX PI: XX
AEDF: Cyclical, Intermittent, no, yes REDF: Cyclical, intermittent, no, yes
Middle cerebral artery:
PI: XX PSV MoM: XX
Ductus venosus:
Umbilical vein:
Non-pulsatile, Pulsatile umbilical vein flow.
Cardiac:
Mild, Moderate, No evidence of, Severe, Trivial tricuspid regurgitation
TEI Index:
Right: XX Abnormal, Borderline, Normal
Left: XX Abnormal, Borderline, Normal
Placental Umbilical Cord Insertion
The placental umbilical cord insertion is Eccentric Right, eccentric superior, inferior right sided, Left, marginal left, marginal right, Right, velamentous left, velamentous right.
Amniotic fluid:
The amniotic fluid volume is decreased, increased, low normal, normal, subjectively reduced, largest single vertical pocket measures XXX cm.
TRANSVAGINAL SCAN
Cervix appears XX cm long by transvaginal scan.
SUMMARY
- Concordantasymmetrically, symmetricallygrown monochorionic diammiotic, monochorionic monoammiotic twin gestation at XX weeks and XX days. Inter twin growth discordance is XX %.
- Fetal anatomy appears normal for both babies within the limits of second trimester ultrasound.
- Detailed cardiac examination appears normal, although small septal defects cannot be completely ruled out.
- Cervical examination appears normal.
- Evidence for Twin to Twin Transfusion Syndrome Stage1.
IMPRESSION:
Recommended Follow Up:
Thank you for the opportunity to participate in her care. Please see consultation letter.