Amnioreduction therapy

Amnioreduction therapy for twin–twin transfusion syndrome

Twin–twin transfusion syndrome (TTTS) is one of the most challenging complications of the monochorionic twinning process. Characterized by high perinatal mortality and morbidity rates, TTTS has stimulated intense research interest globally over the past two decades.

The advent of obstetric ultrasound has enabled the accurate prenatal identification of TTTS and this detection capability has facilitated potential therapeutic interventions. Additionally, the treatment modalities have been refined as knowledge of the pathophysiology of TTTS has improved.


It is evident that TTTS is a complex condition and, as yet, there is no intervention which consistently produces optimal perinatal outcomes. Several therapeutic interventions have been used to improve maternal and perinatal outcomes in TTTS, including medical therapies such as digoxin1 and prostaglandin synthase inhibitors,2 intrauterine transfusion therapies,3 specific surgical interventions (selective fetal delivery,4 selective feticide5,6), amnioreduction,7–9 septostomy,10,11 placental laser ablation,12–14 and delivery if the gestation is in the third trimester.

Only two therapeutic interventions for TTTS have withstood the test of time and medical scrutiny: amnioreduction and placental laser ablation. Although both of these therapies have been demonstrated to improve the perinatal survival rates of severe TTTS, neither is without procedural complications nor is successful in all cases.

It has taken two decades for a randomized controlled trial of therapies for TTTS to be completed and published.16 Further randomized studies on management strategies are clearly required and are awaited with interest by healthcare providers and parents affected by this most fascinating complication of twinning.