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Twin Pregnancy Specialist

Twin-to-Twin Transfusion Syndrome
Diagnosis & Management in Nagpur

TTTS is one of the most serious complications in twin pregnancy — and one where early diagnosis and specialist care makes the greatest difference. At Mayflower, every monochorionic twin pregnancy receives the surveillance it deserves.

Dr. Kunda Shahane — MBBS, MS, FIFM, FMF (London)Pioneer of Fetal Therapy in Vidarbha · Monochorionic Twin Specialist
Affects10–15%
OfMC Twins
SurveillanceEvery 2 Wks
QuinteroStages I–V
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Understanding TTTS

What Is Twin-to-Twin Transfusion Syndrome?

TTTS (Twin-to-Twin Transfusion Syndrome) is a serious complication that affects monochorionic twin pregnancies — where twins share a single placenta. In TTTS, abnormal blood vessel connections (anastomoses) on the shared placenta cause one twin to transfer blood to the other in a one-sided flow.

The result is a donor twin — who gives away blood, becomes anaemic, growth-restricted, and produces too little urine (resulting in too little fluid) — and a recipient twin — who receives excess blood, produces too much urine (resulting in too much fluid), and is at risk of heart failure from circulatory overload.

TTTS affects approximately 10–15% of monochorionic diamniotic (MCDA) twin pregnancies. Without treatment, it carries a very high risk of loss of one or both twins — which is why specialist surveillance every two weeks is the standard of care for all MCDA pregnancies.

👶👶 TTTS At a Glance
Who is at riskMonochorionic diamniotic (MCDA) twins only
Incidence~10–15% of MCDA twin pregnancies
Caused byUnequal placental vascular anastomoses
Staging systemQuintero Stages I–V
SurveillanceEvery 2 weeks from 16 weeks in all MCDA twins
TreatmentAmnioreduction (Mayflower) · Laser ablation (referral)
SpecialistDr. Kunda Shahane, FIFM

What Happens to Each Twin

Twin One

⬇ The Donor Twin

  • Gives blood away through anastomoses
  • Becomes progressively anaemic
  • Growth restriction (IUGR)
  • Reduced urine output → oligohydramnios (too little fluid)
  • Bladder absent or barely visible on scan
  • "Stuck twin" — restricted movement in small fluid sac
Twin Two

⬆ The Recipient Twin

  • Receives excess blood
  • Circulatory overload → cardiac strain
  • Larger size, but at risk of heart failure
  • Excess urine output → polyhydramnios (too much fluid)
  • Enlarged bladder on scan
  • Hydrops in advanced cases
Severity Classification

Quintero Staging — How Severe Is It?

The Quintero staging system classifies TTTS severity from Stage I (mildest) to Stage V (most severe). Staging guides treatment decisions — and changes rapidly, which is why fortnightly surveillance is essential.

I
Stage I — Fluid Volume Discordance

Abnormal amniotic fluid in both sacs (oligohydramnios in donor, polyhydramnios in recipient), but donor bladder is still visible. Doppler flow is normal in both twins.

Management: Close surveillance every 1–2 weeks. May stabilise — but can progress rapidly.

II
Stage II — Absent Donor Bladder

Donor bladder is no longer visible on ultrasound — the donor twin's kidneys are under-perfused and producing no urine. Doppler remains normal.

Management: Intervention strongly considered — amnioreduction or referral for laser ablation evaluation.

III
Stage III — Abnormal Doppler

Abnormal Doppler flow in either twin — absent or reversed end-diastolic flow in the umbilical artery, pulsatile umbilical vein, or reversed ductus venosus flow. Signs of cardiovascular compromise.

Management: Urgent — laser ablation referral at a tertiary centre is the treatment of choice.

IV
Stage IV — Hydrops

Hydrops fetalis in one or both twins — fluid accumulation in body cavities (ascites, pleural effusions, pericardial effusion, or skin oedema). Advanced cardiovascular decompensation.

Management: Emergency — immediate specialist referral for laser ablation. Amnioreduction may be performed urgently to relieve acute symptoms.

V
Stage V — Fetal Demise

Death of one or both twins. When one twin dies in a monochorionic pregnancy, the surviving twin is at significant risk of brain injury due to sudden haemodynamic changes. Immediate specialist assessment is essential.

Management: Urgent MRI and specialist fetal neurology assessment for the surviving twin. Delivery timing and mode planning.

Our Approach

How We Monitor and Manage Monochorionic Twin Pregnancies

All monochorionic diamniotic twin pregnancies at Mayflower are managed on a structured fortnightly surveillance protocol from 16 weeks — the evidence-based standard to detect TTTS before it becomes advanced.

11
11–14 Weeks: Chorionicity Determination

The single most important first step — determining whether twins are monochorionic or dichorionic. The lambda sign (dichorionic) vs T-sign (monochorionic) on the NT scan. If chorionicity is uncertain, Dr. Kunda Shahane determines it definitively at this scan.

16
16 Weeks Onwards: Fortnightly Surveillance Begins

Every 2 weeks — amniotic fluid volumes in both sacs, bladder visibility in both twins, fetal growth, fetal Doppler. Each scan takes 45–60 minutes. Any emerging discordance is documented and trended over visits.

Dx
When TTTS Is Suspected: Same-Day Detailed Assessment

If any feature raises concern for TTTS, a complete Quintero staging assessment is performed on the same day — fluid volumes, bladder assessment, Doppler in all four vessels (umbilical artery, MCA, ductus venosus, umbilical vein), and fetal echocardiography of the recipient twin.

Rx
Stage I–II: Close Surveillance ± Amnioreduction

Stage I may be watched weekly with escalating frequency. Stage II — amnioreduction is considered to relieve polyhydramnios, reduce uterine stretch, and lower the risk of preterm labour. This is performed by Dr. Kunda Shahane at Mayflower Clinic under continuous ultrasound guidance.

🔴
Stage III–IV: Urgent Laser Referral

Advanced TTTS (Stages III–IV) requires fetoscopic laser ablation of the placental anastomoses — a specialist surgical procedure performed at tertiary centres. Dr. Kunda Shahane facilitates urgent referral with full documentation and clinical summary, and continues monitoring after surgery.

🚨 Is Your TTTS Urgent?

If you have been told your TTTS is Stage III or IV, or if your twin pregnancy has suddenly worsened, please contact us immediately. We prioritise urgent TTTS cases for same-day or next-day assessment.

📞 Call 0712-669-2706 💬 WhatsApp URGENT
Beyond TTTS

Other Complications of Monochorionic Twin Pregnancies

Monochorionic twins face other complications beyond TTTS — all of which are monitored and managed at Mayflower Clinic.

TAPS — Twin Anaemia Polycythaemia Sequence A milder imbalance of blood via anastomoses — one twin becomes anaemic, the other polycythaemic. Detected by MCA Doppler every 2 weeks.
sFGR — Selective Fetal Growth Restriction One twin significantly smaller than the other — often with abnormal Doppler. Serial weekly growth and Doppler monitoring.
TRAP — Twin Reversed Arterial Perfusion Sequence Rare condition where one twin (acardiac) is perfused in reverse by the other — cardiac overload risk for the pump twin.
Single Fetal Demise in MC Twins Death of one twin causes sudden haemodynamic shifts to the survivor — urgent brain MRI and specialist assessment for the surviving twin.
Questions & Answers

Frequently Asked Questions About TTTS

What is TTTS?
TTTS (Twin-to-Twin Transfusion Syndrome) is a serious complication that affects monochorionic twin pregnancies — where twins share a single placenta. Abnormal blood vessel connections on the shared placenta cause one twin (the donor) to transfer too much blood to the other (the recipient). The donor becomes anaemic and growth-restricted with too little fluid; the recipient becomes fluid-overloaded and is at risk of heart failure. Without treatment, TTTS can be life-threatening for one or both twins.
Which twin pregnancies are at risk of TTTS?
Only monochorionic (MC) twin pregnancies — specifically monochorionic diamniotic (MCDA) twins who share a placenta but have separate amniotic sacs. Dichorionic twins (separate placentas) are not at risk of TTTS. This is why determining chorionicity at the first trimester scan is critically important in any twin pregnancy.
What are the Quintero stages of TTTS?
Quintero Stage I — fluid discordance with bladder visible; Stage II — donor bladder absent; Stage III — abnormal Doppler in either twin; Stage IV — hydrops; Stage V — fetal demise. Stages I–II may be managed with close surveillance; Stages III–IV require urgent intervention, typically fetoscopic laser ablation.
How often should I be scanned if I have monochorionic twins?
Every 2 weeks from 16 weeks of pregnancy — this is the evidence-based standard. Each scan checks amniotic fluid volumes, bladder filling, fetal growth, and Doppler blood flow. Early detection of TTTS significantly improves outcomes — which is why fortnightly surveillance by a fetal medicine specialist is essential.
What is the treatment for TTTS?
The optimal treatment for Stage II–IV TTTS is fetoscopic laser ablation — sealing the abnormal placental blood vessel connections. This is performed at tertiary centres. Amnioreduction — draining excess fluid from the recipient's sac — provides symptom relief and is used as a bridging measure or for selected cases. Dr. Kunda Shahane performs amnioreduction at Mayflower Clinic and coordinates urgent referral for laser cases.
What is the outlook for twins with TTTS?
Outcomes depend significantly on the stage at diagnosis and speed of treatment. With early detection at Stages I–II, many pregnancies are successfully managed. For Stage III–IV TTTS treated with laser at experienced centres, survival rates for at least one twin exceed 80–90%. Dr. Kunda Shahane provides honest, detailed counselling about prognosis specific to your situation and stage.
"Every monochorionic twin pregnancy I follow carries an extra weight of vigilance. The same placenta that connects these two babies can also be the channel through which one takes from the other. The fortnightly scan is not just a routine check — it is the window through which TTTS is caught at Stage I rather than Stage IV. I have seen what early detection and timely intervention can achieve. Every two-week appointment matters."
— Dr. Kunda Shahane, MBBS, MS (Obs & Gynae), FIFM, FMF (London)
Pioneer of Fetal Therapy in Vidarbha · Mayflower Clinic, Nagpur
Related Services
Amnioreduction Fetal Echocardiography Colour Doppler Growth Scan High-Risk Pregnancy All Fetal Therapy 👩‍⚕️ Dr. Kunda Shahane

Pregnant with Twins? Let a Specialist Take Care of You.

Monochorionic twin pregnancies need expert surveillance from 16 weeks. Book your specialist scan at Mayflower Clinic today.

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⚖️ PCPNDT Act Notice

Mayflower Fetal Medicine Centre strictly complies with the PCPNDT Act, 1994. All ultrasound and fetal therapy services are performed exclusively for lawful medical indications. Sex determination is prohibited by law and is not performed at this centre.

Medical Disclaimer: This page is for patient education only. TTTS is a serious condition requiring urgent specialist assessment. Please contact Dr. Kunda Shahane or your nearest fetal medicine specialist immediately if you suspect TTTS in your twin pregnancy.