In TTTS, it is the polyhydramnios (excess amniotic fluid) which most often leads to the loss of the pregnancy. This common symptom may be managed effectively by reduction amniocentesis. However, the over-expansion of uterus, especially when the diagnosis of TTTS is made late and the uterus is massively enlarged, may damage the uterine cervix (it becomes abnormally too short to keep the babies inside). These TTTS mothers are then at increased risk for premature rupture of the membranes, and labor and delivery of immature to very premature babies. This variable may also be responsible for losses that here-to-fore were thought to be complications of the various treatments (e.g., laser surgery, reduction amniocentesis).

The ultrasound machine can provide important information regarding abnormal cervical changes, before they can be detected by vaginal examination alone. Studies have shown that the shorter the cervix in twin gestation at mid-pregnancy, the more likely a premature delivery (see Skentou et al., attached). If severe shortening is detected early, the physician may stitch the cervix (cerclage procedure) to provide the necessary strength to reach term. Cervical assessment and cerclage placement will improve the outcomes (survival, duration of pregnancy, healthy survivors) that were reported for treatments in the last decade. For instance, it may explain why 25% of TTTS cases treated by laser surgery in one center (see paper by De Lia et al., in Treatments section), had no surviving babies. Since cervical assessment with ultrasound has now become routine in their center, 20-30% of TTTS cases either come with a cerclage in place, have it placed there after the laser, or return home to have it placed. The cervix should be checked frequently by ultrasound in TTTS.

Bed or horizontal rest is another means to reduce pressure on the cervix in multiple gestation, with or without TTTS. Having the mother lie on her side, while on a couch, bed, recliner, lawn chair, or floor with her kids, helps reduce pressure on the cervix. Horizontal rest also improves blood flow to the mother's uterus (where the TTTS twins may be struggling due to the abnormalities in the placenta) and kidneys (where the excess water in the mother is eliminated). We highly recommend that parents call the National Sidelines Organization and order one of their packets on bedrest. We have enclosed some of their information for you to read in the meantime.

Dr. Julian De Lia has investigated the nutritional aspects of TTTS. He recommends that his patients drink 3 cans per day of either Boost or Ensure High Protein in addition to their meals. Dr. De Lia explains, "TTTS patients at mid-pregnancy have severe hypoproteinemia and anemia. These maternal metabolic parameters may influence fetal TTTS characteristics and explain maternal sensitivity to intravenous fluid in complicated multiple pregnancies in general. We believe our data are sufficient to support the use of nutritional supplements in the management of early (monochorionic twins with subtle growth and amniotic fluid differences) and severe TTTS regardless of specific invasive therapy used (i.e., fetoscopic placental laser surgery, reduction amniocentesis, septostomy, etc.)

We at the TTTS Foundation suggest nutritional supplementation and have seen nutritional therapy benefit many women. They report less fatigue and more energy, and on occasion, the fetal signs of TTTS improve (less polyhydramnios) obviating the need for invasive therapy. Mothers also feel immediate satisfaction knowing that that there is something they can do right away to help their babies.

Twin to twin transfusion syndrome is still being described by some as enigmatic and poorly understood. The recognition of the above maternal variables is exciting and new. We have no doubt that adding these to the TTTS paradigm will improve outcomes of TTTS babies regardless of therapy, whether directed at the placenta or the symptoms. Nutritional supplementation, ultrasound assessment of the cervix (with cerclage placement when necessary), and horizontal rest are within the scope of any physician.