Abstract
The study aims to expound upon the imaging-based diagnostic methodologies aimed at identifying twin-to-twin transfusion syndrome (TTTS), a serious, somewhat rare prenatal condition that takes place in pregnancies where identical twins, or other multiples, share a placenta (monochorionic placenta), highlighting how medico-legal outcomes can be affected by provable compliance with consolidated diagnostic guidelines or best practices. It is of utmost importance to produce a prompt identification of TTTS instances; an early diagnosis is in fact critical in order to effectively treat and manage TTTS. By virtue of TTTS being a highly progressive condition, a delay in diagnosis can result in disastrous outcomes; just a few weeks delay in the diagnosis of TTTS can turn out fatal for one or both twins. Hence, most TTTS malpractice claims involve allegations of medical negligence, namely the failure to recognize the condition in a timely fashion, or to proceed with adequate diagnostic and therapeutic pathways. In that regard, case law databases have been pored over (Justia, Lexis, Leagle), and five significant court cases have been examined and discussed in an attempt to identify objective medico-legal standards and bring to the forefront relevant forensic dynamics. In fact, when health professionals are capable of proving adherence to guidelines or best practices, this can shield them from malpractice allegations and ensuing litigation.
Highlights
Twin-to-twin transfusion syndrome (TTTS) results from a hemodynamical imbalance of placental vascular anastomosis connecting the circulation of the two fetuses, whose consequence is the presence of hypovolemia, oliguria, and oligohydramnios in a twin and hypervolemia, polyuria, and polydramnios in the co-twin
The plaintiffs alleged that severe neurological injuries to one newborn and the death of the other were caused by the failure of the defendant physicians to diagnose and treat twin-to-twin transfusion syndrome (TTTS)
Any failure to adhere to surgical safety protocols, clinical practice guidelines, and best practices, and to properly produce documentation reflecting such adherence, will most likely result in courts ruling against healthcare providers and facilities
Summary
Twin-to-twin transfusion syndrome (TTTS) results from a hemodynamical imbalance of placental vascular anastomosis connecting the circulation of the two fetuses, whose consequence is the presence of hypovolemia, oliguria, and oligohydramnios in a twin (donor) and hypervolemia, polyuria, and polydramnios in the co-twin (recipient). TTTS usually occurs in the second trimester and is a dynamic condition that can remain stable, occasionally regress spontaneously, or evolve quickly. It affects 10–15% of monochorionic–diamniotic (MCDA) twin gestations [3] and affects a similar proportion of the MCDA twin pairs in dichorionic–triamniotic (DCTA) triplet gestations [4]. Monochorionic twin pregnancy can be defined as a congenital anomaly of the placenta, due to which the twin vessel systems communicate through vascular anastomoses on the placental surface It is the angioarchitecture of these vascular anastomoses that determines the risk profile [8]. Transfusion between twins is a normal event; the bidirectional artery-artery or vein-vein anastomoses compensate for the hemodynamic imbalance caused by the smaller and deeper one-way arteriovenous anastomoses, but when there is unequal hemodynamic and amniotic fluid balance, it can cause the risk of developing TTTS [5]
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