Serial Amnioreduction Research Articles

Successful antenatal treatment of MAGED2-related Bartter syndrome and review of treatment options and efficacy.

A new form of transient antenatal Bartter syndrome (aBS) was recently identified that is associated with the X-linked MAGED2 variant. Case reports demonstrate that this variant leads to severe polyhydramnios that may result in preterm birth or pregnancy loss. There is limited but promising evidence that amnioreductions may improve fetal outcomes in this rare condition. We report a woman with two affected pregnancies. In the first pregnancy, the patient was diagnosed with mild-to-moderate polyhydramnios in the second trimester that ultimately resulted in preterm labor and delivery at 25weeks with fetal demise. Whole exome sequencing of the amniotic fluid sample resulted after the pregnancy loss and revealed a c.1337G>A MAGED2 variant that was considered diagnostically. The subsequent pregnancy was confirmed by chorionic villi sampling to also be affected by this variant. The pregnancy was managed with frequent ultrasounds and three amnioreductions that resulted in spontaneous vaginal delivery at 37weeks and 6days of a viable newborn with no evidence of overt electrolyte abnormalities suggesting complete resolution. A detailed review of the published cases of MAGED2-related transient aBS is provided. Our review focuses on individuals who received antenatal treatment. A total of 31 unique cases of MAGED2-related transient aBS were compiled. Amnioreduction was performed in 23 cases and in 18 cases no amnioreduction was performed. The average gestational age at delivery was significantly lower in cases without serial amnioreduction (28.7 vs. 30.71weeks, p=0.03). Neonatal mortality was seen in 5/18 cases without serial amnioreduction, and no mortality was observed in the cases with serial amnioreduction. In cases of second trimester severe polyhydramnios without identifiable cause, whole exome sequencing should be considered. Intensive ultrasound surveillance and serial amnioreduction is recommended for the management of MAGED2-related transient aBS.

Twin-to-twin transfusion syndrome: Controversies in the diagnosis and management.

In twin-to-twin transfusion syndrome (TTTS) communicating placental vessels on the chorionic plate between the donor and recipient twins are responsible for the chronic imbalance of blood flow. Evidence demonstrates that fetoscopic laser ablation is superior to serial amnioreductions in terms of survival and neurological outcome for stages II-IV TTTS. However, the optimal management of stage I TTTS remains poorly understood. It is well established that all chorionic plate anastomoses should be closed by laser ablation. Compared to the selective laser method, the Solomon technique yields a significant reduction of recurrent TTTS and post-laser twin anemia polycythemia sequence (TAPS). Over the past 25 years, survival rates after fetoscopic laser surgery have significantly increased. High volume centers report up to 70% double survival and at least one survivor in >90% cases. In this review, we discuss the controversies in the diagnosis and management of TTTS, especially, the optimal management in stage I cases, very early or late diagnosis, and the optimal laser technique. Furthermore, we will discuss a stage-related outcome after laser surgery and examine whether it is necessary at all to distinguish between stages I and II. Finally, the optimal timing as well as mode of delivery after TTTS laser treatment will be discussed.

Optimizing Fetal Outcomes in Twin-Twin-Transfusion Syndrome using Serial Amnioreduction in Resource-Constrained Unit: A Case Report

Background: Twin-twin transfusion syndrome is an important complication of monochorionic placentation in twin pregnancy. The management of this condition in Nigeria and many other developing countries has always been “watchful expectancy” with attendant high perinatal morbidity and mortality. Amnioreduction is a less demanding treatment option compared with fetoscopic laser coagulation management option in terms of cost and expertise, but has not been reported from any unit in Nigeria. Case Presentation: A 28-year-old gravid 2 para 1+0, 1 alive, carrying twin pregnancy was referred at 22 weeks gestation with complaint of mild discomfort due to sudden rapid enlargement of the abdomen. Physical examination and ultrasound scan assessment confirm Quintero stage II Twin-twin transfusion syndrome and she underwent serial amnioreduction at 24, 28 and 31 weeks of gestation with satisfactory outcomes. She had caesarean section at 33 weeks due to an acute episode of severe maternal discomfort and was delivered of 2 live female babies. There were no adverse perinatal events. Conclusion: This case presented demonstrates the role of amnioreduction in the management of carefully selected cases of twin-twin transfusion syndrome and further encouraged its utilization. in resource-constrained units instead of ‘watchful expectancy’ and in the absence of fetoscopic laser photocoagulation

Fetoscopic Laser Coagulation in Twin-Twin Transfusion Syndrome: Case Series

Twin-to-twin transfusion syndrome is a fatal complication and twins with monochorionic/diamniotic placentas are affected due to placental vascular anastomoses, producing volume transfer of blood from one twin to the other. The donor twin becomes hypovolemic with oligohydramnios and the recipient becomes hypervolemic with polyhydramnios. Twin-to-twin transfusion syndrome is associated with increased perinatal morbidity and mortality and expresses longstanding health hazards. Serial amnioreduction and fetoscopic laser photocoagulation of the vascular anastomoses are the main therapeutic approaches for twin-to-twin transfusion syndrome. Higher survival rates after fetoscopic laser ablation of the anastomotic vessels in comparison to serial amnioreduction have been reported in multicenter randomized clinical trials. We report the fetoscopic laser coagulation of three twin-to-twin transfusion syndrome cases at Ankara Dr. Zekai Tahir Burak Health Practice Research Center, Perinatology Clinics.

Maternal Pulmonary Oedema during Foetoscopic Surgery

We report a case of maternal pulmonary oedema necessitating intubation and ventilation with associated hyperchloraemic metabolic acidosis during foetoscopic laser surgery for twin-twin transfusion syndrome (TTTS), believed to be secondary to absorption of normal saline irrigation fluid. TTTS complicates 10% to 20% of monochorionic twin pregnancies and develops due to imbalanced vascular anastomoses and consequent unidirectional transfusion between the twins. The recipient is at risk of cardiac failure due to circulatory overload and the donor twin becomes hypoperfused. The recipient is polyhydramniotic and the donor is oligohydramniotic. Untreated severe TTTS has a mortality rate of up to 90%. Treatment options include delivery if viable, serial amnioreduction or foetoscopic laser ablation of the communicating vessels. Since the Eurofoetus study, laser ablation has been the mainstay of treatment for pre-viable TTTS, involving insertion of endoscopes transabdominally into the polyhydramniotic sac to allow visualisation and ablation of the anastosmotic vessels. Amnioreduction does not correct the underlying pathology and offers very little in advanced disease. Foetoscopic laser ablation leads to an improved survival past 28 days and a lower incidence of neurological complications compared to serial amnioreduction.

Long-term neurologic outcomes after common fetal interventions

Fetal interventions have clearly decreased mortality, but the neurological outcomes of survivors are of critical concern. Here we consolidated available data on long-term neurological outcomes after common fetal interventions to guide counseling, management, and future research. Published studies assessing long-term neurological outcomes after common fetal interventions from 1990 through 2014 were collected. We included all studies with a cohort of more than 5 patients and with follow-up of 1 year or longer. We divided procedures into those performed for singletons and for multiples. Singleton procedures included amnioinfusion for preterm premature rupture of membranes, intrauterine transfusion for red cell alloimmunization-associated anemia, intrauterine transfusion for parvovirus-associated anemia, vesicoamniotic shunts, thoracoamniotic shunts, ventriculoamniotic shunts, fetal endoscopic tracheal occlusion for congenital diaphragmatic hernia, and open fetal cases by myelomeningocele and others. Multiple procedures included those done for monochorionic twins including serial amnioreduction, selective fetoscopic laser photocoagulation, and selective termination. Of 1341 studies identified, 28 met the inclusion criteria. We combined available literature for all procedures. Studies varied in their length of follow-up and method of assessing neurological status. Neurological outcome after intervention varied by procedure but was normal in 40-93%, mildly impaired in 3-33%, and severely impaired in 1-40%. Follow-up to school age was rare with the exception of procedures for monochorionic twins. Fetal treatments have been successful in achieving survival in previously hopeless cases, but success should also be determined by the outcomes of survivors. Except for monochorionic twins, there is a dearth of reported long-term outcomes. Standardized reporting of long-term neurological sequelae is imperative so that meaningful analysis and study comparisons can be made.

Treatment of twin to twin transfusion syndrome – comparison of two therapeutic methods – amnioreduction and lasertherapy

Twin to twin transfusion syndrome occurs in 15% of monochorionic twin pregnancies. Untreated, TTTS has been reported to have a mortality of nearly 100%. Two main therapies include serial amnioreduction and fetoscopic laser coagulation for the vascular anastomoses. The aim of the project was to investigate the optimal diagnostic and therapeutic procedure in pregnancies complicated by TTTS. Additionally the study was supposed to compare non-invasive and invasive methods of treatment and to show antenatal and postnatal follow - up to 4 months of age. 42 pregnant women with twin-to-twin transfusion syndrome were assigned to laser therapy using diode laser and 33 pregnant women underwent only several amnioreductions. Selected parameters characterizing the pregnancy were compared in both groups. In the amnioreduction group, the perinatal survival rate seven days after the delivery was 31.8%. The survival rate of at least one twin was 39.4%. As compared to the amnioreduction group, in the laser group the survival rate of at least one twin was observed in 31 cases (31/42) and it was equal to 74%. Neurological complications in the amninoreduction group were observed in 19% (4/21) of cases, in the laser group and in 5% (2/40) of neonates at 4 months of age. Currently the preferred and only method that addresses the cause of the disease is the endoscopic laser coagulation of anastomoses. Comparison of the two treatments shows better outcomes with higher survival rates and minor neurological defects in cases treated with laser coagulation.

Hepatoblastoma in an infant with paternal uniparental disomy 14

A 29-year-old primigravida developed polyhydramnios at 24 weeks of gestation, requiring six serial amnioreductions. In addition, prenatal ultrasound examinations revealed a fetus with small stomach pouch, small thorax, slightly shortened limbs, and skin edema; paternal uniparental disomy 14(upd(14)pat) phenotype was suspected. At 37 weeks, the patient delivered a 2558 g female infant with characteristic facial features, webbed neck, thoracic deformity, abdominal wall defect, skin edema, overlapping fingers, placentomegaly, and small thorax with 'coat-hanger' appearance of the ribs on chest X-ray. A phenotype consistent with upd(14)pat was confirmed by DNA analysis. Although the infant's condition was initially stable, hepatoblastoma was subsequently detected and right hepatectomy was performed on day 224. On day 382, the infant was discharged with in-home respiratory management.

Treatment of twin–twin transfusion syndrome

Twin–twin transfusion syndrome is characterized by unequal blood exchange from the donor twin to the recipient co-twin through placental vascular anastomoses. Treatment of twin–twin transfusion syndrome consists of serial amnioreduction, septostomy, laser photocoagulation of placental vessels and umbilical cord occlusion of the apparently sick twin. Amnioreduction reduces maternal discomfort due to polyhydramnios and improves fetal circulation by reducing amniotic fluid pressure on the placenta. Septostomy equalizes amniotic fluid pressure between the two gestational sacs. Laser therapy interrupts intertwin blood shunting and restores two independent circulations. Umbilical cord occlusion is offered when signs of imminent death are present, such as hydrops and cardiac failure. Laser therapy is associated with increased neonatal survival rates and lower risk of adverse outcomes compared with other treatments.

Vascular programming in twins: the effects of chorionicity and fetal therapy for twin-to-twin transfusion syndrome.

We assessed vascular programming in genetically identical monochorionic twin pairs with twin-to-twin transfusion syndrome (TTTS) treated differently in utero by serial amnioreduction or fetal laser arterial photocoagulation. This case-control study re-assessed four twin groups at median 11 years comprising 20 pairs of monochorionic diamniotic twins: nine treated by amnioreduction (TTTS-amnio) and eleven by laser (TTTS-laser) with seven monochorionic and six dichorionic control pairs. Outcome measures were current blood pressure (BP), brachio-radial arterial stiffness derived from pulse wave velocity (PWV), resting microcirculation (Flux) and response to heating and post-occlusive reactive hyperaemia measured using laser Doppler. Potential confounders [PWV and BP at first study, current height, weight, heart rate and twin type (ex-recipient, ex-donor or heavier/lighter of pair)] were accounted for by Mixed Linear Models statistical methodology. PWV dichorionic > monochorionic (P = 0.024); systolic and diastolic BP dichorionic > TTTS-amnio and TTTS-laser (P = 0.004, P = 0.02 and P = 0.005, P = 0.02, respectively). Within-twin pair pattern of PWV discordance was similar in laser treated and dichorionic controls (heavier-born > lighter), opposite to TTTS-amnio and monochorionic controls. Flux monochorionic > dichorionic (P = 0.044) and heavier > lighter-born (P = 0.024). TTTS-laser and dichorionic diamniotic showed greatest hyperaemic responses (dichorionic > TTTS-amnio or monochorionic controls (P = 0.007, P = 0.025). Hyperaemic responses were slower in heavier-born twins (P = 0.005). In summary, monochorionic twins had lower BP, arterial stiffness and increased resting vasodilatation than dichorionic twins implying shared fetal circulation affects vascular development. Vascular responses in laser-TTTS were similar to dichorionic and opposite to TTTS-amnio suggesting a lasting effect of fetal therapy on vascular health.

Neurodevelopmental Outcome and Risk Factors for Disability for Twin-Twin Transfusion Syndrome Treated With Laser Surgery

Monochorionic pregnancies are characterized by a single placenta shared by the twin fetuses. Twin-twin transfusion syndrome (TTTS) occurs in up to 15% of such pregnancies and results from unbalanced blood flow between the twins through placental vascular anastomoses. There is a high rate of fetal death and of neurodevelopmental disability among long-term survivors. Although serial amnioreduction improves survival in severe TTTS, it has little effect on the underlying transfusion process and does not prevent development of major neurodevelopmental disability in survivors. Fetoscopic laser ablation, in contrast, interrupts blood flow between the fetuses and has the potential to prevent neurologic injury and reduce neurodevelopmental disability among survivors. The use of fetoscopic laser ablation has been associated with better overall outcomes when compared with amnioreduction, and some investigators have suggested that it is the preferred treatment. Many studies have reported lower rates of cerebral palsy (CP) and neurodevelopmental disability in long-term survivors after laser surgery, but few studies have examined these outcomes in detail.

Prognosis and long-term neurodevelopmental outcome in conservatively treated twin-to-twin transfusion syndrome

BackgroundAmnioreduction remains a treatment option for pregnancies with twin-to-twin transfusion syndrome (TTTS) not meeting criteria for laser surgery or those in which it is not feasible. Amnioreduction is a relatively simple treatment which does not require sophisticated technical equipment. Previous reports of conservative management have indicated that major neurodevelopmental impairment occurs in 14.3-26% of survivors. The purpose of this study was to investigate long-term neurodevelopmental outcome in conservatively treated TTTS.MethodsDuring the nine-year study period from January 1996 to December 2004, all pregnancies with TTTS who were admitted to our center were investigated. TTTS was diagnosed by using standard prenatal ultrasound criteria, and staged according to the criteria of Quintero et al. We reviewed gestational age at diagnosis, gestational age at delivery, the stage of TTTS at diagnosis, and diagnosis to delivery interval. Neonatal cranial ultrasound findings were reviewed and the neurodevelopmental outcomes were evaluated.ResultsTwenty-one pregnancies with TTTS were included. Thirteen pregnancies (62%) were treated with serial amnioreduction. The mean gestational age at delivery was 28 weeks (22 - 34 weeks). The perinatal mortality rate was 42.9%. Twenty survivors were followed up until at least 3 years of age. The mean age at follow-up was 6.3 years (3 - 12 years). Six children (30%) had neurodevelopmental impairment. Four children (20%) had major neurodevelopmental impairment and two children (10%) had minor neurodevelopmental impairment. Children with neurodevelopmental impairment were delivered before 29 weeks of gestation.ConclusionsOur study showed a high rate of perinatal mortality and a high rate of major neurodevelopmental impairment in conservatively treated TTTS. The long-term outcomes for the survivors with TTTS were good when survivors were delivered after 29 weeks of gestation.

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390: Long-term neurodevelopmental outcome in twin-to-twin transfusion syndrome (TTTS) in the eurofoetus trial

390: Long-term neurodevelopmental outcome in twin-to-twin transfusion syndrome (TTTS) in the eurofoetus trial

Syndrome transfuseur-transfusé : physiopathologie, diagnostic et traitement chirurgical

Multiple pregnancies represent 2% of all pregnancies but account for 20% of admissions to neonatal intensive care units. The outcome of multiple pregnancies is mainly dependent on chorionicity. Most perinatal complications are 3 to 12 times more prevalent in monochorionic pregnancies. The increased mortality and morbidity in this setting are mainly related to vascular anastomoses on the chorionic plate, joining the two fetal circulations. Intrauterine death of a monochorionic twin leads to exsanguination of the survivor, with fatal outcome in 20 to 30% of cases and a similar rate of severe ischemic complications. The most severe and acute complication is the twin-to-twin transfusion syndrome (TTTS). The main clinical manifestations of TTTS are the polyuric polyhydramnios--oliguric oligohydramnios sequence in the recipient and donor twin, respectively. TTTS is associated with a perinatal mortality rate of around 90%, and neurological sequelae are present in 20-40% of survivors born at around 25 weeks. Serial amnioreduction was long the only fetal therapy for TTTS, improving the survival rate to around 50% for at least one twin delivered at around 28 weeks, and reducing the risk of sequelae to around 20% among survivors. We have developed an intrauterine fetoscopic surgical treatment for TTTS. A 2-mm endoscope and a diode laser fiber are introduced percutaneously, under local anesthesia, through a single 3-mm trocard Coagulation of feto-fetal anastomoses on the chorionic plate leads to the survival of at least one twin in around 80% of cases at 33 weeks. Fewer than 10% of survivors have sequelae, mainly related to prematurity. We conducted a randomized controlled trial that confirmed the superiority of laser therapy over amnioreduction. The long-term outlook of these infants is good, with up to 6 years of follow-up.

A prospective, randomized, multicenter trial of amnioreduction vs selective fetoscopic laser photocoagulation for the treatment of severe twin-twin transfusion syndrome

The objective of the study was to examine the effect of selective fetoscopic laser photocoagulation (SFLP) vs serial amnioreduction (AR) on perinatal mortality in severe twin-twin transfusion syndrome (TTTS). This was a 5 year multicenter, prospective, randomized controlled trial. The primary outcome variable was 30 day postnatal survival of donors and recipients. There was no statistically significant difference in 30-day postnatal survival between SFLP or AR treatment for donors at 55% (11 of 20) vs 55% (11 of 20) (P = 1.0, odds ratio [OR] 1, 95% confidence interval [CI] 0.242 to 4.14) or recipients at 30% (6 of 20) vs 45% (9 of 20) (P = .51, OR 1.88, 95% CI 0.44 to 8.64). There was no difference in 30 day survival of 1 or both twins on a per-pregnancy basis between AR at 75% (15 of 20) and SFLP at 65% (13 of 20) (P = .73, OR 1.62, 95% CI 0.34 to 8.09). Overall survival (newborns divided by the number of fetuses treated) was not statistically significant for AR at 60% (24 of 40) vs SFLP 45% (18 of 40) (P = .18, OR 2.01, 95% CI 0.76 to 5.44). There was a statistically significant increase in fetal recipient mortality in the SFLP arm at 70% (14 of 20) vs the AR arm at 35% (7 of 20) (P = .25, OR 5.31, 95% CI 1.19 to 27.6). This was offset by increased recipient neonatal mortality of 30% (6 of 20) in the AR arm. Echocardiographic abnormality in recipient twin Cardiovascular Profile Score is the most significant predictor of recipient mortality (P = .055, OR 3.025/point) by logistic regression analysis. The outcome of the trial did not conclusively determine whether AR or SFLP is a superior treatment modality. TTTS cardiomyopathy appears to be an important factor in recipient survival in TTTS.

Incidence, mechanisms, and patterns of fetal cerebral lesions in twin-to-twin transfusion syndrome

Objective. To determine the incidence of fetal cerebral lesions and their characteristics in twin-to-twin transfusion syndrome (TTTS).Design and setting. This was a retrospective analysis at a single center for the period 1999 to 2004 in which 299 cases of severe TTTS at 15–28 weeks of gestation were reviewed.Methods. Only cerebral injuries diagnosed during pregnancy or ischemic lesions diagnosed within the first week of life were considered in order to exclude those related to prematurity. We only included cases resulting in at least one survivor at one week after delivery, as well as fetuses that were terminated because of severe cerebral abnormalities. We excluded all fetuses delivered at <24 weeks of gestation that died prior to undergoing postnatal cranial ultrasonography. The main outcome measures were fetal cerebral lesions, intrauterine death, survival, and neonatal death.Results. Two hundred and ninety-nine pregnancies were evaluated. Three hundred and fifteen fetuses were reviewed. Cerebral abnormalities developed antenatally in 26/315 fetuses (8.25%). All lesions but one were diagnosed prenatally. Prenatal diagnosis of these lesions was achieved primarily by ultrasound (US) and magnetic resonance imaging (MRI), in 20/25 (80%) and in 5/25 (20%) fetuses, respectively. Cerebral abnormalities developed following primary laser coagulation in 12/222 (5.40%), following serial amnioreduction in 9/66 (13.63%), and following expectant management in 3/14 (21.4%) fetuses. Abnormalities developed after single intrauterine fetal death (IUFD) in 14 cases.Conclusions. Cerebral morbidity in TTTS mainly occurs following vascular disruptive lesions. Both donors and recipients are at risk of developing either ischemic or hemorrhagic lesions. The risk of developing cerebral lesions in single survivors is significantly lower following laser treatment. Combined use of a targeted US and fetal MRI could detect most cerebral abnormalities antenatally. Timing of the triggering event is critical for planning serial US and MRI follow-up examinations.

Long-term neurodevelopmental outcome in twin-to-twin transfusion syndrome in the eurofoetus trial

SYNDROME IN THE EUROFOETUS TRIAL LISA ORTQVIST, SYLVIE CHEVRET, LAURENCE BUSSIERES, STEPHANIE STARACI, FABIENNE HUARD, YVES VILLE, Paris-Ouest University VSQ, Department of Gynecology and Obstetrics, Paris, France, Universite Paris 7, INSERM 444, Statistics, Paris, France, Delegation Regionale a la Recherche Clinique, Hopital Saint-Louis, Clinical Research, Paris, France OBJECTIVE: To investigate long-term neuro-developmental outcome of children born in the Eurofoetus RCT comparing endoscopic laser surgery and serial amnioreduction in twin-to-twin transfusion syndrome (TTTS). STUDY DESIGN: Survivors beyond 6 months were followed-up and evaluated by standardized examination (Amiel-Tison and Gosselin) and by the Ages and Stages questionnaires (ASQ). Primary outcome was the incidence of severe neurological abnormalities leading to permanent disability. In addition children were subjected to cognitive evaluation using Wechsler Intelligence Scale for Children (WISC-IV) at the age of 6. RESULTS: 120 children (73 treated with laser (L) and 47 with amnioreduction (A)) survived beyond 6 months. Six were lost to follow-up. 114 children (69 L and 45 A) were examined at a median (25-75 percentile) of 5.3 (4.4-6.1) years. Incidence of major neurological problems was 15/114 (13.1%). Univariate analysis is summarized in Table 1. Multivariate analysis showed that only gestational age at delivery, 1-minute Apgar score and Quintero staging were predictive factors. Neurological evaluation changed over time with improvement or worsening in 4/114 and 5/114 cases but remained stable from the age of 2. Normal ASQ scores were found in 72% and 89% and in 72% and 80% of cases at 2 and 4 years in the L and A groups respectively (NS). IQ was below 85 in 0/10 and 2/9 children in L and A groups at the age of 6. CONCLUSION: Among TTTS survivors, the risk of developing long-term major neurological impairment depends upon perinatal factors but not of fetal treatment.

Peripheral skin necrosis in the recipient of monochorionic twins complicated by twin–twin transfusion syndrome

Twin-twin transfusion syndrome (TTTS) complicates approximately 15% of monochorionic, diamniotic twin pregnancies and if untreated carries a high perinatal loss rate of between 80% and 100%, depending on the stage. The underlying pathology in TTTS appears to be an imbalanced intertwin perfusion difference, secondary to functional unidirectional arteriovenous anastomoses within a monochorionic placenta. We report two cases of monochorionic twin pregnancy complicated by TTTS, in which the pregnancies were treated by serial aggressive amnioreduction. However, the recipient twin in each pregnancy developed 'ischemic damage' to a lower limb.

OC84: How early do imaging changes occur in MC/DA surviving twins following co‐twin demise?

Results: Cerebral abnormalities developed prenatally in 27 fetuses (9.37%, 27/288). Prenatal diagnosis of these lesions was achieved primarily by US and MRI in 21/27 (78%) and in 6/27 (22%) fetuses respectively. Cerebral abnormalities developed following primary laser coagulation, serial amnioreduction or expectant management in 12/222 (5.40%), in 9/124 (13.63%) and in 3/14 (21.4%) fetuses respectively. Abnormalities developed after single intrauterine fetal death (IUD) in 14 cases including 6 severely anemic survivors as a result of exsanguination in their dead co-twin. These lesions developed following primary laser coagulation, amniodrainage and expectant management in 3/55 (5.45%), 7/20 (35%) and 1/14 (7%) cases respectively. Conclusions: Cerebral morbidity in TTTS mainly occurs following vascular disruptive lesions. Both donors and recipients are at risk of developing either ischemic or hemorrhagic lesions. The risk of developing cerebral lesions in single survivors is significantly less following laser treatment. Timing of the triggering event is critical for serial US and MRI follow-up examination.