Survivors Of Twin-twin Transfusion Syndrome Research Articles

Perinatal risk factors of neurodevelopmental impairment after fetoscopic laser photocoagulation for twin-twin transfusion syndrome: systematic review and meta-analysis.

Monochorionic twins with twin-twin transfusion syndrome (TTTS) treated with fetoscopic laser photocoagulation (FLP) are at increased risk of neurodevelopmental impairment (NDI). This meta-analysis aimed to identify the prevalence of and perinatal risk factors for NDI in TTTS survivors treated with FLP. We performed a search in PubMed, EMBASE, Scopus and Web of Science, from inception to 13 February 2021, for studies evaluating perinatal risk factors for NDI in children diagnosed prenatally with TTTS managed by FLP. Data on severity of TTTS at the time of diagnosis, defined according to the Quintero staging system, FLP-related complications and perinatal outcomes were compared between children with a history of TTTS treated with FLP with and those without NDI, which was defined as performance on a cognitive or developmental assessment tool ≥ 2 SD below the mean or a defined motor or sensory disability. A random-effects model was used to pool the mean differences or odds ratios (OR) with the corresponding 95% CIs. Heterogeneity was assessed using the I2 statistic. Nine studies with a total of 1499 TTTS survivors were included. The overall incidence of NDI was 14.0% (95% CI, 9.0-18.0%). The occurrence of NDI in TTTS survivors was associated with later gestational age (GA) at FLP (mean difference, 0.94 weeks (95% CI, 0.50-1.38 weeks); P < 0.0001, I2 = 0%), earlier GA at delivery (mean difference, -1.44 weeks (95% CI, -2.28 to -0.61 weeks); P = 0.0007, I2 = 49%) and lower birth weight (mean difference, -343.26 g (95% CI, -470.59 to -215.92 g); P < 0.00001, I2 = 27%). Evaluation of different GA cut-offs showed that preterm birth before 32 weeks was associated with higher risk for NDI later in childhood (OR, 2.25 (95% CI, 1.02-4.94); P = 0.04, I2 = 35%). No statistically significant difference was found between cases with and those without NDI with respect to Quintero stage of TTTS, recipient or donor status, development of postlaser twin anemia-polycythemia sequence, recurrence of TTTS and incidence of small- for-gestational age or cotwin fetal demise. TTTS survivors with later GA at the time of FLP, earlier GA at delivery and lower birth weight are at higher risk of developing NDI. No significant association was found between Quintero stage of TTTS and risk of NDI. Our findings may be helpful for parental counseling and highlight the need for future studies to understand better the risk factors for NDI in TTTS survivors. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Neurodevelopmental Trajectories of Preterm Born Survivors of Twin–Twin Transfusion Syndrome: From Birth to 5 Years of Age

To investigate the neurodevelopmental outcome at age 2 and 5years in survivors of twin-twin transfusion syndrome (TTTS) treated with fetoscopic laser surgery and born premature and/or small for gestational age. At 2 and 5years of age, standardized neurologic, motor, and cognitive assessments were performed by a neonatologist, a pediatric physical therapist, and a psychologist. Behavior was assessed using a validated questionnaire completed by parents. Neurodevelopmental assessment at both time points was available for 73 survivors of TTTS. Mild to moderate neurodevelopmental impairment (NDI) was detected in 34% of survivors (25 of 73) at 5years, compared with 25% (18 of 73) at 2years (P=.178). Severe NDI was observed in 12% (9 of 73) at 5years and in 3% (2 of 73) at 2years (P=.035). Mean cognitive score was lower at the 5-year follow-up (90.7±12.3 vs 95.6±13.1 at 2years; P=.001), and more children were diagnosed with mild cognitive impairment at 5years (29% vs 11% at 2years; P=.007). When comparing individual outcomes at both time points, 35% (25 of 71) moved from a normal outcome or mild to moderate impairment at 2years toward more severe impairment at 5years. A high rate of mild to moderate cognitive impairment and severe NDI at age 5years was not identified at age 2years. Our data highlight the importance of longitudinal follow-up of survivors of TTTS beyond age 2years and emphasize the precautions that should be taken when diagnosing an absence of impairment before school age.

Fetal neurodevelopmental recovery in donors after laser surgery for twin‐twin transfusion syndrome

Fetal magnetic resonance imaging (MRI) and spectroscopy (MRS) provide a unique opportunity to non-invasively measure markers of neurodevelopment in survivors of twin-twin transfusion syndrome (TTTS). To characterize fetal brain maturation after laser surgery for TTTS by measuring brain volumes and cerebral metabolite concentrations using fetal MRI + MRS. Prospective study of dual surviving fetuses treated with laser surgery for TTTS. At 4-5 postoperative weeks, fetal MRI was used together with novel image analysis to automatically extract major brain tissue volumes. Fetal MRS was used to measure major metabolite concentrations in the fetal brain. Twenty-one twin pairs were studied. The average (±SD) gestational age at MRI was 25.89 (±2.37) weeks. Total brain volume (TBV) was lower in the donors, although cerebral volumes were not different between twin pairs. Recipients showed lower proportions of cortical and cerebellar volumes, normalized to TBV and cerebral volumes. MRS data showed that biochemical differences between twin brains were related to discrepancy in their brain volumes. Although donors have a smaller TBV compared to recipients, proportionality of brain tissue volumes are preserved in donors. MRS maturational markers of fetal brain development show that recovery in donors persists 4 weeks after surgery.

Early postnatal cardiac follow-up of survivors of twin-twin transfusion syndrome treated with fetoscopic laser coagulation.

To assess the cardiac function and prevalence of congenital heart defects (CHD) in twin-twin transfusion syndrome (TTTS) survivors. Prospective follow-up of TTTS pregnancies treated with laser surgery (2015-2018). Echocardiography was performed 1 day and 1 month after birth (corrected for prematurity). Results were compared with a control group of age-matched uncomplicated monochorionic twin-pairs at 1 month. Eighty-nine TTTS (168 neonates) and nine control pregnancies (18 neonates) were enrolled. CHD birth prevalence was 9.2% (8/87) in recipients and 13.6% (11/81) in donors (p = 0.37). Four of 19 (21%) were detected prenatally, all pulmonary stenosis. Donors had lower aortic peak velocities compared with recipients at day 1 (0.66 ± 0.15 m/s vs 0.71 ± 0.19 m/s, p = 0.04) and 1 month (1.04 ± 0.21 m/s vs 1.11 ± 0.18 m/s, p = 0.02), but not compared with controls. CHD prevalence in TTTS survivors is high, with a low prenatal detection of minor abnormalities. Follow-up fetal echocardiograms and a postnatal echocardiogram should be offered.

Behavioural outcome in twin–twin transfusion syndrome survivors treated with laser surgery

ObjectiveEvaluate the incidence of and risk factors for behavioural problems in twin–twin transfusion syndrome (TTTS) survivors treated with fetoscopic laser coagulation.DesignObservational cohort study.SettingNational referral center for fetal therapy, Leiden University...

Congenital Heart Defects in Monochorionic Twins: A Systematic Review and Meta-Analysis.

Monochorionic (MC) twins are at an increased risk of developing congenital heart defects (CHDs) compared to singletons and dichorionic twins. The development of acquired CHDs in this specific group of twins is associated with twin–twin transfusion syndrome (TTTS). We performed a systematic review and meta-analysis to provide an overview of the reported birth prevalence of CHDs in liveborn MC twins with and without TTTS. Twelve studies were included in this review. Compared to the reference population, MC twins were 6.3 times more likely to be born with a CHD (59.3 per 1000 liveborn twins; relative risk (RR) 6.3; 95% confidence interval (CI): 4.4–9.1), and TTTS twins had a 12-fold increased risk of having a CHD at birth (87.3 per 1000 live births; RR 12.4, 95% CI: 8.6–17.8). The increased incidence of CHDs can mainly be attributed to the risk of right ventricular outflow tract obstruction (35/1000 TTTS twin live births vs. 0.5/1000 singleton live births). We recommend an expert fetal echocardiogram in all MC twins, follow-up scans in the event of TTTS, and a postnatal cardiac evaluation in all TTTS survivors.

1052: Brain composition differences in fetuses after laser surgery for twin-twin transfusion syndrome (TTTS)

We describe the maturational pattern differences of various brain tissues between donor versus recipient twins treated with in utero laser surgery for TTTS using 3D MRI reconstruction. This was a prospective study of 20 patients with TTTS and dual survivors 4 weeks postoperatively. Fetal MRI scans were performed with a 1.5-T scanner. Multiple stacks of singleshot fast spin-echo T2-weighted slices of the fetal brain were obtained in the axial, sagittal, and coronal planes for each fetus. The images were reconstructed into 3D MRI volumes after motion correction. Total brain volume (TBV), cortical plate region (CR), developing white matter region (WMR), cerebellum, and ventricles were delineated using a semi-automated, atlas based segmentation method (Figure 1(a)). CR, WMR, cerebellum, and ventricular volumes were normalized by TBV for each subject. The CR and WMR were additionally normalized to the supratentorial structures only, called total parenchymal volume (TPV). Relationship between gestational age (GA), twin status (donor/recipient) and normalized tissue volumes were modeled using robust, multiple linear regression and tested for significance (defined as p<0.05). Eighteen of 20 twin pairs had sufficient image quality for analysis. The median gestational age (GA) at laser surgery was 19.8 (16.4-26.4) weeks, and 25.1 (22.1-30.7) weeks at MRI examination. Figure 1 (b-f) shows the comparative relationship between normalized tissue volumes and gestational age between the donor and recipient twin pairs. TBV was significantly lower in the donor twins (Figure 1b), although TPV were not different between the twin pairs (Figure 1c). Recipients showed significantly lower proportions of CR and cerebellar volumes normalized to TBV compared to donors (Figure 1d,e). Ventricular volumes normalized to TBV were significantly higher in the donor twins (Figure 1f). No significant differences were detected in WMR volumes between the two groups. Recipients showed significantly lower proportions of CR normalized to TPV compared to donors. Although the total brain volume of the donor twin was smaller than that of the recipient twin, the proportional brain tissue volumes of the donor were preserved. Rather, it was the recipient twin that had relatively reduced proportions of cortical plate region and cerebellar volumes.

276: MRI scoring to predict neurodevelopmental outcomes in survivors of twin-twin transfusion syndrome

276: MRI scoring to predict neurodevelopmental outcomes in survivors of twin-twin transfusion syndrome

220: Delivery timing after laser surgery for twin-twin transfusion syndrome

Optimal timing of delivery of dual survivors of twin-twin transfusion syndrome (TTTS) after laser surgery is unknown. The aim was to assess neonatal morbidity based on the gestational age (GA) at delivery in this cohort of patients. Retrospective study of monochorionic diamniotic twins that underwent laser surgery for TTTS with dual survivors at 32 0/7 weeks. The delivery indication was categorized as elective, non-elective (maternal and/or fetal complications), or spontaneous. To simulate expectant management, patients that underwent elective delivery between 32 0/7 to 35 6/7 weeks (“early elective group”) were compared to all patients that delivered ≥ 36 0/7 weeks (“expectant management group”). The primary outcome was a composite [neonatal intensive care unit admission (NICU), small for GA, oxygen supplementation ≥ 1 day, intraventricular hemorrhage, periventricular leukomalacia, hypotension, necrotizing enterocolitis, feeding difficulty, anemia requiring transfusion, polycythemia, stillbirth, or neonatal death]. The primary outcome and its components were tested for the effect of early elective delivery using multiple logistic regression, controlling for Quintero stage, GA at surgery, percent discordance at surgery, and postoperative cervical length. A total of 173 patients had dual survivors at 32 0/7 weeks (Table). Nine were in the early elective group and 75 in the expectant management group and are part of this analysis. There was no difference in the primary outcome between the early elective and expectant management group (OR 0.88 [0.14-5.47], p = 0.8889). However, when the individual morbidities were examined, the early elective group was associated with significantly increased occurrence of NICU admission ≥ 5 days (OR 9.54 [1.67-54.55], p = 0.0112), oxygen supplementation ≥ 1 day (OR 22.72 [2.49-207.80], p = 0.0057), and feeding difficulties (OR 5.59 [1.14-27.46], p = 0.0343). One donor demise (surviving recipient) occurred in the early elective group at a GA of 34 4/7 weeks, with no demises in the expectant management group. Among patients with dual survivors post laser surgery for TTTS at a GA of 32 weeks, elective delivery prior to 36 weeks did not appear to be protective.

Persistent Pulmonary Hypertension of the Newborn in Twin-Twin Transfusion Syndrome: A Case-Control Study

Background: Persistent pulmonary hypertension of the newborn (PPHN) is associated with severe morbidity and mortality. Twin-twin transfusion syndrome (TTTS) is suggested to increase the risk of PPHN. Objectives: To describe the incidence of PPHN in TTTS twins and to identify risk factors in TTTS twins for the development of severe PPHN. Methods: Cases with severe PPHN were extracted from our monochorionic twin database (2002-2016). Severe PPHN was defined as severe hypoxaemia requiring mechanical ventilation and inhaled nitric oxide (iNO) treatment, confirmed by strict echocardiographic criteria. A case-control comparison within TTTS survivors was conducted to identify risk factors for PPHN. Results: The incidence of PPHN in TTTS twins was 4% (24/598, 95% confidence interval [CI] 2.7-5.9%) and 0.4% (2/493, 95% CI 0.1-1.5%) in uncomplicated monochorionic twins (odds ratio [OR] 10.3, 95% CI 2.4-43.9; p = 0.002). Two risk factors were independently associated with PPHN: severe prematurity (OR 3.3, 95% CI 1.0-11.4) and recipient status (OR 3.9, 95% CI 1.4-11.0). In TTTS recipients, another risk factor for PPHN is anaemia at birth (OR 7.2, 95% CI 1.8-29.6). Conclusion: Clinicians caring for neonates with TTTS should be aware of the 10-fold increased risk of PPHN compared to uncomplicated monochorionic twins. PPHN occurs more often in case of premature delivery and in recipient twins, particularly in the presence of anaemia at birth. As the development of severe PPHN is difficult to predict, we advise that all TTTS twins should be delivered in a tertiary care centre with iNO treatment options.

Long-Term Neurodevelopmental Outcome in Survivors of Twin-to-Twin Transfusion Syndrome.

Twin-twin transfusion syndrome (TTTS) is a severe complication of monochorionic (MC) twin pregnancies associated with high perinatal mortality and morbidity rates. Management in TTTS is a major challenge for obstetricians and neonatologists. Twins with TTTS are often born prematurely after an extremely distressing and highly hazardous fetal period. Follow-up studies report varying rates of cerebral palsy (CP) and long-term neurodevelopmental impairment (NDI). This review discusses the latest findings on the long-term outcome of TTTS survivors, possible risk factors for long-term impairment, and provides recommendations for future research.

Twin-twin transfusion syndrome: neurodevelopment of infants treated with laser surgery.

To assess the neurodevelopmental functions of survivors of twin-twin transfusion syndrome (TTTS) treated by fetoscopic laser coagulation (FLC), during the first year of life, comparing them to a control group; and to verify the influence of specific variables on neurodevelopment. This was a prospective, longitudinal study. The sample comprised 33 monochorionic diamniotic twins who underwent FLC for treatment of TTTS and 22 full-term infants of single-fetus pregnancies. Bayley Scales of Infant and Toddler Development Screening Test were used for evaluation. Prenatal, perinatal and postnatal information were obtained. There was an increased frequency of infants in the TTTS group with inadequate performance compared to the control group. The identified variables (fetal donor, low economic income and cardiorespiratory disease) negatively impacted expressive communication and fine motor skills. Although through follow-up is recommended in all TTTS survivors, particular attention is required for the high-risk group as defined in this study.

Blood pressure evaluation in children treated with laser surgery for twin-twin transfusion syndrome at 2-year follow-up

Twin survivors of twin-twin transfusion syndrome (TTTS) may be at risk for early onset of cardiovascular disease. The aim of this study was to determine prevalence and risk factors for elevated blood pressure (BP) among children treated with selective laser photocoagulation of communicating vessels. Data were prospectively collected from surviving children treated for TTTS with laser surgery from 2008 through 2010. Systolic BP (SBP) and diastolic BP (DBP) were obtained from 91 child survivors at age 24 months (±6 weeks) and evaluated based on age, sex, and height percentile. BP percentiles were calculated for each patient and categorized as normal (<95%) or abnormal (>95%). Clinical variables were evaluated using multilevel regression models to evaluate risk factors for elevated BP. BP was categorized as normal in 38% and abnormal in 62% of twin survivors based on percentile for sex, age, and height; a comparable distribution was found for DBP elevation. There were no differences between donor and recipient twins for absolute SBP and DBP or BP classification. In a multivariate analysis, significant risk factors for higher SBP included prematurity (β -0.54; 95% confidence interval [CI], -0.99 to -0.09; P = .02), higher weight percentile (β 0.24; 95% CI, 0.05-0.42; P = .01), and presence of cardiac disease (β 0.50; 95% CI, 0.10-0.89; P = .01). Prematurity was also a significant risk for abnormal DBP (odds ratio, 0.89; 95% CI, 0.80-1.00; P = .05). Child survivors of TTTS had elevated SBP and DBP measurements at 2 years of age, with no differences seen between former donor and recipient twins. Prematurity may be a risk factor for elevated BP measurements in this population. Future studies are warranted to ascertain whether these cardiovascular findings persist over time.

Twin-twin transfusion syndrome: neurodevelopmental screening test.

To assess the neurodevelopmental functions (cognition, language and motor function) of survivors of twin-twin transfusion syndrome (TTTS). Observational cross-sectional study of a total of 67 monochorionic diamniotic twins who underwent fetoscopic laser coagulation (FLC) for treatment of TTTS. The study was conducted at the Center for Investigation in Pediatrics (CIPED), Universidade Estadual de Campinas. Ages ranged from one month and four days to two years four months. Bayley Scales of Infant and Toddler Development Screening Test-III, were used for evaluation. Most children reached the competent category and were classified as having appropriate performance. The preterm children scored worse than term infants for gross motor subtest (p = 0.036). The majority of children reached the expected development according to their age. Despite the good neurodevelopment, children classified at risk should be monitored for development throughout childhood.

Childhood cardiac outcome after intrauterine laser treatment of twin-twin transfusion syndrome is favourable.

Intrauterine laser treatment is used to alleviate abnormal circulatory load and cardiac morbidity affecting foetuses with twin-twin transfusion syndrome (TTTS). We conducted this childhood follow-up study to fill the gap in knowledge about final cardiac outcomes after such interventions. We investigated 19 TTTS pairs - 11 male and eight female - with a mean age of four and a half years (range 1.1-9.9) using 2D, blood flow and tissue Doppler, 3D and speckle tracking echocardiography, and compared them with 19 age-matched and gender-matched singletons. The only observed differences in cardiac structure or function between the donors and recipients were related to diastolic ventricular filling. Recipients had a lower left ventricular ratio of early and late diastolic filling compared with their donor cotwins [1.48(0.35) versus 1.66 (0.28), p < 0.05], but not compared with singleton controls. All observations, except one, were within the reference limits. Speckle tracking could not demonstrate any group differences in systolic ventricular function, besides marginally lower ventricular strain in the donors than controls. Double survivors of laser-treated TTTS showed only minor within-pair differences in diastolic cardiac function at childhood follow-up. Cardiac function in TTTS twins compared well to singleton controls, suggesting a favourable long-term outcome.

PS-019 Childhood Cardiac Outcome Of Twin-twin Transfusion Syndrome After Intrauterine Laser Treatment: An Echocardiographic Study Of Ventricular Function

Background and aim Intrauterine laser treatment of placental vessels is used to alleviate abnormal circulatory load and cardiac morbidity affecting fetuses with twin-twin transfusion syndrome (TTTS). As the final cardiac outcome after such intervention is not known, we conducted this childhood follow-up study of cardiac function in twins treated with intrauterine laser for TTTS. Methods and results Nineteen TTTS pairs (11 male, 8 female) with a mean age of 4.5 (range 1.1–9.9) years were assessed with echocardiography 2D, Doppler, DTI, 3D and speckle tracking, and compared with nineteen age- and gender-matched singletons. Recipients had a lower left ventricular E/A ratio compared with their donor twins [1.48(0.35) vs. 1.66(0.28), p Conclusion Despite significantly different fetal cardiac loading conditions, survivors of laser-treated TTTS show only minor within-pair differences in diastolic cardiac function at follow-up. Cardiac function in TTTS twins compare well to singleton controls, suggesting a favourable long-term outcome.

Improvement in neurodevelopmental outcome in survivors of twin-twin transfusion syndrome treated with laser surgery

To compare the incidence of neurodevelopmental impairment in surviving children from pregnancies with twin-twin transfusion syndrome (TTTS) treated with laser surgery between 2time periods. We compared the neurodevelopmental outcome between the first consecutive cohort of TTTS pregnancies treated with laser surgery from 2000 to 2005, with a cohort treated between 2008 and 2010. Neurologic, cognitive, and motor development was evaluated using Bayley scales at 2 years of age corrected for prematurity. A total of 229 twin pregnancies were treated with laser surgery, 113 in the first cohort and 106 in the recent cohort. Overall survival increased from 70% (158/226) to 80% (170/212) (P= .014). The incidence of neurodevelopmental impairment decreased from 18% (28/152) to 6% (10/155) (P < .01). In multivariate analysis, severe cerebral injury at birth was independently associated with neurodevelopmental impairment (odds ratio, 34.86; 95% confidence interval, 11.83-102.75; P < .01). Overall survival in TTTS has improved over time, with a concomitant reduction in the incidence of neurodevelopmental impairment. Research focused on prevention of cerebral injury is needed to further improve outcomes of these complicated twin pregnancies.

Fetoscopic Laser Therapy for Twin-Twin Transfusion Syndrome

Ever since the first randomized, controlled trial revealed that fetoscopic laser photocoagulation achieved better outcomes than serial amnio-drainage for all stages of twin-twin transfusion syndrome (TTTS) before 26 weeks, many centers have launched their fetoscopic laser therapy program for TTTS. Initially the nonselective method of laser therapy was applied, using the dividing membrane as a landmark to coagulate the placenta vessels, but currently selective methods (selective laser photocoagulation of communicating vessels (SLPCV), sequential SLPCV, and Solomon technique) have evolved to become the mainstream laser treatment modalities. Nevertheless, the nonselective method still has a role in difficult operations. Over the years, with regard to the prognoses of TTTS treated by laser, the attention has gradually shifted from survival rate to the neurological outcomes. The incidence of severe neurodevelopmetal delay remains considerably high in survivors of TTTS treated by FLP, which some reports cited ranging from 6 % to 18 %; learning curve effect exists, affecting both the survival rate and neurological outcomes of TTTS treated by laser. Because more, yet smaller and less-experienced, centers are being set up worldwide, the purpose of this manuscript is to review the basic knowledge and update information about the laser therapy for TTTS.

Developmental genes targeted for epigenetic variation between twin-twin transfusion syndrome children

BackgroundEpigenetic mechanisms are thought to be critical in mediating the role of the intrauterine environment on lifelong health and disease. Twin-twin transfusion syndrome (TTTS) is a rare condition wherein fetuses share the placenta and develop vascular anastomoses, which allow blood to flow between the fetuses. The unequal flow results in reciprocal hypo- and hypervolemia in the affected twins, striking growth differences and physiologic adaptations in response to this significant stressor. The donor twin in the TTTS syndrome can be profoundly growth restricted and there is likely a nutritional imbalance between the twins. The consequences of TTTS on fetal programming are unknown. This condition can now be effectively treated through the use of fetal laparoscopic procedures, but the potential for lifelong morbidity related to this condition during development is apparent. As this condition and the resulting uteroplacental discordance can play a role in the epigenetic process, we sought to investigate the DNA methylation profiles of childhood survivors of TTTS (n = 14). We focused on differences in both global measures and genome-wide CpG specific DNA methylation between donor and recipient children in this pilot study in order to generate hypotheses for further research.ResultsWe identified significant hypomethylation of the LINE1 repetitive element in the peripheral blood of donor children and subtle variation in the genome-wide profiles of CpG specific methylation most prominent at CpG sites which are targets for polycomb group repressive complexes.ConclusionsThese preliminary results suggest that coordinated epigenetic alterations result from the intrauterine environment experienced by infants with TTTS and may, at least in part, be responsible for downstream health conditions experienced by individuals surviving this condition.

Cerebral Injury and Neurodevelopmental Outcome in Twin-Twin Transfusion Syndrome

Twin-twin transfusion syndrome (TTTS) is a severe complication of monochorionic twin pregnancies associated with high perinatal mortality and morbidity rates. Management in TTTS is a major challenge for obstetricians and neonatologists. Twins with TTTS often are born prematurely after an extremely distressing and highly hazardous fetal period. In addition to complications associated with prematurity, surviving twins with TTTS are at increased risk for other complications, including neurological, cardiovascular, renal, and hematologic morbidity. Follow-up studies report varying rates of cerebral palsy and long-term neurodevelopmental impairment. This review focuses on the cerebral injury during the neonatal period as well as long-term neurodevelopmental outcome of TTTS survivors.