Complications in Twin and Triplet Pregnancies (Including TTTS)
Expecting twins or triplets can be a time of joy, anxiety, worry, excitement and anticipation. However, multiple pregnancies carry unique risks and challenges, some of which can have devastating outcomes. At Footprints Baby Loss, we are here to support families navigating these complex journeys, especially those who have experienced the heartbreaking loss of one or more babies.
This page aims to provide clear, compassionate information about complications that can arise in monochorionic pregnancies, where twins or triplets share a placenta, beginning with: Twin-to-Twin Transfusion Syndrome (TTTS).
If you are coming to us you will probably have already been told that your baby or babies might die or have already died. We often find that our families want to understand why so we are including some short explanations of some of the main twin and triplet complications.
Twin-to-Twin Transfusion Syndrome (TTTS)
TTTS is a rare but potentially life-threatening condition that affects approximately 10 to 15 percent of identical twin pregnancies where the twins share a single placenta (monochorionic twins) . In twin-to-twin transfusion syndrome (TTTS), identical twins share a placenta that has blood vessel connections between them. These connections can become unbalanced, so that one twin (the donor) sends more blood to the other twin (the recipient). This imbalance causes the recipient’s body to react by producing more urine, which leads to a buildup of amniotic fluid around them.
At the same time, the donor twin gets less blood, produces less urine, and has less amniotic fluid around them. TTTS is serious because this difference in blood flow and fluid can create complications for both twins, which is why careful monitoring and specialised care are needed.
The main treatment for moderate to severe TTTS is laser surgery. A laser is used to seal off abnormal blood vessel connections on the placenta between the twins to try to stop the unequal blood flow.
We understand that discussing these complications can be distressing, especially for families who have experienced loss. Our hearts go out to you, and we are here to provide support, information, and a community that cares.
Other complications
Twin Anaemia-Polycythaemia Sequence (TAPS)
TAPS (Twin Anaemia Polycythaemia Sequence) is a rare complication that can happen in identical twins who share a placenta. It’s caused by tiny blood vessel connections in the placenta that allow a slow, uneven flow of blood between the twins. As a result, one twin (the donor) develops anaemia, while the other (the recipient) has too many red blood cells (polycythaemia).
TAPS is not the same as twin-to-twin transfusion syndrome (TTTS). While both conditions involve twins sharing a placenta, TAPS does not cause big differences in amniotic fluid. Instead, TAPS is picked up by specialised monitoring, such as Doppler ultrasound, which looks for changes in blood flow in the twins’ brains. The lack of obvious signs means TAPS can be harder to detect unless doctors are specifically looking for it.
Early diagnosis and careful management are crucial to support the health of both babies.
Please see TAPS Support website for more detailed information.
Selective Intrauterine Growth Restriction (sIUGR)
sIUGR occurs when one baby in a twin pregnancy grows at a slower rate than the other, often due to unequal sharing of the placenta or unusual cord insertions. This condition is more common in monochorionic twins, where the placenta is shared. The smaller twin may receive less oxygen and nutrients, leading to growth restrictions. sIUGR can increase the risk of complications for both babies, including preterm birth and, in severe cases, the loss of one twin. Regular ultrasounds and close monitoring are essential to assess the well-being of both babies and to make informed decisions about their care.
Twin Reversed Arterial Perfusion Sequence (TRAP Sequence)
TRAP Sequence is an extremely rare condition that affects identical twins sharing a placenta. In TRAP Sequence, one twin (the “acardiac twin”) lacks a functioning heart and relies on the other twin (the “pump twin”) for blood circulation. This abnormal circulation places extra strain on the pump twin’s heart, potentially leading to heart failure if not managed appropriately. TRAP Sequence can be detected through prenatal imaging, and various treatment options are available to protect the health of the pump twin.
Medical intervention and treatments can have a positive outcome for many of these complications but for those who do sadly lose a baby or babies from their multiple pregnancy, we are here to support them.
Vanishing Twin Syndrome
Vanishing twin syndrome (VTS) occurs when one or more multiples die, or cease to develop in utero, and are absorbed by the mother, placenta, and/or surviving twin (molecular pathways vary based on chorionicty, amnionicity, and other factors).
Vanishing Twin Syndrome can occur in both identical (monozygotic) and non identical (dizygotic) twins and triplets.
Although Vanishing Twin Syndrome can occur at any time during pregnancy, it most often occurs during the first trimester. Identified in 1945, it’s now more commonly diagnosed due to improved ultrasound technology and increased use of assisted reproductive technologies (Zamani & Parekh, 2023).
The three general outcomes of VTS include:
1) Complete vanishment of the twin or multiples, which is the most common outcome. Complete vanishment or resorption typically happens within the first trimester, but may happen at any time before delivery.
2) Persistent remains, such as a small cystic area in the uterus or a blighted ovum, which may be visible at the time of delivery.
3) Fetal remains visible throughout pregnancy or at delivery, usually appearing as a thin, calcified fetus (fetus papyraceus)(Zamani & Parekh, 2023).
Please see the International Vanishing Twin Syndrome Foundation (IVTSF) website for more information.
Support for Families Following the Loss of a Twin, Triplet or more
Losing a baby from a twin pregnancy due to complications such as Twin to Twin Transfusion Syndrome (TTTS), Twin Anemia Polycythemia Sequence (TAPS), or other twin/triplet-related conditions is a devastating and deeply complex experience. At Footprints Baby Loss, we understand that the grief of losing all of your babies or losing one baby while continuing a pregnancy or raising a surviving twin brings a unique set of emotions, challenges, and questions.
We are here to walk alongside you through this journey, with understanding, compassion, and personalised support.
How We Can Support You:
- Befriending Support
Our team of befrienders are bereaved parents themselves. They offer one-to-one emotional support, either by phone, video call, text messages or email. Befrienders listen without judgment, giving you a safe space to talk about your baby and your experience, whenever you’re ready.
- Online Support Groups
We host regular online support groups, providing a space where bereaved parents can come together, share their stories, and feel less alone. These groups are inclusive and welcoming, whether your loss was recent or many years ago, and specifically offer understanding for the complexities of twin loss and the mixed emotions that can follow.
- Online Community
Our private online community is a supportive space where you can connect with other bereaved parents, access shared experiences, and receive peer support. It’s a place where your baby or babies memories can be honoured and your grief held gently by others who truly understand.
- Resources and Information
We provide trusted information and guidance on topics such as the grief of losing a twin, parenting after loss, and navigating milestones. Our resources are designed to support you emotionally and practically as you move forward while carrying your baby’s memory with you.
- Remembering and honouring your twin/s or triplet/s
We offer gentle ways to honour and remember your baby, including our Remembering Day, annual virtual Wave of Light event, memory-making ideas, and opportunities to share your story. Many families find comfort in knowing their babies’ lives are recognised and cherished.
Whether you’ve experienced the death of one twin during pregnancy, at birth, or in the neonatal period, you are not alone.
Footprints Baby Loss is here to support you – today, tomorrow, and always.