J Med Cases
Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access
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Case Report

Volume 8, Number 9, September 2017, pages 269-270


Hematological Characteristics in Neonates With Twin-Twin Blood Transfusion

Sayuri Kondoa, Yosuke Sugitaa, Shunji Suzukia, b

aDepartment of Obstetrics and Gynecology, Japanese Red Cross Katsushika Maternity Hospital, Tokyo, Japan
bCorresponding Author: Shunji Suzuki, Department of Obstetrics and Gynecology, Japanese Red Cross Katsushika Maternity Hospital, 5-11-12 Tateishi, Katsushika-ku, Tokyo 124-0012, Japan

Manuscript submitted July 24, 2017, accepted August 11, 2017
Short title: Reticulocyte in Twin-Twin Transfusion
doi: https://doi.org/10.14740/jmc2882w

Abstract▴Top 

We encountered a case of subacute twin-twin transfusion syndrome (TTTS) with the increased inter-twin reticulocyte count-ratio (calculated by dividing the reticulocyte count of the donor by the reticulocyte count of the recipient). In the current case, inter-twin reticulocyte count-ratio was increased to 1.91 (normal < 1.7); however, we diagnosed the case as subacute TTTS because a myocardial hypertrophy indicating the presence of chronic heart load was not recognized in the twins.

Keywords: Twin-twin transfusion syndrome; Twin anemia-polycythemia sequence; Reticulocyte

Introduction▴Top 

Twin anemia-polycythemia sequence (TAPS) is a rare form of twin-twin transfusion syndrome (TTTS), which is characterized by the presence of large inter-twin hemoglobin difference without signs of twin oligo-polyhydramnios sequence [1, 2]. Postnatal diagnosis of TAPS is based on the presence of chronic anemia with reticulocytosis (as a sign of chronic anemia) in the donor twin and polycythemia in the recipient [1, 2]. Usually, TAPS has been diagnosed based on the postnatal criteria defined as inter-twin hemoglobin difference > 8 g/dL and inter-twin reticulocyte count-ratio (calculated by dividing the reticulocyte count of the donor by the reticulocyte count of the recipient) > 1.7 [3, 4]. The criterion concerning the increased inter-twin reticulocyte count-ratio is based on a previous case-control study (sensitivity and specificity of 100%) by Lopriore et al [5]. However, we encountered a case of subacute TTTS with the increased inter-twin reticulocyte count-ratio.

Case Report▴Top 

A 32-year-old woman, gravida 1, para 0 was referred to our hospital at 29 weeks of gestation for a high-risk obstetric consultation due to monochorionic-diamniotic twin pregnancy with premature labor and selective intrauterine fetal growth restriction. At this time, the estimated fetal weights of twin A and B were 1,277 g (-0.45 SD) and 1,039 g (-0.181 SD), respectively. The amniotic fluid pockets of twin A and B were 6.2 and 4.1 cm, respectively. The Doppler evaluations of umbilical and cerebral arteries of both twins were normal.

At 33 weeks and 6 days of gestation, the fetal cardiotocograms showed reassuring status of both twins. At this time, the Doppler evaluations of both twins were normal. The amniotic fluid pockets of twin A and B were 4.2 and 2.4 cm, respectively. The middle cerebral artery peak systolic velocity (MCA-PSV) in twin A was 39.6 cm/s (normal: < 70 cm/s). At 34 weeks and 1 day of gestation, however, the fetal cardiotocograms showed sinusoidal pattern in twin A. The MCA-PSV of twin A was increased to 90.4 cm/s. An emergency cesarean section was performed. Twin A was a male baby weighing 1,932 g (appropriate for gestational age) with Apgar score of 8 (1 min) and 9 (5 min), respectively, while twin B was a male baby weighing 1,680 g (light for gestational age; 13.0% growth discordance between the twins) with Apgar score of 8 (1 min) and 9 (5 min), respectively. The umbilical artery pH values in twin A and B were 7.315 and 7.295, respectively. The hemoglobin concentration of twin A was 26.8 g/dL (normal: 13 - 22 g/dL) with reticulocyte counts of 3.2% (normal: < 7%), while it was 3.4 g/dL with reticulocyte counts of 6.5% in twin B. The placenta was confirmed as monochorionic with two superficial arterio-venous anastomoses without color difference in placentas.

Discussion▴Top 

In the current case, anemia was recognized in the larger twin with more amniotic fluid, and polycythemia was recognized in the smaller twin with less amniotic fluid. In addition, a myocardial hypertrophy indicating the presence of chronic heart load was not recognized in the twins with polycythemia. The findings are contrary to those of slow process of transfusion; therefore, we diagnosed the case as subacute TTTS despite the increased inter-twin reticulocyte count-ratio of 1.91 (> 1.7). The placenta without color difference will also support our postnatal diagnosis, because color difference in placenta has been reported to be an additional diagnostic criterion of TAPS [6, 7]. Whether or not the reticulocyte level exceeds the normal range may be corresponded to the pathognomonic for TAPS with slowly developed anemia more than inter-twin reticulocyte count-ratio. The hematological characteristics of TAPS can be clarified by the accumulation of similar case reports.


References▴Top 
  1. Lopriore E, Middeldorp JM, Oepkes D, Kanhai HH, Walther FJ, Vandenbussche FP. Twin anemia-polycythemia sequence in two monochorionic twin pairs without oligo-polyhydramnios sequence. Placenta2007;28(1):47-51
    doi pubmed
  2. Lopriore E, Oepkes D. Fetal and neonatal haematological complications in monochorionic twins. Semin Fetal Neonatal Med2008;13(4):231-238
    doi pubmed
  3. Ashwal E, Yinon Y, Fishel-Bartal M, Tsur A, Chayen B, Weisz B, Lipitz S. Twin anemia-polycythemia sequence: perinatal management and outcome. Fetal Diagn Ther2016;40(1):28-34
    doi pubmed
  4. Slaghekke F, Kist WJ, Oepkes D, Pasman SA, Middeldorp JM, Klumper FJ, Walther FJ, et al. Twin anemia-polycythemia sequence: diagnostic criteria, classification, perinatal management and outcome. Fetal Diagn Ther2010;27(4):181-190
    doi pubmed
  5. Lopriore E, Slaghekke F, Oepkes D, Middeldorp JM, Vandenbussche FP, Walther FJ. Hematological characteristics in neonates with twin anemia-polycythemia sequence (TAPS). Prenat Diagn2010;30(3):251-255
    doi
  6. Tollenaar LS, Zhao DP, Middeldorp JM, Slaghekke F, Oepkes D, Lopriore E. Color difference in placentas with twin anemia-polycythemia sequence: an additional diagnostic criterion?. Fetal Diagn Ther2016;40(2):123-127
    doi pubmed
  7. Suzuki S. Twin anemia-polycythemia sequence with placental arterio-arterial anastomoses. Placenta2010;31(7):652
    doi pubmed


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