[好孕] 20w 疑似「雙胞胎輸血症候群」？Twin to Twin Transfusion Syndrome（TTTS）

 

從一開始的兩條線，

到後來發現是同卵雙胞胎，

大家都說雙胞胎是加倍幸福，

但是在懷孕過程中，真的也是加倍煎熬。

初期不穩定，持續性的出血。

到中期13週的部分胎盤剝落，還以為到20週就可以進入穩定放鬆階段，

誰知道，做完高層次超音波檢查之後，現在又有要擔心煩惱的地方了。

其實在台大跟禾馨一知道我是同卵雙胞胎，醫生就有提醒，

一定要特別注意「雙胞胎輸血症候群」。台大徐醫師說，如果突然體重瞬間變重，

或肚子大的很快，千萬不要以為是雙胞胎正常的，尤其是肚子有點像氣球那樣繃繃的，

肚皮變的有點亮亮的那樣，就要趕快回醫院檢查。

這次發現，是在禾馨的高層次，醫生覺得大的寶寶心臟好像有點肥大，

關於禾馨高層次超音波，請見此篇:

[孕] 20W 禾馨高層次超音波-雙胞胎高層次  

醫生說，看兩個小孩的發展狀況，

（體重差距比例、羊水量多寡以及姐姐的心臟可能有點過於肥大，怕做功過強）

一個小孩的羊水太多，另一個小孩的羊水太少。

現在就比較擔心因為羊水的張力導致容易破水之類，

總之，醫生說按照經驗，很有可能會發展成「雙胞胎輸血症候群」。

我問醫生，那我能做什麼？能注意什麼？

卻好像什麼都沒辦法作，只能每個禮拜密切追蹤跟觀察。

 

回家之後，網路上面資料一查，我都快昏倒了。

 

同卵雙胞胎懷孕中，有15%容易發生因胎盤太靠近而造成血管的血流互相流通，這種狀況稱為雙胞胎兒輸血症候群（Twin to Twin Transfusion Syndrome, TTTS），此時可能會有一個胎兒的血流灌注較好，長的較大，血紅素越來越濃；另一個胎兒發育則日趨減緩，體重不增加，血紅素越來越低。接收較多血液的胎兒其腎臟血流量增加、小便量多，所以臨床可見羊水量也會增多許多，也因獲得過多的血量，反而容易造成胎兒的心臟衰竭，全身組織腫脹也就叫作”hydrop’，死亡率高。另一個胎兒則會出現腎臟血流量減少、小便量少、羊水量過少的現象。也因為胎兒們共用一個胎盤，只要任一個胎兒死亡其血液也會經由胎盤傳輸給另一個胎兒，另一個胎兒的死亡率也隨之升高，假使有任一胎兒存活下來，它仍需面對腦部損傷的危機，如果產生雙胞胎兒輸血症候群（Twin to Twin Transfusion Syndrome, TTTS）卻沒有得到妥善的治療，胎兒將有高達70%到80%的死亡率。

 

按照我的高層次產檢報告，a寶寶的羊水最大直徑有9.56cm

雙胞胎輸血症候群 （twin-twin transfusion syndrome， TTTS）診斷判定的三項標準：

1. 同性別雙胞胎
2. 單一胎盤
3. 羊水過多的胎兒maximum vertical pocket （MVP） ≥ 8 cm， 羊水過少的胎兒MVP ≤ 2 cm

b寶寶的羊水量正好在邊緣，所以醫生後來說要繼續觀察。

但很有可能就會成為ttts。

我是在20週高層次的時候發現的，

而在二十六週前出現輸血症候群的寶寶，若未積極治療，只有不到一成可以存活。

即使倖存，也有高達七成五出現腦性麻痺。

我問醫生，有什麼治療方法？

醫生說，在26週以前，會透過雷射手術把兩個小孩有交通的血管阻斷。

26週之後，就是重複性的羊水抽放。

我繼續追問，會有什麼後遺症嗎？做了這些治療，兩個寶寶都會好好的嗎?

醫生想了一下，他說我既然問了，他也不能不說。

因為雷射的風險也很高，

即使重複抽放羊水，出生後胎兒也有腦性麻痺的機率。

目前台灣有進行過ttts手術的例子不多，很多人推薦的是林口長庚。

可點此直接見此篇文章說明。

 

我每天祈禱，希望兩個寶寶可以順利長大，

真的很擔心他們要動手術。

現在，能做的就是每個禮拜回醫院複診，

追蹤兩個孩子的生長狀況。

下面是高層次超音波的最後報告，

若要看高層次超音波的內容請見此篇:

20W 禾馨高層次超音波-雙胞胎高層次

 

最下面的綜合評論，真的讓我很擔心。

這一整個禮拜，都讓我提心吊膽的。

suggest follow up one week later to rule our ttts.

下面是b寶寶的高層次報告，

 

 

我只能每天念經，祈禱兩個寶寶都能健康長大。

雙胞胎輸血症候群只會發生在共用胎盤，而且有兩個羊膜腔的同卵雙胞胎身上，

如果你剛好也跟我的狀況很像，遇到這樣的狀況

在網路上看到了一篇文章很不錯，分享給大家：

你可以向產檢醫生提問的15個關於ttts的問題

原文請點此：http://tttsfoundation.org/index.php

Fifteen Questions You Must Ask Your Doctor About TTTS

 

 

Confirm at Initial Ultrasounds (preferably by 10-16 weeks)

 

1. Is the placenta monochorionic?

 

TTTS only occurs in identical twins with a single, shared monochorionic placenta. Placental type can be determined as early as 6 weeks of pregnancy.

 

2. Are the babies the same gender?

 

Monochorionic twins are identical, so by definition they should be of the same sex, and will carry a risk for TTTS.

 

3. Can you see the dividing membrane?

 

The ‘dividing membrane’ is formed by the two amniotic sacs of the twins meeting in the middle of their placenta. A thin, wispy membrane confirms that the twins are monochorionic. A thick, easy to see dividing membrane is seen when the twins have separate placentas. Inability to see the membrane at all does not always mean same sac (monoamnionic) twins. For instance, in TTTS the membrane may be ‘shrink wrapped’ around a donor baby who lacks amniotic fluid, and further pressed around the donor by the excess fluid in the recipient.

 

4. Is the placenta implanted on the anterior or posterior surface of the womb?

 

Laser surgery may be performed on placentas in either location, but the anterior location presents more challenges. Depending on the doctor’s technique, the twins will have a greater risk of still having open connections with anterior placentas. Placentas that wrap around 3 surfaces (anterior, fundal, and posterior) may also be difficult to operate upon.

 

5. Do the twins’ umbilical cords each have the normal 3 blood vessels, or does one of them have 2 vessels?

 

Identical monochorionic twins should, by definition, be the same in every way. It is not uncommon for the twins (both TTTS and non-TTTS) to share their single placenta unequally. This is the most common reason for size differences, which can be more than 20%. The smaller twin will have the smaller placenta, and its umbilical cord may have only 2 blood vessels in it.

 

6. Are the umbilical cords fully attached to the placenta?

 

Identical monochorionic twins can be more than 20% different in size. Similar to the 2 vessel umbilical cord, the umbilical cord may not insert into the placenta itself, but into the membranes that surround the baby and signify a smaller placental share for that twin. This is called a velamentous cord insertion.

 

Questions to Ask at Weekly Ultrasounds (16 weeks up until delivery)

 

7. What is the largest vertical pocket of amniotic fluid in each baby’s sac?

 

In normal twins, the deepest pocket of amniotic fluid should be around 3-8cm. When the fluid is greater than 8cm (polyhydramnious) and less then 2cm (oligohydramnios), the babies have Stage I TTTS. The fluid level differences are distressing to see, but are the findings most likely to change with treatments such as horizontal rest and nutritional supplements. You can determine the severity of TTTS to some degree, by watching what these numbers are, and how much they vary from the normal range. This information can help you to know when treatment may be needed and why, and gives you a tool to help make these decisions.

 

There are varying opinions as to the number where an amniocentesis should be done. Some experts are wary about putting a needle into the uterus, there are some risks, and so it should be done for a good reason. In TTTS pregnancies genetic abnormalities are extremely rare, so it does not make sense to do an amniocentesis for genetic reasons alone. It may also not make sense to do amnioreductions of small volumes (less than a liter), which is often the case if the deepest pocket measures 8-9cm or less. In higher stages of TTTS (III-IV), placental laser surgery is becoming the preferred treatment. Here the excess amniotic fluid is actually required to perform the operation, and should not be removed until the surgery itself. TTTS after the laser cutoff (over 25 weeks of pregnancy) will be treated with amniocentesis when necessary.

 

8. Can you see the urinary bladder of the donor baby?

 

The baby’s bladder is visible on ultrasound when it contains urine. Urine is the main source of amniotic fluid. If it cannot be visualized within 30 minutes, or if the donor baby has no or little amniotic fluid, its blood volume may be too low (from transfusion into the recipient) to perfuse the kidneys enough to urinate. Recipients always have larger than normal bladders in TTTS. If the ultrasound finds a visible bladder and a 2cm or more pocket, this much better news for the donor. These findings will help give you some perspective on the donor’s status and the seriousness of TTTS.

 

9. What are the weights of the babies in grams? (ask for an update every 2-3 weeks)

 

The relative size differences between monochorionic twins with TTTS (or in general) are best calculated with grams (typically 3 digits) rather than ounces (3 digits rounded to 1 or 2). The percent difference is calculated by taking weight difference in grams, and dividing that number by the weight of the larger baby. If the weight discordance is 20% or more, it is considered significant. The most likely cause of the discordance in monochorionic twins is unequal sharing of their single placenta. The smaller a placenta portion, the less nutrients are delivered to that baby. Small placentas are often associated with two vessel or velamentous umbilical cords, and Doppler flow abnormalities. Since the twins’ shares of the placenta are fixed from the beginning of the pregnancy, and cannot be improved upon, nutritional supplementation and horizontal rest may help maximize the supply of nutrients to the smaller twin and help it thrive.

 

10. Are the Doppler ultrasound studies normal for both babies?

 

The Doppler ultrasound demonstrates how blood is flowing through the umbilical cords and placentas of the babies. It shows how well their hearts are pumping the blood by color (similar to taking a blood pressure which uses sound to determine systolic and diastolic numbers). In TTTS, Doppler is used to study blood flow through the umbilical cords, through the middle cerebral artery to detect anemia in the donor, and in and around the recipient’s heart to detect stress or heart failure.

 

Common abnormal Doppler studies in donor twins include absent diastolic flow in the umbilical cord (blood moves forward only when the heart is contracting), and reverse diastolic flow in the cord (blood moves back toward the heart when the heart relaxes). These studies are influenced by both the size of the transfusion and smaller sizes of a twin’s placenta share. Reverse diastolic flow is much more dangerous, and requires urgent decision making regarding laser surgery or delivery, if feasible at the gestational age. Doppler studies are considered a routine part of monitoring complicated monochorionic twin pregnancy from about 15 weeks onward.

 

11. Is the heart of the recipient baby thickened or enlarged?

 

When the recipient baby’s cardiovascular system is overloaded by a transfusion from the donor, it will show thickening and an increase in size. Here, laser surgery is the only option to stop the transfusion and reverse these TTTS signs (considered stage III). Hearts that are considered ‘in failure’ are also enlarged and thickened, but they are also noted to be poorly contracting. These findings are reversible after laser surgery.

 

12. Does the recipient baby have any signs of hydrops?

 

Eventually a transfusion-related severely stressed heart will fail, and the baby’s body fills up with water (edema) to become hydropic. This is stage IV TTTS.

 

Hydrops is reversible only with laser surgery. Stage IV TTTS babies can survive and be healthy, even after having hydrops, with proper treatment.

 

13. How long is my cervix by ultrasound, and it is showing any signs of funneling or thinning?

 

It is now clear to us, that as much as one-fourth of all the lost babies, as well as babies who survived with disabilities after TTTS, did so because of problems (i.e., abnormal shortening) with the mother’s cervix. Doctors only began routine measurement of the mother’s cervix in multiple pregnancy in 2000. A normal cervix should be more than 3.5cm long without signs of funneling (opening of the upper cervix closest to the baby, rather than at the vagina). A short cervix (< 3.0cm), especially with funneling, is called cervical insufficiency and almost ensures a premature delivery. Cervical insufficiency can be fixed by shoring up the cervix with a stitch (cerclage). Cerclage is performed in some centers in TTTS cases up to 25 weeks, and hospitalization for the duration of pregnancy if it is after 25 weeks.

 

A word of caution: there are doctors and centers that do not perform cerclage under any circumstances, for whatever reason, so be sure to ask what they do if your cervix gets short under their care. Conversely, there are other doctors who are convinced that they have had better outcomes and healthier babies for their TTTS patients, since incorporating cervical ultrasound, and cerclage when necessary, to their TTTS treatment protocols. So, it is crucial to have your cervix looked at every scan since increased amniotic fluid adds to the burden on the cervix. You should always have the cervix checked immediately before traveling to another center (especially by air) for treatment.

 

14. Is the smaller baby growing at the same rate?

 

When monochorionic (single placenta) twins are 20% or more different in size, it is considered significant. The most likely cause for this discordance is unequal sharing of the placenta. Although a size difference can be detected even in the first trimester, this difference can become extreme (> 40%) by mid pregnancy in cases of extreme unequal sharing of the placenta (e.g., the smaller twin has less than 25% of the placenta). However, in the third trimester the babies are having their greatest weight gain, which must be supported by a normal placenta and supply of nutrients from the mother. A twin can actually ‘run out of placenta,’ so monitoring of their rate of growth and difference between their weights is crucial. When a monochorionic twin stops growing, the babies need to be delivered (i.e., better off out than in) or this baby will be become harmed. The monochorionic placenta can be analyzed after birth to determine the twins’ relative shares.

 

15. What is the fundal height measurement?

 

Doctors have long used a centimeter tape to measure the distance from the top of the public bone to the top of the pregnant uterus. In a singleton pregnancy, height in centimeters should equal the weeks of gestation, and then grow appropriately at subsequent visits. In normal multiple pregnancy, roughly 3 to 4cm is added to the number of weeks. This test can be used to find babies that are not growing enough (a low value indicates intrauterine growth restriction – IUGR), or growing too much (like babies of mothers with gestational diabetes). In monochorionic twins at risk for TTTS, an abnormally high fundal height value may be the first (and most common) sign of TTTS – polyhydramnios or too much amniotic fluid. It can be especially important for women having a difficult time getting ultrasounds weekly, or not being told the largest vertical pocket at the ultrasounds they have. You can get this measurement from a qualified nurse or midwife, if they are the only ones available to you. When TTTS is diagnosed, ultrasounds are then used in lieu of fundal height, because the scan provides more specific information on the babies and mother’s cervix.

 

Reprinted with permission from The Twin To Twin Transfusion Syndrome Foundation.

 

———————————————————-

 

 

 

一、寶寶每週超音波記錄

1. [孕] 11W 產檢。超音波 雙胞胎超音波 胎兒大小|11週懷孕身體變化  
2. [孕] 12W 禾馨頸部透明帶+母血唐氏症|台北市民補助|自費產檢|SEARCH早產風險評估 
3. [孕] 13w 超音波、雙胞胎 懷孕三個月出血 
4. [孕] 14W超音波-雙胞胎超音波|自費產檢|禾馨婦產科收費 
5. [孕] 16w超音波、雙胞胎超音波 (寶寶成長週數對照表) 
6. [孕] 17w 台大超音波 
7. [孕] 18W超音波- 雙胞胎18週超音波數據 
8. [孕] 20W 禾馨高層次超音波-雙胞胎高層次  

 

二、媽媽的心情記錄、身材變化及穿搭

1. [孕] 6W-8W 懷孕念經-普門品（妙法蓮華經觀世音菩薩普門品）|求子|保平安 
2. [孕] 8W-10W 驗孕棒的兩條線(懷孕徵兆|腰痠|頻尿|出血)
3. [穿搭] 12W 洋裝變身孕婦裝|遮小腹穿搭|修身|連衣裙 
4. [好孕] 雙胞胎13W 懷孕中期大出血|宮縮|部分胎盤剝離  
5. [穿搭] 20w-22w 淘寶孕婦雪紡洋裝–夏裝秋穿 (薄荷綠露肩小洋裝、碎花露肩洋裝) 
6. [穿搭] 22w-24w 淘寶。斜肩上衣、青花瓷窄管褲|韓系孕婦裝 

 

三、懷孕必買用品

1. [開箱] 8W-10W床上電腦桌、小桌子、摺疊桌|床上桌|小餐桌|臥床方便 
2. [BUY] 10W-12W阿原肥皂推薦(苦茶、白鶴草、月桃) 洗頭水
3. [BUY] 12w-14w 孕婦月亮枕|蝸牛枕|勾形枕|媽媽抱
4. [BUY] 14W-16W MUSTELA 慕之恬廊妊娠霜、腿部舒緩、胸部護理、妊娠油
5. [BUY] 18W-20W 新潮流穀果機|生機調理機|果汁機|研磨機|副食品|調理棒

四、月子中心相關

1. [孕] 2015 台北市月子中心價格比較及參觀心得|康和|璽悅|華悅|賀果|藍田|許世賓 
2. [孕] 大安區。康和月子中心（產後護理之家）|參觀心得|價位|月子餐 
3. [孕] 大安區月子中心。璽悅參觀心得價位分享  
4. [孕] 台北。藍田月子中心(產後護理之家)月子餐試吃及參觀心得 
5. [孕] 台北。華悅月子中心 價格及參觀心得|產後護理之家|大安區 
6. [孕] 大安區。許世賓月子中心（產後護理之家）|參觀心得|價位|信義路 
7. [孕] 禾馨賀果月子中心、產後護理之家參觀心得|價格|

 

 

五、產檢相關

1. [孕] 禾馨婦產科-自費產檢價格一覽表2014.10月新價格 
2. [孕] 自費產檢-巨細胞病毒呈現陽性反應? 什麼是 CMV IgM、 IgG  
3. [孕] 禾馨。第一期自費產檢報告|子宮動脈阻力過大（母血PAPP-A,FREE B-HGC） 
4. [好孕] 雙胞胎。孕期成長全記錄|超音波|產檢|必買用品|懷孕過程 

 

六、其他實用小記錄

推薦好用APP，孕照總動員

 

WEEK	身長	預估體重	頂骨徑長度 (BPD	腹圍長度(AC	大腿骨長度(FL)
10周	3.1-4.2cm	5g
11周	4.4-6cm	8g	1
12周	6.1cm	8-14g		5.7
13周	6.5-7.8cm	13-20g
14周	8-9.3cm	25g
15周	9.3-10.3cm	50g	1.7	8.8
16周	10.8-11.6cm	80g			1
17周	11-12cm	100g
18周	12.5-14cm	150g
19周	13-15cm	200g
20周	14-16cm	260g	3.1	14.1	2.2
21周	18cm	300g	5.22 ± 0.42	15.62 ± 1.84	3.64 ± 0.40
22周	19cm	350g	5.45 ± 0.57	16.70 ± 2.23	3.82 ± 0.47
23周	20cm	455g	5.80 ± 0.44	17.90 ± 1.85	4.21 ± 0.41
24周	21cm	540g	6.05 ± 0.50	18.74 ± 2.23	4.36 ± 0.51
25周	22cm	700g	6.39 ± 0.70	19.64 ± 2.20	4.65 ± 0.42
26周	23cm	910g	6.68 ± 0.61	21.62 ± 2.30	4.87 ± 0.41
27周	24cm (身長總長約34cm)	1000g	6.98 ± 0.57	21.81 ± 2.12	5.10 ± 0.41
28周	25cm (身長總長約35cm)	1100g	7.24 ± 0.65	22.86 ± 2.41	5.35 ± 0.55
29周	26cm (身長總長約37cm)	1250g	7.50 ± 0.65	23.71 ± 1.50	5.61 ± 0.44
30周	27cm (身長總長約38cm)	1350g	7.83 ± 0.62	24.88 ± 2.03	5.77 ± 0.47
31周	28cm (身長總長約40cm)	1600g	8.06 ± 0.60	25.78 ± 2.32	6.03 ± 0.38
32周	29cm (身長總長約42cm)	1800g	8.17 ± 0.65	26.20 ± 2.33	6.43 ± 0.49
33周	30cm (身長總長約43cm)	2000g	8.50 ± 0.47	27.78 ± 2.30	6.42 ± 0.46
34周	32cm (身長總長約44cm)	2280g	8.61 ± 0.63	27.99 ± 2.55	6.62 ± 0.43
35周	33cm (身長總長約45cm)	2500g	8.70 ± 0.55	28.74 ± 2.88	6.71 ± 0.45
36周	34cm (身長總長約46cm)	2750g	8.81 ± 0.57	29.44 ± 2.83	6.95 ± 0.47
37周	35cm (身長總長約47cm)	2950g	9.00 ± 0.63	30.14 ± 2.17	7.10 ± 0.52
38周	35cm (身長總長約47cm)	3100g	9.08 ± 0.59	30.63 ± 2.83	7.20 ± 0.43
39周	36cm (身長總長約48cm)	3250g	9.21 ± 0.59	31.34 ± 3.12	7.34 ± 0.53
40周	37-38cm (身長總長約48-50cm)	3400g	9.28 ± 0.50	31.49 ± 2.79	7.4 ± 0.53

 

 以上小分享，謝謝大家。

 

歡迎繼續閱讀：

[孕] 大安區月子中心。璽悅參觀心得價位分享

[孕] 台北。藍田月子中心(產後護理之家)月子餐試吃及參觀心得  

[孕] 台北。華悅月子中心 價格及參觀心得|產後護理之

[孕] 大安區。康和月子中心（產後護理之家）|參觀心得|價位|月子餐 

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[孕] 驗孕棒的兩條線(懷孕徵兆|腰痠|頻尿|出血) 

 

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