Neonatal management and outcome in complicated monochorionic twins: What have we learned in the past decade and what should you know?

Oct 17, 2026

Monochorionic (MC) twin pregnancies carry elevated neonatal morbidity and mortality because a shared placenta with vascular connections can produce complications such as twin-twin transfusion syndrome, twin anemia polycythemia sequence (TAPS), selective fetal growth restriction, and other hematologic disturbances at birth. Accurate diagnosis requires hemoglobin and reticulocyte measurements, and placenta dye injection to distinguish conditions. Adverse-outcome risks include prematurity, severe cerebral injury, and the specific MC complication type. The review recommends brain ultrasound for all complicated MC twins at birth and hearing-loss screening with automated auditory brainstem response in spontaneous TAPS donors to reduce permanent speech delays.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages11

Reading Time28 min

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Neonatal management and outcome in complicated monochorionic twins

Introduction

Twin-twin transfusion syndrome

Chronic TTTS

Acute peripartum TTTS

Best Practice & Research Clinical Obstetrics and Gynaecology 84 (2022) 218e228 Contents lists available at ScienceDirect Best Practice & Research Clinical Obstetrics and Gynaecology journal [homepage:](homepage: www. elsevier. com/locate/bpobgyn)[ www. elsevier. com/locate/bpobgyn](homepage: www. elsevier. com/locate/bpobgyn) | 19 | | | | --- | --- | --- | | Neonatal management and outcome in complicated monochorionic twins: What have we learned in the past decade and what should you know? | | | | Sophie G. Groene a, b, *, 1, Lisanne S.A. Tollenaar c, 1, Johanna M. Middeldorp c, Enrico Lopriore a
a Division of Neonatology, Willem-Alexander Children's Hospital, Dept. of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands
b Division of Molecular Epidemiology, Dept. of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
c Division of Fetal Therapy, Dept. of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands | | | | Keywords:
Monochorionic twins
Twin-twin transfusion syndrome Twin anemia polycythemia sequence Selective fetal growth restriction Monoamniotic twins | a b s t r a c t
Monochorionic (MC) twin pregnancies are at increased risk of neonatal morbidity and mortality due to the shared placenta with vascular connections that can give rise to various complications, including twin-twin transfusion syndrome, twin anemia polycythemia sequence (TAPS), selective fetal growth restriction, and other hematological imbalances at birth. Each complication presents its own challenges and considerations in the neonatal period. Measurement of hemoglobin levels and reticulocyte count is required to establish a correct diagnosis. Placenta dye injection is needed to properly distinguish between the various conditions. Risk factors for adverse outcome in MC twins include prematurity, severe cerebral injury, and the type of MC pregnancy complication. We, therefore, recommend cerebral ultrasound examinations in all complicated MC twins at birth to rule out a severe brain injury. Lastly, we strongly encourage screening for hearing loss using automated auditory brainstem response in all spontaneous TAPS donors to prevent permanent speech development delay.
© 2022 Published by Elsevier Ltd. | | * Corresponding author. Department of Pediatrics, Leiden University Medical Center, J6-S, Albinusdreef 2, 2333 ZA Leiden, the Netherlands. E-mail address: [S.G.Groene@lumc.nl](S.G.Groene@lumc.nl) (S.G. Groene). 1 Both authors contributed equally to this work. [https://doi.org/10.1016/j.bpobgyn.2022.03.016](https://doi.org/10.1016/j.bpobgyn.2022.03.016) [1521-6934/](1521-6934/)© 2022 Published by Elsevier Ltd. S.G. Groene, L.S.A. Tollenaar, J.M. Middeldorp et al. Best Practice & Research Clinical Obstetrics and Gynaecology 84 (2022) 218e228 Introduction Approximately, 70% of identical twins are monochorionic (MC), indicating that they share a single placenta with vascular connections on its surface allowing for intertwin blood ﬂow [1]. This shared placenta can give rise to a spectrum of complications, among which twin-twin transfusion syndrome (TTTS), twin anemia polycythemia sequence (TAPS), selective fetal growth restriction (sFGR), and other hematological imbalances at birth (Fig. 1). Moreover, a proportion of MC twins is also monoamniotic (MA). All these complications contribute to an overall increased risk of perinatal morbidity and mortality in MC twin pregnancies [2]. In general, MC twins are often delivered prematurely with consequently increased risk of associated neonatal morbidity and mortality. In speciﬁc, each type of MC twin pregnancy complication presents in turn its own challenges and considerations with regard to the neonatal period and requires a different neonatal management approach. Knowledge of the antenatal pathophysiology is essential to make a proper risk assessment. This literature review will provide a complete overvi

FAQs

Why are neonatal risks higher in complicated monochorionic twin pregnancies?

MC twins share a placenta with vascular connections, which can generate multiple neonatal complications. These include TTTS, TAPS, selective fetal growth restriction, and other hematologic imbalances at birth.

How is the correct diagnosis of MC twin complications established?

Diagnosis requires hemoglobin level assessment and reticulocyte count to characterize hematologic imbalance. Placenta dye injection is also needed to properly distinguish between different conditions.

What neonatal evaluations does the article recommend to reduce long-term harm?

It recommends cerebral ultrasound examinations in all complicated MC twins at birth to exclude severe brain injury. It also strongly encourages hearing-loss screening using automated auditory brainstem response in spontaneous TAPS donors to prevent permanent speech development delay.

Oct 17, 2026

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