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Twin Anemia-Polycythemia Sequence
Priyanka Jha, MBBS; Anne Kennedy, MD
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KEY FACTS

  • Terminology

    • Imaging

      • Top Differential Diagnoses

        • Clinical Issues

          • Scanning Tips

            TERMINOLOGY

            • Abbreviations

              • Twin-anemia polycythemia sequence (TAPS)
            • Definitions

              • Monochorionic (MC) twin complication with chronic, slow, unbalanced blood transfusion from donor (D) → recipient (R) twin
                • Most common after laser therapy for twin-twin transfusion syndrome (TTTS)
                • May occur spontaneously; develops > 26 weeks in previously uncomplicated MC twins
                  • Spontaneous TAPS can coexist with TTTS
                  • Isolated TAPS much rarer

            IMAGING

            • General Features

              • Ultrasonographic Findings

                • MR Findings

                  • Imaging Recommendations

                    DIFFERENTIAL DIAGNOSIS

                      PATHOLOGY

                      • General Features

                        • Staging, Grading, & Classification

                          • Gross Pathologic & Surgical Features

                            CLINICAL ISSUES

                            • Presentation

                              • Demographics

                                • Natural History & Prognosis

                                  • Treatment

                                    DIAGNOSTIC CHECKLIST

                                    • Consider

                                      • Image Interpretation Pearls

                                        • Reporting Tips

                                          Selected References

                                          1. Tollenaar LSA et al: Spontaneous twin anemia polycythemia sequence: diagnosis, management, and outcome in an international cohort of 249 cases. Am J Obstet Gynecol. 224(2):213.e1-11, 2021
                                          2. Wang X et al: Longer distance between umbilical cord insertions is associated with spontaneous twin anemia polycythemia sequence. Acta Obstet Gynecol Scand. 100(2):229-34, 2021
                                          3. Araújo Pereira J et al: Twin anemia polycythemia sequence. N Engl J Med. 382(6):e9, 2020
                                          4. Han SJ et al: Short- and long-term outcomes of preterm spontaneous twin anemia-polycythemia sequence. J Perinat Med. ePub, 2020
                                          5. Khalil A et al: Consensus diagnostic criteria and monitoring of twin anemia-polycythemia sequence: Delphi procedure. Ultrasound Obstet Gynecol. 56(3):388-94, 2020
                                          6. Liu B et al: Performance of antenatal diagnostic criteria of twin-anemia-polycythemia sequence. J Clin Med. 9(9), 2020
                                          7. Mao Q et al: Discordant placental oxygenation and autophagy in twin anemia-polycythemia sequence (TAPS). Placenta. 90:9-17, 2020
                                          8. Shanahan MA et al: Placental anatomy and function in twin gestations. Obstet Gynecol Clin North Am. 47(1):99-116, 2020
                                          9. Ting YH et al: Outcomes of radiofrequency ablation for selective fetal reduction in complicated monochorionic pregnancies performed before 16 gestational weeks and thereafter. Ultrasound Obstet Gynecol. ePub, 2020
                                          10. Tollenaar LSA et al: Post-laser twin anemia polycythemia sequence: diagnosis, management, and outcome in an international cohort of 164 cases. J Clin Med. 9(6), 2020
                                          11. Tollenaar LSA et al: High risk of long-term neurodevelopmental impairment in donor twins with spontaneous twin anemia-polycythemia sequence. Ultrasound Obstet Gynecol. 55(1):39-46, 2020
                                          12. Tollenaar LSA et al: Prevalence of placental dichotomy, fetal cardiomegaly and starry-sky liver in twin anemia-polycythemia sequence. Ultrasound Obstet Gynecol. 56(3):395-9, 2020
                                          13. Tollenaar LSA et al: Treatment and outcome of 370 cases with spontaneous or post-laser twin anemia-polycythemia sequence managed in 17 fetal therapy centers. Ultrasound Obstet Gynecol. 56(3):378-87, 2020
                                          14. Visser GL et al: Leukocyte counts and other hematological values in twin-twin transfusion syndrome and twin anemia-polycythemia sequence. Fetal Diagn Ther. 47(2):123-8, 2020
                                          15. Xu J et al: The utility of MRI for measuring hematocrit in fetal anemia. Am J Obstet Gynecol. 222(1):81.e1-13, 2020
                                          16. Zhao D et al: Evaluation of color difference in placenta with twin anemia polycythemia sequence. J Vis Exp. 2020
                                          17. Bahtiyar MO et al: In utero partial exchange transfusion combined with in utero blood transfusion for prenatal management of twin anemia-polycythemia sequence. Fetal Diagn Ther. 45(1):28-35, 2019
                                          18. Hill KM et al: Intrauterine interventions for the treatment of twin anemia-polycythemia sequence: a systematic review. J Obstet Gynaecol Can. 41(7):981-91, 2019
                                          19. Jha P et al: US evaluation of twin pregnancies: importance of chorionicity and amnionicity. Radiographics. 39(7):2146-66, 2019
                                          20. Nicholas LD et al: Twin anemia-polycythemia sequence and routine monitoring practices amongst maternal-fetal medicine specialists in the United States: an initial investigation. J Perinat Med. 47(4):388-92, 2019
                                          21. Nicholas L et al: Dispelling myths about antenatal TAPS: a call for action for routine MCA-PSV doppler screening in the United States. J Clin Med. 8(7), 2019
                                          22. Tavares de Sousa M et al: Role of fetal intertwin difference in middle cerebral artery peak systolic velocity in predicting neonatal twin anemia-polycythemia sequence. Ultrasound Obstet Gynecol. 53(6):794-7, 2019
                                          23. Tollenaar LSA et al: Improved prediction of twin anemia-polycythemia sequence by delta middle cerebral artery peak systolic velocity: new antenatal classification system. Ultrasound Obstet Gynecol. 53(6):788-93, 2019
                                          24. Tollenaar LSA et al: Twin-twin transfusion syndrome with anemia-polycythemia: Prevalence, characteristics, and outcome. J Clin Med. 8(8), 2019
                                          25. Bamberg C et al: Quantified discordant placental echogenicity in twin anemia-polycythemia sequence (TAPS) and middle cerebral artery peak systolic velocity. Ultrasound Obstet Gynecol. 52(3):373-77, 2018
                                          26. Persico N et al: Fetal Doppler changes 1 week after endoscopic equatorial laser for twin-to-twin transfusion syndrome: a longitudinal study. Prenat Diagn. 38(5):344-48, 2018
                                          27. De Paepe ME et al: Redness discordance in monochorionic twin placentas: correlation with clinical and placental findings. Placenta. 60:54-60, 2017
                                          28. Tollenaar LSA et al: Can color difference on the maternal side of the placenta distinguish between acute peripartum twin-twin transfusion syndrome and twin anemia-polycythemia sequence? Placenta. 57:189-93, 2017
                                          29. Fishel-Bartal M et al: Can middle cerebral artery peak systolic velocity predict polycythemia in monochorionic diamniotic twins? Evidence from a prospective cohort study. Ultrasound Obstet Gynecol. 48(4):470-5, 2016
                                          30. Guenot C et al: Fetal intra-peritoneal transfusion for the management of very early spontaneous twin anemia-polycythemia sequence in an obese patient with a whole anterior placenta. Twin Res Hum Genet. 19(2):154-7, 2016
                                          31. Hiersch L et al: Amniotic fluid discordance in monochorionic diamniotic twin pregnancies is associated with increased risk for twin anemia-polycythemia sequence. Prenat Diagn. 36(12):1099-103, 2016
                                          32. Slaghekke F et al: Antenatal management of twin-twin transfusion syndrome and twin anemia-polycythemia sequence. Expert Rev Hematol. 9(8):815-20, 2016
                                          33. Stagnati V et al: Inter-twin discrepancy in middle cerebral artery peak systolic velocity and pregnancy outcome in monochorionic diamniotic twin pregnancies. Ultrasound Obstet Gynecol. 48(1):66-71, 2016
                                          34. Tollenaar LS et al: Twin anemia polycythemia sequence: current views on pathogenesis, diagnostic criteria, perinatal management, and outcome. Twin Res Hum Genet. 19(3):222-33, 2016
                                          35. Bahtiyar MO et al: The North American Fetal Therapy Network consensus statement: prenatal surveillance of uncomplicated monochorionic gestations. Obstet Gynecol. 125(1):118-23, 2015
                                          36. Emery SP et al: The North American Fetal Therapy Network Consensus Statement: management of complicated monochorionic gestations. Obstet Gynecol. 126(3):575-84, 2015
                                          37. Emery SP et al: The North American Fetal Therapy Network Consensus Statement: prenatal management of uncomplicated monochorionic gestations. Obstet Gynecol. 125(5):1236-43, 2015
                                          38. Slaghekke F et al: Middle cerebral artery peak systolic velocity to predict fetal hemoglobin levels in twin anemia-polycythemia sequence. Ultrasound Obstet Gynecol. 46(4):432-6, 2015
                                          39. Van Winden KR et al: Pre-operative twin anemia/polycythemia in the setting of twin-twin transfusion syndrome (TTTS). Fetal Diagn Ther. 37(4):274-80, 2015
                                          40. Trieu NT et al: Evaluation of the measurement of the middle cerebral artery peak systolic velocity before and after placental laser coagulation in twin-to-twin transfusion syndrome. Prenat Diagn. 32(2):127-30, 2012
                                          41. Mari G et al: Expected peak velocity of systolic blood flow in the MCA as a function of gestational age. Focus Information Technology. Copyright 2009. Accessed February 9, 2021. http://perinatology.com/calculators/MCA.htm
                                          Related Anatomy
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                                          Related Differential Diagnoses
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                                          References
                                          Tables

                                          Tables

                                          KEY FACTS

                                          • Terminology

                                            • Imaging

                                              • Top Differential Diagnoses

                                                • Clinical Issues

                                                  • Scanning Tips

                                                    TERMINOLOGY

                                                    • Abbreviations

                                                      • Twin-anemia polycythemia sequence (TAPS)
                                                    • Definitions

                                                      • Monochorionic (MC) twin complication with chronic, slow, unbalanced blood transfusion from donor (D) → recipient (R) twin
                                                        • Most common after laser therapy for twin-twin transfusion syndrome (TTTS)
                                                        • May occur spontaneously; develops > 26 weeks in previously uncomplicated MC twins
                                                          • Spontaneous TAPS can coexist with TTTS
                                                          • Isolated TAPS much rarer

                                                    IMAGING

                                                    • General Features

                                                      • Ultrasonographic Findings

                                                        • MR Findings

                                                          • Imaging Recommendations

                                                            DIFFERENTIAL DIAGNOSIS

                                                              PATHOLOGY

                                                              • General Features

                                                                • Staging, Grading, & Classification

                                                                  • Gross Pathologic & Surgical Features

                                                                    CLINICAL ISSUES

                                                                    • Presentation

                                                                      • Demographics

                                                                        • Natural History & Prognosis

                                                                          • Treatment

                                                                            DIAGNOSTIC CHECKLIST

                                                                            • Consider

                                                                              • Image Interpretation Pearls

                                                                                • Reporting Tips

                                                                                  Selected References

                                                                                  1. Tollenaar LSA et al: Spontaneous twin anemia polycythemia sequence: diagnosis, management, and outcome in an international cohort of 249 cases. Am J Obstet Gynecol. 224(2):213.e1-11, 2021
                                                                                  2. Wang X et al: Longer distance between umbilical cord insertions is associated with spontaneous twin anemia polycythemia sequence. Acta Obstet Gynecol Scand. 100(2):229-34, 2021
                                                                                  3. Araújo Pereira J et al: Twin anemia polycythemia sequence. N Engl J Med. 382(6):e9, 2020
                                                                                  4. Han SJ et al: Short- and long-term outcomes of preterm spontaneous twin anemia-polycythemia sequence. J Perinat Med. ePub, 2020
                                                                                  5. Khalil A et al: Consensus diagnostic criteria and monitoring of twin anemia-polycythemia sequence: Delphi procedure. Ultrasound Obstet Gynecol. 56(3):388-94, 2020
                                                                                  6. Liu B et al: Performance of antenatal diagnostic criteria of twin-anemia-polycythemia sequence. J Clin Med. 9(9), 2020
                                                                                  7. Mao Q et al: Discordant placental oxygenation and autophagy in twin anemia-polycythemia sequence (TAPS). Placenta. 90:9-17, 2020
                                                                                  8. Shanahan MA et al: Placental anatomy and function in twin gestations. Obstet Gynecol Clin North Am. 47(1):99-116, 2020
                                                                                  9. Ting YH et al: Outcomes of radiofrequency ablation for selective fetal reduction in complicated monochorionic pregnancies performed before 16 gestational weeks and thereafter. Ultrasound Obstet Gynecol. ePub, 2020
                                                                                  10. Tollenaar LSA et al: Post-laser twin anemia polycythemia sequence: diagnosis, management, and outcome in an international cohort of 164 cases. J Clin Med. 9(6), 2020
                                                                                  11. Tollenaar LSA et al: High risk of long-term neurodevelopmental impairment in donor twins with spontaneous twin anemia-polycythemia sequence. Ultrasound Obstet Gynecol. 55(1):39-46, 2020
                                                                                  12. Tollenaar LSA et al: Prevalence of placental dichotomy, fetal cardiomegaly and starry-sky liver in twin anemia-polycythemia sequence. Ultrasound Obstet Gynecol. 56(3):395-9, 2020
                                                                                  13. Tollenaar LSA et al: Treatment and outcome of 370 cases with spontaneous or post-laser twin anemia-polycythemia sequence managed in 17 fetal therapy centers. Ultrasound Obstet Gynecol. 56(3):378-87, 2020
                                                                                  14. Visser GL et al: Leukocyte counts and other hematological values in twin-twin transfusion syndrome and twin anemia-polycythemia sequence. Fetal Diagn Ther. 47(2):123-8, 2020
                                                                                  15. Xu J et al: The utility of MRI for measuring hematocrit in fetal anemia. Am J Obstet Gynecol. 222(1):81.e1-13, 2020
                                                                                  16. Zhao D et al: Evaluation of color difference in placenta with twin anemia polycythemia sequence. J Vis Exp. 2020
                                                                                  17. Bahtiyar MO et al: In utero partial exchange transfusion combined with in utero blood transfusion for prenatal management of twin anemia-polycythemia sequence. Fetal Diagn Ther. 45(1):28-35, 2019
                                                                                  18. Hill KM et al: Intrauterine interventions for the treatment of twin anemia-polycythemia sequence: a systematic review. J Obstet Gynaecol Can. 41(7):981-91, 2019
                                                                                  19. Jha P et al: US evaluation of twin pregnancies: importance of chorionicity and amnionicity. Radiographics. 39(7):2146-66, 2019
                                                                                  20. Nicholas LD et al: Twin anemia-polycythemia sequence and routine monitoring practices amongst maternal-fetal medicine specialists in the United States: an initial investigation. J Perinat Med. 47(4):388-92, 2019
                                                                                  21. Nicholas L et al: Dispelling myths about antenatal TAPS: a call for action for routine MCA-PSV doppler screening in the United States. J Clin Med. 8(7), 2019
                                                                                  22. Tavares de Sousa M et al: Role of fetal intertwin difference in middle cerebral artery peak systolic velocity in predicting neonatal twin anemia-polycythemia sequence. Ultrasound Obstet Gynecol. 53(6):794-7, 2019
                                                                                  23. Tollenaar LSA et al: Improved prediction of twin anemia-polycythemia sequence by delta middle cerebral artery peak systolic velocity: new antenatal classification system. Ultrasound Obstet Gynecol. 53(6):788-93, 2019
                                                                                  24. Tollenaar LSA et al: Twin-twin transfusion syndrome with anemia-polycythemia: Prevalence, characteristics, and outcome. J Clin Med. 8(8), 2019
                                                                                  25. Bamberg C et al: Quantified discordant placental echogenicity in twin anemia-polycythemia sequence (TAPS) and middle cerebral artery peak systolic velocity. Ultrasound Obstet Gynecol. 52(3):373-77, 2018
                                                                                  26. Persico N et al: Fetal Doppler changes 1 week after endoscopic equatorial laser for twin-to-twin transfusion syndrome: a longitudinal study. Prenat Diagn. 38(5):344-48, 2018
                                                                                  27. De Paepe ME et al: Redness discordance in monochorionic twin placentas: correlation with clinical and placental findings. Placenta. 60:54-60, 2017
                                                                                  28. Tollenaar LSA et al: Can color difference on the maternal side of the placenta distinguish between acute peripartum twin-twin transfusion syndrome and twin anemia-polycythemia sequence? Placenta. 57:189-93, 2017
                                                                                  29. Fishel-Bartal M et al: Can middle cerebral artery peak systolic velocity predict polycythemia in monochorionic diamniotic twins? Evidence from a prospective cohort study. Ultrasound Obstet Gynecol. 48(4):470-5, 2016
                                                                                  30. Guenot C et al: Fetal intra-peritoneal transfusion for the management of very early spontaneous twin anemia-polycythemia sequence in an obese patient with a whole anterior placenta. Twin Res Hum Genet. 19(2):154-7, 2016
                                                                                  31. Hiersch L et al: Amniotic fluid discordance in monochorionic diamniotic twin pregnancies is associated with increased risk for twin anemia-polycythemia sequence. Prenat Diagn. 36(12):1099-103, 2016
                                                                                  32. Slaghekke F et al: Antenatal management of twin-twin transfusion syndrome and twin anemia-polycythemia sequence. Expert Rev Hematol. 9(8):815-20, 2016
                                                                                  33. Stagnati V et al: Inter-twin discrepancy in middle cerebral artery peak systolic velocity and pregnancy outcome in monochorionic diamniotic twin pregnancies. Ultrasound Obstet Gynecol. 48(1):66-71, 2016
                                                                                  34. Tollenaar LS et al: Twin anemia polycythemia sequence: current views on pathogenesis, diagnostic criteria, perinatal management, and outcome. Twin Res Hum Genet. 19(3):222-33, 2016
                                                                                  35. Bahtiyar MO et al: The North American Fetal Therapy Network consensus statement: prenatal surveillance of uncomplicated monochorionic gestations. Obstet Gynecol. 125(1):118-23, 2015
                                                                                  36. Emery SP et al: The North American Fetal Therapy Network Consensus Statement: management of complicated monochorionic gestations. Obstet Gynecol. 126(3):575-84, 2015
                                                                                  37. Emery SP et al: The North American Fetal Therapy Network Consensus Statement: prenatal management of uncomplicated monochorionic gestations. Obstet Gynecol. 125(5):1236-43, 2015
                                                                                  38. Slaghekke F et al: Middle cerebral artery peak systolic velocity to predict fetal hemoglobin levels in twin anemia-polycythemia sequence. Ultrasound Obstet Gynecol. 46(4):432-6, 2015
                                                                                  39. Van Winden KR et al: Pre-operative twin anemia/polycythemia in the setting of twin-twin transfusion syndrome (TTTS). Fetal Diagn Ther. 37(4):274-80, 2015
                                                                                  40. Trieu NT et al: Evaluation of the measurement of the middle cerebral artery peak systolic velocity before and after placental laser coagulation in twin-to-twin transfusion syndrome. Prenat Diagn. 32(2):127-30, 2012
                                                                                  41. Mari G et al: Expected peak velocity of systolic blood flow in the MCA as a function of gestational age. Focus Information Technology. Copyright 2009. Accessed February 9, 2021. http://perinatology.com/calculators/MCA.htm