Increases in postpartum hemorrhage are not explained by the changing risk profile of women. It may be that changes in management and/or reporting of postpartum hemorrhage have resulted in higher postpartum hemorrhage rates.

Objective-Fetal twin-twin transfusion syndrome (TTTS) presenting in the second trimester has been associated with almost no perinatal survival until recently, when serial drainage of amniotic fluid has improved the prognosis to 70%-80%. Most Clinical manifestations in utero range from mild to critical pulmonary stenosis or lethal cardiomyopathy. Although perinatal prognosis seems to be related to the severity of dysfunction when first diagnosed in utero, follow up in infancy is recommended in view of the possibility of progressive pulmonary stenosis. (Br Heart J 1994;72:74-79) Twin-twin transfusion syndrome (TTTS) is a severe complication of monozygotic twinning. It arises in 4%-26% of diamniotic monochorionic gestations, presumably as the result of vascular anastomoses between the circulation of one twin (the donor) and that of its co-twin (the recipient) leading to circulatory disequilibrium.1 As a result of the transfusion, the donor twin becomes growth retarded and oliguric and develops oligohydramnios, whereas the recipient twin becomes polyuric with severe hydramnios and may develop hydrops. The traditional explanation that transfusion of blood from one twin to the other along placental vascular anastomoses produces hypovolaemia and anaemia in the donor and circulatory overload with polycythaemia and hyperviscosity in the recipient2 may be oversimplified. Recent evidence suggests that haematological discordance is unlikely in second trimester l-l-S as investigated by fetal blood sampling.' Also, umbilical venous pressure is not significantly raised in all hydropic recipient twins.4 These are features inconsistent with the simple explanation of circulatory overload.Severe 'I-'-S presenting in the second trimester has until recently been associated with nearly 100% perinatal death.2 The main cause of perinatal loss is premature delivery due to severe polyhydramnios. Serial amnioreduction now allows survival in 70%-80%56 mainly by allowing prolongation of pregnancy, but also possibly by improving fetal condition6 with most cases of severe second trimester 'TITS now progressing into the third trimester. We have found that most recipient twins develop cardiac dysfunction in utero, predominantly affecting the right ventricle and pulmonary artery, which can result in neonatal morbidity and mortality.This report describes the clinical and echocardiographic features of cardiac dysfunction in recipient twins in second trimester T'1TS. Patients and methodsWe studied five pregnancies complicated with T'-TS. Gestational age at referral was 17-25 weeks (median 19). The inclusion criteria were: (a) monochorial twins of the same sex;

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