Quintero stages for classification of twin-twin transfusion syndrome

Stage I	Oligohydramnios and polyhydramnios sequence*, and the bladder of the donor twin is visible. Dopplers in both twins are normal.
Stage II	Oligohydramnios and polyhydramnios sequence, but the bladder of the donor is not visualized. Dopplers in both twins are normal.
Stage III	Oligohydramnios and polyhydramnios sequence, nonvisualized bladder, and abnormal Dopplers. There is absent/reversed end diastolic velocity in the umbilical artery, reversed flow in a-wave of the ductus venosus, or pulsatile flow in the umbilical vein in either fetus.
Stage IV	One or both fetuses show signs of hydrops.
Stage V	One or both fetuses have died.

Although Quintero staging represents one method of standardization, there are several important limitations. Atypical presentations can occur; for example, the donor twin may have both a persistent bladder and abnormal umbilical Doppler flow. In addition, although higher stages are generally associated with a worsening perinatal prognosis, the clinical presentation of a particular case does not always follow an orderly progression of stages. For example, a stage I case may progress rapidly in several days to stage III and regression of disease can occur in as many as 15 percent of stage I cases and 60 percent of stage II disease.

* Before 20 weeks of gestation, the maximum vertical amniotic fluid pockets for oligohydramnios and polyhydramnios are usually defined as <2 cm and >8 cm, respectively. After 20 weeks, the maximum vertical pocket for polyhydramnios is defined as >10 cm.

Data from: Quintero RA, Morales WJ, Allen MH, et al. Staging of twin-twin transfusion syndrome. J Perinatol 1999; 19:550.

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Quintero stages for classification of twin-twin transfusion syndrome