The National Institute for Health and Clinical Excellence (NICE) issued full guidance to the NHS in England, Wales, Scotland and Northern Ireland on septostomy with or without amnioreduction for the treatment of twin-to-twin transfusion syndrome in December 2006. In accordance with the Interventional Procedures Programme Process Guide, guidance on procedures with special arrangements are reviewed 3 years after publication and the procedure is reassessed if important new evidence is available.

The guidance was considered for reassessment in December 2009 and it was concluded that NICE will not be updating this guidance at this stage. However, if you believe there is new evidence which should warrant a review of our guidance, please contact us via the email address below.


Twin-to-twin transfusion syndrome occurs when unborn identical twins have different sacs in the womb but share the same placenta. This results in blood flow from one twin to the other through connections between blood vessels in the shared placenta becoming unbalanced. The volume of fluid around the twins also becomes uneven. In septostomy with or without amnioreduction, a needle is used to make a hole in the membrane separating the twins to even out the volume of the fluid surrounding the babies. Sometimes excess amniotic fluid may need to be removed with another needle (this procedure is called amnioreduction).

Coding recommendations

R08.8 Other specified therapeutic percutaneous operations for twin to twin transfusion syndrome
Y33.8 Other specified puncture of organ NOC
Y53.2 Approach to organ under ultrasonic control
Y95.- Gestational age

Note:  A code from category Y95.- Gestational age must be assigned in a subsidiary position where this information is available.

Your responsibility

This guidance represents the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take this guidance fully into account, and specifically any special arrangements relating to the introduction of new interventional procedures. The guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer. 

All problems (adverse events) related to a medicine or medical device used for treatment or in a procedure should be reported to the Medicines and Healthcare products Regulatory Agency using the Yellow Card Scheme.

Commissioners and/or providers have a responsibility to implement the guidance, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties. Providers should ensure that governance structures are in place to review, authorise and monitor the introduction of new devices and procedures.

Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.