Delayed recognition of twin-to-twin transfusion syndrome with adverse fetal outcome: a case report

Abstract

Twin-to-Twin Transfusion Syndrome (TTTS) is a serious complication of monochorionic twin pregnancies resulting from imbalanced blood flow through placental vascular anastomoses. It produces a hypovolemic, growth-restricted donor twin and a volume-overloaded recipient twin at risk of cardiac compromise, and carries high perinatal morbidity and mortality if not diagnosed and managed promptly. A 32-year-old unbooked, unsupervised G3P2L2 woman presented at 26 weeks of gestation – at her first antenatal visit – with progressive abdominal distension, breathlessness, reduced urine output, and abdominal pain. Ultrasonography revealed a twin gestation with polyhydramnios in one twin and oligohydramnios with a stuck-twin appearance in the other, along with discordant growth and abnormal Doppler indices, findings compatible with Quintero Stage III TTTS. After counselling regarding all management options, therapeutic amnioreduction was performed for symptomatic relief. Spontaneous preterm labour supervened 14 hours later, and the patient delivered vaginally; the donor twin could not be resuscitated and the recipient twin suffered an early neonatal death. Gross placental examination confirmed monochorionic placentation. This case highlights how absence of early and regular ultrasonographic surveillance in a monochorionic twin pregnancy can delay recognition of TTTS until an advanced, poorly salvageable stage. Routine monochorionic-specific surveillance and prompt referral to a fetal medicine unit capable of fetoscopic laser therapy remain central to improving outcomes.