A case of late-onset twin-twin transfusion syndrome with severe fetal anemia and maternal acute kidney injury

Twin-twin transfusion syndrome (TTTS) is a rare but serious complication of monochorionic twin gestation which forewarns obstetricians about the best management approach. The majority of cases are diagnosed early and managed with laser coagulation, resulting in reduced neonatal mortality. We have managed a late-diagnosis of TTTS Quintero stage 1, who was delivered due to suspicion of severe fetal anemia in the donor and cardiac overload in the recipient twin. The mother developed acute kidney injury in the early third trimester which worsened despite appropriate management. The cause of kidney injury in a mother carrying monochorionic diamniotic (MCDA) twins is unknown, yet restoration of renal function post-delivery suggests a connection. We are presenting this case as a rare presentation of severe fetal anemia in TTTS. This case demands additional research to identify the triggering factors, knowledge of which is expected to reformulate the management of MCDA twins.