Fishing in Murky Waters: The Challenging Route to Diagnosing Twin-Twin Transfusion Syndrome in a Resource-Limited Humanitarian Setting, A Case Study

Abstract Background Twin-to-twin transfusion syndrome (TTTS), though rare, poses risks for fetal demise if undetected. This late-diagnosed TTTS case from South Sudan demonstrates persistent challenges in identifying high-risk pregnancies in humanitarian settings. Case presentation: A 38-year-old multigravida at unknown weeks gestation presented with fever, labour pains, drainage of liquor, and fetal hand prolapse. Her antenatal care only reported non-specific symptoms without most diagnostics. Evaluation revealed malaria, suspected twin pregnancy, and malpresentation. Ultrasound confirmed polyhydramnios and a suspicious intrauterine mass concerning for TTTS. Undiagnosed TTTS became apparent only during emergent cesarean delivery, finding a demised anomalous donor twin. The acute intrapartum decompensation pointed to late-stage V TTTS preventing intervention. While the viable preterm neonate survived, risks from demise were avoidable through earlier detection. Conclusion This case reinforces literature on missed screening opportunities to recognize TTTS before Quintero staging with poorer prognoses. Subtle signs like sudden abdominal enlargement during third trimester were likely overlooked due to limited access to comprehensive ultrasound and Doppler surveillance. Strengthening displacement-sensitive antenatal protocols, building frontline imaging capacity, improving provider awareness, and prompt referrals could help mitigate TTTS-related morbidity and mortality in marginalized populations. Global health efforts must address these persisting care gaps in pregnancy surveillance and access to specialty care, especially in humanitarian settings.