Background: Vascular accidents in the survivor from pregnancies with twin-twin transfusion syndrome have been attributed to the release of thromboplastin from the dead fetus.
Case: In a woman presenting at 22 weeks' gestation with acute polyhydramnios due to twin-twin transfusion syndrome, endoscopic laser coagulation of the communicating vessels was performed. At endoscopy, the toes of the left foot of the recipient fetus were noted to be gangrenous. This fetus had only a left umbilical artery, which was markedly dilated, and Doppler studies demonstrated impaired perfusion of the left leg. In four control fetuses with a single umbilical artery, Doppler studies demonstrated normal waveforms in both legs.
Conclusion: In twin-twin transfusion syndrome, fetal peripheral gangrene may occur before the death of one twin. The ischemic necrosis of the toes probably resulted from the combined effect of polycythemia and umbilical artery steal syndrome. Interruption of twin-twin transfusion syndrome caused resolution of the polycythemia and prevented further damage by removing one of the components of the peripheral ischemia.