A 26-yr-old primigravida with a twin gestation at 30 weeks presents for a USG.The sonogram indicates that the fetuses are both male and the placenta appears to be diamniotic and monochorionic.Twin B is noted to have oligohydramnios and to be much smaller than twin A.In this clinical scenario ,all of the following are concerns for twin A except:

This scenario represents a typical case of twin to twin transfusion syndrome. Twin to twin transfusion syndrome (TTTS) It is always seen in monochorionic placenta. M/C in monochorionic diamniotic pregnancy than monochorionic monoamniotic pregnancy. There is an arteriovenous malformation such that there exists a communication from the umbilical arterial system of the “donor” twin to the umbilical vein of the “recipient” twin. The donor twin is growth restricted, hypovolemic, has oligohydramnios and is anemic because it gives blood to the recipient twin. The recipient is larger, hypervolemic, has polyhydramnios and is plethoric. It has also been termed as Twin Oligohydramnios/Polyhydramnios Sequence (TOPS). The earlier the TOPS appears, worse will be the prognosis. TTTS is more common in female fetuses. TTTS can cause preterm delivery due to polyhydramnios, IUGR or fetal demise. Coming to the question—Twin A is the recipient twin and Twin B is the donor twin since it has oligohydramnios. Thus twin A can have CHF—due to volume overload, can have hydramnios and can have thrombosis since it has polycythemia which can lead to thrombosis, but it will never have anemia.