Twin Transfusion Syndrome (TTTS) Malpractice

Twin-to-twin transfusion syndrome (TTTS) is a rare condition that occurs in some pregnancies in which identical twins are sharing the same placenta (monochorionic pregnancies). Normally, each fetus has its own separate placenta. Monochorionic twin pregnancies occur when identical twins share a single placenta. When this occurs, the blood vessels attaching each twin’s umbilical cord to the placenta may become abnormally connected, resulting in TTTS.

So the TTTS meaning is rooted in a condition affecting monochorionic twin pregnancies, where the twins share a single placenta. Due to abnormal vascular connections between the twins, one baby (the donor) pumps blood into the other (the recipient). Left unchecked, this imbalance leads to polyhydramnios in the recipient and oligohydramnios in the donor. Both extremes are dangerous. The condition progresses rapidly, and failure to act quickly is where most TTTS malpractice cases begin.

We often encounter families who were never even told they had a twin in twin syndrome or who were misinformed about the risk. That is not just a communication breakdown. It is actionable negligence.

TTTS causes abnormal disparity in blood circulation between the twins. The abnormal blood vessel connections inside the shared placenta cause blood to be diverted away from one twin (the “donor”) and circulated to the other twin (the “recipient”). The end result is that the donor twin ends up not getting enough blood supply from the placenta, while the recipient twin is getting too much blood from the placenta. This can be very serious because blood circulation from the placenta is the key to fetal life and development. All of the oxygen and nutrients the fetus needs to survive and grow come from maternal blood exchange through the placenta.

Dangers of TTTS

TTTS is a very uncommon condition. It can only occur in identical twin pregnancies with a shared placenta. Identical twins are relatively uncommon to begin with, and not all identical twins share a placenta. Even with identical twins and a shared placenta, TTTS still only occurs when the umbilical cords attach close enough together on the placenta for the blood vessels to connect abnormally. This occurs in approximately 15% of monochorionic pregnancies. When twin-to-twin transfusion syndrome does occur, however, it can be very serious. Until recently, in fact, TTTS was almost always fatal for one if not both twins.

When TTTS occurs, the donor twin is deprived of blood supply from the placenta, and the condition progressively gets worse. The donor baby’s system responds to the lack of blood by circulating all available blood supply to the brain and the heart. Meanwhile, blood is diverted away from secondary organs. If not corrected, the donor twin will eventually die from organ failure. If the donor twin dies, it immediately puts the recipient twin at high risk of death or injury.

Diagnosis of TTTS

TTTS is diagnosed clinically based on various symptoms, most of which are apparent from ultrasound images. These include disparities in amniotic fluid levels (one twin has too little while the other twin has too much amniotic fluid). TTTS is a progressive condition, meaning it gets worse over time. This means that early diagnosis and intervention is critically important.

Accurate diagnosis of TTTS can be difficult because there is no easy way for doctors to look inside the placenta and see if abnormal blood vessel connections have formed. However, since TTTS is a condition that can only occur in monochorionic pregnancies, the starting point for any TTTS diagnosis is identifying whether identical twins are sharing a single placenta. Making this determination can and should occur fairly early on in the pregnancy. Once the pregnancy is classified as monochorionic, doctors will carefully monitor for clinical symptoms of TTTS.

The primary clinical symptoms used to make a diagnosis of TTTS in monochorionic pregnancies are:

• Amniotic Fluid Levels: When TTTS occurs, the donor twin will have a smaller bladder and low levels of amniotic fluid in the amniotic sac (oligohydramnios, defined as the deepest pocket of amniotic fluid of fewer than 2 centimeters). The recipient twin will have excess amniotic fluid levels (polyhydramnios, defined as the deepest pocket of amniotic fluid greater than 8 centimeters).
• Fetal Size: Another key indicator of TTTS is when one twin is significantly undersized for its fetal age, while the other is oversized.
• Umbilical Cord Differences: With TTTS, the umbilical cord of the recipient twin will often appear larger compared to the donor twin, due to the excess blood levels being circulated.

The Quintero staging system is the best path to diagnose twin-twin transfusion syndrome. This includes measurement of bladder sizes, polyhydramnios/oligohydramnios, Doppler findings, and the presence of hydrops fetalis, which suggests the most advanced and precarious stage of TTTS.

In malpractice cases, doctors will sometimes push back on the victims’ lawyer’s contention that there ever was a twin-twin diagnosis. One argument a defense lawyer makes in this vein is that the fetal echocardiography test was negative. But that test is not adequate to diagnose or stage twin-twin transfusion.

Another common defense argument is that it was not twin-twin transfer but instead an infection. Usually, this argument can be resolved with the assistance of a placental pathologist, who can examine the placenta and identify any findings consistent with infection.

Treatment Options

There are basically two treatment options for TTTS. The first option involves the use of amniocentesis to drain excess amniotic fluid from the recipient twin. Reducing amniotic fluid levels in this situation has been shown to help improve blood circulation. The other treatment option is laser surgery. Doctors can use a fiber-optic camera to enter the womb and examine the blood vessel connections inside the placenta. This allows them to use a laser tool to cut and seal the abnormal connections that are causing the disparity in blood circulation between the twins.

TTTS and Medical Malpractice

Any twin birth injury lawyer will tell you that few cases are as devastating or medically complex as those involving twin-to-twin transfusion syndrome.  For parents, the trauma of losing one or both twins, or seeing a surviving child suffer lifelong neurological damage, is overwhelming.  What a TTTS twin-to-twin transfusion syndrome lawyer needs to do is figure out whether a mistake was made and, if so, show where the healthcare system failed and how earlier detection and intervention could have made the difference.

Failure to Diagnose TTTS Lawsuit: The Legal Foundation

Almost all twin-to-twin transfusion syndrome claims hinge on a failure to diagnose TTTS. The legal theory is straightforward: the standard of care for managing a monochorionic twin pregnancy includes performing ultrasounds at least every two weeks starting at 16 weeks of gestation. These ultrasounds are vital for identifying signs of TTTS, particularly discrepancies in amniotic fluid volume, bladder size, and fetal growth.

If these signs are missed or ignored, and the condition progresses into advanced stages without intervention, that is where a failure to diagnose TTTS lawsuit becomes viable.

It is not enough to show a delay. To succeed in a twin-to-twin transfusion syndrome lawsuit, we must demonstrate that earlier diagnosis—what we often call a missed “window of intervention”—would have led to treatment, usually in the form of fetoscopic laser ablation, which corrects the abnormal blood flow between the twins.

TTTS Diagnosis: What Should Have Happened

A timely TTTS diagnosis depends on vigilance. Providers must flag the pregnancy as monochorionic early. That designation alone triggers the heightened surveillance protocol. When clinicians fail to schedule biweekly scans or overlook obvious red flags on imaging, such as discordant fluid levels or absent bladders, they violate established standards of care.

In deposition, the defense often claims that TTTS can develop suddenly. That is technically true, but it is also misleading. Most cases show early warning signs. The plaintiffs’ medical experts, typically maternal-fetal medicine specialists, can clarify that even a diagnosis made just one week earlier could have allowed for successful intervention. That is the linchpin of many twin-to-twin transfusion syndrome legal cases.

How These Cases Are Won at Trial

To win one of these TTTS twin birth injury claims, you have to do more than check boxes. You have to show jurors the entire story:

• The missed opportunity: The ultrasound that should have happened, the referral that should have been made, the fetal surgery center that never got the chance to intervene.

• The damage: One twin may die in utero or shortly after birth. The other may suffer from cerebral palsy, hearing loss, heart failure, or other injuries tied to hypoxic episodes. This is where the real weight of the claim lies—and why twin birth injury lawyers must build an airtight damages package.

• The timeline: Most jurors are not familiar with TTTS. You have to walk them through what TTTS syndrome is, how it develops, what the twin-twin transfusion symptoms are, and why no reasonable provider could miss it without being negligent.

 Proving Causation in TTTS Cases

Causation is the battleground. The defense will always try to argue that an earlier diagnosis would not have changed the outcome, or that the injury stemmed from unrelated complications. We counter that with experts who know this disease cold—people who have published on TTTS or performed fetal laser surgeries. They can show that with proper monitoring and timely referral, outcomes improve drastically.

This is where twin birth injury claims distinguish themselves from other obstetric malpractice cases. The science is tight. The protocols are clear. The damages are immense. If you can build a timeline showing that a TTTS diagnosis should have happened weeks earlier, and you can prove that fetal surgery would have been effective, then you have the core of a compelling TTTS lawsuit.

TTTS Verdicts and Settlements

Summarized below are verdicts and reported settlements from a few cases involving allegations that TTTS was misdiagnosed or otherwise mishandled by doctors.

• Plaintiff v OB/GYN Group (Massachusetts 2024) $1.75 million settlement: A mother pregnant with triamniotic dichorionic triplets—two of whom were monochorionic, alleged that the medical team failed to recognize early signs of twin-to-twin transfusion syndrome (TTTS). Abnormal ultrasound findings, including amniotic fluid discrepancies and nuchal translucency, were not followed by timely intervention. One twin died in utero, and the surviving twin suffered neurologic injury resulting in permanent disability. The family hired a twin-to-twin transfusion syndrome lawyer and filed a lawsuit. The case settled before trial for $1.75 million.
• J.A.S. v Cambridge Pediatrics (Pennsylvania 2016) $8.4 million verdict: A hospital and pediatric practice were sued for negligently mishandling the pregnancy and premature delivery of identical twins suffering from twin-to-twin transfer syndrome. One of the twins was stillborn, and the surviving twin was extremely premature with a birth weight of only 2 lbs. and an APGAR score of 5. After birth, the surviving twin required a tracheostomy, which was dislodged due to negligent monitoring, causing cardiac arrest. He suffered severe intraventricular hemorrhages and brain damage, leading to a permanent seizure disorder and profound disability.  The mistakes the doctors make were pretty awful. The defendants actually admitted negligence, and the case proceeded to trial solely on the issue of damages. The jury awarded over $8 million.
• Anonymous Infants v Anonymous Physicians (North Carolina 2012) $2.25 million settlement: Twin infants were diagnosed with cerebral palsy after birth due to undiagnosed twin-to-twin transfusion syndrome.  The plaintiffs alleged that the defendant medical providers failed to conduct appropriate prenatal testing and monitoring, including ultrasounds, which would have detected the TTTS. They claimed that, had the condition been properly diagnosed, treatments such as serial amnioreduction or fetal laser ablation could have interrupted the abnormal blood flow between the twins and prevented the injuries. Both twins were born with significant and permanent brain damage, resulting in cerebral palsy. The defendants denied any breach in the standard of care and argued that there were no signs of TTTS during the pregnancy. The case settled for $2.25 million.
• Plaintiff v Defendant (Iowa 2007) $2.3 million: Plaintiff sued OB/GYNs and radiologists, alleging that they failed to timely diagnose and treat her twin-to-twin transfusion syndrome, resulting in one twin dying and the other being born with severe brain injuries. Specifically, the plaintiff claimed that doctors failed to identify that twins were sharing a single placenta and other si
  gns of TTTS when an ultrasound was performed at 18 weeks. By the time the next ultrasound was done at 29 weeks, the donor twin had already died, and the recipient twin had suffered hypoxic brain injury. The case settled days before trial for $2.6 million.
• Pardini v Allegheny General (Pennsylvania 2007) $125,000: father filed his own separate claim for emotional distress based on the death of his twins. He alleged that the defendant hospital and doctors failed to properly diagnose and manage twin transfusion syndrome, which ultimately led to the stillbirths. Mother had already brought a claim on behalf of the deceased twins and received separate settlements. Case settled for $125k.

Contact Miller & Zois About TTTS or Birth Injuries

If you think you may have a malpractice claim involving TTTS or a birth injury, contact the birth injury lawyers at Miller & Zois for a free consultation. Call us at 800-553-8082 or contact us online.

Key TTTS Studies

• Provinciatto HG, et al. Prevention of preterm birth in twin-to-twin transfusion syndrome: a systematic review and network meta-analysis. J Perinat Med. 2024. DOI: 10.1515/jpm-2024-0119.  This study strengthens claims in twin-to-twin transfusion syndrome lawsuits where doctors failed to monitor for cervical shortening or refer for cerclage. It supports the argument that with timely diagnosis and proper management, outcomes could improve, which are key elements in proving both negligence and causation in twin birth injury claims.
• Faden, M, et. al: Characteristic ultrasound findings of resolving twin-twin transfusion syndrome after Solomon laser treatment. ACOG Jan, 220(1):S161.
• Bolch, et. al: Twin-to-twin transfusion syndrome neurodevelopmental follow-up. BMC Pediatr. 2018; 18:256.
• Argoti PS, et.al: Fetoscopic laser ablation outcomes for twin-to-twin transfusion syndrome in dichorionic triamniotic triplets compared to monochorionic diamniotic twins. Ultrasound Obstet Gynecol 2014 Nov;44(5):545-9.
• Molina S, et al: Management of stage I twin-twin transfusion syndrome: An international survey. Ultrasound Obstet Gynecol. 2010 Jul;36(1):42-7.