Survival following twin-to-twin exsanguination in monoamniotic twins: management with peritoneal dialysis

Monochorionic monoamniotic twin pregnancies carry substantial perinatal risk, with co-twin demise potentially causing acute twin-to-twin exsanguination in the survivor. Resultant profound anaemia and cardiovascular compromise may lead to severe acute kidney injury (AKI), while peritoneal dialysis (PD) in premature neonates remains technically challenging because of low birth weight and limited access options. We report a female infant born at 31+6 weeks' gestation following intrauterine co-twin demise from cord entanglement. She developed profound anaemia, metabolic acidosis and anuric stage 3 AKI secondary to acute exsanguination. Despite maximal medical therapy, respiratory deterioration from fluid overload necessitated PD on day 19 of life. Peritoneal access required adaptive strategies, including the use of a biliary drainage catheter. Following dialysis initiation, the infant achieved euvolaemia, respiratory improvement and renal recovery before transfer to a national dialysis and transplant centre. This case demonstrates the feasibility of PD in critically ill low-birth-weight preterm infants.