Most anomalies seen in fetuses and neonates who have chronic twin-to-twin transfusion syndrome (TTTS) represent sequelae of cardiovascular dysfunction or vascular disruption. The placental examination can provide critical information to the neonatologist caring for infants who have a history of TTTS, especially in instances wherein the twins are not necessarily growth-discordant but have cardiovascular or renal dysfunction or neuropathologic findings. In this review, we present an updated discussion of the fetal and neonatal pathologies and adverse sequelae associated with TTTS and advances in antenatal diagnosis and clinical interventions for monochorionic gestations complicated by TTTS. We also present highlights of the placental examination so the neonatologist can inspect the placenta at the time of delivery and possibly gain insights that may affect patient care.

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