Prenatal ultrasound diagnosis of fetal upper gastrointestinal bleeding in a monochorionic twin pregnancy: a case report

Fetal upper gastrointestinal bleeding (UGIB) is an exceptionally rare condition. We report a case of antenatally detected UGIB in a monochorionic diamniotic twin pregnancy, emphasizing key ultrasound features that enabled timely delivery and a favorable neonatal outcome. A 23-year-old woman with a monochorionic diamniotic twin pregnancy complicated by Stage II twin-to-twin transfusion syndrome (TTTS) underwent fetoscopic laser ablation at 23 + 1 weeks. At 33 + 5 weeks’ gestation, routine ultrasound revealed marked gastric and intestinal dilatation with echogenic intraluminal material and echogenic amniotic fluid in the recipient twin, along with elevated middle cerebral artery (MCA) peak systolic velocity (1.53 MoM) suggesting fetal anemia. An emergency cesarean section was performed. The neonate, born in bloody amniotic fluid, presented with hemorrhagic shock due to hemorrhagic gastritis confirmed by endoscopy. After intensive resuscitation, the infant recovered fully and was discharged on Day 23. The coexistence of echogenic bowel content, echogenic amniotic fluid, and increased MCA Doppler should alert clinicians to possible in-utero gastrointestinal bleeding. Early recognition within standardized high-risk pregnancy surveillance protocols may allow life-saving intervention.