If there is a vascular connection across a monochorionic twin placenta, then a twin-twin transfusion syndrome can develop via blood flow between the fetuses. In this condition, there is diminished blood flow to one twin (the "donor") and increased blood flow to the other twin (the "recipient"). The pale appearing donor is smaller and may die for lack of sufficient blood flow. More commonly, the larger plethoric recipient may die from congestive heart failure.