Background <p>Spontaneous triplet pregnancies are rare, with the incidence being 1 in 7000. Twin reversed arterial perfusion (TRAP) sequence or acardiac twinning is a rare complication of monochorionic pregnancies. In this disorder there is an acardiac twin who lacks well defined heart, is nonviable, and there is a normal (pump) twin which feeds the acardiac twin through placental anastomoses.</p> Case presentation <p>A 28-year-old Asian female belonging to lower middle class, second gravida para one live one delivered by lower segment cesarean section (LSCS) was booked at 24–25&#xa0;weeks with triplet pregnancy. Ultrasonographic examination detected dichorionic triamniotic triplets with two fetuses of 24&#xa0;weeks 6&#xa0;days gestational age, adequate amniotic fluid volume, and no structural abnormalities and an Acardiac twin of 15&#xa0;weeks gestational age with abnormal pulsations on Doppler. As there were no features of heart failure in the donor twin, expectant management was planned with twice weekly ultrasound. At 34&#xa0;weeks she developed preterm premature rupture of membranes (PPROM). Two healthy babies were delivered along with an acardiac twin by cesarean section.</p> Conclusion <p>Invasive procedures are not required for all multiple pregnancies. Few triplet pregnancies can be managed expectantly. Treatment should be individualized depending on size of acardiac twin, presence of heart failure in pump twin, and the degree of placental anastomosis.</p> Graphical Abstract <p></p>