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54 Fetal Death of A Twin PDF
54 Fetal Death of A Twin PDF
Dr Mark P Umstad
MBBS, MD, FRCOG,
FRANZCOG
Head of Multiple
Pregnancy Clinic
University Department
of Obstetrics and
Gynaecology, Royal
Womens Hospital,
Melbourne
National Patron
Australian Multiple
Birth Association
Prevalence
Vanishing twin is a term that
has been used to describe the
Aetiology
The aetiology of single fetal loss in a twin pregnancy varies by
placentation and may be iatrogenic or spontaneous in nature.
The loss rate for a single twin during the second and third
trimesters varies widely in reported series from 0.5 per cent to
11.6 per cent. Although monochorionic (MC) twins account for 30
per cent of all twin pregnancies they account for most of the fetal
losses and the vast majority of adverse neurological outcomes. In
several recent series, where accurate data is available, the loss
rates for MC versus dichorionic (DC) twins has been reported as
3.9 per cent versus 1.3 per cent, 11.6 per cent versus 5.0 per cent
and 6.5 per cent versus one per cent, respectively.
Cause of single
fetal death
Continuing
Resolved
Steroids and
magnesium
DCDA twins
Weekly CTG
Weekly US
Deliver
Deliver 34W
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MCDA twins
MCMA twins
>28W
Deliver
<28W
Weekly US
MRI after 3W
Intensive
monitoring
Intracranial
pathology
No intracranial
pathology
Deliver at 28W
Consider
feticide
Deliver at 37W
Fetal reduction
Single fetal loss in a twin pregnancy may be a consequence of
either selective or multifetal pregnancy reduction. The former is
performed for a fetal abnormality. The latter may be performed
either because it is deemed medically unsafe to proceed with a
twin pregnancy or because the parent(s) are unable to cope with a
multiple birth.
Dichorionic diamniotic twins
Spontaneous single fetal loss in dichorionic diamniotic (DCDA)
twins is usually a consequence of growth restriction, frequently
unrecognised. The risk of fetal death increases with the degree
of growth discordance, particularly when discordance exceeds
30 per cent.
Pre-eclampsia may result in the loss of one twin only indeed,
loss of the twin is often associated with a short-term improvement
in the condition.
Other obstetric complications may result in the demise of only
one of a twin pair: placental abruption, gestational diabetes, fetal
abnormalities, intrauterine infections and cord accidents.
Monochorionic diamniotic twins
Twin-twin transfusion (TTTS) accounts for at least 50 per cent of
all single MCDA twin deaths. Even with extensive and careful
surveillance, the risk of sudden fetal death in the third trimester in
these pregnancies is 1.2 per cent to six per cent, depending on the
level of surveillance. Many have advocated planned early delivery to
avoid this complication, but it is controversial.
Selective fetal growth restriction, particularly of the Gratacos type 2
and 3 variants, accounts for significant numbers of fetal deaths in
MCDA twins.
Fetal anomalies, which are much more frequent in MC twins than
either DC twins or singletons and include particularly cardiac and
neurological abnormalities, account for a large proportion of
MCDA single twin deaths. Most MC twins, although monozygotic,
are discordant for fetal abnormalities.
Twin reversed arterial perfusion (TRAP) sequence is a rare
complication of MCDA twins, but whether an acardiac twin can be
counted as a fetal death is dubious.
Cord ligation to treat a fetal abnormality or TTTS is obviously lethal
to the targeted twin. The procedure isolates the circulation of the
co-twin and eliminates the risk of subsequent injury to the survivor.
Clinical circumstances will determine if there may have been a preexisting insult to the fetus.
Laser ablation of communicating vessels to treat TTTS not infrequently
results in the demise of one of the twins. If the laser treatment has
been successful, the placenta has been effectively dichorionised and
there is again no risk of subsequent injury to the survivor, but there
may be concerns about a pre-existing insult to the fetus.
Monochorionic mono-amniotic twins
Cord entanglement in monochorionic monoamniotic (MCMA) twins
accounts for more than 50 per cent of all losses and may involve
one or both twins.
Fetal abnormalities, particularly cardiac and neurological,
complicate approximately 25 per cent of all MCMA twins. The
fiji national
university
The College of
Medicine, Nursing
and Health Sciences
Fiji National University
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