DR - JD - Gemelli - Fetal Demise

FETAL DEMISE
• At any time during multifetal pregnancy, one or more

fetuses may die, either simultaneously or sequentially.
• Causes and incidence of fetal death are related to :
• zygosity,chorionicity, and growth concordance.
• delivery of a normal newborn is followed by expulsion of a
dead fetus that is barely identifiable
• It may be compressed appreciably–fetus compressus
• Flattened remarkably through desiccation—fetus
papyraceus
Cunningham, F.G. et al., 2018. Williams Obstetrics 25th Edition 25 ed.McGraw Hill:1097-1115
• Other factors that affect the prognosis for the surviving twin :
• Gestational age at the time of the demise and duration between the demise and delivery of the
surviving twin.
• The neurological prognosis for a surviving cotwin depends almost exclusively on chorionicity
• 34 weeks, a fivefold higher risk of neurodevelopmental morbidity was identified in monochorionic twins
compared with dichorionic twins
• If the one fetus died after 34 weeks, the likelihood of neurological deficits was essentially the same
between monochorionic and dichorionic twin pregnancies
• Later in gestation, the death of one of multiple fetuses could theoretically trigger coagulation defects in the
mother.
• Only a few cases of maternal coagulopathy after a single fetal death in a twin pregnancy have been
reported  because the surviving twin is usually delivered within a few weeks of the demise
Hillman SC, Morris RK, Kilby MD. Single twin demise: consequence for survivors. Semin Fetal Neonatal Med. 2010 Dec;15(6):319-26. doi: 10.1016/j.siny.2010.05.004. Epub 2010 Jul 2. PMID: 20584634.
PATHOPHYSIOLOGY
• These are ‘transient’ haemodynamic fluctuations between twins and

transchorionic embolisation and coagulopathy.
• However, the former is felt to be more significant in predisposition towards
morbidity and mortality for co-twins post sIUFD.
Death of one twin  Hypoperfusion, Tissue hypoxia, acidosis

transfer of blood from the hypotension and fetal and damage in fetal
surviving fetus a ‘back- anemia in the surviving systems  particularly in
bleed) fetus CNS
Coagulopathy
• The plasma fibrinogen concentration initially decreased but then increased spontaneously, and the
level of serum fibrinogen-fibrin degradation products increased initially but then returned to normal
levels.
• At delivery, the portions of the placenta that supplied the living fetus appeared normal.
• In contrast, the part that had once provided for the dead fetus was the site of massive fibrin
deposition.
Morbidity
• Morbidity in the monochorionic twin survivor is almost always due to vascular anastomoses, which
often cause the demise of one twin followed by sudden hypotension in the other
• death of one but not all fetuses results from a maternal complication such as diabetic ketoacidosis or
severe preeclampsia with abruption.
• Although the risks of subsequent death or neurological damage to the survivor are comparatively
higher for monochorionic twins at this gestational age, the risk of preterm birth is equally increased
in mono and dichorionic twins
Effect to the survivor
• Hypoxic ischaemis lesion of white matter

Central nervous system • Haemorrhagic lesion
• Anomalies secondary to vascular disturbance
• Renal cortical necrosis

• Unilateral damage of a kidney
• Small bowel atresia
Injury to other system • Gastroschisis
• Aplasia cutis
• Terminal limb infarction
Neurological injury and • Surviving twin  increase risk of cerebral

cerebral palsy rates palsy
Management
• Decisions should be based on gestational age, the cause of death, and the risk to the surviving fetus.
• First-trimester losses require no additional surveillance for this specific indication.
• If the loss occurs after the first trimester, the risk of death or damage to the survivor is largely limited
to monochorionic twin gestations.
• if one fetus of a monochorionic twin gestation dies after the first trimester but before viability,
pregnancy termination can be considered
• Delivery generally occurs within 3 weeks of diagnosis of fetal demise, thus antenatal corticosteroids
for survivor lung maturity should be considered
• unless the intrauterine environment is hostile, the goal is to prolong the preterm pregnancy
• After a single fetal death in a monochorionic pregnancy, clinicians should be aware that
the risks to the surviving twin of death or neurological abnormality are of the order of 15%
and 26%, respectively
Timing Delivery
• Debatable
• Dichorionic twins can probably be safely delivered at term.
• Monochorionic twin gestations are more difficult to manage and are often delivered between 34 and
37 weeks’ gestation
• In cases of single fetal death at term, especially when the etiology is unclear, most opt for delivery
instead of expectant management.
Gestation of delivery Mode of Delivery Post Delivery
• Corticosteroid < 34 weeks • Vaginal delivery • Counselled regarding the
gestation • In monochorionic twins postmortem the dead
• Dichorionic if there are no complicated by sIUFD  twin
other obstetric factors  caesarean section avoid • Full examination of the
not advocated before 38 the risk of acute TTTS due surviving neonate
weeks gestation to vascular anastomoses • The surviving twin shoulde
• Monochorionic  delivery be under follow up by
by 38 weeks and some as paediatric
early as 32 – 34 weeks
Impending Death of One Fetus
• Delivery may be the best option for the compromised fetus yet may result in death from immaturity
of the cotwin
• If fetal lung maturity is confirmed, salvage of both the healthy fetus and its jeopardized sibling is
possible.
• Often the compromised fetus is severely growth restricted or anomalous.
• performing amniocentesis for fetal chromosomal analysis In women of advanced maternal age
carrying twin pregnancies is advantageous, even for those who would continue their pregnancies
regardless of the diagnosis
• Chromosomal abnormality identification in one fetus allows rational decisions regarding
interventions.
Fetal surveillance
ULTRASOUND
• Chorionicity :
• Chorionicity cannot be accurately determined by ultrasound after 20 weeks.
• After this time the fetal sexing should be performed and if sex is concordant
then monochorionicity should be assumed
• Doppler studies may be of use, specifically middle cerebral artery peak
systolic velocity to examine for fetal anaemia and to determine which fetus
may benefit from an intrauterine blood transfusion.
Fetal surveillance
MRI
• MRI of the surviving twin’s brain should be performed at least 3 weeks after the
death of a co-twin.
Fetal blood sampling and

intrauterine transfusion
• Fetal blood sampling within 24-48 h after sIUFD would allow clinicians to determine the survivor’s
haemoglobin in addition to checking the fetal haematocrit and acidebase balance.
• intrauterine blood transfusion may prevent death but is less good at preventing brain injury

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FETAL DEMISE

• At any time during multifetal pregnancy, one or more

• These are ‘transient’ haemodynamic fluctuations between twins and

Death of one twin  Hypoperfusion, Tissue hypoxia, acidosis

• Hypoxic ischaemis lesion of white matter

• Renal cortical necrosis

Neurological injury and • Surviving twin  increase risk of cerebral

Fetal blood sampling and

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