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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 8  |  Issue : 3  |  Page : 68-70

Twin pregnancy with intrauterine death of one twin


Department of Obstetrics and Gynaecology, Prathima Institute of Medical Sciences, Karimnagar, Telangana, India

Date of Submission08-Oct-2020
Date of Decision01-Nov-2020
Date of Acceptance04-Nov-2020
Date of Web Publication25-Nov-2020

Correspondence Address:
Dr. Subha Ranjan Samantaray
Qr No-303, Block-C, Prathima Institute of Medical Sciences, Karimnagar - 505 415, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjhs.mjhs_13_20

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  Abstract 


Antepartum death of one twin is an infrequent obstetric complication. It complicates about 6% of twin pregnancies. Death of one twin in second or third trimester is more deleterious with risk for the surviving twin and also risk of disseminated intravascular coagulation to the mother has been reported. Risks are far higher in monochorionic pregnancy than in dichorionic pregnancy. The common foetal circulation between the live and the dead twins may result in foetal cerebral, renal and skin abnormalities. Management depends on the gestational age, chorionicity and the condition of the surviving fetus. High risk obstetric management is required and a careful neonatal and paediatric follow up is advocated.

Keywords: Disseminated intravascular coagulopathy, intrauterine death of twin fetus, intrauterine growth restriction, stuck twin syndrome, twins


How to cite this article:
Mohapatra I, Ponnam V, Samantaray SR, Vivevak A. Twin pregnancy with intrauterine death of one twin. MRIMS J Health Sci 2020;8:68-70

How to cite this URL:
Mohapatra I, Ponnam V, Samantaray SR, Vivevak A. Twin pregnancy with intrauterine death of one twin. MRIMS J Health Sci [serial online] 2020 [cited 2021 Jan 18];8:68-70. Available from: http://www.mrimsjournal.com/text.asp?2020/8/3/68/301478




  Introduction Top


Twin pregnancies are associated with increased risk of perinatal morbidity and mortality as compared to singleton pregnancies. The incidence of multiple pregnancies varies depending on the region, country and population. Antepartum death of one fetus complicates up to 6% of twin pregnancies and can have adverse sequelae for the existing twin.[1] Death of one twin in the first trimester is comparatively common and the pregnancy continues with least complications to the mother and the surviving twin.[2] Death of one twin in second or third trimesters is more deleterious with the risk for the surviving twin and also the risk of disseminated intravascular coagulopathy to the mother.[3] Other adverse events associated with single intrauterine fetal death (IUFD) are: Co-twin IUFD, preterm birth, fetal growth discordance, antenatal and postnatal brain injury and neonatal death.[4] Death of one twin in monochorionic pregnancy can cause risk of death in 25% and neurological abnormality in 25% of the surviving twin.[5] Fetal growth discordance in first trimester shows greater risk of fetal death in the smaller twin. When discordant growth is recognised before 20 weeks, fetal demise occurs in 20% of growth restricted foetuses.[6] Risks are elevated in monochorionic pregnancy than in dichorionic pregnancy.[7] Management depends on the gestational age, chorionicity and the condition of the surviving fetus and the condition of the mother.


  Case Report Top


A 28-year-old lady, residing in Karimnagar, Telangana, belonging to Class 3 socioeconomic status, gravida 3 para 1 living 1 abortion 1, had been referred from a private hospital in view of high blood pressure recordings at 30 weeks 2 days of gestation with circlage insitu. She was already on tablet labetalol 100 mg twice daily. She had started her antenatal check-up at 13 weeks of gestation. An obstetric ultrasound was done, revealing a dichorionic diamniotic pregnancy with crown rump length of 8.1 cm of Twin-1 and 5.6 cm of Twin-2, corresponding to 13–14 weeks of gestational age. Anomaly scan was done at 21 weeks; revealing twin-1 live, intrauterine pregnancy of 17–21 weeks in breech presentation with growth discordance and twin-2 with features of stuck twin syndrome on maternal right side with intrauterine growth restriction, anhydramnios and echogenic bowel. She had her antenatal checkups at a local hospital and had been referred to our institute in view of high blood pressure recordings. On admission her vitals were stable. General physical examination, systemic and obstetric examination were done. Obstetric examination revealed uterus of size 32–34 weeks, relaxed with fetal heart rate of 142/min. Routine blood investigations were ordered. Baseline coagulation profile was normal. Obstetric ultrasound revealed intrauterine twin pregnancy with Twin-1 live, cephalic with mean gestational age of 30–31 weeks. Twin-2 was in breech presentation with mean gestational age of 16–17 weeks, absent cardiac activity, suggestive of IUFD. We managed the patient conservatively by giving antenatal steroids for foetal lung maturity, weekly ultrasound and coagulation profile to monitor foetal growth and to rule out maternal disseminated intravascular coagulation. After 2 weeks of admission foetal Doppler revealed raised velocity in right uterine artery with resistance index of 0.63. She was planned for elective caesarean section at 35 completed weeks in view of abnormal findings on foetal Doppler. Twin-1 male baby delivered with birth weight of 2.1 kg with delayed cry at birth with APGAR score of 5/10 and 7/10 at 1 and 5 min respectively. Twin-2 was found adherent to the placenta and the sac suggestive of foetus papyraceous with weight of 300 g [Figure 1]. Twin-1 was admitted to neonatal intensive care unit and was kept on continuous positive airway pressure because of respiratory distress. Baby was slowly tapered to oxygen with nasal prongs and hood till postdelivery day 8 and was discharged on postdelivery day 10. Patient came for follow up after 15 days. Baby was healthy, accepting breast milk well. At 6 months the baby was immunized till date and had attained mile stones according to its age.
Figure 1: (a) Placenta of twin-1 with twin-2 within the sac adherent to the placenta. (b) Foetus papyraceous having discordant growth with the placenta

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  Discussion Top


Twin pregnancies are associated with increased risk of perinatal morbidity and mortality as compared to singleton pregnancies. The incidence of multiple pregnancies varies depending on the region, country and population. The natural twin birth rate is <8 in 1000 births in East Asia and Oceania, 9–16 per 1000 births in USA, Europe and India, 17 and more per 1000 births in African countries.[8] Antepartum death of one fetus complicates up to 6% of twin pregnancies and can have adverse sequelae for the surviving twin.[9] Antepartum death of one twin is a rare obstetric complication. The incidence of antepartum death among the monochorionic twins is 3.7%.[10] The prevalence of monochorionicity in single intrauterine death in twins is 50%–70%.[2] The reasons for fetal death vary and include twin-twin transfusion, placental insufficiency, intrauterine growth restriction, infections, velamentous insertion of the cord, cord stricture, cord around the neck, and congenital and structural abnormalities. Risks are comparatively common in monochorionic pregnancy than in dichorionic pregnancy. First twin demise can induce ischemic brain damage of the surviving twin resulting in sudden hypotension of the surviving twin. The neurological outlook for a surviving twin depends exclusively on the chorionicity. Neurological abnormality is observed in 18% and 1% of monochorionic and dichorionic placentation respectively.[6] Ultrasonographic monitoring of the surviving twin is the main stay of management.[11] Rapid delivery is usually not recommended unless there are significant changes in the cardiotocography or evidence of foetal anaemia by middle cerebral artery Doppler study. All such pregnancies require close antenatal surveillance. Antenatal and postnatal magnetic resonance imaging of brain for the surviving twin will help to detect any neurodevelopmental morbidity.[12] A baseline maternal coagulation profile is recommended as there is a risk of maternal DIC due to retention of dead twin by the release of fibrin and tissue thromboplastins in to the circulation.[10] Antenatal steroids should be covered at 24–34 weeks if the delivery is expected within 7 days for the surviving twin lung maturity.[13]


  Conclusion Top


Twin pregnancy is associated with adverse maternal and neonatal outcomes. The consequence of a single fetal death in late second or third trimester is linked with significant morbidity and mortality in the surviving twin. It indicates the need for screening programs for early detection of twin pregnancies, prompt referral, better antenatal care and delivery at a tertiary institution with good neonatal care unit. Antenatal and postnatal brain imaging and examining neurodevelopmental co-morbidity in the surviving twin should be standardised with adequate follow-up as the outcome will affect the quality of life of the surviving twin as well as the family. Management of such pregnancies should be individualised. Dichorionic twins can probably be safely delivered at term. Monochorionic twins need to be delivered between 34 and 37 weeks of gestation. Our goal is to avoid the preterm pregnancy and its consequences.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mackie FL, Rigby A, Morris RK, Kilby MD. Prognosis of the co-twin following spontaneous single intrauterine fetal death in twin pregnancies: A systematic review and meta-analysis. BJOG 2019;126:569-78.  Back to cited text no. 1
    
2.
Jain D, Purohit RC. Review of twin pregnancies with single fetal death: Management, maternal and fetal outcome. J Obstet Gynaecol India 2014;64:180-3.  Back to cited text no. 2
    
3.
Giwnewer U, Wiznitzer A, Freidler JM, Sergienko R, Sheiner E. Intrauterine Fetal Death of One twin of diamniotic twins is associated with adverse perinatal outcome of the co-twin. J Matern Fetal Neonatal Med 2012;25:1453-5.  Back to cited text no. 3
    
4.
Upreti P. Twin pregnancies: Incidence and outcomes in a tertiary health centre of Uttarakhand, India. Int J Reprod Contracept Obstet Gynecol 2018;7:3520-5.  Back to cited text no. 4
    
5.
Agarwal N. Multiple gestation. In: Misra R, editor. Ian Donald's Practical Obstetric Problem. 6th ed. New Delhi: B.I. Publications Pvt. Limited; 2006. p. 345-63.  Back to cited text no. 5
    
6.
Leveno KJ, Spong CY, Dashe JS, Casey BM, Hoffman BL, Cunningham FG, et al. Williams Obstetrics. 25th ed. New York: McGraw-Hill Education; 2018. p. 881-4.  Back to cited text no. 6
    
7.
Rao A. Obstetric complications of twin pregnancy. Best Pract Res Clin Obstet Gynecol 2004;18:557-6.  Back to cited text no. 7
    
8.
Smits J, Monden C. Twinning across the Developing World. PLoS One 2011;6:e25239.  Back to cited text no. 8
    
9.
Pharoah P, Adi Y. Consequences of in-utero death in a twin pregnancy. Lancet 2000;355:1597-602.  Back to cited text no. 9
    
10.
Enbom JA. Twin pregnancy with intrauterine death of one twin. Am J Obstet Gynecol 1985;152:424-9.  Back to cited text no. 10
    
11.
D' Alton ME, Dudley DK. Ultrasonographic prediction of chorionicity in twin gestation. Am J Obstet Gynecol 1989;160:557-61.  Back to cited text no. 11
    
12.
Melnick M. Brain damage in survivor after in-utero death of monozygous co-twin. Lancet 1977;2:1287.  Back to cited text no. 12
    
13.
Miracle X, Di Renzo GC, Stark A, Fanaroff A, Carbonell-Estrany X, Saling E. Guideline for the use of antenatal corticosteroids for fetal maturation. J Perinat Med 2008;36:191-6.  Back to cited text no. 13
    


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