Single Intrauterine Death in Twins: The Importance of Fetal Order

Prognosis of remaining fetus in twin pregnancy after demise of one fetus according to its location

BACKGROUND

To investigate the prognosis of the remaining fetus in twin pregnancy after experiencing one fetal demise in the first trimester according to the location of the demised fetus.

METHODS

This was a retrospective study of twin pregnancies with one fetal demise after the first trimester (14 weeks of gestation) delivered between September 2004 and September 2022. The study population was divided into two groups based on the location of the demised fetus as determined by the last recorded ultrasonography results: Group 1 included twin pregnancies where the presenting fetus was demised (n = 36) and Group 2 included twin pregnancies where the non-presenting fetus was demised (n = 44). The obstetric and neonatal outcomes were also reviewed.

RESULTS

A total of 80 pregnant women were included. The median gestational age for the diagnosis of fetal demise was 24.1 weeks. The gestational age of the demised fetus was not different between Groups 1 and 2; however, the gestational age of the remaining fetus at delivery was significantly earlier in Group 1 than it was in Group 2 (33.8 vs. 37.3 weeks, P = .004). The rate of preterm birth before 28 weeks was almost five times higher in Group 1 than in Group 2 (22.2% vs. 4.5%, P = .037). Regression analysis demonstrated significant differences between Groups 1 and 2. Respiratory distress syndrome, bronchopulmonary dysplasia, patent ductus arteriosus, retinopathy of prematurity, and jaundice were more common in Group 1 than in Group 2; however, the association was not significant after adjusting for gestational age at delivery.

CONCLUSIONS

When the presenting fetus is demised in a twin pregnancy, the remaining fetus tends to be delivered earlier than when the non-presenting fetus is demised.

Intraoperative finding of papyraceous twin fetus in pregnant woman without specialized follow-up: A summary of difficulties in accessing prenatal services in low- and middle-income countries

Introduction and importance

The papyraceous fetus is the product of the intrauterine fetal death of a twin in early pregnancy, with retention of the fetus for a minimum of 10 weeks, resulting in mechanical compression of the small fetus. It is a finding that can be found early by ultrasound to avoid increased obstetric risk, but in low- to middle-income countries it is not always available.

Case presentation

We present the case of a 22-year-old multipara patient was remitted to the emergency department due to a one-hour history of premature rupture of the membranes. Only one control ultrasound was performed at 25 weeks of pregnancy. Cesarean section was performed and two products were found, one of them a papyraceous fetus.

Clinical discussion

Almost 50% of women in low- and middle-income countries don't receive adequate antenatal care. It has been estimated that up to half of twins and almost all triplets are born premature and have a higher risk of dying compared to those born at term; specifically, this risk is much higher if the pregnancy is accompanied by rare pathological conditions.

Conclusion

The papyraceous fetus is a rare condition that represents a risk to the health of the mother and other babies, in case of multiple pregnancy; but it can be diagnosed early through imaging studies. Socio-cultural, socio-economic and direct difficulties of the health system may be the cause of the delay in the diagnosis of this pathological entity, making it an unexpected finding during delivery or intraoperatively.

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The papyraceous fetus is a rare condition that can be diagnosed early through imaging studies.

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Enhanced access to prenatal care in third world countries is mandatory.

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Undiagnosed conditions during pregnancy may increase the risk of complications.

The Metabolic Signatures of Surviving Cotwins in Cases of Single Intrauterine Fetal Death During Monochorionic Diamniotic Pregnancy: A Prospective Case-Control Study

Introduction: Single intrauterine fetal death (sIUFD) in monochorionic diamniotic (MCDA) twin pregnancy may be associated with adverse clinical outcomes and possible metabolic changes in the surviving co-twin. Metabolomic profiling has not been undertaken before in these complex twin pregnancies.

Methods: In this prospectively collected case-control study, three cross-cohort comparisons were made between sIUFD MCDA (n = 16), uncomplicated MCDA (n = 16, eight pairs), and uncomplicated singleton pregnancies (n = 8). To identify major sources of variation within the sIUFD MCDA cohort, a secondary comparison was conducted between spontaneous sIUFD (n = 8) and sIUFD in MCDA twins due to selective termination of a single abnormal fetus by radiofrequency ablation (RFA) (n = 8). Metabolomics analysis of placental tissue and umbilical cord plasma was performed using LC-MS profiling. The underlying metabolic networks and pathways were analyzed by web-based platforms. Associations and statistical correlations of all identified differential metabolites with neonatal birthweight and birth length were assessed by multivariable linear regression, adjusted for maternal age and gestation.

Results: Across four comparisons, 131 and 111 differential metabolites were identified in placental tissue and cord plasma, respectively, with the highest variation seen between the spontaneous vs. single-induced IUFD in MCDA twins by RFA in the cord plasma. Conversely, the number of viable fetuses and the presence of sIUFD in MCDA twins had the highest impact on metabolite variation in placental tissue. Compounds correlated with fetal growth including placental acylcarnitines and gangliosides, along with specific amino acids (e.g., histidinyl-hydroxyproline), xenobiotics and biliverdin in cord plasma.

Conclusion: sIUFD in MCDA twin pregnancy correlates with distinctive metabolic signatures, mostly in fatty acyls and complex lipids, in placental tissue and cord plasma of the surviving cotwin. Some metabolites are also associated with fetal growth.