Management of single fetal demise in a multiple gestation

Magnetic resonance neuroimaging after laser for twin-twin transfusion syndrome with single fetal demise

BACKGROUND

Neurologic injury in the surviving twin is a risk after single fetal demise in a monochorionic pregnancy.

OBJECTIVE

This study aimed to describe fetal magnetic resonance neuroimaging findings in pregnancies complicated by single fetal demise after laser photocoagulation for twin-twin transfusion syndrome.

STUDY DESIGN

This was a single-center retrospective analysis of a cohort of prospectively collected patients in a monochorionic twin registry who had fetoscopic laser photocoagulation for twin-twin transfusion syndrome with single fetal demise at follow-up. Magnetic resonance neuroimaging was offered 3 to 4 weeks after the demise to assess for potential neurologic sequelae. Magnetic resonance images were interpreted by 2 board-certified neuroradiologists and classified as normal, mildly abnormal, or severely abnormal. The groups were compared on the basis of recipient vs donor demise using the Fisher exact test and Mann-Whitney U test. Multivariate logistic regression was performed to determine risk factors for abnormal magnetic resonance neuroimaging.

RESULTS

In 378 laser photocoagulation procedures, 64 cases (16.9%) of single demise were identified (36 in the donor group and 28 in the recipient group). Of note, 6 patients had rupture of membranes with nonviable delivery (3 from each group). Moreover, 40 patients (69%) underwent magnetic resonance imaging. Of those patients, 12 (30%) had abnormal findings: 10 (83%) were associated with mild changes, and 2 (17%) were associated with severe findings. Abnormal magnetic resonance neuroimaging was seen in 3 of 22 patients (14%) after donor demise and 9 of 18 patients (50%) after recipient demise (P=.02). Logistic regression revealed that recipient vs donor demise was an independent risk factor for abnormal magnetic resonance imaging. In addition, 2 pregnancies with severe magnetic resonance imaging findings had complicated courses.

CONCLUSION

Mildly abnormal magnetic resonance neuroimaging findings were common after laser photocoagulation for twin-twin transfusion syndrome complicated by single fetal demise and were more common in cases of recipient demise than donor demise. Severe magnetic resonance neuroimaging findings in this series were limited to patients with complicated peri- or postoperative courses.

Obstetric Outcomes in the Surviving Fetus after Intrauterine Fetal Death in Bichorionic Twin Gestations

Twin pregnancies are high-risk gestations that increase the odds of obstetrical complications. They can also present specific and rare complications such as single intrauterine fetal death (IUFD). This complication has been extensively studied in monochorionic but not in bichorionic gestations. Today, the repercussions of IUFD may have on the surviving fetus, mother and bichorionic pregnancy are not known. Our objective was to study materno-obstetrical, fetal, and immediate delivery neonatal complications in bichorionic twin gestations with single IUFD compared to those with both fetuses alive. A retrospective and observational case-control study was performed in bichorionic biamniotic twin pregnancies, 22 complicated with single IUFD after 14 weeks (cases; IUFD group) and 51 with both fetuses alive (controls; non-IUFD group, from Obstetrics Service of La Paz Hospital (Madrid, Spain). The data were collected from obstetrical records. No significant differences were found in the rates of gestational diabetes, gestational hypertension, preeclampsia, neonatal complications, and prematurity between IUFD and non-IUFD groups. Statistical differences were found for the incidence of intrauterine growth restriction in the surviving fetus compared to first fetus of pregnancy with both fetuses alive (22.7% versus 2.0%, respectively; p-value = 0.012). There were no differences compared to second fetus (11.8%; p-value = 0.23). There was a high C-section rate in both groups (IUFD = 63.6%, non-IUFD = 64.7%; p-value = 0.19). In conclusion, single IUFD in bichorionic biamniotic twin gestations is a rare complication that should be closely monitored. It is essential that these gestations be attended by a clinical multidisciplinary team.

Imaging diagnosis and legal implications of brain injury in survivors following single intrauterine fetal demise from monochorionic twins - a review of the literature

Brain injury of the surviving twin from monochorionic pregnancies following intrauterine fetal demise during the second and third trimesters is a rare but severe complication. Monochorionicity and gestational age at the time of stillbirth seem to be decisive factors in terms of long-term neurologic outcome prediction for the survivor. Magnetic resonance imaging (MRI), diffusion weighted imaging (DWI) in particular, seem to bring the earliest and most accurate diagnosis. Ultrasound detection of brain damage is possible in later stages of fetal brain injury. It is essential to provide early diagnosis and multidisciplinary counsel to the parents to ensure informed decision making. For couples who choose to terminate pregnancy legislation related to late abortion might lead to further distress. Our paper aims to stress the importance of MRI DWI in the evaluation of surviving twins following single intrauterine fetal demise in monochorionic pregnancies and the delicate context of the medical professionals and parents facing this clinical situation, sometimes complicated by legal constraints.

Single Intrauterine Death in Twins: The Importance of Fetal Order

Perinatal mortality is higher in twins. Effects of twin order have not previously been studied in the context of single fetal demise. Our objective was to determine whether death of the fetus more proximal to the cervix will result in worse perinatal outcomes. Our population included multiple pregnancies with two viable fetuses confirmed prior to 20 weeks' gestation with the subsequent death of at least one twin. All the pregnancies were managed at The Royal Women's Hospital, Melbourne between 2006 and 2014. We excluded pregnancies of higher order multiples, the death of both twins simultaneously, and cases with incomplete outcome data. Maternal and neonatal data were reviewed. Of 46 pregnancies included, in 24 (52%), the dead twin was presenting. Gestational age at delivery was significantly earlier in these cases (mean difference: -5.0 weeks, 95% CI [-7.4, -2.6], p < .001), and emergency cesarean rates were higher 67% versus 32% (OR 4.29, 95% CI [1.25, 14.7], p = .02). There were no differences in the frequency of chorioamnionitis, preterm prelabor rupture of membranes, or placental abruption. Survival rates for co-twins were similar in both groups (presenting 83%; not presenting 91%; OR 0.41, 95% CI [0.07, 2.50], p = .29). The increase in neonatal morbidities was related to prematurity rather than to order. Findings were more common in dichorionic twins. Analysis was limited by a small sample size. If the dead twin is presenting, delivery is likely to occur earlier, with associated morbidity for the survivors. This is especially relevant for dichorionic twin pregnancies.

Assesment of pregnancy outcomes among twin pregnancies with single fetal demise regarding chorionicity and fetal death time

Objective

The objective of this study was to assess maternal and perinatal outcomes of twin pregnancies with single fetal demise in terms of chorionicity and fetal death time.

Material and Methods

All deliveries between January 2008 and July 2015 were reviewed retrospectively and 85 twin pregnancies with single fetal demise were included. These cases were grouped according to chorionicity and fetal death time.

Results

The incidence of single fetal demise was 4.7%. The mean delivery week was later in the dichorionic group (34.16±4.65) than in the monochorionic group (31.1±3.83). The ratios of deliveries before the 34^th gestational week were 71.4% in monochorionics and 35% in dichorionics. Monochorionics had a 13 times greater risk for having delivery before the 37^th gestational week and a 4 times greater risk for having delivery before the 34^th gestational week compared with dichorionics. Furthermore, monochorionics had a 7 times greater risk for having abruptio placenta compared with dichorionics. The newborn intensive care unit admission ratios were 61.3% in dichorionics and 85.7% in monochorionics. Also, monochorionics had a 3.7 times greater risk for admission to newborn intensive care unit compared with dichorionics.

Conclusion

We recommend follow-up of twin pregnancies with single fetal demise in terms of premature birth, regardless of chorionicity. Also, close monitoring is recommended for monochorionic twin pregnancies with single fetal demise in terms of premature birth before 34 weeks of gestation, abruptio placenta, the need for neonatal intensive care, and respiratory distress syndrome.

Health professionals' perspectives on bereavement following loss from a twin pregnancy: a qualitative study

OBJECTIVE

To provide an in-depth understanding of the perspectives of health professionals caring for parents who have lost a baby from a twin pregnancy, either during pregnancy or in the neonatal period.

STUDY DESIGN

A qualitative study involving semi-structured interviews. Twenty-six health professionals were interviewed from maternity and neonatal departments in one hospital. Data were analyzed using a generative thematic approach.

RESULTS

Three main themes were identified from the data: health professionals' lack of confidence in their interactions with bereaved parents; their desire to learn more about bereavement; and a consideration of sensitive health-care practices for bereaved parents.

CONCLUSIONS

Health professionals acknowledged that parents who experience the loss of a twin have specific needs, some of which can be addressed by relatively small changes to clinical practices and behaviors. They felt, however, that they needed education about bereavement in order to react more effectively to bereaved parents' needs.

Single Fetal Demise at 10 - 14 Weeks of Monochorionic and Dichorionic Twin Pregnancy

Background

We examined the perinatal outcomes in cases of at least one fetal demise in monochorionic and diamniotic twin pregnancies.

Methods

We reviewed the obstetric records of all Japanese twin pregnancies managed beyond 9 weeks’ gestation at Japanese Red Cross Katsushika Maternity Hospital between 2008 and 2014.

Results

The incidence in the monochorionic twin pregnancies was significantly higher than that in the dichorionic twin pregnancies (8.3% vs. 2.6%, odds ratio: 3.40, 95% confidence interval: 1.5 - 7.6, P < 0.01). Of these, 60.0% were diagnosed as fetal demise of both fetuses at the same time (vs. dichorionic twin pregnancy: odds ratio: 12.0, 95% confidence interval: 1.3 - 120, P = 0.04). The rate of “vanishing twin” in cases of at least one fetal demise at 10 - 14 weeks’ gestation in the monochorionic twin pregnancies was significantly lower than that in the diamniotic twin pregnancies (30.0% vs. 88.9%, odds ratio: 0.05, 95% confidence interval: 0.01 - 0.53, P = 0.01).

Conclusion

The incidence of fetal demise and the influence on the co-twin in monochorionic twin pregnancy is greater than those in dichorionic twin pregnancy.

Early 2nd trimester fetal demise in a monochorionic twin pregnancy: A cautionary tale

It is well established that the death of one fetus in a monochorionic twin pregnancy places the surviving twin at significant risk for neuro-developmental delay or death. Although the early 1st trimester "vanishing twin" has not traditionally been considered a major risk, the precise gestational threshold beyond which a surviving twin is at risk remains uncertain. Most experts recommend serial ultrasounds and fetal MRI in the survivor, to look for evidence of ischaemic brain injury. We present a case of early monochorionic twin demise at 14-16 weeks, with evolving ventriculomegaly and ischaemic changes on fetal MRI in the co-twin, leading to termination of pregnancy at 28 weeks.

Impact of chorionicity on risk and timing of intrauterine fetal demise in twin pregnancies

OBJECTIVE

We sought to estimate the association between chorionicity and intrauterine fetal demise (IUFD) of one or both fetuses in twin pregnancies.

STUDY DESIGN

In a retrospective cohort of twins undergoing anatomic survey, risk of IUFD in monochorionic and dichorionic twins was compared. The primary outcome was IUFD of one or both fetuses; secondary outcomes included nonanomalous fetal deaths.

RESULTS

Of 2161 twin pregnancies meeting inclusion criteria, 86 had at least 1 IUFD and 32 experienced a double fetal loss. Monochorionic pregnancies had an increased risk of a single demise (adjusted odds ratio, 1.69; 95% confidence interval, 1.04-2.75) and a double demise (adjusted odds ratio, 2.11; 95% confidence interval, 1.02-4.37). Of all double demises, 70% occurred <24 weeks.

CONCLUSION

Monochorionic twins carry an increased risk of fetal death compared to dichorionic twins. Double demise occurs primarily <24 weeks, regardless of chorionicity.

Multiple gestations: timing of indicated late preterm and early-term births in uncomplicated dichorionic, monochorionic, and monoamniotic twins

In this work we review the indications for late preterm and early-term birth in uncomplicated dichorionic, monochorionic, and monoamniotic twin gestations. Uncomplicated dichorionic twins have optimal outcomes when delivered at 38 weeks' gestation. Monochorionic twins, however, are at greater risk for unexpected stillbirth, and a management plan of late preterm delivery (34-37 weeks) after informed consent is reasonable. Monoamniotic twins are at even greater risk for sudden intrauterine fetal demise, and it is recommended that these expectant mothers be managed by inpatient hospitalization with fetal testing 1-3 times per day and delivery between 32 and 34 weeks' gestation. Recommendations are also provided for the circumstance of single intrauterine fetal demise in a twin gestation.

Single twin demise: consequence for survivors

Multiple pregnancies, the majority of which are twins, are at substantially higher risk of fetal morbidity and mortality when compared with singleton pregnancies. Single fetal demise occurs in up to 6.2% of all twin pregnancies. It may cause considerable risk for the co-twin including increased risk of fetal loss, premature delivery, neurovascular injury and end-organ damage. In this review we seek to summarise the most contemporary literature on the aetiology of single twin demise, the pathophysiology of injury to the surviving twin and the evidence for current management strategies.

Prognosis for the co-twin following single-twin death: a systematic review

BACKGROUND

Following single-twin death, the perinatal mortality and morbidity for the surviving co-twin is increased but difficult to quantify. We present data on prognosis from a systematic review.

OBJECTIVES

We aimed to determine the incidence of a) co-twin death, b) neurological abnormality and c) preterm delivery for the surviving co-twin following single-twin death after 14 weeks of gestation.

SEARCH STRATEGY

Literature was identified by searching two bibliographical databases and specialist journals between 1990 and 2005.

SELECTION CRITERIA

The selected studies of > or = 5 cases reported on perinatal death and/or neurodevelopmental delay of the surviving co-twin.

DATA COLLECTION AND ANALYSIS

Studies were assessed for quality and data extracted to allow computation of rates. The data were inspected for heterogeneity using a Forrest plot and examined statistically using the chi-square test. Data from individual studies were pooled within subgroups defined by prognosis.

MAIN RESULTS

The search strategy yielded 632 potentially relevant citations. Full manuscripts were retrieved for 54 citations and 28 studies were finally included in the review. Following the death of one twin, the risk of monochorionic and dichorionic co-twin demise was 12% (95% CI 7-11) and 4% (95% CI 2-7), respectively. The risk of neurological abnormality in the surviving monochorionic and dichorionic co-twin was 18% (95% CI 11-26) and 1% (95% CI 0-7), respectively. The risk of preterm delivery was 68% (95% CI 56-78) and 57% (95% CI 34-77), respectively. Where there was comparative data within studies, the odds of monochorionic co-twin intrauterine death was six times that of dichorionic twins (OR 6.04 [95% CI 1.84-19.87]). Neurological abnormality was also higher in monochorionic compared with dichorionic pregnancies (OR 4.07 [95% CI 1.32-12.51]).

AUTHOR'S CONCLUSIONS

More prospective research is required to inform decision making on this subject, especially with data that allow stratification based upon chorionicity.

Maternal physiology and complications of multiple pregnancy

Approximately 1% to 3% of all pregnancies in the United States are multiple gestations. The vast majority (97-98%) are twin pregnancies. Multiple pregnancies constitute significant risk to both mother and fetuses. Antepartum complications-including preterm labor, preterm premature rupture of the membranes, intrauterine growth restriction, intrauterine fetal demise, gestational diabetes, and preeclampsia-develop in over 80% of multiple pregnancies as compared with approximately 25% of singleton gestations. This article reviews in detail the maternal physiologic adaptations required to support a multiple pregnancy and the maternal complications that develop when these systems fail or are overwhelmed.

LPA3-mediated lysophosphatidic acid signalling in embryo implantation and spacing

Every successful pregnancy requires proper embryo implantation. Low implantation rate is a major problem during infertility treatments using assisted reproductive technologies. Here we report a newly discovered molecular influence on implantation through the lysophosphatidic acid (LPA) receptor LPA3 (refs 2-4). Targeted deletion of LPA3 in mice resulted in significantly reduced litter size, which could be attributed to delayed implantation and altered embryo spacing. These two events led to delayed embryonic development, hypertrophic placentas shared by multiple embryos and embryonic death. An enzyme demonstrated to influence implantation, cyclooxygenase 2 (COX2) (ref. 5), was downregulated in LPA3-deficient uteri during pre-implantation. Downregulation of COX2 led to reduced levels of prostaglandins E2 and I2 (PGE2 and PGI2), which are critical for implantation. Exogenous administration of PGE2 or carbaprostacyclin (a stable analogue of PGI2) into LPA3-deficient female mice rescued delayed implantation but did not rescue defects in embryo spacing. These data identify LPA3 receptor-mediated signalling as having an influence on implantation, and further indicate linkage between LPA signalling and prostaglandin biosynthesis.