Management of dead twin
The risk of single fetal death in multiple pregnancy is 2-6%.
Psychological trauma maybe considerable because 1.the parent prepared for the challenge of
looking after 2babies. 2.the loss is hidden frome the other the mother still pregnant. 3.real concern
about the safety of the remaining twin.
Aetiology:
1.single fetal death occur more commonly in monochorionic twin may result frome twin-twin
transfusion syndrome.
2.growth restriction due to placental problems but affecting only one twine ,bwt discordance found
in about 11-12%.
3.Congenital abnormality.
4.Cord complication such as velamentous cord insertion.
5.Maternal condition such as pre-eclampsia.
Complication:
Fetal complication:
1.Death of the other twin: in mc twin death of 2nd twin occur in 25% .in dc twin survival rate
increase with GA ,71%at 20-24wk ,98% beyond 37wk.
2.Cerebral damage: cp occur in 25-45%follow fetal death in mc twin,3per 1000 infant in dc twin
In general cp in same-sex twin 3time higher than different-sex twin.
Cerebral damage often detected sonographicaly but need weeks to became apparent.MRI may
detect the lesion earlier.sonographic change include porencephaly,multicystic encephalomalacia
.ventriculomegaly;cerebral atrophy and cerebeller infarction.
Mechanism of cerebral damage: 1.transfusion of thromboplastic protein frome dead fetus lead to
DIC.
2.Heamodynamic unstability:large amount of blood frome surviving twin to the low
resistant dead twin cause fluctuation in intravascular pressures ~ intraventricular hg~cp.
3.other complication include:renal cortical necrosis, small bowel atresia , aplasia cutis ,limb
infarction.
Maternal complication:
Miscarriage,preterm labour,infection fom retianed fetus,DIC,obstructed labour from low-lying
dead twin.
MANGMENT:Depend on
1.chorionicity
2.GA.
Dichorionic twin:
The mangment depend on the GA and whether there is any underlying pathology such as
PE.
Usually the parent will request delivery when on baby dies and probably beyond 34wk it
is reasonable to accede to this remembering the importance of offering steroid when the
pregnancy less than 36wk. rout of delivery will depend on the presentation of live twin
which if breech by c\s.if the dead twin leads better to consider c\s.
When death occur before 34wk delay in delivery reduce the effect of prematurity .this
can be difficult psychological problem for the parents and obviously the patient’s view
need to be taken into account ,but the problem of prematurity need to be carefully
explained to them, so that thy e understanding reason for delaying delivery.
Monitoring of the remaining twin by CTG,U\S and Doppler weekly.monitoring of
maternal clotting factors by weekly fibrinogen level ,pt,ptt and platlet count .marked
changes indicat the need to consider delivery .
Monochorionic twins:
The problem in mc twin different as associated with death or damage to the remaining
fetus in 50% of the cases.
The damage to survivor brain may take up to 5wk to became apparent .so for mc twin the
best plane is to delay delivery of the live fetus for as long as possible so that any
intracranial damage became apparent.the presence of these damage should determined
by weekly U\S of fetal brain ,MRI may consider.when sever damage diagnosed the parent
may wish feticide and delivery. In addition to evaluation of fetal condition ,monitoring of
maternal clotting screen should remembered.
Rescue transfusion in ttts:
Doppler of MCA effective in detection of fetal anemia after ttts and obviate the need for
cordocentesis.rescue transfusion may prevent co-twin death but not prevent brain injury.
After birth thorough neonatal evaluation should be perform to detect neurological
,renal,circulatory and cutaneous defects. All survival should undergo an early neonatal
brain scan and enrolled for long term neurodevelopmental follow up.
Pregnancy complication:
The presence of pregnancy complication such as PE is important not just from point of
view of the mother but also the remaining fetus .condition lead to death of one fetus it is
reasonable that remaining fetus at risk and delivery should be expedited,this apply for
both mc and dc twin.