Resultados obstétricos y perinatales tras la muerte fetal de un solo gemelo en un embarazo monocorial biamniótico: reporte de caso y revisión bibliográfica
[Obstetric and perinatal outcomes following fetal death of a single twin in a biamniotic monochorionic pregnancy: case report and literature review]Julio César Rodríguez1, Gerardo Edu Castillo López2, Ana Karen Resendiz Olascoaga3, Sandra Ivonne Pacheco Ruíz4, Luis Cuauhtémoc Márquez Bravo2, José González Macedo5
1. Programa de Residencia en Ginecología y Obstetricia, Departamento de Ginecología y Obstetricia, Hospital General Dr. Miguel Silva, Michoacán, México; 2. Programa de Residencia en Imagenología diagnóstica y terapéutica, Departamento de Imagenología, Hospital General Dr. Miguel Silva, Michoacán, México; 3. Medicina Materno-Fetal, Hospital Ángeles Morelia, Michoacán, México; 4. Programa de Residencia de Medicina Materno-Fetal, Instituto Nacional de Perinatología, Michoacán, México; 5. Departamento de Ginecología y Obstetricia, Hospital General Dr. Miguel Silva, Michoacán, México.
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Resumen
ANTECEDENTES: Las gestaciones múltiples sugieren un mayor riesgo de mortalidad perinatal. Dentro de estas estadísticas, la muerte de un solo gemelo ocurre en hasta el 6% de los embarazos múltiples. La incidencia general después de las 20 semanas de gestación (sdg) se estima entre el 2.6% y el 6.2% de todos estos embarazos. Se ha demostrado que es la coriónicidad, más que la cigosidad, la que influye en el resultado de esta complicación, debido a la angioarquitectura placentaria de las circulaciones en los embarazos monocoriónicos. Las tasas de pérdida de hasta el 30-50% se han asociado con embarazos monocoriónicos y monoamnióticos. Si ocurre antes de las 14 sdg, el embrión puede desaparecer; entre las 14 y las 20 sdg, el feto se reduce en tamaño y volumen. Y, si ocurre después de 20 sdg, el feto permanece dentro del útero hasta el final de la gestación.
CASO CLÍNICO: femenina de 18 años de edad, quien acudió a revisión obstétrica con reporte ultrasonográfico de un embarazo gemelar monocorial biamniótico de 30.4 sdg, y muerte de uno de los gemelos. Tras demostrar estabilidad hemodinámica del feto sobreviviente, así como estabilidad materna, se decidió internamiento para monitoreo estrecho. Una semana después desarrolló trabajo de parto pretérmino y se decidió la interrupción de la gestación de manera urgente. Se obtuvo un recién nacido masculino con edad gestacional sugestiva de 32 sdg, con dificultad respiratoria y requirió hospitalización para monitoreo estrecho del recién nacido prematuro. Madre egresó a las 48 horas, nunca desarrolló datos de coagulación intravascular diseminada (CID) y el recién nacido se mantuvo en hospitalización aproximadamente 3 semanas y media hasta que se egresó por adecuada adaptación. Nunca se demostró afectación neurológica o de algún otro órgano o sistema. CONCLUSIONES: Los factores más importantes al considerar el riesgo para el gemelo sobreviviente son la edad gestacional a la que ocurre la muerte del otro feto, y la corionicidad. El manejo debe incluir ecografías seriadas y programadas para el crecimiento. Estudios de Doppler arterial/venoso periférico e intracardiaco y una resonancia magnética al menos 3 semanas después de la muerte fetal para buscar cambios en el cerebro del gemelo sobreviviente. A pesar de que existen casos reportados de manejo conservador, es necesario el seguimiento estricto de datos de CID maternos, así como de desprendimiento prematuro de placenta normoinserta.
Abstract
BACKGROUND: Multiple gestations suggest an increased risk of perinatal mortality. Within these statistics, death of a single twin occurs in up to 6% of multiple pregnancies. The overall incidence after 20 weeks gestation (sdg) is estimated to be between 2.6% and 6.2% of all such pregnancies. Chorionicity, rather than zygosity, has been shown to influence the outcome of this complication, due to the placental angioarchitecture of the circulations in monochorionic pregnancies. Loss rates of up to 30-50% have been associated with monochorionic and monoamniotic pregnancies. If it occurs before 14 sdg, the embryo may disappear; between 14 and 20 sdg, the fetus is reduced in size and volume. And, if it occurs after 20 sdg, the fetus remains inside the uterus until the end of gestation.
CLINICAL CASE: 18-year-old female, who attended an obstetric check-up with an ultrasonographic report of a biamniotic monochorionic twin pregnancy of 30.4 sdg, and death of one of the twins. After demonstrating hemodynamic stability of the surviving fetus, as well as maternal stability, it was decided to hospitalize her for close monitoring. One week later she developed preterm labor and it was decided to terminate the pregnancy urgently. A male newborn was obtained with a gestational age suggestive of 32 sdg, with respiratory distress and required hospitalization for close monitoring of the premature newborn. Mother was discharged at 48 hours, never developed disseminated intravascular coagulation (DIC) and the newborn remained in hospital for approximately 3 and a half weeks until he was discharged due to adequate adaptation. No neurologic or other organ or system involvement was ever demonstrated.
CONCLUSIONS: The most important factors when considering the risk to the surviving twin are the gestational age at which the death of the other fetus occurs, and chorionicity. Management should include serial and scheduled ultrasounds for growth. Peripheral arterial/venous and intracardiac Doppler studies and MRI at least 3 weeks after fetal death to look for changes in the brain of the surviving twin. Although there are case reports of conservative management, close monitoring of maternal DIC data, as well as normoinsert placental abruption, is necessary.
Citas
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