Obstetric and perinatal outcomes following fetal death of a single twin in a biamniotic monochorionic pregnancy: case report and literature review
[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;
Downloads
Abstract
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.
References
[1] Hillman, S. C., Morris, R. K., & Kilby, M. D. (2010). Single twin demise: consequence for survivors. Seminars in fetal & neonatal medicine, 15(6), 319–326. https://doi.org/10.1016/j.siny.2010.05.004
[2] De la Calle Fernández-Miranda M, Cruceyra-Bertriu M, Rodríguez-González R, Magdaleno-Dans F, Omeñaca-Teres F, González-González A. Gestación gemelar con muerte intraútero de uno de los fetos: pronóstico materno y neonatal del feto superviviente. Ginecol Obstet Mex 2012;80(4):254-262.
[3] Cleary-Goldman, J., & D'Alton, M. (2004). Management of single fetal demise in a multiple gestation. Obstetrical & gynecological survey, 59(4), 285–298. https://doi.org/10.1097/01.ogx.0000120165.52159.04
[4] Blickstein, I., & Perlman, S. (2013). Single fetal death in twin gestations. Journal of perinatal medicine, 41(1), 65–69. https://doi.org/10.1515/jpm-2012-0019
[5] Hillman, S. C., Morris, R. K., & Kilby, M. D. (2011). Co-twin prognosis after single fetal death: a systematic review and meta-analysis. Obstetrics and gynecology, 118(4), 928–940. https://doi.org/10.1097/AOG.0b013e31822f129d
[6] Lees, C. C., Stampalija, T., Baschat, A., da Silva Costa, F., Ferrazzi, E., Figueras, F., (2020). ISUOG Practice Guidelines: diagnosis and management of small-for-gestational-age fetus and fetal growth restriction. Ultrasound in obstetrics & gynecology: the official journal of the International Society of Ultrasound in Obstetrics and Gynecology, 56(2), 298–312. https://doi.org/10.1002/uog.22134
[7] West, C. R., Adi, Y., & Pharoah, P. O. (1999). Fetal and infant death in mono- and dizygotic twins in England and Wales 1982-91. Archives of disease in childhood. Fetal and neonatal edition, 80(3), F217–F220. https://doi.org/10.1136/fn.80.3.f217
[8] Nicolini, U., Pisoni, M. P., Cela, E., & Roberts, A. (1998). Fetal blood sampling immediately before and within 24 hours of death in monochorionic twin pregnancies complicated by single intrauterine death. American journal of obstetrics and gynecology, 179(3 Pt 1), 800–803. https://doi.org/10.1016/s0002-9378(98)70086-9
[9] Ong, S. S., Zamora, J., Khan, K. S., & Kilby, M. D. (2006). Prognosis for the co-twin following single-twin death: a systematic review. BJOG: an international journal of obstetrics and gynaecology, 113(9), 992–998. https://doi.org/10.1111/j.1471-0528.2006.01027.x
[10] Kilby, M. D., Govind, A., & O'Brien, P. M. (1994). Outcome of twin pregnancies complicated by a single intrauterine death: a comparison with viable twin pregnancies. Obstetrics and gynecology, 84(1), 107–109.
[11] O'Brien, W. F., Knuppel, R. A., Scerbo, J. C., & Rattan, P. K. (1986). Birth weight in twins: an analysis of discordancy and growth retardation. Obstetrics and gynecology, 67(4), 483–486.
[12] Tan, T. Y., & Yeo, G. S. (2005). Intrauterine growth restriction. Current opinion in obstetrics & gynecology, 17(2), 135–142. https://doi.org/10.1097/01.gco.0000162181.61102.d7
[13] Gratacós, E., Lewi, L., Muñoz, B., Acosta-Rojas, R., Hernandez-Andrade, E., Martinez, J. M., (2007). A classification system for selective intrauterine growth restriction in monochorionic pregnancies according to umbilical artery Doppler flow in the smaller twin. Ultrasound in obstetrics & gynecology : the official journal of the International Society of Ultrasound in Obstetrics and Gynecology, 30(1), 28–34. https://doi.org/10.1002/uog.4046
[14] Kennelly, M. M., & Sturgiss, S. N. (2007). Management of small-for-gestational-age twins with absent/reversed end diastolic flow in the umbilical artery: outcome of a policy of daily biophysical profile (BPP). Prenatal diagnosis, 27(1), 77–80. https://doi.org/10.1002/pd.1630
[15] Ishii, K., Murakoshi, T., Takahashi, Y., Shinno, T., Matsushita, M., Naruse, H., (2009). Perinatal outcome of monochorionic twins with selective intrauterine growth restriction and different types of umbilical artery Doppler under expectant management. Fetal diagnosis and therapy, 26(3), 157–161. https://doi.org/10.1159/000253880
[16] Rossi, A. C., & D'Addario, V. (2009). The efficacy of Quintero staging system to assess severity of twin-twin transfusion syndrome treated with laser therapy: a systematic review with meta-analysis. American journal of perinatology, 26(7), 537–544. https://doi.org/10.1055/s-0029-1215430
[17] Rossi, A. C., & D'Addario, V. (2009). Comparison of donor and recipient outcomes following laser therapy performed for twin-twin transfusion syndrome: a meta-analysis and review of literature. American journal of perinatology, 26(1), 27–32. https://doi.org/10.1055/s-0028-1091397
[18] Evans, M. I., Goldberg, J. D., Horenstein, J., Wapner, R. J., Ayoub, M. A., Stone, J., (1999). Selective termination for structural, chromosomal, and mendelian anomalies: international experience. American journal of obstetrics and gynecology, 181(4), 893–897. https://doi.org/10.1016/s0002-9378(99)70321-2
[19] Nicolini, U., & Poblete, A. (1999). Single intrauterine death in monochorionic twin pregnancies. Ultrasound in obstetrics & gynecology : the official journal of the International Society of Ultrasound in Obstetrics and Gynecology, 14(5), 297–301. https://doi.org/10.1046/j.1469-0705.1999.14050297.x
[20] Benirschke K. (1993). Intrauterine death of a twin: mechanisms, implications for surviving twin, and placental pathology. Seminars in diagnostic pathology, 10(3), 222–231.
[21] Malinowski, W., Koktysz, R., & Stawerski, P. (2005). The case of monochorionic twin gestation complicated by intrauterine demise of one fetus in the first trimester. Twin research and human genetics : the official journal of the International Society for Twin Studies, 8(3), 262–266. https://doi.org/10.1375/1832427054253077
[22] Murphy KW. Intrauterine death in a twin: implications for the survivor. In: Ward RH, Whittle M, editors. Multiple pregnancy. RCOG Press; 1995. pp. 218–30.
[23] Fusi, L., McParland, P., Fisk, N., Nicolini, U., & Wigglesworth, J. (1991). Acute twin-twin transfusion: a possible mechanism for brain-damaged survivors after intrauterine death of a monochorionic twin. Obstetrics and gynecology, 78(3 Pt 2), 517–520.
[24] Bajoria, R., Wee, L. Y., Anwar, S., & Ward, S. (1999). Outcome of twin pregnancies complicated by single intrauterine death in relation to vascular anatomy of the monochorionic placenta. Human reproduction (Oxford, England), 14(8), 2124–2130. https://doi.org/10.1093/humrep/14.8.2124
[25] O'Donoghue, K., Rutherford, M. A., Engineer, N., Wimalasundera, R. C., Cowan, F. M., & Fisk, N. M. (2009). Transfusional fetal complications after single intrauterine death in monochorionic multiple pregnancy are reduced but not prevented by vascular occlusion. BJOG : an international journal of obstetrics and gynaecology, 116(6), 804–812. https://doi.org/10.1111/j.1471-0528.2009.02128.x
[26] Adegbite, A. L., Castille, S., Ward, S., & Bajoria, R. (2005). Prevalence of cranial scan abnormalities in preterm twins in relation to chorionicity and discordant birth weight. European journal of obstetrics, gynecology, and reproductive biology, 119(1), 47–55. https://doi.org/10.1016/j.ejogrb.2004.06.016
[27] Behrendt, N., & Galan, H. L. (2021). Fetal Growth in Multiple Gestations: Evaluation and Management. Obstetrics and gynecology clinics of North America, 48(2), 401–417. https://doi.org/10.1016/j.ogc.2021.02.009
[28] Gratacós, E., Carreras, E., Becker, J., Lewi, L., Enríquez, G., Perapoch, J., (2004). Prevalence of neurological damage in monochorionic twins with selective intrauterine growth restriction and intermittent absent or reversed end-diastolic umbilical artery flow. Ultrasound in obstetrics & gynecology : the official journal of the International Society of Ultrasound in Obstetrics and Gynecology, 24(2), 159–163. https://doi.org/10.1002/uog.1105
[29] Roberts, D., Neilson, J. P., Kilby, M. D., & Gates, S. (2014). Interventions for the treatment of twin-twin transfusion syndrome. The Cochrane database of systematic reviews, (1), CD002073. https://doi.org/10.1002/14651858.CD002073.pub3
[30] Graef, C., Ellenrieder, B., Hecher, K., Hackeloer, B. J., Huber, A., & Bartmann, P. (2006). Long-term neurodevelopmental outcome of 167 children after intrauterine laser treatment for severe twin-twin transfusion syndrome. American journal of obstetrics and gynecology, 194(2), 303–308. https://doi.org/10.1016/j.ajog.2005.07.040
[31] Sutcliffe, A. G., Sebire, N. J., Pigott, A. J., Taylor, B., Edwards, P. R., & Nicolaides, K. H. (2001). Outcome for children born after in utero laser ablation therapy for severe twin-to-twin transfusion syndrome. BJOG : an international journal of obstetrics and gynaecology, 108(12), 1246–1250. https://doi.org/10.1111/j.1471-0528.2001.00294.x
[32] Gratacós, E., Antolin, E., Lewi, L., Martínez, J. M., Hernandez-Andrade, E., Acosta-Rojas, R., (2008). Monochorionic twins with selective intrauterine growth restriction and intermittent absent or reversed end-diastolic flow (Type III): feasibility and perinatal outcome of fetoscopic placental laser coagulation. Ultrasound in obstetrics & gynecology : the official journal of the International Society of Ultrasound in Obstetrics and Gynecology, 31(6), 669–675. https://doi.org/10.1002/uog.5362
[33] Senat, M. V., Bernard, J. P., Loizeau, S., & Ville, Y. (2002). Management of single fetal death in twin-to-twin transfusion syndrome: a role for fetal blood sampling. Ultrasound in obstetrics & gynecology : the official journal of the International Society of Ultrasound in Obstetrics and Gynecology, 20(4), 360–363. https://doi.org/10.1046/j.1469-0705.2002.00815.x
[34] Fichera, A., Zambolo, C., Accorsi, P., Martelli, P., Ambrosi, C., & Frusca, T. (2009). Perinatal outcome and neurological follow up of the cotwins in twin pregnancies complicated by single intrauterine death. European journal of obstetrics, gynecology, and reproductive biology, 147(1), 37–40. https://doi.org/10.1016/j.ejogrb.2009.07.002
[35] Hu, L. S., Caire, J., & Twickler, D. M. (2006). MR findings of complicated multifetal gestations. Pediatric radiology, 36(1), 76–81. https://doi.org/10.1007/s00247-005-0021-1
[36] Glenn O. A. (2010). MR imaging of the fetal brain. Pediatric radiology, 40(1), 68–81. https://doi.org/10.1007/s00247-009-1459-3
[37] Jelin, A. C., Norton, M. E., Bartha, A. I., Fick, A. L., & Glenn, O. A. (2008). Intracranial magnetic resonance imaging findings in the surviving fetus after spontaneous monochorionic cotwin demise. American journal of obstetrics and gynecology, 199(4), 398.e1–398.e3985. https://doi.org/10.1016/j.ajog.2008.06.062
[38] Fusi, L., & Gordon, H. (1990). Twin pregnancy complicated by single intrauterine death. Problems and outcome with conservative management. British journal of obstetrics and gynaecology, 97(6), 511–516. https://doi.org/10.1111/j.1471-0528.1990.tb02521.x
[39] Falip, C., Toussaint, I., Lahutte, M., André, C., & Adamsbaum, C. (2010). Ecografía transfontanelar. EMC - Pediatría, 45(1), 1–11. https://doi.org/10.1016/s1245-1789(10)70184-0
[40] Hwang, M., Tierradentro-García, L. O., Syed, &, Hussaini, H., Cajigas-Loyola, S. C., Kaplan, S. L., (2022). Ultrasound imaging of preterm brain injury: fundamentals and updates. Pediat Radiol, 52:817-836 https://doi.org/10.1007/s00247-021-05191-9/Published
License
Copyright (c) 2024 Infomedic Intl.Derechos autoriales y de reproducibilidad. La Revista RevCog es un ente académico, sin fines de lucro, que forma parte de la Sociedad Centroamericana de Ginecología y Obstetricia. Sus publicaciones son de tipo ACCESO GRATUITO y PERMANENTE de su contenido para uso individual y académico, sin restricción. Los derechos autoriales de cada artículo son retenidos por sus autores. Al Publicar en la Revista, el autor otorga Licencia permanente, exclusiva, e irrevocable a la Sociedad para la edición del manuscrito, y otorga a la empresa editorial, Infomedic International Licencia de uso de distribución, indexación y comercial exclusiva, permanente e irrevocable de su contenido y para la generación de productos y servicios derivados del mismo.
