Perinatal outcome and neurological follow up of the cotwins in twin pregnancies complicated by single intrauterine death.
ABSTRACT To review the outcome of twin pregnancies complicated by single fetal intrauterine death (IUD) managed at our Centre and to evaluate the neurological follow up of the surviving cotwins.
Twenty-three twin pregnancies (10 dichorionic and 13 monochorionic diamniotic) complicated by IUD in the II or III trimester were seen at our Centre during the study period (2001-2006). All patients were managed conservatively unless non-reassuring signs of fetal well-being were present at ultrasound examination or CTG after 28 weeks, suggesting immediate delivery. Serial scans after the diagnosis of single death were performed and, in addition, eight monochorionic twin pregnancies underwent prenatal MRI in order to identify the presence of cerebral lesions in the survivors. Live born surviving cotwins underwent neurological follow up.
In the monochorionic group one cotwin died in utero and one in the neonatal period with a perinatal survival rate of 83.4% (10/12) (excluding one case who opted for termination of pregnancy); in the dichorionic group perinatal survival rate was 100%. In all monochorionic cases there were no signs of ischemic brain lesions in the surviving cotwins at the diagnosis of single death and during ultrasonographic follow up. In monochorionic pregnancies prenatal MRI, when performed, was negative for signs of brain damage in the surviving cotwins. Gestational age at delivery was not statistically different between monochorionic and dichorionic pregnancies (36 (range, 28.4-40.2) vs. 34.6 (range, 28.2-41.3) weeks) (p=0.6) and the rate of early preterm delivery before 32 weeks was 23.8% (5/21) and independent from chorionicity (18.2% vs. 30%, p=0.5). Neurodevelopmental follow up was available for 18/20 live born survivors (85%) and was normal in all but one twin; this case was born from a dichorionic pregnancy with a suspicion of congenital infection.
Our data confirmed a trend to a higher risk of perinatal mortality of cotwins in monochorionic twin pregnancies compared to dichorionic ones. In our experience prenatal ultrasound and MRI were useful to exclude cerebral lesions in utero and subsequent neurological sequelae in surviving monochorionic cotwins, even if definitive conclusions, especially on MRI, are limited by the small number of cases in our study.
- Ultrasound in Obstetrics and Gynecology 12/1999; 14(5):297-301. · 3.56 Impact Factor
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ABSTRACT: 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. 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. Literature was identified by searching two bibliographical databases and specialist journals between 1990 and 2005. The selected studies of > or = 5 cases reported on perinatal death and/or neurodevelopmental delay of the surviving co-twin. 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. 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]). More prospective research is required to inform decision making on this subject, especially with data that allow stratification based upon chorionicity.BJOG An International Journal of Obstetrics & Gynaecology 09/2006; 113(9):992-8. · 3.76 Impact Factor
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ABSTRACT: To assess the feasibility of the prenatal diagnosis using fetal neurosonography of brain injuries in the surviving fetus after the demise of a monochorionic cotwin. This was a retrospective observational study in the period 1990-2004 of monochorionic twin pregnancies with a single fetal demise. A detailed sonographic evaluation of the intracranial anatomy of the surviving twin had been performed whenever possible using a multiplanar approach and from 1999, fetal magnetic resonance imaging was offered as well. Postnatal follow-up was obtained in all cases. In six of nine cases, abnormal neurosonographic findings were identified including intracranial hemorrhage, brain atrophy, porencephaly and periventricular echogenicities evolving into polymicrogyria. Prenatal diagnosis of brain lesions was confirmed postnatally and all affected infants who survived had severe neurological sequelae. Two fetuses had normal cerebral structures both on the prenatal neurosonogram and on postnatal imaging and were following normal developmental milestones, one at 1 and the other at 5 years of age. In one case the neurosonographic examination was suboptimal and the infant was found at birth to have a porencephalic cyst. Fetal magnetic resonance imaging was performed in two cases and confirmed the ultrasound diagnosis. Prenatal neurosonography is a valuable tool for the prediction of neurological outcome in fetuses surviving after the intrauterine death of a monochorionic cotwin. Although our experience is limited, we suggest that magnetic resonance imaging should also be offered.Ultrasound in Obstetrics and Gynecology 06/2006; 27(5):517-21. · 3.56 Impact Factor