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Fetal death of second twin in second trimester
Rozier, Brown, and Berne
REFERENCES I. Ross :0.1G. Mintz MC, Toumala R, Frigoletto FD. The diagnosis of puerperal ovarian vein thrombophlebitis by computed axial tomography scan. Obstet Gynecol1983;62: 131. 2. Angel JL, Knuppel RA. Computed tomography in the diagnosis of puerperal ovarian vein thrombosis. Obstet Gynecol1984;63:6l. 3. Brown CE, Lowe TW, Cummingham FG, Weinreb JC. Puerperal pelvic thrombophlebitis: impact on diagnosis
September !98H Am .J Obstet Gvnecol
and treatment using x-ray computed tomography and magnetic resOnance imaging. Obstet Gynecol 1986;68:789. 4. Munsick RA, GiUanders LA. A review of the syndrome of puerperal ovarian vein thrombophlebitis. Obstet Gynecol Surv 1981;36:57. 5. Zerhouni EA, Klemens HB, Seigelman SS. Demonstration of venous thrombosis by computed tomography. Am J Roentgenol 1980;134:752.
Fetal death of second twin in second trimester James D. Puckett, MD Greenville, South Carolina Intrauterine fetal death of one twin is a rare obstetric complication. The choice of management of the mother and the viable twin is very complex and difficult. A case that was managed successfully in a conservative manner is presented. A review of the current literature is discussed. (AM J Ossrer GYNECOL 1988;159:740-1.)
Key words: Twins, intrauterine death of twin fetus, retained stillborn twin, fetal disseminated intravascular coagulation
This is a case of an intrauterine fetal death of a single twin and the conservative management of the mother and the viable second twin. Very close high-risk obstetric management must be used, and both the family and pediatrician must be made aware of the extremely high incidence of problems in the surviving twin.
Case report A 29-year-old primigravid woman with a completely negative past medical history had a normal examination at 6 to 7 weeks' gestation. At 16 weeks an elevated o:-fetoprotein level was discovered and subsequent realtime pelvic ultrasound revealed a twin gestation without difficulty. A vertex-vertex presentation was present. Based on head, abdomen, and femur length measurements, twin A was slightly larger, measuring 16 to 17 weeks, whereas twin B (upper) measured 15 weeks. A septum was found at that time and the twins were felt to be diamniotic. The pregnancy progressed uneventfully until 21 weeks' gestation, at which time a follow-up ultrasound was done; twin A was recorded as 21.4 weeks and twin Bas 19.9 weeks. Twin B showed no evidence of cardiac activity and no signs of maceration. From the Department of Obstetrics and Gynecology, Greenville Hospital System. Presented as Official Guest at the Fiftieth Annual Meeting of the South Atlantic Association of Obstetricians and Gynecologists, Palm Beach, Florida, January 10-13, 1988. Reprint requests: James D. Puckett, MD, 86 Villa Road, Greenville, 29615.
sc
740
The mother was managed conservatively with weekly monitoring of coagulation factors, including prothrombin time, partial thromboplastin time, platelet count, and fibrinogen along with complete blood counts. Weekly nonstress tests and daily fetal movement charts were begun at 28 weeks. At 25 weeks the patient developed premature labor that was controlled with bed rest, intravenous hydration, and subcutaneous terbutaline therapy (0.25 mg). Terbutaline was continued subcutaneously every 2 hours until contractions ceased. The patient then began a regimen with oral terbutaline, 5 mg every 4 hours. The patient was discharged from the hospital taking oral terbutaline and with at-home fetal monitoring of her uterine contractions. Electronic monitoring was done via telephone transfer and was done twice daily. The patient required hospitalization and tocolysis at 30 weeks and again at 33 weeks' gestation. Short hospitalizations were required on both occasions and the patient was treated with intravenous magnesium sulfate, 2 to 3 gm/hr until contractions ceased. She was again discharged with oral terbutaline. Subsequent ultrasounds revealed twin B to be getting progressively smaller, with signs of maceration. Twin A continued to have serial increments of growth that were considered to be within I week of the expected size for gestation based on head circumference, biparietal diameter, abdominal circumference, and femur length. Both amniotic sacs remained intact. There was no ultrasound evidence of intracranial hemorrhage in twin A. At 36 weeks' gestation, amniocentesis documented expected lung maturity. Tocolytic agents were stopped and spontaneous labor ensued. During labor, the pa-
Volume 159 Number 3
tient was monitored electronically by use of an internal scalp electrode. Prolonged variable deceleration with decreased variability occurred and the patient was delivered by cesarean section. A 5 lb 10 oz female infant with Apgar scores of 9 at 1 and 5 minutes was delivered. Examination of the membranes revealed a fetus papyraceous and what appeared to be a diamniotic membrane. Pathologic examination of the placenta revealed two amnions and a single chorion, with evidence of vascular anastomoses.
Comment The incidence of antepartum death of one twin is 1: 184 twin births.' A review of the literature reveals the absence of any large individual series that have studied this particular problem. The risks of premature delivery with its associated problems must be weighed against the risk of a hostile environment for the surviving fetus. The potential exists for a consumptive coagulopathy defect, not only for the mother but also for the surviving fetus. Of serious concern is the reported incidence of increased morbidity and mortality rates in the surviving twin with a monochorionic and diamniotic placenta. The extensive vascular anastomosis (risk factor of 16% to 17%) is felt to subject the surviving twin to embolytic material from the dead fetus. There certainly seems to be a difference in the incidence of certain complications in twin pregnancies according to the zygosity, and the ultrasonic identification of a monoamniotic configuration could be of great help in the management of a twin pregnancy. Each patient must be managed in a highly individualized manner. It has been found that early delivery has not prevented serious brain damage or renal and cutaneous complications from intrauterine disseminated intravascular coagulation. Thus by itself, this does not appear to be a reason for premature delivery. 2 The presence of a double amnion is helpful in the confirmation, but certainly cannot lead one to become complacent, because monozygotic twins have separate
Death of second twin in second trimester
741
ammouc cavtues and can still have vascular anastomoses. Delivery is predicted on many factors and certainly should be considered if there are abnormal fetal test results, pregnancy-induced hypertension, a maternal coagulation defect, or other high-risk factors. A review of the literature reveals no documented cases of delayed ·,epsis after fetal death in twins. The survival of a li' e-born twin was noted in 82.1% of the cases evalua•.ed. However, the incidence of death and major fetal morbidity combined was 46%. 1 Lung maturity as determined by amniocentesis should be considered at 33 to 34 weeks' gestation, and most agree it is better to proceed with delivery as early as possible. The pediatrician should be alerted to the anticipated problems, and placental pathologic evaluation immediately after delivery to determine zygosity would be helpful in determining those infants that might be more susceptible to intrauterine disseminated intravascular coagulation. The pathologist should be asked to search diligently for vascular anastomoses in the placenta, and the examiner also should check the membranes and placenta very carefully. Newborn follow-up is needed to assess progressive growth and neurologic development. This particular case demonstrates that conservative management can succeed in a patient experiencing the antepartum death of one twin. It is emphasized that very close high-risk obstetric management must be used and a careful pediatric follow-up must be done with monozygotic twins. The family must be made aware that the premature and neonatal death rates are extremely high in the surviving twins. In this particular case, the home uterine contraction monitoring and tocolysis were beneficial and contributed to the favorable outcome. REFERENCES 1. Enbom JA. Twin pregnancy with intrauterine death of one twin. AM j 0BSTET GYNECOL 1985; 152:424-9. 2. Hanna JH, Hill JM. Single intrauterine fetal demise in multiple gestation. Obstet Gynecol 1984;63: 126-30.
REFERENCES I. Ross :0.1G. Mintz MC, Toumala R, Frigoletto FD. The diagnosis of puerperal ovarian vein thrombophlebitis by computed axial tomography scan. Obstet Gynecol1983;62: 131. 2. Angel JL, Knuppel RA. Computed tomography in the diagnosis of puerperal ovarian vein thrombosis. Obstet Gynecol1984;63:6l. 3. Brown CE, Lowe TW, Cummingham FG, Weinreb JC. Puerperal pelvic thrombophlebitis: impact on diagnosis
September !98H Am .J Obstet Gvnecol
and treatment using x-ray computed tomography and magnetic resOnance imaging. Obstet Gynecol 1986;68:789. 4. Munsick RA, GiUanders LA. A review of the syndrome of puerperal ovarian vein thrombophlebitis. Obstet Gynecol Surv 1981;36:57. 5. Zerhouni EA, Klemens HB, Seigelman SS. Demonstration of venous thrombosis by computed tomography. Am J Roentgenol 1980;134:752.
Fetal death of second twin in second trimester James D. Puckett, MD Greenville, South Carolina Intrauterine fetal death of one twin is a rare obstetric complication. The choice of management of the mother and the viable twin is very complex and difficult. A case that was managed successfully in a conservative manner is presented. A review of the current literature is discussed. (AM J Ossrer GYNECOL 1988;159:740-1.)
Key words: Twins, intrauterine death of twin fetus, retained stillborn twin, fetal disseminated intravascular coagulation
This is a case of an intrauterine fetal death of a single twin and the conservative management of the mother and the viable second twin. Very close high-risk obstetric management must be used, and both the family and pediatrician must be made aware of the extremely high incidence of problems in the surviving twin.
Case report A 29-year-old primigravid woman with a completely negative past medical history had a normal examination at 6 to 7 weeks' gestation. At 16 weeks an elevated o:-fetoprotein level was discovered and subsequent realtime pelvic ultrasound revealed a twin gestation without difficulty. A vertex-vertex presentation was present. Based on head, abdomen, and femur length measurements, twin A was slightly larger, measuring 16 to 17 weeks, whereas twin B (upper) measured 15 weeks. A septum was found at that time and the twins were felt to be diamniotic. The pregnancy progressed uneventfully until 21 weeks' gestation, at which time a follow-up ultrasound was done; twin A was recorded as 21.4 weeks and twin Bas 19.9 weeks. Twin B showed no evidence of cardiac activity and no signs of maceration. From the Department of Obstetrics and Gynecology, Greenville Hospital System. Presented as Official Guest at the Fiftieth Annual Meeting of the South Atlantic Association of Obstetricians and Gynecologists, Palm Beach, Florida, January 10-13, 1988. Reprint requests: James D. Puckett, MD, 86 Villa Road, Greenville, 29615.
sc
740
The mother was managed conservatively with weekly monitoring of coagulation factors, including prothrombin time, partial thromboplastin time, platelet count, and fibrinogen along with complete blood counts. Weekly nonstress tests and daily fetal movement charts were begun at 28 weeks. At 25 weeks the patient developed premature labor that was controlled with bed rest, intravenous hydration, and subcutaneous terbutaline therapy (0.25 mg). Terbutaline was continued subcutaneously every 2 hours until contractions ceased. The patient then began a regimen with oral terbutaline, 5 mg every 4 hours. The patient was discharged from the hospital taking oral terbutaline and with at-home fetal monitoring of her uterine contractions. Electronic monitoring was done via telephone transfer and was done twice daily. The patient required hospitalization and tocolysis at 30 weeks and again at 33 weeks' gestation. Short hospitalizations were required on both occasions and the patient was treated with intravenous magnesium sulfate, 2 to 3 gm/hr until contractions ceased. She was again discharged with oral terbutaline. Subsequent ultrasounds revealed twin B to be getting progressively smaller, with signs of maceration. Twin A continued to have serial increments of growth that were considered to be within I week of the expected size for gestation based on head circumference, biparietal diameter, abdominal circumference, and femur length. Both amniotic sacs remained intact. There was no ultrasound evidence of intracranial hemorrhage in twin A. At 36 weeks' gestation, amniocentesis documented expected lung maturity. Tocolytic agents were stopped and spontaneous labor ensued. During labor, the pa-
Volume 159 Number 3
tient was monitored electronically by use of an internal scalp electrode. Prolonged variable deceleration with decreased variability occurred and the patient was delivered by cesarean section. A 5 lb 10 oz female infant with Apgar scores of 9 at 1 and 5 minutes was delivered. Examination of the membranes revealed a fetus papyraceous and what appeared to be a diamniotic membrane. Pathologic examination of the placenta revealed two amnions and a single chorion, with evidence of vascular anastomoses.
Comment The incidence of antepartum death of one twin is 1: 184 twin births.' A review of the literature reveals the absence of any large individual series that have studied this particular problem. The risks of premature delivery with its associated problems must be weighed against the risk of a hostile environment for the surviving fetus. The potential exists for a consumptive coagulopathy defect, not only for the mother but also for the surviving fetus. Of serious concern is the reported incidence of increased morbidity and mortality rates in the surviving twin with a monochorionic and diamniotic placenta. The extensive vascular anastomosis (risk factor of 16% to 17%) is felt to subject the surviving twin to embolytic material from the dead fetus. There certainly seems to be a difference in the incidence of certain complications in twin pregnancies according to the zygosity, and the ultrasonic identification of a monoamniotic configuration could be of great help in the management of a twin pregnancy. Each patient must be managed in a highly individualized manner. It has been found that early delivery has not prevented serious brain damage or renal and cutaneous complications from intrauterine disseminated intravascular coagulation. Thus by itself, this does not appear to be a reason for premature delivery. 2 The presence of a double amnion is helpful in the confirmation, but certainly cannot lead one to become complacent, because monozygotic twins have separate
Death of second twin in second trimester
741
ammouc cavtues and can still have vascular anastomoses. Delivery is predicted on many factors and certainly should be considered if there are abnormal fetal test results, pregnancy-induced hypertension, a maternal coagulation defect, or other high-risk factors. A review of the literature reveals no documented cases of delayed ·,epsis after fetal death in twins. The survival of a li' e-born twin was noted in 82.1% of the cases evalua•.ed. However, the incidence of death and major fetal morbidity combined was 46%. 1 Lung maturity as determined by amniocentesis should be considered at 33 to 34 weeks' gestation, and most agree it is better to proceed with delivery as early as possible. The pediatrician should be alerted to the anticipated problems, and placental pathologic evaluation immediately after delivery to determine zygosity would be helpful in determining those infants that might be more susceptible to intrauterine disseminated intravascular coagulation. The pathologist should be asked to search diligently for vascular anastomoses in the placenta, and the examiner also should check the membranes and placenta very carefully. Newborn follow-up is needed to assess progressive growth and neurologic development. This particular case demonstrates that conservative management can succeed in a patient experiencing the antepartum death of one twin. It is emphasized that very close high-risk obstetric management must be used and a careful pediatric follow-up must be done with monozygotic twins. The family must be made aware that the premature and neonatal death rates are extremely high in the surviving twins. In this particular case, the home uterine contraction monitoring and tocolysis were beneficial and contributed to the favorable outcome. REFERENCES 1. Enbom JA. Twin pregnancy with intrauterine death of one twin. AM j 0BSTET GYNECOL 1985; 152:424-9. 2. Hanna JH, Hill JM. Single intrauterine fetal demise in multiple gestation. Obstet Gynecol 1984;63: 126-30.