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 Table of Contents  
CASE REPORTS
Year : 2022  |  Volume : 10  |  Issue : 1  |  Page : 36-39

Twin pregnancy with intrauterine fetal demise


Department of Obstetrics and Gynecology, Dr. D. Y. Patil Medical College, Pune, Maharashtra, India

Date of Submission13-Jun-2021
Date of Acceptance19-Jul-2021
Date of Web Publication19-Sep-2022

Correspondence Address:
Meenal Patvekar
Dr. D.Y. Patil Medical College and Hospital, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/DYPJ.DYPJ_33_21

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  Abstract 

Multiple gestations are very commonly associated with higher rates of every complication of pregnancy with the exception of postterm pregnancy and macrosomia. It, therefore, increases the risk of perinatal morbidity and mortality as compared with singleton pregnancies. Fetal loss in twin gestation involves the various factors and is an unfortunate event, which is uncommon. The incidence of single fetal death in twin gestation is 2.5%–5.0% as compared to 0.3%–0.6% in singleton pregnancy. The presence of death twin in rare occasions creates a hostile environment for the surviving twin. This may lead to most feared complication like disseminated intravascular complication, which is fatal to both the mother and the surviving twin. Hence, the early detection of fetal demise in multiple gestations is important as they carry all potential obstetric complications.

Keywords: Intrauterine death, surviving twin, twin pregnancy


How to cite this article:
Patvekar M, Suryarao P, Khumujam PP, Laxmi KD, Sree K D. Twin pregnancy with intrauterine fetal demise. D Y Patil J Health Sci 2022;10:36-9

How to cite this URL:
Patvekar M, Suryarao P, Khumujam PP, Laxmi KD, Sree K D. Twin pregnancy with intrauterine fetal demise. D Y Patil J Health Sci [serial online] 2022 [cited 2022 Oct 6];10:36-9. Available from: http://www.dypatiljhs.com/text.asp?2022/10/1/36/356513




  Introduction Top


The incidence of multiple pregnancies varies significantly among different regions, countries and populations. There has been an increasing trend with multiple order gestation due to rise of assisted reproductive techniques (ART).

Smits and Monden et al. reported that India has twining rates 9/1000 births. Differences in twin gestation among the countries are due to the variations in the frequency of dizygotic twins.[1] The complications commonly associated with twins include preterm labor, fetal malformations, fetal growth restriction, fetal loss, twin-twin transfusion syndrome, amniotic disorders, preeclampsia, cord prolapse, and birth trauma. The causes of intra-uterine fetal death include twin-twin transfusion, placental insufficiency, intra-uterine growth retardation, velamentous insertion of the cord, cord around the neck, and congenital malformations.

Fetal loss in twin pregnancy is an uncommon event.[2] Fetal loss in the first trimester is common and does not impair the development of surviving twin.[2] However, fetal death occurring after mid gestation (17 weeks) increases the risk of fetal growth restriction, preterm labor, preeclampsia, and perinatal mortality in the surviving twin.[3] The incidence of vanishing twin is common over the age group of 30 years with 21%–30% of multiple pregnancies.[4] The incidence of intrauterine death (IUD) in one twin in twin pregnancy ranges between 0.5% and 6.8%.[5]

The perinatal mortality in monochorionic twin pregnancy is double than with dichorionic placentation.[6] When death of one twin occurs after mid gestation, there is 17% chance that the surviving twin in a monochorionic gestation will either die or suffer with major morbidity. When intra-uterine death occurs in monochorionic pregnancy, it is associated with bad prognosis up to 20% of significant neurological morbidity for the surviving co-twin, such as multicystic encephalomalacia.[7] The same is unlikely to occur in the surviving twin of a dichorionic gestation.[6]

Therefore, the management of such a case depends upon gestational age and chorionicity. In addition, we need to consider maternal comorbidities associated with pregnancy and other risk factors associated with it. Early detection, diagnosis, and regular follow up are essential for the favorable outcome of surviving co-twin.


  Case Report Top


A 23-year-old female, primigravida with 38 weeks of gestation registered in our institution presented with complaints labor pains. She had a history of twin pregnancy in the first degree relative. She was followed up throughout her antenatal period weekly with relevant investigations and scan to detect any complications and ensure well-being of the surviving twin.

General physical examination was normal. Her obstetric examination showed term size uterus in the latent phase of labor. During present pregnancy, first trimester scan (9 weeks) ultrasonography (USG) shows dichorionic diamniotic live twins. At 16 weeks, her obstetric scan shows live first twin and IUD of second twin. Serial scans were done at 20, 25, 28, and 32 weeks showing persistent of dead fetus in the right side of the uterine wall. Her obstetric scan with Doppler study done at 35 weeks showed dichorionic diamniotic membrane live Twin A single with the loop of the cord around the neck with normal Doppler study and echogenic foci in the fundic region adherent to decidua suggestive of remnant fetal tissue of Twin B.

Her laboratory investigations showed deranged coagulation profile with prothrombin time – 14 sec International Normalized Ratio - 1.21 activated partial thromboplastin time - 33.8 sec s. fibrinogen 370 mg/dl D-dimer – 810 ng/dL and was suggestive of early disseminated intravascular complication (DIC). The patient explained the need to terminate pregnancy and complications associated with DIC. The patient was transfused with fresh-frozen plasma. The patient was taken up for cesarean section and delivered female baby 2.6 kg shifted to mother side. Placenta was sent for the histopathological confirmation.

Placenta sent for the histopathological examination:

Grossly placenta measured 23 cm × 14 cm × 0.5 cm. Above shows dichorionic diamiotic placenta. Maternal surface of placenta showed two thickened areas, with larger one measuring 12.5 cm, greyish white areas, smaller one 7 cm × 5 cm, showing thickened areas. Fetal surface of placenta showed white calcifications with congested blood vessels

Microscopic findings

On microscopic examination, areas of infarcts along with trophoblastic tissue, areas of calcifications noted. Sections show areas of bony tissue, muscle tissue, cartilaginous elements, columnar epithelium, and foci of squamous epithelium. Histopathological features were consistent with fetus papyraceus.

Histopathological features were consistent with fetus papyraceus.

The postoperative period was uneventful, and the patient was discharged on day 5. She was followed up every week for 6 weeks with no further complications.


  Discussion Top


The incidence of single fetal death in twin gestation is 2.5%–5.0% as compared to 0.3%–0.6% in singleton pregnancy.[8] The various causes of single IUD in twin pregnancy include twin-twin transfusion, placental insufficiency, cord abnormalities, cord around the neck, eclampsia, and congenital abnormalities. Intrauterine fetal demise of a single twin can have profound consequences on the surviving twin including an increased risk of preterm birth, neurologic morbidity, and an increased risk of mortality. This however depends on the chronicity and the gestational age. Depending on the gestational age at which the fetal death occurs, there are three forms of complications: vanishing twin syndrome in the first trimester, fetal papyraceous in the second trimester, and macerated twin in the third trimester.

Intrauterine fetal death of one twin in the first trimester is common and is known as “vanishing twin.”[5] Vanishing twin is reabsorption of one twin early in pregnancy mainly in the first trimester. The cause of vanishing twin remains unknown, but certain factors help to be associated with loss of embryo like advanced maternal age, chromosomal abnormalities, use of ART, increase in the incidence of multiple gestation, small placenta, and genetic and teratogenic factors. The incidence of vanishing twin is common over the age group of 30 years with 21%–30% of multiple pregnancies.[4] The incidence of IUD in one twin in twin pregnancy ranges between 0.5% and 6.8%.[5] This rarely poses a threat to the surviving twin and most of the time the surviving twin has low risk of perinatal morbidity and mortality.

Fetal demise in mid gestation is associated with fetal complications in the surviving twin. When the fetus dies in early gestation, the amniotic fluid and placental tissue is absorbed and the fetus is compressed between the membranes with the coliving twin. Appearance of fetal papyraceous indicates the presence of hostile intaruterine environment.[8]

This was a registered case with regular ante-natal visits with positive family history of multiple pregnancy. USG was done at gestational age of 16 weeks showed absent fetal cardiac activity and movements, Spalding sign in Twin B, and normal study in Twin A. The serial USG follow-up showed echogenic foci in the fundic region suggestive of remnant fetal tissue of Twin B and live Twin A with normal study [Figure 1][Figure 2][Figure 3].
Figure 1: Obstertric scan in 35 weeks

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Figure 2: Placenta with fetal papyraceous

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Figure 3: (a) Trophoblastic tissue (b) respiratory epithelium (c) bony fragments (d) squamous cells

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Fetal papyraceous is defined as a compressed fetus, the mummified parchment like remains of dead twins that is retained in utero after IUD in the second trimester.[9] Incidence of fetal papyraceous has been reported as 1 in 12,000 pregnancies and range between 1:184 and 1:200 twin pregnancies.[8] After 8 weeks death of one embryo with resorption of amniotic fluid and mummification of fetal parts will cause a Fetus papyraceous. The degree of compression depends upon the time interval between delivery and the death of the fetus. Rarely, single fetal death causes release of fibrin and tissue thromboplastins in circulation, causing DIC. Most of the times complications associated with twin pregnancy are associated with monochorionic twin than dichoronic twin gestation. Monochorionic placentas have vascular anastomoses between the two fetuses, and this sometimes leads to detriment of one fetus[7] with favor of other one. Twin to twin transfusion syndrome occurs in 5%–10% of twin gestation with monochorionic placentas and over all perinatal mortality rate is 71%.[10]

The presence of fetal papyraceous indicates hostile intrauterine environment.[8] This definitely poses a risk to the well-being of the surviving twin compared to live dichorionic diamniotic twin pregnancy. The prognosis of this surviving twin will depend on various factors such as the number of live gestation, amniotic conditions, chorionicity and time of death. In addition, we have other contribution factors such as maternal comorbidities and failure to follow-up. It is worth noting that amidst COVID pandemic, many pregnant patients had lost regular antenatal follow-up and this itself increasing the risk of grave complication and danger to the life of the surviving twin in similar cases.

Our primary aim focuses on good obstetric outcome and the safe delivery of the surviving twin. Close supervision, monitoring of fetal well-being by closely spaced scans, and regular follow-up with laboratory parameters combined with patient education about daily fetal movement count was important for favorable outcome of the surviving twin. Counseling of the patient and relatives and helping them make informed decisions was an important part of her management. Relevant investigation and serial coagulation profile done on regular follow help in identifying any complication setting in that will lead to fatal maternal and fetal outcome. If ante-partum death occurs near term, delivery of surviving co-twin is considered. If fetal death occurs far from term, we suggest that conservative management of such conditions is wiser[4] and there is no role of prompt delivery unless fetal jeopardy, maternal coagulopathy, and patient becomes toxic.


  Conclusion Top


Twin pregnancy is associated with greater maternal morbidity and a higher rate of maternal death than singleton pregnancy. Therefore, all twin pregnancies with one dead fetus should be closely monitored, regularly followed up with high index of suspicion for any complications. It should be managed in tertiary referral centers with sufficient neonatal support. Educated and informed patient with close monitoring is required for delivering proper care and management which can salvage a good number of babies.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Smits J, Monden C Twinning across the Developing World. PLoS One 2011;6:e25239.  Back to cited text no. 1
    
2.
Enbom JA Twin pregnancy with intrauterine death of one twin. Am J Obstet Gynecol 1985;152:424-9.  Back to cited text no. 2
    
3.
Landy HJ, Weingold AB Management of a multiple gestation complicated by an antepartum fetal demise. Obstet Gynecol Surv 1989;44:171-6.  Back to cited text no. 3
    
4.
Sampson A, de Crespigny LC Vanishing twins: The frequency of spontaneous fetal reduction of a twin pregnancy. Ultrasound Obstet Gynecol 1992;2:107-9.  Back to cited text no. 4
    
5.
Bianchi DW, Crombleholme TM, D’Alton ME, Malone FD. editorsFetology: Diagnosis and Management of the Fetal Patient. 2nd ed. McGraw Hill; 2010. Available from: https://obgyn.mhmedical.com/content.aspx?bookid=1306&sectionid=75203590. [Last accessed on 2022 Apr 26].  Back to cited text no. 5
    
6.
Nylander PP Perinatal mortality in twins. Acta Genet Med Gemellol (Roma) 1979;28:363-8.  Back to cited text no. 6
    
7.
Melnick M Brain damage in survivor after in-utero death of monozygous co-twin. Lancet 1977;2:1287.  Back to cited text no. 7
    
8.
Cleary-Goldman J, D'Alton M Management of single fetal demise in a multiple gestation. Obstet Gynecol Surv 2004;59:285-98.  Back to cited text no. 8
    
9.
Usharani N, Joshi SD, Veena D Fetus papyraceous: A rare case report and review of literature. Int J Sci Stud 2015;3:184-7.  Back to cited text no. 9
    
10.
Burke MS Single fetal demise in twin gestation. Clin Obstet Gynecol 1990;33:69-78.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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