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Objective To review our experience with selective feticide in complicated monochorionic (MC) twin pregnancies, using ultrasound-guided cord coagulation with a bipolar forceps. Design Retrospective analysis.Setting All consecutive umbilical cord coagulations performed at our institution in the second trimester of pregnancy between November 1999 and 2003. Population Consecutive cases of complicated MC pregnancies with an indication for selective termination.Methods Ultrasound-guided coagulation of the umbilical cord with a 2.5-mm bipolar forceps under local anaesthesia. Main outcome measures Indications, gestational age at the procedure, perinatal outcome and neonatal follow up. Results Forty-six patients with MC twin pregnancies underwent this procedure. Indications included twin reverse arterial perfusion sequence (n ¼ 17), severe malformation in one twin (n ¼ 7) and agonal presentation or cerebral anomalies of one twin in twin-to-twin transfusion syndrome (TTTS) after laser treatment or serial amniodrainage (n ¼ 22). The procedure resulted in six intrauterine fetal demise (IUFD, 13%), with a rate of 41% and 3% when performed at 16 -17 weeks or later, respectively (Fisher P ¼ 0.002). Preterm rupture of the membranes (PROM) before 28 weeks and between 28 and 34 weeks occurred in 9% and 14% of the cases, respectively. All neonatal deaths (four) occurred in cases with PROM at 28 weeks or earlier. Paediatric follow up showed that all infants discharged alive but one were neurologically normal at 3 -42 months, which corresponds to 70% of the 46 cases. Conclusions This technique is effective when the natural history is likely to severely affect the development of the normal co-twin. The overall intact survival rate was 70% and our results support justification of later surgery. Prematurity remains a significant complication of the procedure.

Objective To evaluate the incidence, risk factors and consequences of intrauterine fetal demise (IUFD) of at least one twin in twin-to-twin transfusion syndrome (TTTS) treated by laser.Design Retrospective analysis.Setting Experience of a single centre between 1999 and 2004.Population A subgroup of 45 cases with fetal demise of one or both twins from a series of 120 cases of TTTS treated by laser.Methods All cases were entered prospectively into a dedicated database and the results were analysed retrospectively.Main outcome measures Fetal demise prognostic factors, survival, fetal anaemia, brain lesions, neonatal death and intact survival.Results IUFD of one twin occurred in 40 of 120 cases (19 donors and 21 recipients). IUFD of both twins occurred in another five cases. From these 40 cases, miscarriage occurred in two and pregnancy termination was requested in another two cases because of antenatal brain lesions. Two neonates died and two presented severe morbidity, survivors were therefore neurologically normal at 6-44 months of life in 89% (32/36) of the cases. Univariate analysis showed that preoperative abnormal umbilical artery Doppler in the donor before laser treatment and in the recipient following laser treatment was associated with their demise. Incomplete coagulation was suspected in cases where anaemia or cerebral lesions developed following the death of the first twin (10).Conclusions IUFD of one or both twins occurred in 45 of 120 (38%) cases of severe TTTS treated by laser. In these, separation of the placental circulations was incomplete in at least 22% (10/45) of the cases. Umbilical artery Doppler abnormalities before laser were found to be risk factors for the donors' demise following the procedure.

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