Intensive management and early delivery reduce antenatal mortality in monoamniotic twin pregnancies

Abstract

Background. Intensive management and elective delivery between 32 and 35 weeks of monoamniotic twin pregnancies were suggested as improving perinatal outcome. We sought to evaluate this management as viewed by the outcome of monoamniotic twin pregnancies in our population. Methods. A retrospective systematic chart review of all monoamniotic twin pregnancies, diagnosed from January 1986 to June 2002, was performed in three medical centers. Demographics, pregnancy course, and perinatal outcome were evaluated. The management and outcome were compared between the group of survivors and the groups of intrauterine fetal demise (IUFD) and miscarriage. Results. Thirty-three pairs of monoamniotic twins were identified. Excluded were three women, who chose to terminate the pregnancy. Total survival rate was 60% (of 60 fetuses, 36 were born alive, but one neonate died due to sepsis). None of the IUFD occurred in hospitalized patients, and two pairs of twins died after 32 weeks. In the 10 twin pairs who died in utero, cord entanglement was documented in eight (80%). There were two cases of twin discordance and two cases of twin-to-twin transfusion syndrome. One twin of the live-born group had congenital transposition of the great arteries. Furthermore, one of the hospitalized patients was delivered by means of an emergency cesarean section because of a non-reassuring non-stress test at 30 weeks. Conclusions. Women with monoamniotic twin pregnancies should be advised about the very high mortality and morbidity rate. Early diagnosis, close in-hospital antenatal surveillance starting at fetal viability, and elective delivery at 32 weeks would reduce the antenatal mortality.

Perinatal outcome and clinical features of monochorionic monoamniotic twin gestation

“…To prevent fetal loss after 32 weeks of gestation, a few studies support elective delivery at 32 weeks. 17,18 However, others do not, in view of the high neonatal morbidity due to prematurity. 11,15 Fetal surveillance to extend the prenatal period is a controversial topic subject to much debate.…”

Prenatal Management of Monoamniotic Twin Pregnancies

“…ine and neonatal death with perinatal mortality ranging between 10 and 40%. [1][2][3][4][5][6] This high perinatal mortality rate is partially the result of an increased incidence in congenital anomalies (up to 26%) 1 as well as to twin-reversed-arterial-perfusion sequence and conjoined twinning. 7 Another contributor to perinatal mortality in monoamniotic twins is the fact that two fetuses share a single placenta and a single amniotic cavity.…”

“…11,12 There is, however, little evidence supporting either the optimal intrauterine surveillance strategy or its setting (inpatient compared with ambulatory outpatient), although some reports suggest that inpatient surveillance may be associated with improved fetal outcomes. 3,4,13 In uncomplicated monoamniotic twin pregnancies, delivery by cesarean is usually planned between 32 and 34 weeks of gestation because, at that gestation, the prospective risk of intrauterine fetal death is felt to outweigh the risk of neonatal death. 8 However, studies balancing detailed neonatal outcomes compared with intrauterine risks to help with determining the optimal timing of delivery are lacking.…”

Monoamniotic twin pregnancy

“…Perinatal mortality of monoamniotic twins has been reported to be as high as 30-70%. 1,3,4 Congenital malformations, twin-to-twin transfusion syndrome (TTTS), twin reversed arterial perfusion (TRAP) and cord entanglement are thought to be responsible for the majority of these losses. 5,6 The absolute risk for these complications is difficult to estimate because of variations in study design, the populations investigated, the complications evaluated and gestation at inclusion into the study.…”

“…Furthermore, there is a paucity of data regarding optimal timing of delivery in monoamniotic twins, but, regardless of this, elective delivery at 32-34 weeks is often undertaken. 4,[10][11][12][13][14]…”