Single fetal demise in monochorionic pregnancies: incidence and patterns of cerebral injury

Klink, Jeanine M.M. van; Steenis, Andrea van; Steggerda, Sylke J.; Genova, Lorenza Di; Sueters, Marieke; Oepkes, Dick; Lopriore, Enrico

doi:10.1002/uog.14722

Cited by 55 publications

(49 citation statements)

References 12 publications

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“…If the sIUFD occurred after 28 weeks, it is more likely to be associated with a brain injury compared to before 28 weeks (4/20 [20%] vs. 4/111 [3.6%] respectively; p = .02; O'Donoghue et al, 2009). This is supported by another study that also showed that the later the gestation of sIUFD, the greater the association with brain injury (OR 1.14 for each week [95% CI 1.01-1.29] p = .01; van Klink et al, 2015). This is thought to be because the placental anastomoses grow larger as the pregnancy progresses and therefore the impact of the exsanguination will be greater.…”

Section: Predicting Brain Injury In Co-twin Survivor In Siufdmentioning

confidence: 70%

“…After 28 weeks' gestation, the grey matter was more likely to be affected, containing the neuronal cell bodies, synapses, and capillaries. The commonest lesions reported by Van Klink et al (2015) in the surviving co-twin in sIUFD were: cystic periventricular leukomalacia, MCA infarction or injury to the basal ganglia, thalamus, and/or cortex.…”

Section: Different Types Of Fetal Brain Injurymentioning

confidence: 99%

“…Hypoxic ischemic injury to the white matter, which most often affects the area supplied by the middle cerebral artery (MCA) causing multicystic encephalomalacia, porencephaly, microcephaly, and hydranencephaly. Hypoxic-ischemic injuries are the most common type of injuries in sIUFD (van Klink et al, 2015). 2.…”

Section: Different Types Of Fetal Brain Injurymentioning

confidence: 99%

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Fetal Brain Injury in Survivors of Twin Pregnancies Complicated by Demise of One Twin: A Review

2016

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Perinatal mortality is increased considerably in multiple pregnancies compared to singleton pregnancies, with single intrauterine fetal demise (sIUFD) presenting a rare but unique perinatal problem. Monochorionic pregnancies are at particular risk of sIUFD due to bidirectional inter-twin placental vascular anastomoses. The resulting inter-twin blood flow can become unbalanced, causing acute and chronic inter-twin transfusion and profound anemia secondary to fetal exsanguination into the low-pressure circulation of the dead fetus. If the sIUFD occurs after 14 weeks' gestation it is believed to have the most significant effect on the continuing pregnancy as the co-twin is at increased risk of preterm delivery, long-term neurological complications, and death. This article will focus on fetal brain injury in the surviving co-twin in the case of sIUFD, as it is the most common kind of injury in sIUFD, and one which concerns parents and may be the basis for terminating the pregnancy. We will outline how these brain injuries are thought to occur and describe potential pathophysiological mechanisms. We will discuss risk factors for brain injury in cases of sIUFD, including: chorionicity, cause of the sIUFD (spontaneous or secondary to an underlying pathological process such as twin-to-twin transfusion syndrome), gestation of delivery and how to prevent brain injury in the co-twin. We also review modes of imaging, discuss the difficulties in predicting the long-term outcome for co-twin survivors, and highlight the dearth of research in this area.

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Section: Predicting Brain Injury In Co-twin Survivor In Siufdmentioning

confidence: 70%

Section: Different Types Of Fetal Brain Injurymentioning

confidence: 99%

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Fetal Brain Injury in Survivors of Twin Pregnancies Complicated by Demise of One Twin: A Review

2016

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“…In contrast, abundant data exists on monochorionic diamniotic twin gestations after sIUD. Exaggerated mortality but also morbidity have been observed in monochorionic twins following sIUD, the most severe being brain injuries in approximately 1 out of 4 cases [17][18][19][20]. Brain damage in the surviving twin can occur as early as 30 min post mortem of the co-twin and has been reported to be present in postnatal cranial imaging in approximately 34% of monochorionic single survivors [21,22].…”

Section: Discussionmentioning

confidence: 99%

A Modified Technique for Cord Transection in Monochorionic Monoamniotic Twin Pregnancies

Greimel¹,

Csapó²,

Haeusler³

et al. 2018

Fetal Diagn Ther

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Monochorionic monoamniotic (MA) twins are at increased risk for intrauterine demise (IUD) and discordant anomalies. Selective feticide by cord occlusion may be an option in case of unfavorable discordant problems. In MA pregnancies, however, the surviving co-twin still remains at serious risk for IUD due to progressive cord entanglement. Cord transection has therefore been recommended to protect the survivor. This procedure may turn out to be difficult. We herein describe a modified fetoscopic technique for laser transection using a grasping forceps. We present technical details and clinical outcome in 2 cases of cord transection: one following cord occlusion and the other following spontaneous IUD. Cord transection was performed at 19 and 26 weeks gestation, respectively. A 3 Fr grasping forceps with a working length of 35 cm was used for controlled manipulation of the umbilical cord during transection. There were no procedure-related complications and both surviving co-twins had favorable neonatal outcome. Cord transection using a grasping forceps facilitates easy and precise fetoscopic release of the umbilical cord. To the best of our knowledge, this is the first report on post mortem cord transection after spontaneous single IUD with favorable outcome for the survivor.

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“…[35][36][37] The suspected mechanism is acute exsanguination of the surviving twin into the low-pressure vascular circuit of the deceased twin through patent vascular anastomoses, resulting in sudden and profound hypotension, hypovolemia, and anemia with consequent tissue hypoxia and acidosis. 35 Urgent delivery after an unwitnessed twin death is unlikely to improve the cotwin's outcome and may unnecessarily expose the survivor to complications of prematurity.…”

Section: Loss Of One Twinmentioning

confidence: 99%

The North American Fetal Therapy Network Consensus Statement

Emery

Bahtiyar

Dashe

et al. 2015

Obstetrics &Amp; Gynecology

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Owing to vascular connections within a single placenta, monochorionic gestations present distinctive prenatal management challenges. Complications that can arise as a result of unbalanced hemodynamic exchange (twin-twin transfusion syndrome and twin anemia polycythemia sequence) and unequal placental sharing (selective fetal growth restriction) should be kept in mind while prenatal management is being planned. Because of unique monochorionic angioarchitecture, what happens to one twin can directly affect the other. Death of one twin can result in death or permanent disability of the co-twin. Early detection of these unique disease processes through frequent ultrasonographic surveillance may allow the opportunity for earlier referral, intervention, or both and potentially better outcomes. Therefore, monochorionic gestations should be managed differently than dichorionic gestations or singletons. The purpose of this document is to present in detail methods for monitoring and management of uncomplicated monochorionic gestations and to review the evidence for the roles of these methods for detection of complications in clinical practice. Finally, we present evidence-based and expert opinion-supported recommendations developed by the North American Fetal Therapy Network for the diagnosis, surveillance, and delivery of uncomplicated monochorionic gestations.

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Single fetal demise in monochorionic pregnancies: incidence and patterns of cerebral injury

Abstract: (OR, 5.0 (95% CI,); P = 0.02) and a lower gestational age at birth (OR, 0.83 (95% CI, for each week of gestation; P = 0.04). Conclusions

Cited by 55 publications

References 12 publications

Fetal Brain Injury in Survivors of Twin Pregnancies Complicated by Demise of One Twin: A Review

Fetal Brain Injury in Survivors of Twin Pregnancies Complicated by Demise of One Twin: A Review

A Modified Technique for Cord Transection in Monochorionic Monoamniotic Twin Pregnancies

The North American Fetal Therapy Network Consensus Statement

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