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for marking please Posted by narmin B.
A 30 year old woman with a twin pregnancy complains of reduced foetal movements at 30 weeks gestation. Ultrasound scan reveals intrauterine death of one twin. Justify your subsequent management of her pregnancy.

Following the death of one twin, the surviving twin is at risk of intrauterine death, intrauterine growth retardation and prematurity. Also the mother is at risk of coagulation disorders and disseminated intravascular coagulation (DIC). Therefore the subsequent management includes, counselling the mother about the risks, administration of steroids, regular maternal blood test for coagulation, close monitoring of the surviving foetus and plan for delivery, and follow-up.

Mother should be counselled in a sympathetic and supportive way, as this is a very difficult time for her. Since the parents are very anxious to know the cause of death, if there is any reason such as twin to twin transfusion (TTT) syndrome in monochorionic twins, it should be explained. Although in the majority of cases it is difficult to determine the cause of death at this stage. The risks to the second twin and the plan of management should be explained, as the mother should understand the need for frequent monitoring of the foetal wellbeing and the need for performing regular blood tests.

As there is high risk of preterm delivery, corticosteroids should be given to the mother. The usual method is the administration of two doses of dexamethasone 12 mg, 12 hours apart. Corticosteroids reduce the incidence of respiratory distress syndrome and intraventricular haemorrhage. Repeat doses are not indicated as there is no evidence about its efficacy or safety.

Maternal blood should be sent for coagulation tests every week, as there is risk of coagulopathy after intrauterine death. If coagulation profile was abnormal, induction of labour is indicated because of the risk of DIC and bleeding. Although it is uncommon, but DIC and bleeding may be seen which should be managed by administration of whole blood, and coagulation factors and cryoprecipitate and fresh frozen plasma.

Close monitoring of the foetal wellbeing is mandatory. Weekly Doppler studies and amniotic fluid index and fortnightly growth scans should be performed. In the presence of absent or reversed end diastolic flow or oliogohydramnios; the mother should be admitted for delivery because these abnormal results are associated with foetal distress in the majority of cases. Since there is a risk of intrauterine death in spite of normal Doppler studies and amniotic fluid index, induction of labour is advisable at 34 weeks. Induction of labour at this stage of pregnancy is associated with high failure rate because the cervix is usually unfavourable and malpresentation such as breech is more common. Therefore caesarean section can be the first choice in some cases.

After delivery the foetuses should be examined for gross abnormalities. The parents should be seen to review the process of labour and delivery and also to obtain a consent form for performing an autopsy. Another appointment should be arranged for the mother to be seen in the postnatal clinic six weeks after delivery. In this visit the whole period of pregnancy and delivery and the steps that have been taken should be reviewed. Also the result of post mortem examination should be discussed. Some mothers may need further counselling which should be arranged. Also there are some support groups for multiple pregnancies which can provide further help and support.