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MRCOG Part 2, MRCOG II

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Forum >> ESSAY 258 - twin pregnancy
ESSAY 258 - twin pregnancy Posted by PAUL A.
Wed Jan 30, 2008 02:13 am
A healthy 40 year old primigravida attends the day assessment unit complaining of reduced fetal movements at 32 weeks gestation. She is known to have a twin pregnancy following IVF treatment. Ultrasound shows that one twin has died. (a) What will you tell her about this finding? [9 marks](b) Justify your subsequent investigations [6 marks]. (c ) Evaluate the factors that will influence the decision on timing of delivery [5 marks].
Posted by hoping ..
Wed Jan 30, 2008 04:30 am
This is traumatic experience for parents and medical staff dealing with situation. Patient needs to be informed sensitively about death of one twin. Information should be provided in clear manner with empathy.She should be informed that other twin is alive but at increased risk of morbidity and mortality.Twin pregnancy is associated with higher perinatal morbidity especialy cerebral palsy and mortality compared to singleton pregnancy.Further investigations would be required to possibly diagnose cause inorder to plan management to avoid harm to other twin and her health.If cause is abruption then mother is at risk of severe complications like DIC.If twins ae dichorionic and reason was congenital structural anamoly or chromosomal anamoly then other twin is not at immediate risk. Maternal reason for fetal demise like infection or medical complication carry increased risk for other twin. As she is 40 years of age with twin pregnancy she has higher risk of preeclampsia and gestational diabetes.If maternal and viable twins condition permit pregnancy may be allowed to continue to gain maturity of viable twin. This requires close monitoring ideally in tertiary care centre. There is increased risk of preterm delivery of second twin. Betamethasone halves risk of respiratory problems and also reduces risk of intraventricular haemorrhage and necrotising enterocolitis if preterm delivery happens.

Maternal FBC should be performed to look for anaemia, platelet levels and white cell count as there is possibility of bleeding and infection.Coagulation profile should also be checked as there is risk of clotting derangement. Her liver and renal function should be checked as dysfunction could be primary as in preeclampsia, acute fatty liver or secondary to fetal death. TORCH screen and EB virus screen should be requested. Maternal blood glucose levels should be assesed as twin pregnancy as higher risk of gestational diabetes and is linked with stillbirth. Detailed ultrasound should be done to rule out any obvious structural anamolies in dead fetus. If chorionicity has not been determined so far which is unlikely then fetal sex determination can reliably confirm hetergenous sexes to be of dichorionic origin and thus have better prognosis.If monochorionic twin to twin transfusion syndrome must be looked for. Growth and liquor of viable twin should be checked. Presentation of presenting twin and of viable twin should be checked.Daily monitoring of fetal cardiotocography should be done. At delivery liquor and placental condotion of affected fetus should be checked and documented. Demised fetus should be checked to rule out any obvious cause and postmorten should be offered.Placenta can be sent for histopathological examination if patient consents.
Determining cause of event and its effect on maternal and other twins health is important in determining further management. If mother or other twin is at immediate risk then delivery should be carried out. This will likely be caesarean section unless cervix is dilated and early delivery is anticipated. If condition allows then risk and benefits of continuing should be weighed against prematurity. Monochorionic twins woulsd have lower threshold of delivery compared to dichorionic twins.Availability of neonatal cots in area, tertiary centre are important considerations.Parents wishes need to be taken into account.
Posted by Idris O.
Wed Jan 30, 2008 03:02 pm
a) This is an unpleasant news and is a very traumatic period for the patient.I would inform her of the ultrasound finding in a very sensitive and empathetic manner. I would discuss with her the possible duration of fetal demise if more than 24h may be suggested by ultrasound finding of an overlapping skull bone and gas bubble in the fetal heart. I would discuss the possible cause of the fetal demise. This may include fetal causes like IUGR or twin ?to ?twin transfusion syndrome. I would inform her the implication of this diagnosis would depend on the cause of the fetal demise and the chorionicity of the pregnancy. If there are any obvious causes for the demise of one of the twins, this hostile environment posses potential threat to the survivng twin. If the pregnancy is monochorionic, there is a 25% chance of fetal death in the surviving twin.This is usually due to communicating vessels causing pressure changes within the circulatory system or from chemical mediators. There is also up to 20-25% incidence of neurological damage in the form of cerebral palsy, poroencephaly,hydrocephalus and cerebral infarction. Renal cortical necrosis may also occur. I would inform her in a dichorionic, diamniotic twins,it is uncommon to have vascular connections and the main risk for the the surviving twin is prematurity due to spontaneous or iatrogenic delivery. I would inform her fetal survival at this gestation is more than 75% and the risk of longterm handicap is less than 10%. I would counsel and offer her steroids to promote pulmonary maturation in the event of preterm delivery. I would also inform her disseminated intravascular coagulation may affect up to 25% of the mothers after 3weeks of the demise and immediate and weekly assessment of the coagulation studies would be necessary.I would offer her information leaflet on twin pregnancy.

b)I would check her FBC,Wcc and platelets due to the risk of DIC and correct anemia with ferrous sulpate and folic acid. I would arrange weekly clotting profile, fibrinogen levels and fibrin degradation products to diagnose DIC early. Twice weekly antenatal cardiotocograph to monitor fetal wellbeing.
She would have weekly Doppler scans and 10-14days growth scan for fetal wellbeing. If monochorionic, weekly brain scans to identify signs of brain damage and need for delivery. I would also arrange weekly biophysical profile to guide the appropriate timing of delivery .

c) The additional time gained in utero would improve fetal survival The risks of keeping the fetus in utero would need to balanced against the risks of prematurity . If more than 24h has elapsed since the demise in a monochorionic pregnancy, the risk of ischaemic brain injury or death from feto-fetal transfusion diminishes and the possibility of gaining one to weeks with fetal surveillance may be entertained. In a dichorionic pregnancy , delivery may be expedited after 36 weeks as there is very little benefit to fetal survival therafter.The fetal indications that may influence timing of delivery include abnormal CTG or dopplers. An evidence of abnormal biophysical profile or ischaemic changes on brain scan would also determine decisions on delivery. The psychological status of the mother and her preferences would be taken into account as this situation is likely to be associated with maternal anxiety and pressure about delivery.





Posted by S M.
Wed Jan 30, 2008 04:09 pm
Death of a twin, specially an IVF twin in a 40 year old primp, can cause immense grief, distress and axiety. The situation needs to be dealt with sensitively and empathically. I will take the lady and her patner to a quiet room and ensure that I am not disturbed during my conversation with them. I will empathically explain the scan findings to her. I will reassure her that the other twin is well. I will tell her that I do not know what caused the death of one twin and that in most of the cases, the cause of Intra uterine death is not known. I will tell her that we would perform some investigations to find out the underlying cause but that they might not show anything wrong. I will tell her that death of one twin can have potentially serious consequence with regards to the survival and well being of the second twin and also maternal wellbeing. The factors that caused demise of 1st twin might affect the second twin. Also 25% of monochorionic twins are at a risk of having neurological damage and renal lesions following demise of one twin. And there is a risk of infection and Disseminated Intravascular coagulation to the mother. We would need to weigh these risks against the risks of prematurity and deliver the baby if there are any signs of fetal or maternal compromise. Thus we would need to keep a close eye on the fetus (by performing regular test for fetal well being) and the mother herself. I will tell her that we would give her steroids to mature the lungs of the baby just in case we have to deliver the baby before 34 completed weeks. All this information can be overwhelming for the mother. I would therefore ensure that her partner and her midwife understand the intricacies of the situation and are there to give her support. I will offer bereavement counselling and also give her information about support groups.

The aim of carrying out investigations is to find out the cause of death of first twin and treat it (if it is treatable), to ensure maternal and fetal wellbeing and last but not the least to decide the timing of delivery of the other twin.
I would carry out a thrombophilia screen, kliehauer test, serum HbA1C levels test, Autoantibody screen (anti phospholipis, anti cardiolipin and lupus anticoagulant), viral screen, u&es, lfts and HVS on the mother to find the cause for IUD.
I will arrange daily CTGs and serial biophysical profiles and USS and Doppler studies for the fetus. I would deliver the baby if there were sign of fetal distress or abscent/reversed end diastolic flows on Doppler studies.
I would monitor maternal wellbeing by performing daily clinical examiations and weekly FBC, CRP and clotting profiles. If there is eveidence of infection or impending DIC, i would agressively manage the same and then deliver the baby.

I would compare the risks of prematurity with the risk of increased perinatal mortality and morbidity to the live fetus and psychological trauma to the mother. Also I will need to ensure that the SCABU is happy to have the baby or else I would need to transfer the mother to a unit where there are facilities to manage the premature newborn.
If there are any signs of fetal disress, in form of abnormal CTGs or abscent or reversed dopplers, I will deliver the baby. If all is well, I would like to extend the pregnancy to 34 completed weeks. The risk of neurological damage to the second twin is unpredicatble and it is not advisable to deliver prematurely just because of its fear.
Also I would keep close eye on mother and any signs of maternal compromise in form of impending infection or DIC would prompt delivery.
Posted by Anna A.
Wed Jan 30, 2008 05:07 pm
a.The women should be approach with sensitive manner and ultrasound finding should be explained carefully. Fetal demise is associated with maternal grieving and would lead to serious psychological impact. She should understand that the chorionicity plays an important role in managing her pregnancy. The underlying cause of fetal demise and gestational age are essential factor to determine the fetal outcome and management the rest of her pregnancy. She should know that the death of one twin (especially in monochoroinic twin) is associated with 25% brain damage and 25% risk another fetal loss in the surviving twin. The underlying pathology like the release of thromboplastin from the dead twin and cardiovascular consequences should be explained carefully to the patient and her partner. The death one of the twin will also lead to higher risk of cerebral palsy of the co-twin. Risk of premature delivery is also increased. Coagulation derangement may occur after 4 weeks of fetal demised, thus the patient should be fully informed. Leaflet information, further follow up and support group should be provided.
b. Maternal blood pressure and urine protein should be obtained to look for maternal causes of the dead co- twin. Early delivery is indicated if there is presence of severe pre-eclapmisa to avoid intrauterine death in the surviving twin. Ultrasound scan should be done to determine the chorionicity of her twin pregnancy as monochorionic twin is associated with higher risk of brain and other organ damage in the surviving twin. Features of twin-twin pregnancy like presence of fetal hydrop and growth restricted fetus and discrepancy of liqour amount could be the reason of fetal demise in the co-twin. Presence of fetal anomaly should be looked for as this may be the possible causes of fetal demise. Scan of the fetal brain should be arranged weekly to look for any damage or changes in the surviving fetal brain. MRI may be justified to confirm the diagnosis. If there is brain abnormality noted, the fetal outcome is poor. Growth scan should be arranged to surviving twin to look for evidence of growth restriction. Coagulation profile should be sent as there is possibility of coagulation derangement after 4 weeks of fetal demised. Prompt action should be taken to avoid maternal bleeding.
c.Chorionicity will determine the timing of delivery. Monochoronic twin is associated with fetal brain damage and increased risk of fetal loss in the surviving twin. If there is evidence of brain damage in the surviving twin, fetocide and delivery should be discussed to the patient. Presence of maternal diseases like severe pre-eclampsia should lead to early delivery to avoid fetal and maternal mortality. Period of gestation has important role in determine the timing of delivery. This patient is at 32 weeks of pregnancy, if she has dichorionic twin then the delivery can be delayed up to 34 weeks as this gestational age has less risk of premature complication like RDS. Evidence of IUGR will need timely delivery to avoid risk of stillbirth.
Posted by S M.
Wed Jan 30, 2008 11:20 pm
A healthy 40 year old primigravida attends the day assessment unit complaining of reduced fetal movements at 32 weeks gestation. She is known to have a twin pregnancy following IVF treatment. Ultrasound shows that one twin has died. (a) What will you tell her about this finding? [9 marks](b) Justify your subsequent investigations [6 marks]. (c ) Evaluate the factors that will influence the decision on timing of delivery [5 marks].

a) I will tell her that one twin has died. Twin pregnancy is associated with an increased risk of an intrauterine death. The cause of death is unknown but could be due to congenital abnormalities. She has three factors that put her at increased risk of the fetus having a congenital abnormality. They are her age, twin pregnancy and conception with IVF. The death of one twin puts the second twin at increased risk of growth restriction, prematurity and intrauterine death. These risks are less with dichorionic diamnotic twins and greater with monochorionic twins. Therefore the first trimester scan will need to be reviewed to confirm the chorionicty. Maternal risks include sepsis and preterm labour and delivery. Intramuscular steroids can be administered to her to improve the maturity of the lungs in case delivery is required before 34 weeks. MAternal and fetal wellbeing will dictate delivery. We would aim to deliver her at 38 weeks gestation but it may be earlier if the second twin develops problems. Therefore she would need close monitoring. I will provide her with an information leaflet.

b) My subsequent investigations include a full blood count and CRP for thrombocytopenia and infection. They also function as baseline investigations to be compared to future results. A low vaginal swab for microscopy, culture and sensitivity to identify bacterial vaginosis or other infections. A detailed ultrasound scan to idenify malformations of both twins including cardiac abnormalities and hydrops. The placental vasculature should be reviewed for evidence of twin to twin transfusion. The growth, liquor and dopplers should be measured to identify growth restriction, oliguria and poor blood flow through the umbilical vessels. Amniocentesis to obtain amniotic fluid to allow for karyotyping.

c) Evidence of chorioamniotis or sepsis will be an indication for immediate delivery. The development of coagulopathy would also lead to immediate delivery. Poor fetal wellbeing which may present as growth restriction, oliguria and abnormal dopplers will necessitate delivery.
Posted by Hala T.
Thu Jan 31, 2008 12:19 am
a)The finding is associated with significant maternal emotional distress. In a sympathetic manner and in the presence of her partner and midwife , I have to tell her that one of the twins died in-utero. I would tell her that twins pregnancy may be monochorionic ( same placenta ) or dichorionic ( two placentae ) , and that information pertaining to choronicity is helpful in the assessing the potential presence of placental anastomosis .
Communicating vessels are very uncommon in dichorionic twins . A monochorionic placenta would indicate a raised risk of shared circulation , putting the surviving twin at particular risk.
Momnochorionic twins pregnancy shows a high incidence of mortality of the surviving twin and morbidity in the form of neurological damage such as cerebral infarction ,hydrocephalus , porencephaly and cerebral palsy. Renal problems may occur such as renal cortical necrosis. I would tell her that maternal coagulopathy is uncommon and may affect 25% of the mothers beyond 3 weeks of fetal demise.
I would tell her that the causes are unpredictable and unavoidable . some tests may be performed to identify the cause , however in the majority of cases , no cause could be identified.
I would tell her that prophylactic steroids should be given to reduce the risk associated with prematurity , if delivery is imminent .She should be informed about the need for appropriate management in a centre with fetal medicine expertise. Careful sensitive conversation is crucial for dealing with her emotional upset and grief. I would provide information leaflet and social support.
b) Investigations for Intrauterine fetal demise should be performed to identify causes that may guide for the management , such as thrombophilia screen , viral serology , serum glucose , Kleihauer test , antibody screen . The focus must be on assessing the risk to the second twin , therefore , ultrasound based fetal assessment may identify potential causes of death such as hydrops , IUGR ,TTTS if monochorionic twins pregnancy.
Serial biophysical monitoring , umbilical Doppler measurements and cardiotocography should be performed up to the time of delivery , as the cause of death of one twin may be the hostile environment which is the potential threat to the surviving twin.
Weekly maternal coagulation studies should be performed until the time of delivery.
c) Accurate timing of the fetal death in gestation and information about chorionicity is helpful in determining the time of the delivery. After 34-35 weeks gestation , the risk of premature delivery is less than the risk of continuing with the pregnancy and therefore delivery would be expedited. As neonatal care improves , earlier delivery may be contemplated following discussion with the paediatricians . Expectant management of the surviving twin may be contemplated , especially if more than 24 hrs has elapsed since the event. This is because feto-fetal transfusion is an acute process following co-twin death ,and it is better for delivery to delay to establish whether the surviving twin has suffered an intracerebral insult. The psychological status of the mother and her preferences should be taken into account before deciding the timing of the delivery.
Posted by Farina A.
Thu Jan 31, 2008 01:14 am
I would like to break this bad news to the couple in an empathetic manner as this pregnancy seems to be a precious pregnancy to the couple (IVF and 40 yrs age).
This may result in a significant psychological and emotional trauma to the couple.
The patient may like to know about the cause of this event which in most cases is unclear. However if a cause is obvious like abruption immediate delivery is a prudent option. I would like to tell her about the prognosis of the surviving twin which is influenced significantly by the chorionicity of the twins. Monochorionic twins have 25% chances or intrauterine hypoxia resulting in cerebral palsy and 25% chances of death of the other twin so most of the time delivery is conducted taking the risk of prematurity. The baby?s lungs are supported by giving betamethasone before preterm delivery. The above mentioned risks are low in case of a dichorionic twins and delivery can be delayed upto 34 completed wks. If the mother is suffering from a disease like hypertension and diabetes which is likely to effect both the twins then the delivery may be needed to be conducted earlier. A remote risk of DIC in the mother is preventable and treatable. She is to be informed about the investigations to be done to identify the cause and she should be told that the investigations may or may not reveal the cause. If the delivery is planned to be delayed she should know about the various fetal surveillance techniques (daily CTG, Doppler US of fetal umbilical arteries and biophysical profile. she should be provided with written information, contacts of support groups.

Full blood count, blood grouping and Kliehaurs test give us an idea about anemia and RH isoimunisation. Coagulation profile is required to exclude a remote possibility of DIC. HbA1c can tell us about her past glycemic status. LFT and KFT to rule out HELLP syndrome and acute fatty liver of pregnancy, bile salts to rule out obstetric cholestasis and TORCH profile with Parvovirus B19 serology can be performed especially if hydrops is a finding. A detailed US is required to find out any congenital anomaly in the dead twin, the presentation of the presenting twin, the presentation of the surviving twin and its amount of liquor, Doppler us and biophysical profile of the surviving twin, all can help in decision regarding mode and timing of delivery. After delivery postmortem examination of the dead twin and histopathology of its placenta can reveal or confirm the cause of the fetal death.

Chorionicity has important influence on timing of delivery as monochorionic twins are likely to be deliverd preterm. If the cause of the fetal death is identified and is believed to be effecting the other twin, preterm delivery is likely, however if the twins are dichorionic and all investigations are normal pregnancy can be prolonged with daily CTG, BPP and Doppler studies. Availability of neonatal cots and paediatric services can influence the timing of delivery.
Posted by Srivas  P.
Thu Jan 31, 2008 12:11 pm
(a) The news that one fetus has died has to be conveyed with lot of sympathy and care and the couple should be encouraged to grieve for the lost baby. Their concern about the surviving twin needs to be addressed. Counselling regarding further management and prognosis for surviving twin needs further review of her case. Chorionicity is an important factor in determining fetal survival chances. The monochorionic fetuses have 30% risk of death of other twin compared to 3% with dichorionic fetuses. Details on chorionicity maybe available on her 1st trimester USG. Discordance in sex of the two fetuses would also point to a dichorionic fetus. At age 40 years there is likelihood of baby carrying congenital anomalies and it is important to review if any preimplantation genetic tests were done or she had CVS/amniocentesis earlier. An anomaly scan at 20 weeks might show structural abnormalities. Risks to the other baby would be based on these reports and I would advice accordingly.

In this healthy woman even if the other fetus is structurally and chromosomally normal, there are inherent problems with this pregnancy. There is 6% risk of mother getting DIC and she would need to be monitored closely for this. She is likely to develop preecclamsia, preterm labor, and psychological stress.

The surviving fetus has increased risk of IUD depending on chorionicity, increased risk of microcephaly, hydrocephaly and porencephaly. There is also increased risk of cerebral palsy, intestinal atresia, pulmonary, hepatic and splenic infarction.

I will her there is no effective means to prevent these complications and the usual fetal monitoring like NST, Umbilical artery Doppler or BPP may not detect some of these changes. USG may detect some renal and brain changes but it cannot be used to monitor and prevent its development. I would advise her early delivery if the fetus shows jeopardy balancing risk of prematurity with risk of continuing in utero.

(b) She should have weekly platelets and fibrinogen levels to detect DIC. I would do her TORCH studies as intra uterine infection could have contributed to IUD of one twin and could now cause death of other twin also. Her Blood group antigens and Kleihauer test if she is Rh negative as Rh antibodies might have caused fetal death.

I would do biweekly surveillance of the baby by NST, BPP, doppler to detect fetal jeopardy early, though it would not detect any brain damage. Doppler could detect any knots in cord, any placental vascular anastomosis causing TTTS.

A high resolution USG can detect renal, hepatic, splenic infarcts and can also detect intracranial hemorrhage, encephaloclastic lesions. This helps assess prognosis for the baby and likelihood of postpartum development of neurological complaints. USG can detect retroplacental clots and any sign of hydrops fetalis in both fetuses. USG will also aid if amniocentesis is done to detect any intrauterine infections like TORCH and parvoviruses.

(c) Chorionicity is an important factor in deciding timing of delivery. Dichorionic fetuses are at less risk of IUD and can be allowed up to 37 weeks. For monochorionic twins decision to deliver will depend on gestational age, condition of surviving fetus and cause of death of other fetus. If the same cause or condition is likely to affect this baby early delivery should be considered except with major congenital anamolies which would not be benefited by early delivery.

If fetus is normal, decision to deliver will depend on fetal condition and evidence of fetal maturity. For monochorionic twin, showing pulmonary maturity, early delivery can be contemplated at 34-36weeks. If fetus shows compromise at the present 32 wks Gest age, baby can be delivered following corticosteroid administration.

Mother showing signs of DIC is another factor prompting early delivery.
Posted by Azza S.
Thu Jan 31, 2008 03:21 pm
Breaking this bad news is a distressing job. She should be counseled in a sensitive way in the presence of her partner and senior midwife if she allowed. Intra-uterine fetal death [IUFD] is always distressing, but in her situation being a primigravida, 40 years old and an IVF pregnancy that all add more pressure. After she take that news the risk for her own health, and to the wellbeing of her other twin should be explained in clear way. There is greater risk of a pre-term labour regardless of the chorionicity and as many as 90% may deliver within 3 weeks. If her pregnancy was diagnosed as monochorionic then she should be informed that there is a risk of IUFD of the other twin of 20% and a risk of neural and renal necroses. There increased risk of cerebral palsy in the surviving twin. These risks are not prevented by immediate delivery. Regarding her health there is small risk of developing a disseminated intra-vascular coagulation [DIC] due to retained dead fetus. A written information and contact number should be given. She should also informed about the increased need of surveillance of the other twin.
The woman\'s blood group and Rhesus status should be checked. A test for red-cells antibodies as chronic feto-materal haemorrage may lead to unusual anti bodies formation. A coagulation profile as a retained dead fetus may trigger a DIC particularly fibrinogen degradation products will be raised. A Keulaheire test to detect fetal blood in maternal circulation in case of feto-maternal bleeding. A glucose tolerance test to detect if she developed gestational diabetes millets as well as checking blood pressure and proteinuria as she has increase risk for developing them and any of them may cause IUFD. Check fetal well being by umbilical artery Doppler ,biophysical profile, non-stress CTG and kick-chart.
Chorionicity greatly influence the decision on timing of delivery. In a dichorionic twins one can aim to reach 37 weeks of gestation. In monochorionic twins may be 34 weeks should be the aim. Mother\'s decision should be respected. In case of fetal compromise then pregnancy should be terminated. The neonatologist should be consulted ,if there no available cot so either to delay delivery if possible or to transfer to a tertiary service..
Posted by K P.
Thu Jan 31, 2008 03:29 pm
I will see her in a quiet and private room. I will ask if she would like her partner or family member to come with her. I will tell her that one twin has died in a sensitive and empathetic manner. I would explain that we will try to ascertain the cause of the death and this would depend on a history and examination suggestive of preeclampsia, infecion, premature rupture of membranes. I would explain that we would also investigate and do more tests to find a cause of death but there is a possibility that we may not find a cause. I will explain that the 2nd Twin may be affected by the death of the first twin and we would do further investigations to ascertain this. I would explain that she will need admission for further evaluation and may need monitoring under the fetal maternal unit. It is important to ascertain that although one twin has died it is important to focus on the the fact that the other twin is alive and every effort would be made to optimise the health of the other twin. I would also inform the bereavement midwives and offer the patient the option to see her. I would also give her the phone number for support groups such as SANDS.

I would do blood tests, FBC, U+E, LFT, uric acid to ascertain if there if evidence of preeclampsia. I would also do a urinalysis and check for proteinuria and send off a 24 hour collection if there is evidence of proteinuria. I would also do a TORCH screen looking for possible evidence of intrauterine infection. I would also do a clotting looking for fibrinogen , PT and APTT looking for evidence of DIC. I would also do a group and save if she warranted a blood transfusion should she go into DIC. I would then look through her notes for a first trimester scan looking for the chorionicity of the pregnancy. A dichorionic pregnancy would mean that there are no neurologic or renal consequences to the surviving twin however a monochorionic twin pregnancy could imply serious neurologic, renal and cardiac compromise in the surviving twin. I would also do an ultrasound assessment of the surviving twin assesing for gowth, liquor volume and umbilical artery doppler. I would also perform a middle cerebral artery peak systolic velocity and ductus venosus doppler looking for evidence of raised peak systoic velocity or ductus venosus doppler indicating imminent compromise. If it is a monochorionic pregnancy and there is eveidence of neurological and renal compromise on ultrasound scan I would preform a fetal MRI looking for cystic changes in the surviving fetus\' brain indicating a poorer outcome.

This depends of fetal and maternal factors. Prematurity would be my first concern. At 32 weeks, the fetus may benefit 2 more weeks in utero if all other parameters are normal (growth, liquour volume, umbilical artery doppler, middle cerebral artery systolic velocity). However if these parameters are abnormal delivery may be the safer option with steroid cover. Evidence of ischaemic changes in the brain of surviving twin will also prompt delivery especially if we don\'t know the time interval since the death of the first twin in a monochorionic pregnancy. Maternal factors include evindence of severe preeclampsia (either sever hypertension not controllable with antehypertensives) or abnormal biochemical indices. She would also warrant delivery if there was evidence of DIC. Whether it is maternal of fetal factors, 2 doses of steroids should be given to aid fetal lung maturity prior to delivery at 32 weeks.
Posted by M M A.
Thu Jan 31, 2008 04:30 pm
(a)This lady will need sensitive counselling and sympathy. We inform her that death of one fetus exposes the other to many risks and these risks are different according to chorionicity.

If her pregnancy is monochorionic, the co-twin will be exposed to acute hypotension and demise within 12 hours after death of the first one, therefore, urgent delivery is required and usually she ill need as caesarean section.
However, if the fetus survive this acute attack, it will be exposed to neurological sequelae due to brain ischemia.

This risk is not present if the pregnancy is DC because the placentae usually are not communicated, however, the cause of death of the first fetus still can cause death of the second one. We explain to her that in majority of cases, it is difficult to detect specific cause of death.

We inform her also that if she opt to continue pregnancy, she will be at risk of preterm delivery whether the pregnancy is MC or DC and therefore corticosteroid is required to improve fetal lung maturity.

We tell her that she will need regular monitoring and we should explain to her that occurrence of complication is difficult to predict nor to be prevented and there are no method or test for fetal surveillance that can confirm fetal well being for sure.

We tell her also that risk of maternal coagulopathy which usually occur after death of fetus in singleton pregnancy is extremely rare in her conditions.

We provide patient information leaflet and give her contact addresses of support groups.

(b)We offer detailed US examination of the dead fetus to detect if there is any congenital malformation as this will affect further management.
We do also Doppler examination of umbilical artery and middle cerebral artery of the surviving twin to detect impending fetal demise.
We do FBC including platelet count and screening for thrombophilia, also screening for virology to detect a possible cause of death. In addition GTT is done to detect gestational DM. Kleihauer\'s test is done also to detect isoimmunization.
Urine analysis to detect proteinuria
Serial MRI of fetal brain to detect cystic spaces in brain or encephlomalasia.
We advice for Biophysical profile weekly and serial growth scan fortnightly for the growth and liquor assessment of the surviving twin.

(c)Condition and gestational age of the surviving twin can affect time of delivery. Expedite delivery is needed if there is impending demise. Also if the fetus near term, delivery is advised.

Fresh death of fetus in monochorionic twin pregnancy will require urgent delivery to prevent fetal morbidity and mortality of the other fetus.
Maternal wishes and preferences should be respected after she had given an adequate information and counselling.
If a cause of death is found or there are other additional risk factors like pregnancy induced hypertension or DM also affect decision of delivery.

Also if the local SCBU lacks beds or facilities, we can defer delivery to allow for in-utero transfer for tertiary centre if patient situation allow.



Posted by maha G.
Fri Feb 1, 2008 01:20 am
{A}
This finding is likely to be associated with maternal anxiety, so sensitive empathic approach is warranted. I would explain to her that death of co-twin occurs in about 5-6.5% of twin gestation. I should detect if it is monochorionic or dichorionic before proper counseling, if monochorionic pregnancy, there is risk of death of the co-twin in about 25%. Furthermore, there is risk of nouro-developmental sequelae such as cerebral palsy, cerebral infarcts and hydrocephalus in approximately 25%. Close monitoring is needed for fetal wellbeing.
Also, I would explain to her that further investigations are needed to detect the cause of fetal demise and if maternal cause detected, delivery should be expedited. Also, the need for postmortem examination of the dead fetus is explained after full informed consent.
There is also maternal implication of fetal death such as DIC and risk of post-partum hemorrhage.
There is a risk of prematurity, so I would explain to her the need for antenatal corticosteroids to reduce the risk of RDS and interventricular hemorrhage.
I would counsel her properly taking into consideration her psychological make up and her wishes.
{B}
The needed investigations aimed at detection of the cause of the fetal demise and at wellbeing of the surviving twin. I would request liver function test to exclude cholestasis of pregnancy, klhaieur?s test and screening for atypical antibodies to check if there is any iso-immunization.
The woman is 40 years old, so she is at risk of GDM and proteinuric hypertension. That is why I would check her blood glucose level and hemoglobin A1C as well as dipstick for proteinuria.
Virology screening for her is needed particularly CMV, Parvo virus 19. Ultrasound can help to determine the cause of fetal death such as IUGR, hydrops or TTTs if mono-chorionic twin. Furthermore, it will detect the chorionicity type of the twin pregnancy if it has not done early in pregnancy.
I would request coagulation profile weekly as DIC may happen after 5 weeks.
Investigation for fetal wellbeing include ultrasound scan, Doppler and biophysical profile are recommended weekly or twice weekly. Check for any cerebral changes MRI may be needed post delivery to detect any cerebral changes.
{C}
The most important prognostic factor is the chorionicity of the twin gestation. Mono-chorionic gestation is associated with higher morbidity and mortality so proper counseling is mandatory as well as close monitoring before allowing continuation of pregnancy. On the other hand, di-chorionic pregnancy is known to be associated with the risk of prematurity as allowing pregnancy beyond 34 weeks will be associated with increased maternal anxiety as well as the risk of DIC and PPH.
Gestational age has also detrimental effect because of the risk or prematurity and in-utero transfer should be considered if the facility of special neonatal care unit is not available.
If maternal cause of fetal demise detected ,the delivery should be expedited.
Fetal well being of the co-twin has a detrimental effect as cerebral changes are unpredictable and unavoidable.
I would consider the psychological status of woman and her wishes,also asking her to share in the decision.


Posted by PAUL A.
Fri Feb 1, 2008 04:59 pm
This is traumatic experience for parents and medical staff dealing with situation. Patient needs to be informed sensitively about death of one twin (1) . Information should be provided in clear manner with empathy (1) .She should be informed that other twin is alive but at increased risk of morbidity and mortality (1) .Twin pregnancy is associated with higher perinatal morbidity especialy cerebral palsy and mortality compared to singleton pregnancy.Further investigations would be required to possibly diagnose cause (1) inorder to plan management to avoid harm to other twin and her health. If cause is abruption then mother is at risk of severe complications like DIC is the risk of DIC ONLY if there was an abruption? .If twins ae dichorionic what if they are monochorionic? and reason was congenital structural anamoly or chromosomal anamoly then other twin is not at immediate risk. Maternal reason for fetal demise like infection or medical complication carry increased risk for other twin. As she is 40 years of age with twin pregnancy she has higher risk of preeclampsia and gestational diabetes.If maternal and viable twins condition permit pregnancy may be allowed to continue to gain maturity of viable twin. This requires close monitoring ideally in tertiary care centre. There is increased risk of preterm delivery of second twin. Betamethasone halves risk of respiratory problems and also reduces risk of intraventricular haemorrhage and necrotising enterocolitis if preterm delivery happens bereavement counselling, written information, support groups .

Maternal FBC should be performed to look for anaemia, platelet levels and white cell count as there is possibility of bleeding and infection. Coagulation profile how often will you check this? should also be checked as there is risk of clotting derangement. Her liver and renal function should be checked as dysfunction could be primary as in preeclampsia, acute fatty liver or secondary to fetal death. TORCH screen and EB virus screen should be requested (1) . Maternal blood glucose levels should be assesed as twin pregnancy as higher risk of gestational diabetes and is linked with stillbirth ? Kleihauer test, blood group & antibodies . Detailed ultrasound (1) should be done to rule out any obvious structural anamolies in dead fetus. If chorionicity has not been determined so far which is unlikely (1) then fetal sex determination can reliably confirm hetergenous sexes to be of dichorionic origin and thus have better prognosis.If monochorionic twin to twin transfusion syndrome must be looked for. Growth and liquor of viable twin ? BPP should be checked. Presentation of presenting twin and of viable twin should be checked.Daily monitoring of fetal cardiotocography should be done. At delivery liquor and placental condotion of affected fetus should be checked and documented WHAT DOES CHECKING THE LIQUOR MEAN? . Demised fetus should be checked to rule out any obvious cause and postmorten should be offered.Placenta can be sent for histopathological examination if patient consents.
Determining cause of event and its effect on maternal and other twins health is important in determining further management. If mother or other twin is at immediate risk then delivery should be carried out (1) . This will likely be caesarean section unless cervix is dilated and early delivery is anticipated. If condition allows then risk and benefits of continuing should be weighed against prematurity (1) . Monochorionic twins woulsd have lower threshold of delivery compared to dichorionic twins why? With monochorionic twin, injury to the surviving twin occurs at the time of death of the co-twin and will therefore not be prevented by early delivery .Availability of neonatal cots in area, tertiary centre are important considerations.Parents wishes (1) need to be taken into account ? time to administer corticosteroids .
Posted by Reiaz M.
Fri Feb 1, 2008 07:13 pm
This finding can be very distressing to thye patient, her family and those involved in her care.
She is informed that one of the babies have died in a very sensitive and supportive manner. This should be done in a private setting and she should be allowed to have other persons present for support if she so desires.
She will be told that it is difficult to ascertain the cause of demise at this time. Possible causes of death include aneuploidy, congenital anomalies and intrauterine infection. The majority of cases of intrauterine demise have no identifiable cause. A post mortem examination performed after delivery of the baby can help in determining the cause of the babys death.
The effect of fetal demise on the surviving twin depend on the chorionicity. Following IVF dichorionic twins are more likely. There is no increased chance of adverse fetal outcome in the surviving twin if they were dichorionic. If the twins are monochorionic there is a 25 % chance of subsequent demise of the survivng twin. There is also a 25% risk of ischemic renal and neurological sequelae in the surviving twin. There is also a risk of anemia and subsequent hydrops in the survivg twin.
The maternal risks include coagulopathy and psychological problems such as depression. She should be reassured that the fetal demise is not her fault. She is provided with informatioin on support groups eg SANDS.
The patient should be provided with informaion leaflets to supplement the discussion.

b) A complete blood count should be done to determine the hematocrit and platelet count. A baseline clotting screen should be done as she is at risk of coagulopathy. If she is rhesus negative a kleihauer test is done to determine the extent of isoimmunisation.
An ultrasound scan will be done to assess fetal hydrops. Fetal growth parameters are assessed every 2 weeks. Doppler of the fetal middle cerebral artery is done to assess for fetal anemia and doppler of the umbilical artery is doen to assess placental function.
An ultrasound scan or MRI of the fetal brain is done to assess for neurological changes.

c) The main factor that will determine timing of delivery is the chorionicity of the twins. Dichorionic twins can be managed expectantly with recourse to early delivery if the well being of the fetus changes. Evidence of placental insufficiency, fetal compromise or maternal coagulopathy should prompt delivery.
The estimated fetal weight and likelihood of survival at particular gestational age is another important factor. Whether the apteint received antenatal corticosteroids should also be considered. Presence of fetal anemia or neurological changes should consider delivery. Finally the mothers wishes are paramount in determining the timing of delivery.
Posted by PAUL A.
Fri Feb 1, 2008 09:02 pm
a) This is an unpleasant news and is a very traumatic period for the patient.I would inform her of the ultrasound finding in a very sensitive and empathetic manner (1) . I would discuss with her the possible duration of fetal demise if more than 24h may be suggested by ultrasound finding of an overlapping skull bone and gas bubble in the fetal heart. I would discuss the possible cause of the fetal demise. This may include fetal causes like IUGR or twin ?to ?twin transfusion syndrome. I would inform her the implication of this diagnosis would depend on the cause of the fetal demise and the chorionicity of the pregnancy. If there are any obvious causes for the demise of one of the twins, this hostile environment posses potential threat to the survivng twin (1) . If the pregnancy is monochorionic, there is a 25% chance RISK ? chance refers to positive outcomes: Chances of success, risks of failure? of fetal death in the surviving twin.This is usually due to communicating vessels causing pressure changes within the circulatory system or from chemical mediators. There is also up to 20-25% incidence of neurological damage in the form of cerebral palsy, poroencephaly,hydrocephalus and cerebral infarction (1) . Renal cortical necrosis may also occur. I would inform her in a dichorionic, diamniotic twins,it is uncommon to have vascular connections and the main risk for the the surviving twin is prematurity due to spontaneous or iatrogenic delivery. I would inform her fetal survival at this gestation is more than 75% is it 76% or 96%? If you are going to quote a figure then it must be precise. >75% at 32 weeks is too vague to be accurate and the risk of longterm handicap is less than 10%. I would counsel and offer her steroids to promote pulmonary maturation in the event of preterm delivery. I would also inform her disseminated intravascular coagulation (1) may affect up to 25% of the mothers after 3weeks of the demise and immediate and weekly assessment of the coagulation studies would be necessary.I would offer her information leaflet on twin pregnancy will this be an appropriate leaflet to give her? Bereavement counselling, support groups .

b)I would check her FBC, Wcc and platelets are these different tests from FBC? due to the risk of DIC and correct anemia with ferrous sulpate and folic acid. I would arrange weekly clotting profile, fibrinogen levels and fibrin degradation products to diagnose DIC early (1) . Twice weekly antenatal cardiotocograph to monitor fetal wellbeing.
She would have weekly Doppler scans and 10-14days growth scan for fetal wellbeing (1) . If monochorionic, weekly brain scans to identify signs of brain damage and need for delivery. I would also arrange weekly biophysical profile to guide the appropriate timing of delivery Does your hospital protocol recommend any additional tests in the event of intra-uterine fetal death? Blood group, antibodies, Kleihauer, glucose?What about detailed fetal scan for structural anomalies? .

c) The additional time gained in utero would improve fetal survival not necessarily ? may result in death of second twin The risks of keeping the fetus in utero would need to balanced against the risks of prematurity (1) . If more than 24h has elapsed since the demise in a monochorionic pregnancy, the risk of ischaemic brain injury or death from feto-fetal transfusion diminishes the risk of injury does not diminish ? injury occurs at the time of death of the co-twin and the passage of time does not affect the risk of such injury. and the possibility of gaining one to weeks with fetal surveillance may be entertained. In a dichorionic pregnancy , delivery may be expedited after 36 weeks as there is very little benefit to fetal survival therafter is there benefit at 35 weeks? If you are going to set a precise gestation age, you should have the evidence .The fetal indications that may influence timing of delivery include abnormal CTG or dopplers. An evidence of abnormal biophysical profile or ischaemic changes on brain scan would also determine decisions on delivery delivery will not prevent or reduce the impact of such injuries which occurred at the time of death of the co-twin . The psychological status of the mother and her preferences would be taken into account (1) as this situation is likely to be associated with maternal anxiety and pressure about delivery.
Posted by PAUL A.
Fri Feb 1, 2008 09:29 pm
Death of a twin, specially an IVF twin in a 40 year old primp, can cause immense grief, distress and axiety. The situation needs to be dealt with sensitively and empathically (1) . I will take the lady and her patner to a quiet room and ensure that I am not disturbed during my conversation with them. I will empathically explain the scan findings to her (1) . I will reassure her that the other twin is well how do you know? . I will tell her that I do not know what caused the death of one twin and that in most of the cases, the cause of Intra uterine death is not known . I will tell her that we would perform some investigations to find out the underlying cause but that they might not show anything wrong (1) . I will tell her that death of one twin can have potentially serious consequence with regards to the survival and well being of the second twin and also maternal wellbeing. The factors that caused demise of 1st twin might affect the second twin (1) you just told her the other twin was ?well? . Also 25% of monochorionic twins are at a risk of having neurological damage and renal lesions following demise of one twin (1) . And there is a risk of infection why? Where will the infection come from? and Disseminated Intravascular coagulation to the mother. We would need to weigh these risks against the risks of prematurity and deliver the baby if there are any signs of fetal or maternal compromise. Thus we would need to keep a close eye on the fetus (by performing regular test for fetal well being) and the mother herself. I will tell her that we would give her steroids to mature the lungs of the baby just in case we have to deliver the baby before 34 completed weeks. All this information can be overwhelming for the mother. I would therefore ensure that her partner and her midwife understand the intricacies of the situation and are there to give her support. I will offer bereavement counselling (1) and also give her information about support groups (1) .

The aim of carrying out investigations is to find out the cause of death of first twin and treat it (if it is treatable), to ensure maternal and fetal wellbeing and last but not the least to decide the timing of delivery of the other twin.
I would carry out a thrombophilia screen how reliable is this in pregnancy, especially in the presence of a dead fetus? , kliehauer test, serum HbA1C levels test what is serum? Is there Hb in serum? , Autoantibody screen (anti phospholipis, anti cardiolipin and lupus anticoagulant) is this not part of a thrombophilia screen? It suggests you do not know what a thrombophilia screen is , viral screen which viruses? , u&es WHY? , lfts and HVS are there causes of IUD which you can identify from the HVS?? on the mother to find the cause for IUD.
I will arrange daily CTGs and serial biophysical profiles and USS , It is apparent that you do not understand the value of the tests you are requesting. BPP includes CTG and USS. So what else are you looking for on USS? and Doppler studies for the fetus. I would deliver the baby if there were sign of fetal distress or abscent/reversed end diastolic flows on Doppler studies.
I would monitor maternal wellbeing by performing daily clinical examiations and weekly FBC, CRP and clotting profiles (1) . If there is eveidence of infection or impending DIC, i would agressively manage the same and then deliver the baby.

I would You are not answering the question. When asked: evaluate the factors? Your answer should begin: the most important factor is?You were not asked about what you will do. Once you get this wrong, your answer is unlikely to pass compare the risks of prematurity with the risk of increased perinatal mortality and morbidity to the live fetus and psychological trauma to the mother (1) . Also I will need to ensure that the SCABU is happy to have the baby or else I would need to transfer the mother to a unit where there are facilities to manage the premature newborn.
If there are any signs of fetal disress, in form of abnormal CTGs or abscent or reversed dopplers, I will deliver the baby. If all is well, I would like to extend the pregnancy to 34 completed weeks. The risk of neurological damage to the second twin is unpredicatble and it is not advisable to deliver prematurely just because of its fear.
Also I would keep close eye on mother and any signs of maternal compromise in form of impending infection how do you know if infection is ?impending?? Inflammatory markers will not rise in advance of infection / inflammation or DIC would prompt delivery.
Posted by PAUL A.
Fri Feb 1, 2008 10:40 pm
a.The women should be approach with sensitive manner and ultrasound finding should be explained carefully (1) . Fetal demise is associated with maternal grieving and would lead to serious psychological impact. She should understand that the chorionicity plays an important role in managing her pregnancy. The underlying cause of fetal demise and gestational age are essential factor to determine the fetal outcome and management the rest of her pregnancy. She should know that the death of one twin (especially in monochoroinic twin) is associated with 25% brain damage and 25% risk another fetal loss in the surviving twin (1) . The underlying pathology like the release of thromboplastin from the dead twin and cardiovascular consequences should be explained carefully to the patient and her partner. The death one of the twin will also lead to higher risk of cerebral palsy of the co-twin. Risk of premature delivery is also increased. Coagulation derangement (1) may occur after 4 weeks of fetal demised, thus the patient should be fully informed. Leaflet information, further follow up and support group (1) should be provided.
b. Maternal blood pressure ? investigation and urine protein should be obtained to look for maternal causes of the dead co- twin. Early delivery is indicated if there is presence of severe pre-eclapmisa to avoid intrauterine death in the surviving twin you were asked about investigation not management . Ultrasound scan should be done to determine the chorionicity can you reliably determine chorionicity at 32 weeks? of her twin pregnancy as monochorionic twin is associated with higher risk of brain and other organ damage in the surviving twin. Features of twin-twin pregnancy ? meaning?? like presence of fetal hydrop and growth restricted fetus and discrepancy of liqour amount could be the reason of fetal demise in the co-twin. Presence of fetal anomaly (1) should be looked for as this may be the possible causes of fetal demise. Scan of the fetal brain should be arranged weekly to look for any damage or changes in the surviving fetal brain. MRI may be justified to confirm the diagnosis. If there is brain abnormality noted, the fetal outcome is poor. Growth scan should be arranged to surviving twin to look for evidence of growth restriction (1) . Coagulation profile should be sent as there is possibility of coagulation derangement after 4 weeks of fetal demised so will you wait for 4 weeks before testing? . Prompt action should be taken to avoid maternal bleeding.
c.Chorionicity will determine the timing of delivery (1) . Monochoronic twin is associated with fetal brain damage and increased risk of fetal loss in the surviving twin. If there is evidence of brain damage in the surviving twin, fetocide and delivery should be discussed to the patient. Presence of maternal diseases identifiable cause ? should not necessarily lead to early delivery but allows a more precise assessment of risks & benefits of continuing pregnancy like severe pre-eclampsia should lead to early delivery to avoid fetal and maternal mortality. Period of gestation has important role in determine the timing of delivery. This patient is at 32 weeks of pregnancy, if she has dichorionic twin then the delivery can be delayed up to 34 weeks as this gestational age has less risk of premature complication like RDS. Evidence of IUGR will need timely delivery to avoid risk of stillbirth maternal anxiety / wishes, time to administer corticosteroids .
Posted by Lekshmi B.
Sat Feb 2, 2008 02:56 pm
A) Breaking the bad news will be done with utmost care and sympathy in the presence of the partner and family members who can give her psychological support. I will tell her that death of one fetus has occurred and this can have adverse effects on the surviving twin and on herself which needs careful monitoring. The effect on the surviving twin, mainly the risk of ischaemic brain damage depends on the chorionicity which might be mentioned in her previous ultrasound reports. If monochorionic twins there is a risk of vascular anastomosis between twins hence detailed assessment of surviving twin will be needed to rule out fetal anaemia and brain damage. This will need a detailed USS and fetal Doppler in a fetal medicine unit.. Any evidence of fetal compromise will require immediate delivery. In a dichorionic twin pregnancy even though the risk to the surviving fetus is less serial growth monitoring and CTG assessment for fetal wellbeing at fortnightly intervals will be required .There is a risk of premature delivery of the live fetus and she will be offered corticosteroids to promote lung maturity There is also a risk of maternal coagulopathy, hence weekly assessment of coagulation profile is needed in case of expectant management of this pregnancy. If the lady is Rh negative she needs Anti D prophylaxis as there is a risk of sensitization.

B) Review of previous ultrasound reports will be done to see if chorionicity has been noted. If not attempts will be made to assess chorionicity by USS even though it is difficult at this period of gestation. Maternal coagulation parameters and platelet count will be done to rule out coagulopathy and if normal it will be repeated at weekly intervals. Complete blood count will be done to assess hemoglobin status and blood sent for grouping if not done before. If the history of decreased fetal movement and ultra sound findings suggest recent death in a monochorionic twin immediate detailed USS with Doppler evaluation of MCA will be arranged in a fetal medicine unit to predict risk of fetal anaemia and brain damage. Fetal MRI will be done in suspicious cases to confirm. In dichorionic twins serial follow up growth scans every 2 weeks with weekly CTG will be done to monitor fetal wellbeing. Any evidence of hydrocephalous,porencephaly and cerebral infarct will be looked for in USS.After delivery USS brain or MRI brain will be done to assess brain function.

C) The timing of delivery will be planned after assessing the risks of prematurity and comparing it with the risks of continuing pregnancy. This again depends on chorionicity.Risks to surviving twin being more in monochorionic twins termination of pregnancy can be offered at 34 weeks when the risk of prematurity appear to be less. In dichorionic twin expectant management can be offered till 36 weeks if all growth parameters and maternal coagulation status are normal. These options will be discussed with the mother and her partner and their wishes will be taken into consideration while planning optimal time of delivery Delivery has to be in a tertiary care unit with all neonatal resuscitation facilities. Any evidence of fetal or maternal compromise early will be followed by immediate delivery after discussion with the neonatologist.
Posted by Dr seema jain J.
Sat Feb 2, 2008 06:12 pm

The loss of a baby is a major traumatic experience for a mother and such a situation should be handled with a lot of empathy. Psychological counselling should be recommended. The main concern for this woman would be that related to the well being of the surviving twin and the cause of death of the foetus. I will explain to the woman that the death of the foetus is in no way related to anything that she did or did not do so that she does not feel any guilt or remorse. Depending on whether it was a dichorionic or monochorionic pregnancy, I will explain her the consequences. In case it is a dichorionic pregnancy, I will explain her that a co - twin death does not entail risk to the surviving baby and expectant management can be offered. There is a risk that she can go into preterm labour. If it is a monochorionic pregnancy, the risk of the surviving twin developing hematological and or neurological complications especially periventricular leukomalacia are high. In some case it can cause death of the surviving twin.Long term neurodevelopmental problems in the surviving twin can occur. The mother also stands the risk of developing hematological complication especially coagulation abnormality. I will explain to her that in case of it being a monochorionic pregnancy, it is better that she delivers as early as possible (after steroid coverage) so as to avoid maternal or fetal complication, In case she chooses not to, I will tell her that she will need weekly blood test and fetal blood sampling for monitoring of the surviving twin. In case it was death of a monochorionic twin then I will explain her that the death could have been because of twinto twin transfusion, TRAP syndrome or cord accident. I will refer to support groups of parents with similar experience

The subsequent investigations will include weekly blood tests for the mother for coagulation abnormality. For the surviving twin serial growth scans of the baby along with umbilical artery Color Doppler should be done. MRI of the surviving fetus to check for development of any cystic spaces suggestive of periventricular leukomalacia should be offered. Fetal blood sampling to check for coagulation abnormalities and anaemia should be done. If needed, cardiotocography should be done.
The most important factors determining the timing of delivery is the chorionicity of the foetus, the status of the surviving fetus and the parents?s wishes.. In case it is a dichorionic pregnancy, expectant management can be offered whereas in case of a monochorionic pregnancy delivery should be expedited if there are signs of the baby being affected. Delivery may also need to be expedited if the mother shows any signs of coagulation abnormality. In case the mother and the surviving fetus are doing fine, prolonging the pregnancy till 37 weeks can be done. In case the mother does not wish to prolong the pregnancy then it is necessary to consider her wishes and deliver her at a centre where best neonatal care is available.
Posted by Maud V.
Sat Feb 2, 2008 08:04 pm
a) Twin pregnancies are more common following IVF treament and carry a higher risk than singleton pregnancies of intra-uterine death. Most of them will be dizygotic and therfore dichorionic, but a small amount could still be monochorionic and have the risk of twin to twin transfusion syndrome.
The woman will be upset and a sensitive approach with reflection of her emotions must be taken. She will want to know why this has happened. Possible causes are abruption, fetal hydrops, fetal infection, chorio-amnionitis, major fetal anomolies or abnormal karyotype. Some of these, like abruption and fetal infection, could affect the other twin as well. Others could be confined to the deceased twin. The deceased twin can get necrotic and cause intra-uterine infection, chorio-amnionitis and maternal sepsis, which puts both the other twin and the mother at risk. However, the live twin is premature, which is also a risk for mortality and morbidity folowing delivery at this gestation. The majority of babies will survive and survival is more likely following steroid injections to promote lung maturity, but the baby will have to go to a high dependancy neonatal unit.

After delivery, if the mother wishes, more inverstigations can be done to find the cause of the fetal demise, including placental swabs, karyotyping following skin biopsy and a post-mortem examination.

b) A CTG should be done to assess whether fetal compromise should be suspected in the live twin. A pathological CTG would warrant immediate delivery. If the CTG is normal and the woman is clinically well, there is time to do more investigations and to give 2 doses of steroids 24 hours apartwhile awaiting the results.
A full blood count and group & save should be taken. Anaemia can follow abruption, a high white cell count could be a sign of infection and a group will be needed at the time of delivery, which may be soon. If the woman has high blood pressure or symptoms of pre-eclampsia, a midstream urine sample should be tested for proteinuria with a dipstick and a sent for a urine protein-creatinine ratio and microscopy. If there is significant proteinuria, a 24 hour urine collection to measure the amount of protein should be started and blood tests for urea, creatinine, electrolytes, urate and liver function tests, to confirm whether she has pre-eclampsia.
An ultrasound assessment of the twins should be taken measuring the size of both and the liquor volumes. If the fetuses are small and the liquor volume low, this could be a sign of placental defiency and this can be confirmed with umbilical artery dopplers. This will influence the decision how soon the woman needs to be delivered.

c) At 32 weeks there is a significant risk of neonatal morbidity and mortality following delivery. The majority of babies will survive, but will need high dependency care in a neonatal unit for at least a month. There is, however, also a risk of intra-uterine death for the live twin, as the deceased twine can become necrotic and cause chorio-amnionitis. This can also put the woman at risk of sepsis.
If the CTG is abnormal, immediate delivery is warranted, as this can be a sign of hypoxia or infection, which puts the surviving twin at risk of demise or brain damage. If the CTG is normal and the woman hasn\'t yet had any courses of steroids, it would be advised for her to have two doses of steroids first, given 24 hours apart. The mother needs to be monitored for signs and symptoms of infection and the fetus with CTG\'s. If there are concerns about maternal or fetal wellbeing, delivery should be advised. In the absence of signs or symptoms of infection, abruption or ruptured membranes, delivery could be postponed untill the fetus is more mature. Whether this can be done, depends on the wishes and anxiety levels of the woman.
Posted by PAUL A.
Sun Feb 3, 2008 02:05 pm
a) I will tell her that one twin has died you must make clear you recognise she will be upset and present the information in a sensitive manner . Twin pregnancy is associated with an increased risk of an intrauterine death. The cause of death is unknown but could be due to congenital abnormalities. She has three factors that put her at increased risk of the fetus having a congenital abnormality. They are her age, twin pregnancy and conception with IVF ? relevance? Is this what you will tell her? . The death of one twin puts the second twin at increased risk of growth restriction, prematurity and intrauterine death. These risks are less with dichorionic diamnotic twins and greater with monochorionic twins (1) . Therefore the first trimester scan will need to be reviewed to confirm the chorionicty. Maternal risks include sepsis and preterm labour and delivery. Intramuscular steroids can be administered to her to improve the maturity of the lungs in case delivery is required before 34 weeks. MAternal and fetal wellbeing will dictate delivery. We would aim to deliver her at 38 weeks gestation but it may be earlier if the second twin develops problems. Therefore she would need close monitoring. I will provide her with an information leaflet (1) .

b) My subsequent investigations include a full blood count and CRP for thrombocytopenia and infection. They also function as baseline investigations to be compared to future results. A low vaginal swab for microscopy, culture and sensitivity to identify bacterial vaginosis or other infections are these associated with fetal death? . A detailed ultrasound scan to idenify malformations of both twins including cardiac abnormalities and hydrops (1) . The placental vasculature should be reviewed for evidence of twin to twin transfusion. The growth, liquor and dopplers should be measured to identify growth restriction, oliguria and poor blood flow through the umbilical vessels. Amniocentesis to obtain amniotic fluid to allow for karyotyping why? Blood group & antibodies, Kleihauer test, serial growth scans & BPP monitoring, screening for diabetes mellitus.

c) Evidence of chorioamniotis is she at increased risk of chorioamnionitis? or sepsis will be an indication for immediate delivery. The development of coagulopathy would also lead to immediate delivery. Poor fetal wellbeing which may present as growth restriction, oliguria and abnormal dopplers will necessitate delivery you were not asked about indications for delivery. You were asked to EVALUATE (attach a sense of value to) the factors ? .
Posted by PAUL A.
Sun Feb 3, 2008 02:20 pm
a)The finding is associated with significant maternal emotional distress (1) . In a sympathetic manner and in the presence of her partner and midwife , I have to tell her that one of the twins died in-utero (1) . I would tell her that twins pregnancy may be monochorionic ( same placenta ) or dichorionic ( two placentae ) , and that information pertaining to choronicity is helpful in the assessing the potential presence of placental anastomosis .
Communicating vessels are very uncommon in dichorionic twins . A monochorionic placenta would indicate a raised risk of shared circulation , putting the surviving twin at particular risk.
Momnochorionic twins pregnancy shows a high incidence of mortality of the surviving twin and morbidity in the form of neurological damage such as cerebral infarction ,hydrocephalus , porencephaly and cerebral palsy (1) . Renal problems may occur such as renal cortical necrosis. I would tell her that maternal coagulopathy (1) is uncommon and may affect 25% of the mothers beyond 3 weeks of fetal demise.
I would tell her that the causes are unpredictable and unavoidable are all causes of fetal death unpredictable / unavoidable?? . some tests may be performed to identify the cause , however in the majority of cases , no cause could be identified (1) .
I would tell her that prophylactic steroids should be given to reduce the risk associated with prematurity , if delivery is imminent .She should be informed about the need for appropriate management in a centre with fetal medicine expertise. Careful sensitive conversation is crucial for dealing with her emotional upset and grief. I would provide information leaflet and social support (1) .
b) Investigations for Intrauterine fetal demise should be performed to identify causes that may guide for the management , such as thrombophilia screen ? value in pregnancy especially in the presence of a dead fetus , viral serology , serum glucose , Kleihauer test , antibody screen do not write a list ? you will not get marks in a post-grad exam. For instance, how does the examiner know which antibodies you are screening for? Rubella?? Are you measuring random or fasting serum glucose and why? Which viruses are you screening for????? . The focus must be on assessing the risk to the second twin , therefore , ultrasound based fetal assessment (1) may identify potential causes of death such as hydrops , IUGR ,TTTS if monochorionic twins pregnancy.
Serial biophysical monitoring , umbilical Doppler measurements and cardiotocography should be performed up to the time of delivery (1) , as the cause of death of one twin may be the hostile environment which is the potential threat to the surviving twin.
Weekly maternal coagulation studies (1) should be performed until the time of delivery.
c) Accurate timing of the fetal death in gestation and information about chorionicity (1) is helpful in determining the time of the delivery. After 34-35 weeks gestation , the risk of premature delivery is less than the risk of continuing with the pregnancy and therefore delivery would be expedited risk profile is mainly dependent on the cause of death of the co-twin, not on gestation age. The balance of risks may be in favour of delivery much earlier . As neonatal care improves , earlier delivery may be contemplated following discussion with the paediatricians . Expectant management of the surviving twin may be contemplated , especially if more than 24 hrs has elapsed since the event. This is because feto-fetal transfusion is an acute process following co-twin death ,and it is better for delivery to delay to establish whether the surviving twin has suffered an intracerebral insult does this apply to dichorionic twins as well? . The psychological status of the mother (1) and her preferences should be taken into account before deciding the timing of the delivery.
Posted by PAUL A.
Sun Feb 3, 2008 02:50 pm
I would like to break this bad news to the couple in an empathetic manner as this pregnancy seems to be a precious pregnancy this is inappropriate ? all pregnancies are precious to the couple (IVF and 40 yrs age).
This may result in a significant psychological and emotional trauma to the couple (1) .
The patient may like to know about the cause of this event which in most cases is unclear. However if a cause is obvious like abruption immediate delivery is a prudent option is the presentation suggestive of abruption? . I would like to tell her about the prognosis of the surviving twin which is influenced significantly by the chorionicity of the twins. Monochorionic twins have 25% chances risk or intrauterine hypoxia resulting in cerebral palsy and 25% chances risk ? chance refers to positive outcomes: chances of success, risks of failure of death of the other twin so most of the time delivery is conducted taking the risk of prematurity are you suggesting that delivery is indicated if the twins are monochorionic? Will this reduce the risk of cerebral injury? . The baby?s lungs are supported by giving betamethasone before preterm delivery. The above mentioned risks are low in case of a dichorionic twins and delivery can be delayed upto 34 completed wks you have been asked about factors influencing timing of delivery in (c ) . If the mother is suffering from a disease like hypertension and diabetes which is likely to effect both the twins then the delivery may be needed to be conducted earlier. A remote risk of DIC in the mother is preventable and treatable how would you prevent DIC in this situation?? . She is to be informed about the investigations to be done to identify the cause and she should be told that the investigations may or may not reveal the cause (1) . If the delivery is planned to be delayed she should know about the various fetal surveillance techniques (daily CTG, Doppler US of fetal umbilical arteries and biophysical profile. she should be provided with written information, contacts of support groups (1) .

Full blood count, blood grouping and Kliehaurs test give us an idea about anemia and RH isoimunisation (1) . Coagulation profile is required to exclude a remote possibility of DIC will you repeat this? . HbA1c can tell us about her past glycemic status (1) . LFT and KFT to rule out HELLP syndrome and acute fatty liver of pregnancy, bile salts to rule out obstetric cholestasis and TORCH profile with Parvovirus B19 serology can be performed especially if hydrops is a finding (1) . A detailed US (1) is required to find out any congenital anomaly in the dead twin, the presentation of the presenting twin, the presentation of the surviving twin and its amount of liquor, Doppler us and biophysical profile of the surviving twin serial monitoring , all can help in decision regarding mode and timing of delivery. After delivery postmortem examination of the dead twin and histopathology of its placenta can reveal or confirm the cause of the fetal death.

Chorionicity (1) has important influence on timing of delivery as monochorionic twins are likely to be deliverd preterm. If the cause of the fetal death is identified (1) and is believed to be effecting the other twin, preterm delivery is likely, however if the twins are dichorionic and all investigations are normal pregnancy can be prolonged with daily CTG, BPP and Doppler studies. Availability of neonatal cots and paediatric services can influence the timing of delivery ? time to administer corticosteroids; maternal anxiety .
Posted by PAUL A.
Sun Feb 3, 2008 06:22 pm
(a) The news that one fetus has died has to be conveyed with lot of sympathy and care (1) and the couple should be encouraged to grieve for the lost baby. Their concern about the surviving twin needs to be addressed. Counselling regarding further management and prognosis for surviving twin needs further review of her case. Chorionicity is an important factor in determining fetal survival chances. The monochorionic fetuses have 30% risk of death of other twin compared to 3% with dichorionic fetuses. Details on chorionicity maybe available on her 1st trimester USG. Discordance in sex of the two fetuses would also point to a dichorionic fetus. At age 40 years there is likelihood of baby carrying congenital anomalies is there a maternal age at which there is NO likelihood of anomalies? and it is important to review if any preimplantation genetic tests were done or she had CVS/amniocentesis earlier PGD, amnio / CVS will detect chromosomal / genetic abnormalities. They do not detect / exclude congenital anomalies, the majority of which are unrelated to gene / chromosomal defects . An anomaly scan at 20 weeks might show structural abnormalities. Risks to the other baby would be based on these reports and I would advice accordingly.

In this healthy woman even if the other fetus is structurally and chromosomally normal, there are inherent problems with this pregnancy. There is 6% risk of mother getting DIC is this at the time of diagnosis of fetal death or over a period of time? (1) and she would need to be monitored closely for this. She is likely to develop preecclamsia, preterm labor, and psychological stress.

The surviving fetus has increased risk of IUD depending on chorionicity you discussed chorionicity earlier. How does the examiner know that you know that these risks relate to monochorionic twins? You have not specified, increased risk of microcephaly, hydrocephaly and porencephaly. There is also increased risk of cerebral palsy, intestinal atresia, pulmonary, hepatic and splenic infarction.

I will her there is no effective means to prevent these complications and the usual fetal monitoring like NST what is this? , Umbilical artery Doppler or BPP may not detect some of these changes. USG may detect some renal and brain changes but it cannot be used to monitor and prevent its development. I would advise her early delivery if the fetus shows jeopardy balancing risk of prematurity with risk of continuing in utero.

(b) She should have weekly platelets and fibrinogen levels to detect DIC (1) . I would do her TORCH studies (1) as intra uterine infection could have contributed to IUD of one twin and could now cause death of other twin also. Her Blood group antigens and Kleihauer test if she is Rh negative as Rh antibodies might have caused fetal death (1) will you not do a Kleihauer test if she is Rh positive?.

I would do biweekly surveillance of the baby by NST what is this? If you mean a CTG then it suggests you do not recognise that BPP includes CTG , BPP, doppler (1) to detect fetal jeopardy early, though it would not detect any brain damage. Doppler could detect any knots in cord Could it? What will you do if you think you have detected a knot? Can you tell if this is a true / false knot? What is the evidence that detecting knots reduces perinatal mortality / morbidity? (-1) , any placental vascular anastomosis causing TTTS.

A high resolution USG can detect renal, hepatic, splenic infarcts and can also detect intracranial hemorrhage, encephaloclastic lesions (1) . This helps assess prognosis for the baby and likelihood of postpartum development of neurological complaints. USG can detect retroplacental clots and any sign of hydrops fetalis in both fetuses. USG will also aid if amniocentesis is done to detect any intrauterine infections like TORCH and parvoviruses.

(c) Chorionicity is an important factor in deciding timing of delivery (1) . Dichorionic fetuses are at less risk of IUD and can be allowed up to 37 weeks. For monochorionic twins decision to deliver will depend on gestational age, condition of surviving fetus and cause of death of other fetus does cause of death not affect the management of dichorionic twins? . If the same cause or condition is likely to affect this baby early delivery should be considered except with major congenital anamolies which would not be benefited by early delivery.

If fetus is normal, decision to deliver will depend on fetal condition and evidence of fetal maturity what will you use as evidence of fetal maturity? . For monochorionic twin, showing pulmonary maturity how will you assess this?? , early delivery can be contemplated at 34-36weeks is this ?early? in a monochorionic twin pregnancy? . If fetus shows compromise at the present 32 wks Gest age, baby can be delivered following corticosteroid administration.

Mother showing signs of DIC is another factor prompting early delivery.
Posted by PAUL A.
Sun Feb 3, 2008 06:36 pm
Breaking this bad news is a distressing job you will not be expected to be distressed . She should be counseled in a sensitive (1) way in the presence of her partner and senior midwife if she allowed. Intra-uterine fetal death [IUFD] is always distressing, but in her situation being a primigravida, 40 years old and an IVF pregnancy that all add more pressure. After she take that news the risk for her own health, and to the wellbeing of her other twin should be explained in clear way. There is greater risk of a pre-term labour regardless of the chorionicity and as many as 90% may deliver within 3 weeks. If her pregnancy was diagnosed as monochorionic then she should be informed that there is a risk of IUFD of the other twin of 20% and a risk of neural and renal necroses (1) . There increased risk of cerebral palsy in the surviving twin. These risks are not prevented by immediate delivery. Regarding her health there is small risk of developing a disseminated intra-vascular coagulation [DIC] (1) due to retained dead fetus. A written information and contact number (1) support groups, bereavement counselling should be given. She should also informed about the increased need of surveillance of the other twin.
The woman\'s blood group and Rhesus status should be checked. A test for red-cells antibodies as chronic feto-materal haemorrage may lead to unusual anti bodies formation (1) . A coagulation profile as a retained dead fetus may trigger a DIC particularly fibrinogen degradation products will be raised will you repeat it? . A Keulaheire test to detect fetal blood in maternal circulation in case of feto-maternal bleeding. A glucose tolerance test to detect if she developed gestational diabetes millets as well as checking blood pressure and proteinuria as she has increase risk for developing them and any of them may cause IUFD. Check fetal well being by umbilical artery Doppler ,biophysical profile, non-stress CTG does BPP not include CTG? (1) and kick-chart ? evidence that kick charts are of value .
Chorionicity (1) greatly influence the decision on timing of delivery. In a dichorionic twins one can aim to reach 37 weeks of gestation. In monochorionic twins may be 34 weeks should be the aim. Mother\'s decision should be respected. In case of fetal compromise then pregnancy should be terminated do you mean the second twin should be sacrificed? If not, why have you used the word ?terminated? rather than ?delivered? which you used earlier? . The neonatologist should be consulted ,if there no available cot so either to delay delivery if possible or to transfer to a tertiary service the most important factor will be the identification of cause of death of the co-twin as this will allow more precise risk assessments ..
Posted by PAUL A.
Mon Feb 4, 2008 01:10 am

I will see her in a quiet and private room. I will ask if she would like her partner or family member to come with her. I will tell her that one twin has died (1) in a sensitive and empathetic manner (1) . I would explain that we will try to ascertain the cause of the death and this would depend on a history and examination suggestive of preeclampsia, infecion, premature rupture of membranes. I would explain that we would also investigate and do more tests to find a cause of death but there is a possibility that we may not find a cause (1) . I will explain that the 2nd Twin may be affected (1) by the death of the first twin and we would do further investigations to ascertain this. I would explain that she will need admission for further evaluation and may need monitoring under the fetal maternal unit. It is important to ascertain that although one twin has died it is important to focus on the the fact that the other twin is alive and every effort would be made to optimise the health of the other twin. I would also inform the bereavement midwives and offer the patient the option to see her (1) . I would also give her the phone number for support groups (1) such as SANDS.

I would do blood tests, FBC, U+E, LFT, uric acid to ascertain if there if evidence of preeclampsia. I would also do a urinalysis and check for proteinuria and send off a 24 hour collection if there is evidence of proteinuria. I would also do a TORCH screen looking for possible evidence of intrauterine infection (1) . I would also do a clotting looking for fibrinogen , PT and APTT looking for evidence of DIC will you repeat this test? . I would also do a group and save if she warranted a blood transfusion should she go into DIC. I would then look through her notes for a first trimester scan looking for the chorionicity (1) of the pregnancy. A dichorionic pregnancy would mean that there are no neurologic or renal consequences to the surviving twin however a monochorionic twin pregnancy could imply serious neurologic, renal and cardiac compromise in the surviving twin. I would also do an ultrasound assessment of the surviving twin assesing for gowth, liquor volume and umbilical artery Doppler (1) . I would also perform a middle cerebral artery peak systolic velocity and ductus venosus doppler looking for evidence of raised peak systoic velocity or ductus venosus doppler indicating imminent compromise. If it is a monochorionic pregnancy and there is eveidence of neurological and renal compromise on ultrasound scan I would preform a fetal MRI looking for cystic changes in the surviving fetus\' brain indicating a poorer outcome.

This depends of fetal and maternal factors. Prematurity would be my first concern. At 32 weeks, the fetus may benefit 2 more weeks in utero if all other parameters are normal (growth, liquour volume, umbilical artery doppler, middle cerebral artery systolic velocity) what about risk of death from whatever killed the co-twin? . However if these parameters are abnormal delivery may be the safer option with steroid cover. Evidence of ischaemic changes in the brain of surviving twin will also prompt delivery what is the benefit of delivery? Ischaemic injury would have occurred at the time of death of the co-twin especially if we don\'t know the time interval since the death of the first twin in a monochorionic pregnancy. Maternal factors include evindence of severe preeclampsia (either sever hypertension not controllable with antehypertensives) or abnormal biochemical indices. She would also warrant delivery if there was evidence of DIC. Whether it is maternal of fetal factors, 2 doses of steroids should be given to aid fetal lung maturity prior to delivery at 32 weeks the most important factor will be identification of cause of death of the co-twin as this allows more precise risk assessment .
Posted by PAUL A.
Mon Feb 4, 2008 01:22 am

(a)This lady will need sensitive counselling and sympathy (1) . We inform her that death of one fetus exposes the other to many risks (1) and these risks are different according to chorionicity.

If her pregnancy is monochorionic, the co-twin will be exposed to acute hypotension and demise within 12 hours can you confidently identify time of delivery on which you will base a decision to deliver immediately?? after death of the first one, therefore, urgent delivery is required and usually she ill need as caesarean section.
However, if the fetus survive this acute attack, it will be exposed to neurological sequelae due to brain ischemia.

This risk is not present if the pregnancy is DC because the placentae usually are not communicated, however, the cause of death of the first fetus still can cause death of the second one. We explain to her that in majority of cases, it is difficult to detect specific cause of death (1) .

We inform her also that if she opt to continue pregnancy, she will be at risk of preterm delivery whether the pregnancy is MC or DC and therefore corticosteroid is required to improve fetal lung maturity.

We tell her that she will need regular monitoring and we should explain to her that occurrence of complication is difficult to predict nor to be prevented and there are no method or test for fetal surveillance that can confirm fetal well being for sure.

We tell her also that risk of maternal coagulopathy (1) which usually occur after death of fetus in singleton pregnancy is extremely rare in her conditions.

We provide patient information leaflet and give her contact addresses of support groups (1) .

(b)We offer detailed US examination (1) of the dead fetus to detect if there is any congenital malformation as this will affect further management.
We do also Doppler examination of umbilical artery and middle cerebral artery of the surviving twin to detect impending fetal demise.
We do FBC including platelet count and screening for thrombophilia ? value during pregnancy especially in the presence of a dead fetus , also screening for virology ? which tests? to detect a possible cause of death. In addition GTT is done to detect gestational DM. Kleihauer\'s test is done also to detect isoimmunization (1) .
Urine analysis to detect proteinuria
Serial MRI of fetal brain to detect cystic spaces in brain or encephlomalasia.
We advice for Biophysical profile weekly and serial growth scan fortnightly for the growth and liquor assessment of the surviving twin (1) .

(c)Condition and gestational age of the surviving twin can affect time of delivery. Expedite delivery is needed if there is impending demise. Also if the fetus near term, delivery is advised she is 32 weeks pregnant .

Fresh death of fetus in monochorionic twin pregnancy will require urgent delivery NO ? how do you know when death occurred and that injury to the surviving twin has not already occurred? to prevent fetal morbidity and mortality of the other fetus.
Maternal wishes and preferences (1) should be respected after she had given an adequate information and counselling.
If a cause of death is found (1) or there are other additional risk factors like pregnancy induced hypertension or DM also affect decision of delivery.

Also if the local SCBU lacks beds or facilities, we can defer delivery to allow for in-utero transfer for tertiary centre if patient situation allow.
Posted by PAUL A.
Mon Feb 4, 2008 03:05 am
{A}
This finding is likely to be associated with maternal anxiety, so sensitive empathic approach is warranted (1) . I would explain to her that death of co-twin occurs in about 5-6.5% of twin gestation. I should detect if it is monochorionic or dichorionic before proper counseling, if monochorionic pregnancy, there is risk of death of the co-twin in about 25%. Furthermore, there is risk of nouro-developmental sequelae such as cerebral palsy, cerebral infarcts and hydrocephalus in approximately 25% (1) . Close monitoring is needed for fetal wellbeing.
Also, I would explain to her that further investigations are needed to detect the cause of fetal demise and if maternal cause detected, delivery should be expedited. Also, the need for postmortem examination of the dead fetus is explained after full informed consent.
There is also maternal implication of fetal death such as DIC (1) and risk of post-partum hemorrhage.
There is a risk of prematurity, so I would explain to her the need for antenatal corticosteroids to reduce the risk of RDS and interventricular hemorrhage.
I would counsel her properly taking into consideration her psychological make up and her wishes. bereavement counselling, written information, support groups
{B}
The needed investigations aimed at detection of the cause of the fetal demise and at wellbeing of the surviving twin. I would request liver function test to exclude cholestasis of pregnancy, klhaieur?s test and screening for atypical antibodies the Kleihauer test does not detect antibodies to check if there is any iso-immunization.
The woman is 40 years old, so she is at risk of GDM and proteinuric hypertension. That is why I would check her blood glucose level and hemoglobin A1C as well as dipstick for proteinuria (1) .
Virology screening for her is needed particularly CMV, Parvo virus 19. Ultrasound (1) can help to determine the cause of fetal death such as IUGR, hydrops or TTTs if mono-chorionic twin. Furthermore, it will detect the chorionicity can you determine chorionicity at 32 weeks? type of the twin pregnancy if it has not done early in pregnancy.
I would request coagulation profile weekly as DIC (1) may happen after 5 weeks.
Investigation for fetal wellbeing include ultrasound scan, Doppler and biophysical profile are recommended weekly or twice weekly (1) . Check for any cerebral changes MRI may be needed post delivery to detect any cerebral changes.
{C}
The most important prognostic factor is the chorionicity (1) cause of death will be the most important of the twin gestation. Mono-chorionic gestation is associated with higher morbidity and mortality so proper counseling is mandatory as well as close monitoring before allowing continuation of pregnancy. On the other hand, di-chorionic pregnancy is known to be associated with the risk of prematurity as allowing pregnancy beyond 34 weeks will be associated with increased maternal anxiety as well as the risk of DIC and PPH.
Gestational age has also detrimental effect ? meaning?? because of the risk or prematurity and in-utero transfer should be considered if the facility of special neonatal care unit is not available.
If maternal cause of fetal demise detected ,the delivery should be expedited maternal cause does not necessitate delivery but allows a more precise risk-benefit analysis to be made .
Fetal well being of the co-twin has a detrimental effect ? meaning?? as cerebral changes are unpredictable and unavoidable.
I would consider the psychological status of woman and her wishes (1) ,also asking her to share in the decision.
Posted by Sahathevan S.
Mon Feb 4, 2008 03:10 am
(a) What will you tell her about this finding? [9 marks]
Women must be very anxious and worried therefore careful counseling and fetal surveillance needed. I will review the notes and find information of chorionicity in assessing the potential presence of placental anastomosis. I will tell her cause of the death of one twin may be a hostile environment, which is a potential threat to the surviving twin. Potential complications to the surviving twin in a monochorionic twin pregnancy is associated with are in the form of isheamic brain damage, renal damage and increase mortality and morbidity (46%). these problems are very uncommon in dichorionic gestation. Therefore main risk for surviving twin is prematurity but to spontaneous or iatrogenic delivery.
She will be referred to Fetal medicine unit for further investigation and management. Possible Maternal causes for fetal death need to exclude and if identified the delivery may need to be expedited. If there is no maternal cause found pregnancy can be continued but she should understand the risk of fetal brain damage is high. Weekly scan will be arranged to examine gross brain damage. She needs weekly coagulation investigations.
If preterm delivery is indicated for fetal reasons C-Section is generally the preferred route.

(b) Justify your subsequent investigations [6 marks].
DIC may affect as many as 25% of the mothers beyond 3 weeks of the demise therefore immediately and weekly assessment of coagulation studies of the mother is therefore necessary. Evaluation of fetal structural anomalies and weekly scans of status of the surviving twin. Biophysical profile also useful. If there is any evidence of brain damage, fetocide should be offered. If the brain remains normal, intensive fetal monitoring is mandatory and postnatal MRI should be arranged.

(c ) Evaluate the factors that will influence the decision on timing of delivery [5 marks].
Chorionicity is an important factor to determine the timing of delivery, monochiorionic pregnancy associated with cerebral palsy, porencephaly, hydrocephalus and cerebral infarction there fore early delivery more likely. If maternal cause for the death identified, delivery will be expedited soon. If the fetus is more than 34 wks gestation, there are fewer benefits for continuing the pregnancy; labour should be induced unless there is obstetric indication for Caesarian section. Timing also depend on whether patient received steroid or not or delaying for steroid administration. The psychological status of the mother and her preferences should be taken into account before deciding the timing of the delivery. Brain damage of the baby and fetal death of survived twin also important factors to take in consideration. Neonatal care facilities and availability of neonatal cot in tertiary centre also play a role in timing of delivery
Posted by PAUL A.
Mon Feb 4, 2008 03:16 am

This finding can be very distressing to thye patient, her family and those involved in her care.
She is informed that one of the babies have died in a very sensitive and supportive manner (1) . This should be done in a private setting and she should be allowed to have other persons present for support if she so desires.
She will be told that it is difficult to ascertain the cause of demise at this time. Possible causes of death include aneuploidy, congenital anomalies and intrauterine infection. The majority of cases of intrauterine demise have no identifiable cause (1) . A post mortem examination performed after delivery of the baby can help in determining the cause of the babys death.
The effect of fetal demise on the surviving twin depend on the chorionicity. Following IVF dichorionic twins are more likely. There is no increased chance of adverse fetal outcome in the surviving twin if they were dichorionic. If the twins are monochorionic there is a 25 % chance risk of subsequent demise of the survivng twin. There is also a 25% risk of ischemic renal and neurological sequelae in the surviving twin (1) . There is also a risk of anemia and subsequent hydrops in the survivg twin.
The maternal risks include coagulopathy (1) and psychological problems such as depression. She should be reassured that the fetal demise is not her fault (1) . She is provided with informatioin on support groups eg SANDS (1) .
The patient should be provided with informaion leaflets to supplement the discussion.

b) A complete blood count should be done to determine the hematocrit and platelet count. A baseline clotting screen should be done as she is at risk of coagulopathy (1) . If she is rhesus negative a kleihauer test is done to determine the extent of isoimmunisation a Kleihauer test detects feto-maternal haemorrhage and should not be restricted to Rh neg women .
An ultrasound scan will be done to assess fetal hydrops will ultrasound detect anything else? Congenital anomaies? . Fetal growth parameters are assessed every 2 weeks. Doppler of the fetal middle cerebral artery is done to assess for fetal anemia and doppler of the umbilical artery is doen to assess placental function (1) .
An ultrasound scan or MRI of the fetal brain is done to assess for neurological changes.

c) The main factor that will determine timing of delivery is the chorionicity of the twins (1) identified cause of death is more important . Dichorionic twins can be managed expectantly with recourse to early delivery if the well being of the fetus changes. Evidence of placental insufficiency, fetal compromise or maternal coagulopathy should prompt delivery.
The estimated fetal weight and likelihood of survival at particular gestational age is another important factor. Whether the apteint received antenatal corticosteroids should also be considered. Presence of fetal anemia or neurological changes should consider delivery will delivery prevent such injury? . Finally the mothers wishes (1) are paramount in determining the timing of delivery.
Posted by PAUL A.
Mon Feb 4, 2008 03:28 am

A) Breaking the bad news will be done with utmost care and sympathy (1) in the presence of the partner and family members who can give her psychological support. I will tell her that death of one fetus has occurred (11) and this can have adverse effects on the surviving twin (1) and on herself which needs careful monitoring. The effect on the surviving twin, mainly the risk of ischaemic brain damage depends on the chorionicity which might be mentioned in her previous ultrasound reports. If monochorionic twins there is a risk of vascular anastomosis between twins hence detailed assessment of surviving twin will be needed to rule out fetal anaemia and brain damage more detail ? what type of brain damage? . This will need a detailed USS and fetal Doppler in a fetal medicine unit.. Any evidence of fetal compromise will require immediate delivery. In a dichorionic twin pregnancy even though the risk to the surviving fetus is less serial growth monitoring and CTG assessment for fetal wellbeing at fortnightly intervals will be required .There is a risk of premature delivery of the live fetus and she will be offered corticosteroids to promote lung maturity There is also a risk of maternal coagulopathy (1) , hence weekly assessment of coagulation profile is needed in case of expectant management of this pregnancy. If the lady is Rh negative she needs Anti D prophylaxis as there is a risk of sensitization.

B) Review of previous ultrasound reports will be done to see if chorionicity (1) has been noted. If not attempts will be made to assess chorionicity by USS even though it is difficult at this period of gestation. Maternal coagulation parameters and platelet count will be done to rule out coagulopathy and if normal it will be repeated at weekly intervals (1) . Complete blood count will be done to assess hemoglobin status and blood sent for grouping if not done before. If the history of decreased fetal movement and ultra sound findings suggest recent death in a monochorionic twin immediate detailed USS with Doppler evaluation of MCA will be arranged in a fetal medicine unit to predict risk of fetal anaemia and brain damage. Fetal MRI will be done in suspicious cases to confirm. In dichorionic twins serial follow up growth scans every 2 weeks with weekly CTG will be done to monitor fetal wellbeing (1) . Any evidence of hydrocephalous,porencephaly and cerebral infarct will be looked for in USS.After delivery USS brain or MRI brain will be done to assess brain function.
TORCH screen, screening for diabetes mellitus, Kleihauer test
C) The timing of delivery will be planned after assessing the risks of prematurity and comparing it with the risks of continuing pregnancy. This again depends on chorionicity (1) .Risks to surviving twin being more in monochorionic twins termination of pregnancy DO YOU MEAN DELIVERY? can be offered at 34 weeks when the risk of prematurity appear to be less. In dichorionic twin expectant management can be offered till 36 weeks if all growth parameters and maternal coagulation status are normal. These options you were not asked about options. You were asked about factors that will influence your decision. Evaluate = attach a sense of value / importance will be discussed with the mother and her partner and their wishes (1) will be taken into consideration while planning optimal time of delivery Delivery has to be in a tertiary care unit with all neonatal resuscitation facilities. Any evidence of fetal or maternal compromise early will be followed by immediate delivery after discussion with the neonatologist.
Posted by PAUL A.
Tue Feb 5, 2008 10:54 pm
The loss of a baby is a major traumatic experience for a mother and such a situation should be handled with a lot of empathy (1) . Psychological counselling should be recommended. The main concern for this woman would be that related to the well being of the surviving twin and the cause of death of the foetus. I will explain to the woman that the death of the foetus is in no way related to anything that she did or did not do (1) so that she does not feel any guilt or remorse. Depending on whether it was a dichorionic or monochorionic pregnancy, I will explain her the consequences. In case it is a dichorionic pregnancy, I will explain her that a co - twin death does not entail risk to the surviving baby and expectant management can be offered. There is a risk that she can go into preterm labour. If it is a monochorionic pregnancy, the risk of the surviving twin developing hematological and or neurological complications (1) especially periventricular leukomalacia not a typical feature are high. In some case it can cause death of the surviving twin.Long term neurodevelopmental problems in the surviving twin can occur. The mother also stands the risk of developing hematological complication especially coagulation abnormality (1) . I will explain to her that in case of it being a monochorionic pregnancy, it is better that she delivers as early as possible not necessarily ? injury occurs at the time of death of the co-twin and is not prevented by early delivery (after steroid coverage) so as to avoid maternal or fetal complication, In case she chooses not to, I will tell her that she will need weekly blood test and fetal blood sampling why? What will you measure in fetal blood?? for monitoring of the surviving twin. In case it was death of a monochorionic twin then I will explain her that the death could have been because of twinto twin transfusion, TRAP syndrome or cord accident. I will refer to support groups of parents with similar experience

The subsequent investigations will include weekly blood tests for the mother for coagulation abnormality (1) . For the surviving twin serial growth scans of the baby along with umbilical artery Color Doppler should be done (1) . MRI of the surviving fetus to check for development of any cystic spaces suggestive of periventricular leukomalacia should be offered. Fetal blood sampling to check for coagulation abnormalities which disease / disorder causes fetal coagulation abnormalities? and anaemia should be done. If needed, cardiotocography should be done how will you decide if it is needed? .
The most important factors determining the timing of delivery is the chorionicity of the foetus (1) cause of fetal death is more important , the status of the surviving fetus and the parents?s wishes.. In case it is a dichorionic pregnancy, expectant management can be offered whereas in case of a monochorionic pregnancy delivery should be expedited if there are signs of the baby being affected will delivery prevent neurological injury which occurs at the time of death of the co-twin? . Delivery may also need to be expedited if the mother shows any signs of coagulation abnormality. In case the mother and the surviving fetus are doing fine, prolonging the pregnancy till 37 weeks in a monochorionic twin? can be done. In case the mother does not wish to prolong the pregnancy then it is necessary to consider her wishes (1) and deliver her at a centre where best neonatal care is available.

Posted by PAUL A.
Tue Feb 5, 2008 10:54 pm
a) Twin pregnancies are more common following IVF treament and carry a higher risk than singleton pregnancies of intra-uterine death. Most of them will be dizygotic and therfore dichorionic, but a small amount could still be monochorionic and have the risk of twin to twin transfusion syndrome is this part of what you will tell her? If not, why are you writing it? .
The woman will be upset and a sensitive approach (1) with reflection of her emotions must be taken. She will want to know why this has happened. Possible causes are abruption, fetal hydrops, fetal infection, chorio-amnionitis, major fetal anomolies or abnormal karyotype unless you know the cause, you must avoid speculation . Some of these, like abruption and fetal infection, could affect the other twin as well (1) . Others could be confined to the deceased twin. The deceased twin can get necrotic and cause intra-uterine infection, chorio-amnionitis and maternal sepsis how could this happen? In the absence of an opening to a non-sterile environment, how does a dead fetus lead to sepsis? Where do the microbes come from??? , which puts both the other twin and the mother at risk. However, the live twin is premature, which is also a risk for mortality and morbidity folowing delivery at this gestation. The majority of babies will survive and survival is more likely following steroid injections to promote lung maturity, but the baby will have to go to a high dependancy neonatal unit.

After delivery, if the mother wishes, more inverstigations can be done to find the cause of the fetal demise, including placental swabs, karyotyping following skin biopsy and a post-mortem examination.

b) A CTG should be done to assess whether fetal compromise should be suspected in the live twin. A pathological CTG would warrant immediate delivery. If the CTG is normal and the woman is clinically well, there is time to do more investigations and to give 2 doses of steroids 24 hours apartwhile awaiting the results.
A full blood count and group & save red cell antibody screen, Kleihauer test should be taken. Anaemia can follow abruption, a high white cell count could be a sign of infection and a group will be needed at the time of delivery, which may be soon. If the woman has high blood pressure or symptoms of pre-eclampsia, a midstream urine sample should be tested for proteinuria with a dipstick and a sent for a urine protein-creatinine ratio and microscopy. If there is significant proteinuria, a 24 hour urine collection to measure the amount of protein should be started and blood tests for urea, creatinine, electrolytes, urate and liver function tests, to confirm whether she has pre-eclampsia.
An ultrasound assessment of the twins should be taken measuring the size of both and the liquor volumes. If the fetuses are small and the liquor volume low, this could be a sign of placental defiency what is placental deficiency?? and this can be confirmed with umbilical artery dopplers. This will influence the decision how soon the woman needs to be delivered. Look up your unit protocol for investigating IUD ? FBC, blood group + red cell antibodies, Kleihauer, screening for diabetes mellitus, detailed ultrasound scan for congenital anomalies / hydrops PLUS monitoring of surviving twin?

c) At 32 weeks there is a significant risk of neonatal morbidity and mortality following delivery. The majority of babies will survive, but will need high dependency care in a neonatal unit for at least a month. There is, however, also a risk of intra-uterine death for the live twin, as the deceased twine can become necrotic and cause chorio-amnionitis Intra-uterine death at 32 weeks does not cause chorioamnionitis . This can also put the woman at risk of sepsis where are the bacteria coming from? .
If the CTG is abnormal, immediate delivery is warranted, as this can be a sign of hypoxia or infection, which puts the surviving twin at risk of demise or brain damage. If the CTG is normal and the woman hasn\'t yet had any courses of steroids, it would be advised for her to have two doses of steroids first, given 24 hours apart (1) . The mother needs to be monitored for signs and symptoms of infection and the fetus with CTG\'s. If there are concerns about maternal or fetal wellbeing, delivery should be advised. In the absence of signs or symptoms of infection, abruption or ruptured membranes, delivery could be postponed untill the fetus is more mature. Whether this can be done, depends on the wishes and anxiety levels of the woman (1) .
Posted by PAUL A.
Tue Feb 5, 2008 10:55 pm
(a) What will you tell her about this finding? [9 marks]
Women must be very anxious and worried therefore careful counseling and fetal surveillance needed. I will review the notes and find information of chorionicity in assessing the potential presence of placental anastomosis. will you tell her that one of the fetuses is dead? I will tell her cause of the death of one twin may be a hostile environment, which is a potential threat to the surviving twin (1) . Potential complications to the surviving twin in a monochorionic twin pregnancy is associated with are in the form of isheamic brain damage, renal damage and increase mortality and morbidity (46%) (1) . these problems are very uncommon in dichorionic gestation. Therefore main risk for surviving twin is prematurity but to spontaneous or iatrogenic delivery.
She will be referred to Fetal medicine unit for further investigation and management. Possible Maternal causes for fetal death need to exclude and if identified the delivery may need to be expedited. If there is no maternal cause found pregnancy can be continued but she should understand the risk of fetal brain damage is high is this true for dichorionic twins? . Weekly scan will be arranged to examine gross brain damage. She needs weekly coagulation investigations.
If preterm delivery is indicated for fetal reasons C-Section is generally the preferred route.
written information / support groups
(b) Justify your subsequent investigations [6 marks].
DIC may affect as many as 25% of the mothers beyond 3 weeks of the demise therefore immediately and weekly assessment of coagulation studies of the mother is therefore necessary (1) you wrote this in (a). You will not be given marks twice for the same fact in the same exam, let alone the same question. . Evaluation of fetal structural anomalies (1) and weekly scans of status what is a scan of status??? of the surviving twin. Biophysical profile how is this different from ?scan of status? also useful. If there is any evidence of brain damage, fetocide should be offered. If the brain remains normal, intensive fetal monitoring is mandatory and postnatal MRI should be arranged. investigation of IUD ? FBC, blood group + red cell antibodies, Kleihauer, screening for diabetes mellitus ?. See your unit protocol for investigating IUD

(c ) Evaluate the factors that will influence the decision on timing of delivery [5 marks].
Chorionicity is an important factor to determine the timing of delivery (1) , monochiorionic pregnancy associated with cerebral palsy, porencephaly, hydrocephalus and cerebral infarction so why did you not tell her about this in (a)?? there fore early delivery more likely will early delivery prevent such injury? . If maternal cause for the death identified, delivery will be expedited soon the most important factor is an identified cause of death as this will allow more precise risk-benefit analyses . If the fetus is more than 34 wks gestation, there are fewer benefits for continuing the pregnancy; labour should be induced unless there is obstetric indication for Caesarian section. Timing also depend on whether patient received steroid or not or delaying for steroid administration (1) . The psychological status of the mother and her preferences should be taken into account (1) before deciding the timing of the delivery. Brain damage of the baby and fetal death of survived twin also important factors to take in consideration. Neonatal care facilities and availability of neonatal cot in tertiary centre also play a role in timing of delivery
Posted by PAUL A.
Wed Feb 6, 2008 10:07 pm
A good candidate should

(a)
? Recognise that fetal death would be associated with maternal distress and anxiety about the outcome of the co-twin (1)
? Explain the findings to the woman (1)
? Reassure her that fetal death is not due to any actions on her part (1)
? Explain that investigations will be undertaken to find the cause but it is likely that no cause will be found (1)
? Explain that whatever caused the death of one twin may constitute an on-going threat to the surviving twin (1)
? If the twins are mono-chorionic, death of one twin associated with a high incidence of neurological damage in the surviving twin including cerebral palsy, hydrocephalus, cerebral infarction (1)
? Explain that there is a small risk of maternal coagulation problems due to prolonged fetal death (1)
? Offer bereavement counselling (1)
? Provide further appointment, written information and contact details of support groups (1)

(b) With respect to subsequent investigations

? Review early scans for chorionicity (1)
? Detailed ultrasound examination to identify potential causes including structural anomalies, fetal size, presence of hydrops (1)
? Know the value of ultrasound based biophysical monitoring of surviving twin (1)
? Maternal investigations include Kleihauer, blood group and antibodies, infection (TORCH) screen and screening for diabetes mellitus according to unit guidelines (2)
? Weekly maternal coagulation profile because of small risk of DIC (1)

(c) With respect to factors influencing timing of delivery

? The most important factor will be the presence of an identifiable cause of fetal death as this provides information on the risk to the co-twin (1)
? If mono-chorionic, there is a high incidence of neurological abnormalities in the surviving twin and it is advisable to delay delivery to allow identification of abnormalities. However, these may not be predictable (2)
? Time needed to administer corticosteroids for fetal lung maturity (1)
? Maternal anxiety about survival of the co-twin may necessitate early delivery (1)
s Posted by PAUL A.
Mon May 7, 2012 01:39 am

s