Question: How to manage a pregnancy with the death of one co-twin at 30 weeks in a dichorionic pregnancy?
Help us improve clinical query answers - just fill in a survey after reading this page
Please note: the search for this response was carried out over 1 year ago.
Eligible users may request an update of the evidence by submitting a new Clinical Query here.
Answer: The RCOG Study Group on Multiple Pregnancy (1) says that:
“[Death of a co-twin] Management depends on chorionicity, gestation and time since death. A conservative policy of increased surveillance with delivery at 37 weeks is recommended in DC pregnancies"
The American College of Obstetricians and Gynecologists have published a guideline on complicated multiple pregnancies (2). This notes that
“..authorities disagree about the preferred antepartum surveillance method and management once a demise has occurred. Some investigators have advocated immediate delivery of the remaining fetuses. However, if the death is the result of an abnormality of the fetus itself rather than maternal or uteroplacental pathology, and the pregnancy is remote from term, expectant management may be appropriate.”
(Evidence level IV)
The National Institute for Health and Clinical Excellence (NICE) are currently preparing a guideline on the management of multiple pregnancy. The guideline is due to be published in September 2011, but a draft(3) is available for consultation from February to April 2011. Chapter 8 considers death of one twin as an indicator for referral to subspecialty services and says:
"No studies were identified which directly examined the effectiveness of referral to subspecialist care in twin or triplet pregnancies complicated by discordant fetal growth, discordant fetal anomaly or single fetal death, nor in monochorionic monoamniotic pregnancies or triplet pregnancies generally. Two studies (very low quality) conducted at tertiary care centres examined perinatal outcomes in women with complicated twin pregnancies (the complications included but were not limited to discordant fetal growth, discordant fetal anomaly and single fetal death; neither of the studies reported inclusion of monochorionic monoamniotic pregnancies). These studies reported worse perinatal outcomes in referred women than in women who booked and received care at the same centre throughout pregnancy, although the results may simply reflect the risks associated with complicated twin pregnancies rather than direct effects of receiving subspecialist care."
Two recent review articles may also be of interest(4,5).
References:
- Multiple pregnancy. Edited by M Kilby et al. RCOG Press: London, 2006. Consensus views available here
- American College of Obstetricians and Gynecologists (ACOG). Multiple gestation: complicated twin, triplet, and high-order multifetal pregnancy. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2004 Oct. 15 p. (ACOG practice bulletin; no. 56). Summary available here
Other References:
3. Multiple pregnancy: the management of twin and triplet pregnancies in the antenatal period / National Institute for Health and Clinical Excellence. Draft guidance available at http://guidance.nice.org.uk/CG/Wave16/8 [Accessed 21 Feb 2011]
4. Twin pregnancy: controversies in management / Priscilla Devaseelan and Stephen Ong. The Obstetrician and Gynaecologist 2010;12(3) 179-185. Abstract available here and full text available to RCOG Fellows, Members and Trainees here
5. Single twin demise: consequence for survivors. Hillman SC. Morris RK. Kilby MD. Seminars In Fetal & Neonatal Medicine. 15(6):319-26, 2010 Dec. Abstract available here
Search date: February 2011
Classification of evidence levels
Ia Evidence obtained from meta-analysis of randomised controlled trials.
Ib Evidence obtained from at least one randomised controlled trial.
IIa Evidence obtained from at least one well-designed controlled study without randomisation.
IIb Evidence obtained from at least one other type of well-designed quasi-experimental study.
III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies.
IV Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities.
This clinical query answer was produced following the clinical query protocol as described
The RCOG will not be liable for any special or consequential damages arising from the use or reliance on information contained within the Query Bank.
