Maternal and neonatal outcome of twin pregnancies complicated by single fetal death.

OBJECTIVE: To study the maternal and neonatal outcome of twin pregnancies complicated by the intrauterine death of one fetus after 20 weeks of gestation. DESIGN: Retrospective, observational study of 7 twin pregnancies out of 185 twin pregnancies with the diagnosis of a single intrauterine death over a 5-years period in a university hospital. RESULTS: The incidence of single fetal death in twin gestation after 20 weeks was 3.8% in the study population with a high incidence of intrauterine growth retardation (IUGR) of the remaining fetus and preeclampsia in the further course of pregnancy. The incidence of preterm delivery was 71% with a mean gestational age of 33.0 +/- 1.0 weeks. The median interval from diagnosis of single fetal death to delivery was 10.2 +/- 4.1 days (range 1-28 days). 5 of 7 (71%) cases were delivered by cesarean section for standard obstetrical reasons. Neither perinatal nor neonatal death of the remaining twin were observed. Two cases of neurologic injury were diagnosed after delivery by ultrasound and MRI. No maternal coagulopathy related to single fetal death occurred. CONCLUSION: Expectant management of single fetal death in twin pregnancies might be advisible under close surveillance of both, mother and the surviving fetus.     

Single umbilical artery and umbilical cord torsion leading to fetal death. A case report

BACKGROUND: Intrauterine fetal death is a complication that cannot often be predicted by standard obstetric management. Cord accident may be responsible for about 5% of cases. Umbilical cord torsion is an extremely rare cause of intrauterine fetal death. CASE: An 18-year-old, nulliparous woman presented with a complaint of decreased fetal movement at 38 weeks' gestation. Intrauterine fetal death was diagnosed on ultrasound. The pathologic examination revealed umbilical cord torsion and confirmed a single umbilical artery that was diagnosed on ultrasound. CONCLUSION: Umbilical cord torsion that leads to intrauterine fetal death is extremely rare. A pregnancy with a single umbilical artery may need fetal monitoring during the third trimester.     

Kazal type trypsin inhibitor in amniotic fluid in fetal developmental disorders

The amniotic fluid concentrations of the Kazal type trypsin inhibitor were studied in pregnancies with fetal developmental disorders. The samples were obtained by amniocentesis between 14 and 19 weeks of gestation. In cases with fetal malformations, the level was below the normal 10th centile in 15 out of 28 cases (54 per cent, p less than 0.05) and above the normal 90th centile in 2 cases (7.1 per cent). Low values were common in cases with intrauterine fetal death or congenital nephrosis. The levels were normal in fetal chromosomal aberrations.     

Complete chorioamniotic membrane separation. Case report and review of the literature

We present a patient who developed complete chorioamniotic membrane separation (CMS) in two consecutive pregnancies. The first pregnancy ended with an intrauterine fetal death at 25 weeks of gestation. The entire separated amniotic sac had twisted around the umbilical cord. In the subsequent pregnancy, a complete CMS was diagnosed at 34 weeks of gestation. In both pregnancies, the patient underwent an early 2nd-trimester genetic amniocentesis. A review of the literature shows that extensive CMS is associated with miscarriage, in utero fetal death, umbilical cord complications, and preterm delivery. Most reported cases occurred after invasive intrauterine procedures.     

Monoamnotic twin pregnancy. Multicenter study

OBJECTIVE: The purpose of this study was to evaluate of perinatal mortality and morbidity of monoamniotic twins. STUDY DESIGN: This was a multicenter retrospective analysis of 26 monoamniotic twin gestations identified between 1985 and 2004 in a 3 perinatal departments. Of these 26 pregnancies, 11 women were admitted electively for inpatient fetal monitoring. Overall mortality rates, the risk of intrauterine fetal death and neonatal mortality and morbidity, pregnancy complications and fetal anomalies were calculated. RESULTS: Monoamniotic twin pregnancies were diagnosed reliably prenatally by ultrasound in 22 women and at delivery in 4 cases. Of the 26 gestations, spontaneous fetal losses before 22 weeks of gestation were 4 cases. The overall loss rate and the perinatal mortality rate were 52% and 19.4%, respectively. Twenty-two women had both twins alive at 24 weeks of gestation; 11 women were admitted electively for inpatient fetal monitoring at 26-27 week of gestation. In this group there were 2 neonatal deaths. No intrauterine fetal death occurred in any hospitalized patient. In our series there were 100% incidence of prematurity, 38,5% of umbilical cord entaglement, 23% of TTTS, 3.6% of TRAP and 9.6% fetal congenital anomalies. CONCLUSION: Monoamniotic twins are at extremly risk of pregnancy complications and fetal loss. These pregnancies can be diagnosed reliably by ultrasound in most cases. Electively admitted women for inpatient fetal monitoring could be improved neonatal survival and decreased perinatal morbidity.     

Intrauterine death of one fetus during the first trimester of monochorionic diamniotic twin gestation

OBJECTIVES: The goal of our study was the clinical and pathological characteristics of the monochorionic diamniotic twin gestations complicated by the intrauterine death of one fetus during the first trimester. MATERIAL AND METHODS: This study is a prospective review of 9 monochorionic diamniotic twin gestations involving the intrauterine death of one fetus during the first trimester. RESULTS: During the study period 178 twin gestations were identified sonographically during the first trimester. Forty three of them (24,2%) were complicated by the intrauterine death of one fetus before the end of 12th gestation week. Nine cases were monochorionic diamniotic. Gestational age of one fetus demise ranged from 5 to 11 (mean 7,4) weeks. Prognoses for surviving fetus were adverse. In 8 cases there was a death of a second fetus after the period of 1 to 3 weeks, with abortion of both fetuses. Only in one case, the gestation has finished in 40th week by delivery of liveborn infant. Maternal coagulation changes did not occur in those cases. One liveborn infant was without evidence of hematological and neurological abnormalities. The postdelivery examination allowed to establish a presence of monochorionic diamniotic placentation in all cases. In two of them, the probable causes of death were established (developmental defect, presence of anastomoses between blood vessels). CONCLUSION: These results suggest that the risk of mortality for the living twin is very high, after the death of its sibling, in case of monochorionic placentation. Morphological examination of placenta and fetal membranes lets to establish a type of placenta, and in some cases a probable cause of intrauterine death of one twin during the first trimester of monochorionic diamniotic twin gestation.     

Omphalocele and umbilical cord cyst. Prenatal diagnosis

We present a case of intrauterine fetal death at 32 week's gestation with omphalocele, umbilical cord allantoic cyst and polyhydramnios. Ultrasound diagnosis of anomalies was performed at 23 weeks of gestation. Fetal karyotype was normal: 46 XX. This association has been found to have a high rate of chromosomal abnormalities, especially trisomy 18. It's difficult to explain the reason why intrauterine fetal death has happened; one possible hypothesis is that the cord cyst, compressing umbilical vessels, have caused intrauterine vascular compromise of blood flow.     

Twenty-four cordocenteses in one woman.

We report on 2 consecutive pregnancies in a woman with a history of neonatal death secondary to Rhesus alloimmunization. Her first subsequent pregnancy was complicated by fetal hydrops at 20 weeks of gestation. The fetus received a total of 11 intrauterine transfusions, and was delivered at 38 weeks. In the patient's next pregnancy, the fetus developed hydrops at 18 weeks of gestation. Thirteen intrauterine transfusions were given to correct fetal anemia, and a healthy baby was delivered at 38 weeks of gestational age. Continuation of intravascular transfusion therapy may represent a reasonable alternative to selective premature delivery even in cases with highly aggressive maternal Rhesus alloimmunization.     

Discordance of fetal genotype or phenotype in monozygotic twins: a report of 2 cases

BACKGROUND: Discordance of fetal genotype or phenotype in a monozygotic twin pregnancy is rare. CASE: In case 1, a 28-year-old woman at 15 weeks' gestation was found to have a dichorionic twin pregnancy with 1 fetus affected with hydrop fetalis. The result of chromosomal study showed that the structurally normal fetus was 46,XY and that the hydropic fetus was 45,X. One week after selective termination of the hydropic fetus at 19 weeks' gestation, the cotwin died in utero. In case 2, a 30-year-old woman at 20 weeks' gestation, was found to have a monochorionic twin pregnancy with 1 fetus presenting with omphalocele. The result of chromosomal study showed that both fetuses were 46,XX. The fetus with omphalocele died in utero at 29 weeks' gestation, and the normal cotwin was delivered later due to fetal distress. Analysis by short tandem repeat markers in both cases indicated that they were monozygotic twins. CONCLUSION: These cases emphasize the importance of zygosity/chorionicity identification in twin pregnancy even though discordance of fetal genotype or phenotype was found. In monozygotic monochorionic twins, the normal cotwin is at risk for an adverse fetal outcome after 1 spontaneous intrauterine fetal death or selective termination. In monozygotic dichorionic twins, the risk of intrauterine fetal demise of the cotwin after selective termination still exists.     

Ultrasonographic identification and measurement of the human fetal adrenal gland in utero: clinical application

The size of the fetal adrenal gland was determined using ultrasonography in 346 fetuses with no complications at 28-40 weeks of gestation and in 12 fetuses of abnormal pregnancies (8 intrauterine growth retardations, 2 anencephalies, 1 intrauterine fetal death and 1 fetus of a mother who had been on steroids for treatment of systemic lupus erythematosus). The fetal adrenal gland area (FAGA), circumference (FAGC) and length (FAGL) were calculated. In 12 abnormal fetuses, FAGA values always fell below the mean +/- 2 SD. Deviations from the normal values were seen in 9 out of 12 cases (75%) in FAGC and in 4 out of 12 cases (33.3%) in FAGL. Of these pregnancies, 4 (33.3%) resulted in intrauterine fetal or neonatal death, and 2 neonates (16.6%) had to be admitted to the neonatal intensive care unit. Measurement of the fetal adrenal gland, especially of the FAGA, should be a pertinent diagnostic tool for perinatologists to manage and control high-risk pregnancies.     

Intrauterine fetal death in twins after 32 weeks of gestation

A retrospective review of the outcome in multifetal pregnancies from January 1, 1980 to July 31, 1983 was undertaken to evaluate the role of nonstress test, followed by contraction stress test when indicated, in reduction of intrauterine fetal deaths in twins after 32 weeks of gestation. Of the 90 twin pregnancies managed under the authors' protocol, there were no intrauterine fetal deaths. Intervention leading to delivery occurred in six twin pregnancies with an abnormal nonstress test followed by an equivocal or positive contraction stress test. The authors believe that routine use of weekly nonstress tests after 30 weeks of gestation coupled with contraction stress tests when indicated, and use of other parameters of fetal assessments such as ultrasound, intrauterine fetal death in twin gestation after 32 weeks of gestation, can be significantly reduced.     

Fetal pathology in intrauterine death due to parvovirus B19 infection

Objective To study the pathological features of fetuses dying because of parvovirus B19 infection, with particular reference to the presence of hydrops; to assess the usefulness of immunochemistry as a screening method for the detection of parvovirus infection at post-mortem examination.
Design Review of clinical, sonographic, serological and pathological data; immunohistochemical staining of post-mortem tissue.
Sample Cases of intrauterine fetal death occurring during the 18-month period January 1993 to June 1994 inclusive, referred for post-mortem examination to the Pathology Department, Royal Victoria Infirmary, Newcastle upon Tyne.
Results Eleven cases of fetal death due to parvovirus infection were identified. Seven fetuses were less than 18-week size. Three fetuses showed conspicuous hydropic change. One of the 11 cases was detected for the first time by retrospective immunochemical screening. Of cases originating from the Newcastle district, parvovirus infection was responsible for about 10YO of all non-malformed fetal deaths occurring between 10 and 24 weeks of gestation referred for pathological examination.
Conclusions During the period of study, parvovirus infection was a relatively common cause of mid-trimester fetal death. Many fetuses dying because of this infection are not noticeably hydropic, and the possibility of parvovirus infection should be considered in any case of intrauterine fetal death. Immunochemistry can be used to confirm the histopathological diagnosis, and may be of particular help where there is advanced autolysis; immunohistochemical screening may detect occasional cases not initially identified by examination of routinely stained tissue sections.     

Should apparently uncomplicated monochorionic twins be delivered electively at 32 weeks?

Objectives.?We aimed to estimate the optimal time of delivery and investigated the residual risk of fetal death after viability in otherwise uncomplicated monochorionic diamniotic twin pregnancies.

Study design.?A database of 576 completed multiple pregnancies that were managed in our tertiary referral fetal medicine department between 1996 and 2007 was reviewed and the uncomplicated 111 monochorionic and the 290 dichorionic diamniotic twin pregnancies delivered after 24 weeks were selected. The rate of fetal death was derived for two-week periods starting at 24 weeks’ gestation and the prospective risk of fetal death was calculated by determining the number of intrauterine fetal deaths that occurred within the two-week block divided by the number of continuing uncomplicated monochorionic twin pregnancies during that same time period.

Results.?The unexpected single intrauterine deaths rate was 2.7% versus 2.8% in previously uncomplicated monochorionic and dichorionic diamniotic pregnancies, respectively. The prospective risk of unexpected stillbirth after 32 weeks of gestation was 1.3% for monochorionic and 0.8% for dichorionic pregnancies.

Conclusions.?In otherwise apparently uncomplicated monochorionic diamniotic pregnancies this prospective risk of fetal death after 32 weeks of gestation is lower than reported and similar to that of dichorionic pregnancies, so does not sustain the theory of elective preterm delivery.     

Fetal morbidity and mortality after acute human parvovirus B19 infection in pregnancy: prospective evaluation of 1018 cases

OBJECTIVE: To determine more precisely the incidence of fetal complications following maternal parvovirus B19 infection at various gestational ages. METHODS: An observational prospective study of 1018 pregnant women whose acute B19 infection was serologically confirmed in our laboratory. RESULTS: The observed rate of fetal death throughout pregnancy was 6.3% (64/1018) (95% confidence interval [CI]: 4.9, 8.0). The fetal death rate for those infected within the first 20 weeks of gestation (WG) was 64/579 (11.0%). Fetal death was only observed when maternal B19 infection occurred before the completed 20 WG. The observed stillbirth proportion was 0.6% (6/960). Three of six stillbirth cases presented with fetal hydrops. The overall risk of hydrops fetalis was 3.9% (40/1018) (95% CI: 2.8, 5.3). Three of 17 cases with non-severe hydrops and 13 of 23 cases with severe hydrops received intrauterine transfusion(s). The proportion of fetuses with severe hydrops that survived following fetal transfusions was 11/13 (84.6%). All of the non-transfused fetuses with severe hydrops died. CONCLUSION: Our data demonstrate a relevant B19-associated risk of fetal death, which is largely confined to maternal B19 infection in the first 20 WG. Timely intrauterine transfusion of fetuses with severe hydrops fetalis reduces the risk of fetal death. Parvovirus B19-associated stillbirth without hydropic presentation is not a common finding.     

Outcome of fetal cystic hygroma and experience of intrauterine treatment

OBJECTIVE: To review our cases of fetal cystic hygroma and to examine the prognostic factors with the goal of establishing criteria for the intrauterine treatment for cystic hygroma. PATIENTS AND METHODS: Thirty-one cases of fetal cystic hygroma were managed by us from January 1988 to December 1997, and 21 cases were available for analysis. Three prognostic factors, namely chromosomal abnormality, structural anomaly and hydrops fetalis, were evaluated. We treated 2 cases of cystic hygroma associated with hydrops fetalis in utero using OK-432 injection under ultrasound guidance. RESULTS: The fetuses without any of the prognostic factors listed above showed a good prognosis throughout the fetal and neonatal periods. However, in this group, 2 infants with large tumors died of hemorrhage from the tumor at 6 months and 3 years of age, respectively. Cases with hydrops fetalis without chromosomal abnormalities or structural anomalies (5 cases) resulted in either intrauterine fetal death (IUFD, 2 cases) or early perinatal neonatal death (early PND, 3 cases). The cause of early PND was circulatory failure. Most of the hydrops cases with either a chromosomal abnormality or structural anomaly resulted in IUFD before 22 weeks of gestation. The size of the cyst decreased in 1 of 2 cases treated in utero. CONCLUSIONS: The fetal cases of cystic hygroma showing hydrops fetalis without chromosomal abnormalities or structural anomalies are considered to be possible candidates for intrauterine therapy. Those with very large cystic hygroma without any of the three prognostic factors are also thought to be candidates for fetal treatment. Based on our clinical experience, sclerotherapy using OK-432 is considered to be a treatment option in selected cases with fetal cystic hygroma.     

Second trimester total human chorionic gonadotropin,alpha-fetoprotein and unconjugated estriol in predicting pregnancy complications other than fetal aneuploidy

OBJECTIVE: To assess the value of alpha-fetoprotein (AFP), total human chorionic gonadotropin (ThCG) and unconjugated estriol in predicting certain complications of pregnancy other than fetal aneuploidy. STUDY DESIGN: Among 2384 women that underwent biochemical screening between 15 and 22 weeks of gestation, pregnancy outcome was evaluated in 677 women under 35 years of age according to serum marker levels by using cut-off points discriminative for Down syndrome or neural tube defect (NTD). RESULTS: High alpha-fetoprotein levels (MoM>/=2.0) were found to be significantly more frequent (P<0.05) in cases of fetal growth restriction (odds ratio=2.7), miscarriage (odds ratio=4.4) and intrauterine fetal death (odds ratio=5.8). High chorionic gonadotropin levels (MoM>/=2.02) were associated with intrauterine growth restriction (odds ratio=2.1; P<0.05), miscarriage (odds ratio=4; P<0.01), preterm birth (odds ratio=2.5; P<0.05), and intrauterine fetal death (odds ratio=4.2; P<0.01). Among pregnancies with intrauterine growth restriction and threatening preterm delivery, low unconjugated estriol levels (MoM相似文献   

Thrombotic thrombocytopenic purpura in pregnancy. A case report

Thrombotic thrombocytopenic purpura (TTP) is characterized by microangiopathic hemolytic anemia and thrombocytopenia, accompanied by microvascular thrombosis that causes variable degrees of tissue ischemia and infarction. About 10-20% of TTP cases are associated with the pregnancy. Preterm delivery and intrauterine fetal death are frequent pregnancy complications of TTP. The following paper presents the case of a 32-year-old woman with TTP relapse at 10 weeks of her second pregnancy. Despite regular fresh frozen plasma transfusions, intrauterine fetal death occurred at 21 weeks of gestation. Current views on TTP management during pregnancy have been presented in the article as well.     

Morbidity associated with prenatal disruption of the dividing membrane in twin gestations

We report eight cases of intrauterine rupture of the dividing membranes in diamniotic twin gestations and the resulting perinatal morbidity and mortality. The poor outcomes associated with these intrauterine amniotic ruptures included fetal and neonatal death secondary to cord entanglement, preterm rupture of the membranes, preterm labor and delivery, and amniotic band syndrome. The overall perinatal mortality rate was 44% (seven of 16), and the mean gestational age at delivery was 29 weeks (range 22-34). Possible etiologies for this intrauterine diamniotic rupture include fetal trauma to the dividing membranes, amniocentesis, infection, and developmental disturbances. A new theory is examined to explain the surviving twin's morbidity associated with intrauterine death of the co-twin. This study suggests that intrauterine rupture of diamniotic twin membranes carries a perinatal mortality consistent with that of true monoamniotic gestations and that, in fact, this entity may be more common than previously thought. Finally, a suspected monoamniotic gestation cannot be ruled out by the historic presence of a dividing membrane on previous ultrasound examination.     

Prospective risk of fetal death in uncomplicated monochorionic twins

A retrospective cohort study was carried out in a university teaching hospital to determine the prospective risk of unexpected fetal death in uncomplicated monochorionic diamniotic (MCDA) twin pregnancies after viability. All MCDA twins delivered at or after 24 weeks' gestation from July 1999 to July 2007 were included. Pregnancies with twin-twin transfusion syndrome, growth restriction, structural abnormalities, or twin reversed arterial perfusion sequence were excluded. Of the 144 MCDA twin pregnancies included in our analysis, the risk of intrauterine death was 4.9%. The prospective risk of unexpected intrauterine death was 1 in 43 after 32 weeks' gestation and 1 in 37 after 34 weeks' gestation. Our results demonstrate that despite close surveillance, the unexpected intrauterine death rate in uncomplicated MCDA twin pregnancies is high. This rate seems to increase after 34 weeks' gestation, suggesting that a policy of elective preterm delivery warrants evaluation.     

双胎之一胎儿宫内死亡原因及处理19例临床分析

目的 :探讨双胎妊娠中一个胎儿宫内死亡的原因及处理。方法 :回顾性分析 1995～ 2 0 0 0年我院收治的 19例双胎之一胎儿宫内死亡的原因及妊娠结局。结果 :5例 <2 8周者 4例放弃胎儿作引产术 ,1例孕 2 6周及 7例 2 8～ 34周从确诊一个胎儿死亡后继续保胎到存活儿分娩 ,平均延长 6周 ,5例 >34周者确诊后随即行剖宫产 ,此 13例新生儿均存活。另 2例足月但未及时处理 ,活胎死亡。死亡主要原因 :脐带因素 2例、帆状胎盘 3例 ,胎儿畸形 2例 ,原因不明 12例。妊娠并发症比例较高占 6 3.16 %。结论 :孕周 <2 8周者一般作终止妊娠处理 ;妊娠 2 8～ 34周存活的胎儿继续妊娠到孕 34周预后良好 ;对孕 34周以后发现的应及时终止妊娠抢救存活儿