Assessment of Intrauterine Death
  of One Twin


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    Fetal loss of a twin during first trimester is not an uncommon event [1]. Loss of one twin in the first trimester does not appear to impair the development of the surviving twin. However, fetal death occurring after midgestation (17 weeks' gestation) may increase the risk of IUGR, preterm labor, preeclampsia and perinatal mortality [2,3]. Consequently, serial assessments of fetal growth and well-being should be considered.

    Maternal coagulopathy following twin demise appears to be uncommon [3, 4]. However, coagulopathy has been reported to occur up to 3 weeks following fetal demise [5]. Therefore, when fetal demise occurs in multiple gestation after the first trimester an initial maternal clotting profile with reassessment in two to three weeks is not unreasonable.  Monitoring of maternal coagulation factors is not necessary when fetal loss occurs prior to 13 weeks' gestation [12].

    When fetal demise occurs after midgestation there is a 17% chance that the "surviving twin" in a monochorionic gestation will either die or suffer major morbidity [6]. Morbidity and mortality approach 50% when twin-to twin transfusion is present [7]. Major morbidity is unlikely to occur in the surviving twin of a dichorionic gestation [6, 8]. Antenatal necrosis of the cerebral white matter has been associated with the presence of intrauterine fetal death of a co-twin , artery-to-artery, and vein-to-vein anastomosis. However, vein-to-vein anastomosis has the strongest association with antenatal necrosis of the cerebral white matter in affected twin pregnancies [9]. DNA zygosity studies may be used to assess the risk to the normal twin in the event of the co-twin's demise [10].

    Prompt delivery following the death of a co-twin has not been shown to prevent preexisting neurological injury or injury that occurred at the time of the co-twin’s death. Delivery for the purpose of preventing injury should, therefore, be weighed against the risks of premature delivery.  [11]. In known monozygotic twins with impending death preterm delivery may be considered to prevent neurological injury. However, the risks of neurological injury should be weighed against the risks associated with premature delivery.


    1. Varma TR. Ultrasound evidence of early pregnancy failure in patients with multiple conceptions. Br J Obstet Gynaecol. 1979 ;86:290-2. MEDLINE
    2. Prompeler HJ, et al.. Twin pregnancies with single fetal death. Acta Obstet Gynecol Scand. 1994 73:205-8. MEDLINE
    3. Axt R, et al.  Maternal and neonatal outcome of twin pregnancies complicated by single fetal death. J Perinat Med. 1999;27:221-7. MEDLINE
    4. Petersen IR, Nyholm HC. Multiple pregnancies with single intrauterine demise. Description of twenty-eight pregnancies.Acta Obstet Gynecol Scand. 1999;78:202-6. MEDLINE
    5. Romero R, et al: Prolongation of a preterm pregnancy complicated by death of a single twin in utero and disseminated intravascular coagulation. N Engl J Med 310:772, 1984. MEDLINE
    6. Carlson NJ, Towers CV: Multiple gestation complicated by the death of one fetus. Obstet Gynecol 73:685, 1989. MEDLINE
    7. van Heteren CF, et al.. Risk for surviving twin after fetal death of co-twin in twin-twin transfusion syndrome. Obstet Gynecol. 1998;92:215-9. PMID: MEDLINE
    8. Saito K, et al. . Perinatal outcome and management of single fetal death in twin pregnancy: a case series and review. J Perinat Med. 1999;27:473-7. MEDLINE
    9. Bejar R, et al, . Antenatal origin of neurologic damage in newborn infants. II. Multiple gestations. Am J Obstet Gynecol. 1990;162:1230-6. MEDLINE
    10. Norton ME, et al. . Molecular zygosity studies aid in the management of discordant multiple gestations. J Perinatol. 1997;17:202-7. MEDLINE
    11. D'Alton ME, et al. Intrauterine fetal demise in multiple gestation. Acta Genet Med Gemellol (Roma). 1984;33:43-9. MEDLINE
    12. Usha Chitkara and Richard L. Berkowitz : Multiple Gestations. In: Gabbe ed: Obstetrics - Normal and Problem Pregnancies, 4th ed New York, NY, Churchill Livingstone; 2002: p848

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    Created: 2/21/2004
    Last Update: 2/21/2004