Смерть одного из плодов двойни. Тактика ведения беременности?

[dr_medvedev]

У кого есть опыт ведения таких беременных?

[dr_medvedev]

Human Reproduction, Vol. 14, No. 8, 2124-2130, August 1999
© 1999 European Society of Human Reproduction and Embryology

Outcome of twin pregnancies complicated by single intrauterine death in relation to vascular anatomy of the monochorionic placenta
Rekha Bajoria1, Ling Y. Wee, Shaheen Anwar and Stuart Ward

University of Manchester, St Mary's Hospital, Department of Obstetrics & Gynaecology, Whitworth Park, Manchester M13 OJH, UK

The objective of this study was to determine the relationship between the type of placentation, vascular anatomy of the monochorionic (MC) placenta and the perinatal outcome of the surviving twin following a single intrauterine fetal death (IUFD). In this retrospective study, 92 twin pregnancies complicated by a single intrauterine death were identified from three tertiary referral centres [50 MC and 42 dichorionic (DC)]. Antenatal and neonatal data as well as information on the chorionicity, vascular anastomoses, and autopsy findings were also obtained. The percentage risk of IUFD (26 versus 2.4; P < 0.001), anaemia (51.4 versus 0; P < 0.001) and intracranial lesions at birth (46 versus 0; P < 0.001) was greater in MC than in DC twins. In MC twins without twin–twin transfusion syndrome (TTTS), perinatal mortality was higher in the group with superficial arterioarterial (AA)/venovenous (VV) channels than those with only multiple bidirectional arteriovenous (AV) anastomoses (12/15 versus 0/8; P < 0.001). However, in the TTTS pregnancies (n = 26), perinatal outcome of the surviving twin was dependent on whether the recipient (n = 16) or the donor twin (n = 10) died first. Incidence of IUFD (9/16 versus 0/10; P < 0.001), severe anaemia (7/7 versus 1/10; P < 0.001) and intracranial lesions at birth (6/7 versus 2/10; P < 0.001) was common in pregnancies where the recipient twin died first. In the TTTS group, unidirectional AV anastomotic channels were found in all but two placentae. In conclusion, this study suggests that the outcome of twin pregnancies complicated by IUFD is dependent on the type of vascular anastomoses and TTTS.

[dr_medvedev]

Human Reproduction, Vol. 15, No. 7, 1632-1636, July 2000
© 2000 European Society of Human Reproduction and Embryology

Doppler detection of arterio-arterial anastomoses in monochorionic twins: feasibility and clinical application
M.J.O. Taylor1,3, M.L. Denbow1, S. Tanawattanacharoen1, C. Gannon2, P.M. Cox2 and N.M. Fisk1

1 Centre for Fetal Care, Department of Materno-Fetal Medicine and 2 Department of Perinatal Pathology, Imperial College School of Medicine, Queen Charlotte's & Chelsea Hospital, Goldhawk Road, London W6 0XG, UK

The accuracy of in-vivo detection of arterio-arterial anastomoses (AAA) in monochorionic (MC) twins and its predictive value for twin–twin transfusion syndrome (TTTS) was assessed in 105 consecutive MC twins scanned at fortnightly intervals. AAA were sought using spectral and colour energy Doppler and ultrasound findings were compared with placental injection studies. AAA were identified in vivo in 59 (56%) pregnancies and at injection study in 68 (65%). The overall sensitivity and specificity was 85 and 97.3% respectively for the detection of AAA. Detection rates were higher at later gestations, with anterior placentae and with larger diameter AAA. The median insonation time to detect an AAA was 10 min (range 1–30). Where an AAA was identified, 15% of pregnancies (nine of 59) developed TTTS compared to 61% (28 of 46) when no AAA was seen (odds ratio 8.6). We conclude that AAA can be detected in vivo with high sensitivity and specificity without undue prolongation of scanning times and have a role in risk stratification in the antenatal assessment of MC twins.

Key words: arterio-arterial anastomoses/Doppler/monochorionic twins/twin-twin transfusion

3 To whom correspondence should be addressed at: Centre for Fetal Care, Department of Materno-Fetal Medicine, Imperial College School of Medicine, Queen Charlotte's & Chelsea Hospital, Goldhawk Road, London W6 0XG, UK. E-mail: [Ссылки доступны только зарегистрированным пользователям ]

[dr_medvedev]

Archives of Disease in Childhood Fetal and Neonatal Edition 2002;86:F9-F15
© 2002 Archives of Disease in Childhood Fetal and Neonatal Edition

ORIGINAL ARTICLE
Fetal or infant death in twin pregnancy: neurodevelopmental consequence for the survivor
S V Glinianaia1, P O D Pharoah1, C Wright2 and J M Rankin1 On Behalf Of The Northern Region Perinatal Mortality Survey Steering

1 Department of Epidemiology and Public Health, and Regional Maternity Survey Office, University of Newcastle, Newcastle upon Tyne NE2 4HH, UK
2 Department of Pathology and Regional Maternity Survey Office, 25 Claremont Place, Newcastle upon Tyne NE2 4AA, UK

Correspondence to:
Dr Glinianaia, Department of Epidemiology and Public Health, School of Health Sciences, The Medical School, University of Newcastle, Framlington Place, Newcastle upon Tyne NE2 4HH, UK;
[Ссылки доступны только зарегистрированным пользователям ]

Aim: To determine the neurodevelopmental morbidity in the surviving twin after fetal or infant death of the co-twin.

Methods: Twin pregnancies with an antepartum or infant death delivered between 1981 and 1992 were identified from the Northern Perinatal Mortality Survey. Information on the neurodevelopmental morbidity of infant survivors of a deceased co-twin was obtained by a questionnaire sent to the community paediatrician or general practitioner.

Results: A total of 111 children who survived infancy after the fetal death of the co-twin (group 1) and 142 from liveborn twin pairs in which one twin died in infancy (group 2) were traced. Responses were received from 97 (87%) and 130 (92%) respectively. In group 1, the cerebral palsy prevalence was 93 (95% confidence interval (CI) 43 to 169) per 1000 infant survivors; it was more common in like-sex pairs (8/70) with a prevalence of 114 (95% CI 51 to 213) compared with 45 (95% CI 1 to 228) per 1000 infant survivors in unlike-sex pairs (1/22). The overall prevalence of neurodevelopmental morbidity (including developmental delay) was 175 (95% CI 106 to 266) per 1000. In group 2, the cerebral palsy prevalence was 154 (95% CI 84 to 223) per 1000 infant survivors in like-sex (16/104) and 77 (95% CI 9 to 251) in unlike-sex (2/26) survivors; the overall prevalence of neurodevelopmental morbidity was 246 (95% CI 172 to 320) per 1000.

Conclusions: The risk of cerebral palsy is increased in the surviving twin after a fetal or infant co-twin death compared with the general twin population. Like-sex twins are at greater risk than unlike-sex. The probable cause, in addition to the consequences of prematurity, is twin-twin transfusion problems associated with monochorionicity.

[dr_medvedev]

Arch Dis Child Fetal Neonatal Ed 1999;80:F217-F220 ( May )

Fetal and infant death in mono- and dizygotic twins in England and Wales 1982-91
C R West, Y Adi, P O D Pharoah

Foundation for the Study of Infant Deaths, Unit of Perinatal and Paediatric Epidemiology, Department of Public Health, University of Liverpool, Liverpool L69 3GB


Correspondence to: Emeritus Professor POD Pharoah.

Accepted 26 November 1998

AIMTo quantify the level of risk for stillbirth and infant death in singleton compared with twin pregnancies, using national data; to determine the independent effects of zygosity, sex, and birthweight on these risks in twin pregnancies.
METHODSA retrospective national study was carried out of all singleton and twin birth and death registrations in England and Wales 1982-91, according to sex and birthweight group. Weinberg's rule was applied to the twin pairs to differentiate mono- from dizygotic twins. Relative risks for mono- compared with dizygous twins for both twins being stillbirths and for one of the pair being a stillbirth were determined. For twins where one was stillborn and the other live born, the relative risk of neonatal and infant mortality in the surviving co-twin was determined.
RESULTSThere were 6 563 834 registered singletons and 70772 registered twin pairs for the period under study. Monozygotic twins had a relative risk of: 18.91 (95% CI 12.48-28.64) for both twins being stillborn; 1.63 (95% CI 1.48-1.79) for one twin being a stillbirth; and 2.26 (95% CI 1.45-3.52) for the live born co-twin dying as a neonate. When both twins were live born and among singletons, the odds ratio for neonatal mortality of being male was 1.41 (95% CI 1.37-1.45) and there was a highly significant negative association with birthweight. After adjusting for birthweight group and sex, twins had a reduced neonatal mortality compared with singletons: odds ratio 0.91 (95% CI 0.85-0.96).
CONCLUSIONSFetal death in one of monozygotic twins has serious implications for survival of the co-twin. Monochorionicity is probably the essential feature of the increased risk to the co-twin. It is imperative that all fetal deaths in multiple pregnancies are recorded and chorionicity determined if parents are to be adequately counselled.
(Arch Dis Child Fetal Neonatal Ed 1999;80:217-220)

[dr_medvedev]

Obstetrics & Gynecology 2002;99:698-703
© 2002 by The American College of Obstetricians and Gynecologists

Survival of Other Fetuses After a Fetal Death in Twin or Triplet Pregnancies
Courtney D. Johnson, MPH and Jun Zhang, PhD, MD

From the Epidemiology Branch, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland.

Address reprint requests to: Jun Zhang, PhD, MD, National Institutes of Health, National Institute of Child Health and Human Development, Epidemiology Branch, Building 6100, Room 7B03, Bethesda, MD 20892-7510; E-mail: [Ссылки доступны только зарегистрированным пользователям ].

OBJECTIVE: To estimate the frequency of fetal death in multifetal pregnancies and the probability of survival to age 1 year for twins or triplets in which at least one fetal death occurred at 20 weeks’ gestation or more.

METHODS: We used the Matched Multiple Birth File from the US National Center for Health Statistics, which included 152,233 sets of twins and 5356 sets of triplets registered from 1995 to 1997. The Cox proportional hazards model was used to estimate the adjusted relative risk of death before age 1 year for remaining twins and triplets.

RESULTS: Fetal death at 20 weeks’ gestation or later was uncommon, occurring in 2.6% of twin and 4.3% of triplet gestations. After adjustment for confounders, the survival of the remaining fetuses was inversely related to the time of the first fetal demise. Same-sex twins were two times more likely than opposite-sex twins to die after an intrauterine demise at 25–32 weeks’ gestation and were more than three times more likely to die after a death at 33 weeks’ gestation or more.

CONCLUSION: After a fetal death in a multifetal pregnancy at 20 weeks’ gestation or later, the survival of the remaining fetuses is inversely related to the time the death occurred. Among twins, survival also depends on sex concordance, with opposite-sex twins more likely than same-sex twins to survive.

[azerin]

такой опыт есть в отделении невынашивания беременности в центре Акушерства и гинекологии.под руководством Сидельниковой В.М.
был один случай: Двойня после эко.гибель одного плода в сроке 23-24 недели..вторую девочку доносили и родили.

[DENVER]

Не могу утверждать, что опыт большой, но такие случаи встречались. Многоплодная беременность - это такая загадочная штука, что при ней не наступают такие грозные процессы как при одноплодной беременности с антенатальной гибелью плода. Тут сама природа идёт на встречу и даёт возможность выносить второй плод. А ведение, это: динамическое наблюдение, КТГ, УЗС, антибактериальная терапия 5-6 дней и профилактика всего всего. Ведение конечно в условиях стационара. Как правило второй плод доншивается до срока родов, а погибший рождается мумифицированным. Всё зависит от времени прошедшего со дня гибели первого плода до родов.

[silver]

Сообщение от dr_medvedev

У кого есть опыт ведения таких беременных?

ВИДЕЛ 1 РАЗ
ОДНАКО ЧИТАЛ -ВОТ ССЫЛКА НА БАЗОВЫЙ УЧЕБНИК PAGE 790-792 MULTIFETAL PREGNANCY WILLIAMS OBSTETRICS 21ED
2001

[prozektor]

Видела 1 раз. Двойня после ЭКО, редукция эмбриона с множ пороками в 16 нед. Антибиотикопрофилактика в течении 10 дней, родоразрешение путем КС в сроке 37 нед, редуцированный эмбрион выглядел как мешочек со слизью, никакой мумификации. Исход операции без осложнений.

[sibiriachka]

Видела 1 раз. СИтуация похожа. Двойня (спонтанная) у возрастной 1родящей. Гибель 1эмбриона в сроке около 11 недель, в связи с генетич пороками (трисомия 18, если не ошибаюсь). Самопроизвольные роды в срок, б/о. Мумифицированный Э.