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Fetal Brain Injury in Survivors of Twin Pregnancies Complicated by Demise of One Twin: A Review

  • Fiona L. Mackie (a1) (a2), R. Katie Morris (a1) (a2) and Mark. D. Kilby (a1) (a2)

Abstract

Perinatal mortality is increased considerably in multiple pregnancies compared to singleton pregnancies, with single intrauterine fetal demise (sIUFD) presenting a rare but unique perinatal problem. Monochorionic pregnancies are at particular risk of sIUFD due to bidirectional inter-twin placental vascular anastomoses. The resulting inter-twin blood flow can become unbalanced, causing acute and chronic inter-twin transfusion and profound anemia secondary to fetal exsanguination into the low-pressure circulation of the dead fetus. If the sIUFD occurs after 14 weeks’ gestation it is believed to have the most significant effect on the continuing pregnancy as the co-twin is at increased risk of preterm delivery, long-term neurological complications, and death. This article will focus on fetal brain injury in the surviving co-twin in the case of sIUFD, as it is the most common kind of injury in sIUFD, and one which concerns parents and may be the basis for terminating the pregnancy. We will outline how these brain injuries are thought to occur and describe potential pathophysiological mechanisms. We will discuss risk factors for brain injury in cases of sIUFD, including: chorionicity, cause of the sIUFD (spontaneous or secondary to an underlying pathological process such as twin-to-twin transfusion syndrome), gestation of delivery and how to prevent brain injury in the co-twin. We also review modes of imaging, discuss the difficulties in predicting the long-term outcome for co-twin survivors, and highlight the dearth of research in this area.

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Copyright

Corresponding author

Address for correspondence: Dr Fiona L. Mackie, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK. E-mail: fionamackie@doctors.org.uk

References

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Barigye, O., Pasquini, L., Galea, P., Chambers, H., Chappell, L., & Fisk, N. M. (2005). High risk of unexpected late fetal death in monochorionic twins despite intensive ultrasound surveillance: A cohort study. PLoS Medicine, 2, e172.
D'Alton, M., Newton, E. R., & Cetrulo, C. l. (1984). Intrauterine fetal demise in multiple gestation. Acta Genetica Medici Gemellologica (Roma), 33, 4349.
de Laveaucoupet, J., Audibert, F., Guis, F., Rambaud, C., Suarez, B., Boithias-Guérot, C., & Musset, D. (2001). Fetal magnetic resonance imaging (MRI) of ischemic brain injury. Prenatal Diagnosis, 21, 729736.
Griffiths, P. D., Sharrack, S., Chan, K. L., Bamfo, J., Williams, F., & Kilby, M. D. (2015). Fetal brain injury in survivors of twin pregnancies complicated by demise of one twin as assessed by in utero MR imaging. Prenatal Diagnosis, 35, 583591.
Hillman, S., Morris, R. K., & Kilby, M. (2011). Co-twin prognosis after single fetal death: A systematic review and meta-analysis. Obstetrics & Gynecology, 118, 928940.
Hillman, S., Morris, R. K., & Kilby, M. D. (2010). Single twin demise: Consequence for survivors. Seminars in Fetal and Neonatal Medicine, 15, 319326.
Hoffmann, C., Weisz, B., Yinon, Y., Hogen, L., Gindes, L., Shrim, A., . . . Lipitz, S. (2013). Diffusion MRI findings in monochorionic twin pregnancies after intrauterine fetal death. American Journal of Neuroradiology, 34, 212216.
Kilby, M., Govind, A., & O'Brien, P. M. (1994). Outcome of twin pregnancies complicated by a single intrauterine death: A comparison with viable twin pregnancies. Obstetrics & Gynecology, 84, 107109.
Kline-Fath, B. M., Calvo-Garcia, M. A., O'Haran, S. M., Crombleholme, T. M., & Racadio, J.M. (2007). Twin-twin transfusion syndrome: Cerebral ischemia is not the only fetal MR imaging finding. Pediatric Radiology, 37, 4756.
Lewi, L., & Deprest, J. (2005). Fetal problems in multiple pregnancy. In James, D., Steer, P., & Weiner, C. (Eds.), High risk pregnancy management options (pp. 539–539). London: Saunders Elsevier.
Lewi, L., Deprest, J., & Hecher, K. (2013). The vascular anastomoses in monochorionic twin pregnancies and their clinical consequences. American Journal of Obstetrics & Gynecology, 208, 1930.
Lewi, L., Gucciardo, L., Van Mieghem, T., de Koninck, P., Beck, V., Medek, H., . . . Deprest, J. (2010). Monochorionic diamniotic twin pregnancies: Natural history and risk stratification. Fetal Diagnosis and Therapy, 27, 121133.
Merhar, S., Kline-Fath, B. M., Meinzen-Derr, J., Schibler, K. R., & Leach, J. L. (2013). Fetal and postnatal brain MRI in premature infants with twin-twin transfusion syndrome. Journal of Perinatology, 33, 112118.
Murphy, K. (1995). Intrauterine death in a twin: Implications for the survivor. In Ward, R. & Whittle, M. (Eds.), Multiple pregnancy (pp. 218230). London: RCOG Press.
National Institute Health and Care Excellence (NICE). (2015). Preterm labour and birth (NG25). London: National Institute Health and Care Excellence.
O'Donoghue, K., Rutherford, M. A., Engineer, N., Wimalasundera, R. C., Cowan, F. M., & Fisk, N. M. (2009). Transfusional fetal complications after single intrauterine death in monochorionic multiple pregnancy are reduced but not prevented by vascular occlusion. BJOG, 116, 804812.
Ong, S., Zamora, J., Khan, K., & Kilby, M. D. (2006). Single twin demise: Consequences to the survivor. In Kilby, M., Baker, P., & Critchley, H. (Eds.), Multiple pregnancy (pp. 149165). London: RCOG Press.
Pharoah, P., & Adi, Y. (2000). Consequences of in-utero death in a twin pregnancy. Lancet, 355, 15971602.
Righini, A., Salmona, S., Bianchini, E., Zirpoli, S., Moschetta, M., Kustermann, A., . . . Triulzi, F. (2004). Prenatal magnetic resonance imaging evaluation of ischemic brain lesions in the survivors of monochorionic twin pregnancies: Report of 3 cases. Journal of Computer Assisted Tomography, 28, 8792.
Roberts, D. (2010). Antenatal corticosteroids to reduce neonatal morbidity (Green-top Guideline No. 7). London: RCOG.
Rossi, A., Vanderbilt, D., & Chmait, R. H. (2011). Neurodevelopmental outcomes after laser therapy for twin–twin transfusion syndrome. Obstetrics & Gynecology, 118, 11451150.
Santema, J., Swaak, A. M., & Wallenberg, H. C. S. (1995). Expectant management of twin pregnancy with single fetal death. British Journal of Obstetrics & Gynecology, 102, 2630.
Senat, M. V., Deprest, J., Boulvain, M., Paupe, A., Winer, N., & Ville, Y. (2004). Endoscopic laser surgery versus serial amnioreduction for severe twin-to-twin transfusion syndrome. New England Journal of Medicine, 351, 136144.
Senat, M. V., Loizeau, S., Couderc, S., Bernard, J. P., & Ville, Y. (2003). The value of middle cerebral artery peak systolic velocity in the diagnosis of fetal anemia after intrauterine death of one monochorionic twin. American Journal of Obstetrics & Gynecology, 189, 13201324.
Shek, N. W. M., Hillman, S. C., & Kilby, M. D. (2014). Single-twin demise: Pregnancy outcome. Best Practice & Research Clinical Obstetrics & Gynaecology, 28, 249263.
Simonazzi, G., Segata, M., Ghi, T., Sandri, F., Ancora, G., Bernardi, B., . . . Pilu, G. (2006). Accurate neurosonographic prediction of brain injury in the surviving fetus after the death of a monochorionic cotwin. Ultrasound in Obstetrics and Gynecology, 27, 517521.
Spruijt, M., Steggerda, S., Rath, M., van Zwet, E., Oepkes, D., Walther, F., & Lopriore, E. (2012). Cerebral injury in twin-twin transfusion syndrome treated with fetoscopic laser surgery. Obstetrics & Gynecology, 120, 1520.
van Klink, J. M. M., van Steenis, A., Steggerda, S. J., Genova, L., Sueters, M., Oepkes, D., & Lopriore, E. (2015). Single fetal demise in monochorionic pregnancies: Incidence and patterns of cerebral injury. Ultrasound in Obstetrics and Gynecology, 45, 294300.

Keywords

Fetal Brain Injury in Survivors of Twin Pregnancies Complicated by Demise of One Twin: A Review

  • Fiona L. Mackie (a1) (a2), R. Katie Morris (a1) (a2) and Mark. D. Kilby (a1) (a2)

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