Management Of Monoamniotic Twins Research Articles

Prenatal diagnosis and management of monoamniotic twins.

The purpose of this article is to investigate the perinatal outcomes of monoamniotic twins under current standards of prenatal management involving intensive fetal surveillance. The incidence of perinatal mortality in monoamniotic twins has fallen over the last 2 decades. Umbilical cord entanglement has long been considered one of the main causes of poor outcome among monoamniotic twins; however, new evidence shows that it appears to be less important than prematurity and congenital anomalies. If intensive fetal surveillance is provided, the risk of perinatal mortality is acceptably low regardless of setting. In uncomplicated monoamniotic twin pregnancies, delivery at around 33 weeks of gestation might reduce the risk of neonatal adverse events without increasing the risk of perinatal death. Perinatal outcome in monoamniotic twins improved if intensive fetal surveillance was performed under either outpatient or inpatient management. Planned delivery in uncomplicated monoamniotic twin pregnancies can be considered at around 33 weeks of gestation.

Management of monoamniotic twins at district general hospital

Monoamniotic twins occur in approximately in 1% of monozygotic twins. The reported incidence varies from 1:1650- 1:93734 live births. Perinatal mortality of twin pregnancy is high, ranging from 28%-70%. The...

Current antenatal management of monoamniotic twins: a survey of maternal-fetal medicine specialists

Objective: To assess current management of monoamniotic (MA) twins by US maternal-fetal medicine providers. Methods: We conducted a mailed survey to members of the Society for Maternal-Fetal Medicine regarding fetal surveillance practices and preferred gestational age (GA) for elective delivery with respect to MA twins. Results: Responses from 837 (43%) were received with most (83.9%) recommending elective admission for inpatient monitoring, 53.5% favoring 26–28 weeks as earliest GA for admission and 75% performing intermittent fetal monitoring (of these 81% monitored 2–3 times/day). Respondents in practice less than 10 years were less likely to use outpatient management (p < 0.05). Median GA for elective delivery was 34 weeks but was higher for those who favored outpatient management, admitted >28 weeks, and were private practitioners (p < 0.05). Conclusions: Despite a paucity of evidence, most practitioners admit MA to perform daily intermittent fetal monitoring and deliver at 34 weeks. Antenatal management protocols may also influence timing of delivery. Due to their rarity, a national registry may be a better tool to analyze the outcomes of these pregnancies.

35: Monoamniotic twin pregnancy: continuous inpatient electronic fetal monitoring (CIEFM)- an impossible goal?

To determine the feasibility and utility of CIEFM in monoamniotic twin pregnancies. A retrospective cohort study of monoamniotic twins delivered at a single institution from 2000 to 2009 was performed. All subjects were hospitalized, received CIEFM, and planned to deliver electively via cesarean section at 34 weeks gestational age (GA). The entire electronic fetal heart tracing was reviewed for each patient and the percentage of time that 0, 1, and 2 fetuses were successfully monitored was recorded. Each subject′s hospitalization was stratified by gestational age (<27 weeks, 27-30 weeks, and >30 weeks) and the percentage of time of successful monitoring was compared across gestational age. 17 twin pairs were studied. Admission for CIEFM was at 27 +/− 3 weeks GA (mean +/− SD). A total of 10, 402 hours of CIEFM recordings were analyzed. Average length of stay was 31.7 +/− 15.6 days (mean +/− SD). Successful monitoring of both fetuses occurred 50.4% +/− 14.5% of the time of total hospitalization. Increasing GA was associated with a significant increase in the percentage of time that both fetuses were monitored (38.2% at <27 weeks; 50.2% at 27-30 weeks; 55.8% at>30 weeks; p<0.01). 7/17 (40%) subjects were delivered emergently <34 weeks GA for non-reassuring CIEFM. GA at delivery in this group was 31.5 +/− 2 weeks GA. 5/17 (30%) went into labor <34 weeks GA; and 5/17 (30%) were delivered as planned at 34 weeks GA. All patients delivered via cesarean section. There were no fetal deaths in our population. Successful CIEFM improves with increasing GA. CIEFM is attainable 50% of the time. Despite this finding, non-reassuring CIEFM precipitated delivery in 40% of cases. We believe that the limitations of CIEFM do not negate its role in the management of monoamniotic twins, but invite further research in optimal strategies for intermittent inpatient EFM.

Inpatient versus Outpatient Management of Monoamniotic Twins and Outcomes

A recent literature review holds that approximately one in 10 cases of monoamniotic twinning ends with perinatal death. An entangled umbilical cord may be fatal and is not a predictable complication. This multicenter retrospective records review was undertaken to learn whether outcomes might be improved by hospitalization when monoamniotic twins are at 24 to 28 weeks gestation and close fetal surveillance is maintained until delivery at 32 to 34 weeks. Review of a recent 10-year period at 4 centers totaling approximately 15,000 deliveries annually yielded 23 sets of monoamniotic twins, 11 managed as inpatients and 12 given outpatient care. Women in the inpatient group had continuous external fetal monitoring and underwent ultrasound (to monitor fetal growth) and Doppler flow studies at 4-week intervals. Outpatient management included nonstress testing or biophysical profiling at least 3 times a week. There were no fetal deaths in the inpatient group, but 3 such deaths occurred with outpatient management. Inpatients had gestational ages of 30 to 36 weeks when delivered. There were 7 elective operative deliveries in the inpatient group, and 4 sections were done because of a nonreassuring fetal heart tracing. Eleven infants had respiratory distress syndrome; 3, intraventricular hemorrhage; 3, anomalies; and one, sepsis. Two infants were apparently free of complications. In the outpatient group, gestational ages at delivery ranged from 27 to 34 weeks. Three cesarean sections were done electively and 6 others because of a nonreassuring fetal heart tracing. There were 2 cases each of preterm labor and intrauterine fetal demise and one each of severe preeclampsia, increased liver enzymes, and abruption. Sixteen infants in this group had respiratory distress syndrome, 4 had sepsis, and one each had intraventricular hemorrhage and atrial septal defect. Three infants each had patent ductus arteriosis and retinopathy of prematurity, whereas 4 were free of complications. It is not likely that a randomized trial comparing inpatient with outpatient management of monoamniotic twin pregnancies will prove feasible. Pending such a study, the investigators propose that inpatient management be considered.

Antenatal Diagnosis and Management of Monoamniotic Twins

Antenatal Diagnosis and Management of Monoamniotic Twins

Antenatal diagnosis and management of monoamniotic twins

Double survival of monoamniotic twins is rare. Three consecutive cases in which double survival occurred are presented. Accurate antenatal diagnosis, intensive fetal surveillance, and operative delivery should improve neonatal outcome.