Monoamniotic Twin Pregnancy Research Articles

Outcomes of monoamniotic twin pregnancies managed primarily in outpatient care-a Danish multicenter study.

Monoamniotic twin pregnancies are high-risk pregnancies, and management by inpatient or frequent outpatient care is recommended. We report the outcomes of a national cohort of monoamniotic twin pregnancies managed primarily as outpatients. We prospectively analyzed the recorded data from the Danish Fetal Medicine Database, local databases, and medical records of all monoamniotic twin pregnancies diagnosed at the first trimester scan or later, and managed at the six major fetal medicine centers in Denmark over a 10-year period. Sixty-one monoamniotic twin pregnancies were included. Thirteen pregnancies were terminated early. Of the remaining 48 pregnancies with a normal first trimester scan, there were 36 fetal losses (25 spontaneous miscarriages <22+0 weeks, 3 late terminations and 8 intrauterine deaths >22weeks) and 60 liveborn children (62.5%), all of whom were delivered by cesarean delivery at a median gestational age of 33+0 weeks. Three children had minor malformations and there was 1 pregnancy with twin-to-twin transfusion syndrome. After 26+0 weeks, 78.8% were managed as outpatients. Intrauterine death occurred in 3.8% of outpatients and in 28.6% of inpatients (admitted due to complications). At weeks 32, 33 and 34, the prospective risk of intrauterine death was 6.9%, 4.2% and 5.9%, respectively. In this nationwide, unselected population, only 62.5% of fetuses with a normal first trimester scan were born alive. In contrast, the mortality was 3.8% after 26weeks among the 78.8% of the cohort that was managed as outpatients. More knowledge is still needed to predict which pregnancies are at the highest risk of intrauterine death.

OC18.04: Short‐term and long‐term neurodevelopmental outcome of monochorionic monoamniotic twin pregnancy

OC18.04: Short‐term and long‐term neurodevelopmental outcome of monochorionic monoamniotic twin pregnancy

Siamese twin pregnancy in peritoneal dialysis : first case in the world

Introduction: The probability of conception is low in peritoneal dialysis (PD), and the probability of successful pregnancy is even lower. Nearly 60 years after the first reported case of successful pregnancy in a dialysis patient, many questions about pregnancy during dialysis remain unresolved, namely the required dialysis dose, the follow-up rhythm, the choice of the the most appropriate dialysis technique.&#x0D; Case report: We report the first case worldwide of twin Siamese pregnancy in a patient on continuous ambulatory peritoneal dialysis (CAPD). The pregnancy was diagnosed at 7 weeks of amenorrhea (WA). The patient was initially under 2 exchanges per day, with 2-liter bags of Dianealof 1.36% glucose. As soon as the pregnancy was discovered, the prescription was modified, putting the patient under 3 exchanges a day with the same concentrates. The infusion volume was maintained at 2 liters up to 18 WA , and then reduced to 1.5 liters due to patient discomfort and abdominal hyperpressure. Daily ultrafiltration ranged from 180 to 800 ml with 1 liter diuresis. The blood pressure was well controlled, with an average of 125/80 mmHg, without need of antihypertensive drugs. On a biological level, the Kt / V was 2.2, nPCR was 0.8, and the weekly clearance was 80 L / 1.73 m². The average hemoglobin was 11.5 g / dl under erythropoietin 9000 units per week. At 20 WA, obstetrical ultrasound revealed a mono-chorionic, mono-amniotic twin pregnancy. Due to high maternal and fetal risks, closer obstetrical control was indicated. At 24 WA, morphological obstetrical ultrasound coupled with Doppler examination of the uterine and umbilical arteries favored the diagnosis of mono-amniotic mono-chorionic twin pregnancy with strong suspicion of Siamese contiguous to the pelvis, with a cerebral malformation in one of the fetuses. The patient experienced intense contractions and pelvic pain leading to an emergency cesarean section with two surviving Siamese twins, contiguous to the pelvis, weighing 900g, but who died one day after delivery.&#x0D; Conclusion: Pregnancy during dialysis is at high maternal and fetal risks. It is necessary to prepare and follow this pregnancy to optimize the chances of success. This implies an adaptation of the medical treatment and dialysis prescription, including the volume and modality of exchanges. The same holds true for gynecological and obstetrical follow-up, which must be regular and strict, in order to prevent any maternal-fetal complications.

Incidental Septostomy after Laser Surgery for Twin-Twin Transfusion Syndrome: Perinatal Outcomes and Antenatal Management

Introduction: Incidental septostomy, or inadvertent perforation of the twins’ dividing membranes, can create a functional monoamniotic twin pregnancy. Our aim was to describe the perinatal outcomes and antenatal management of patients with incidental septostomy after laser surgery for twin-twin transfusion syndrome (TTTS). Materials and Methods: Monochorionic diamniotic multiple gestations with a gestational age (GA) between 16 and 26 weeks that underwent laser surgery from March 2006 to December 2015 were studied retrospectively. Perinatal outcomes were compared for patients with and without an incidental septostomy. A subgroup analysis was performed to evaluate antenatal management. Results: Of 532 TTTS patients who underwent laser surgery, incidental septostomy occurred in 34 (6.4%). Compared to all others, patients with a septostomy had an earlier median (range) GA at delivery (30.8 [18.6–37.9] vs. 34.0 [19.3–40.4] weeks, p < 0.0001) and lower 30-day survival of at least one twin (85.3 vs. 94.6%, p = 0.0452). We found no evidence that inpatient fetal surveillance was protective. Discussion: Incidental septostomy in TTTS patients treated via laser surgery appeared to be associated with lower GA at delivery and perinatal survival of at least one twin. Further study is required to determine the optimal antenatal surveillance strategy.

A case report of twin reversed arterial perfusion sequence with expectant management

Acardiac twin or TRAP (twin reversed arterial perfusion) sequence is a rare complication of monochorionic pregnancies. In these cases, the heart is either absent or non-functional. It’s controversial whether conservative management or therapeutic treatment is better in TRAP-sequence. In this case, we present a 19-years old, primigravida diagnosed with spontaneous monochorionic monoamniotic twin pregnancy at 7th week of gestation. One of the fetuses had a crown-rump length of 8 mm and fetal heart rate 122/minute while the other one had a crown-rump of 7 mm with no detected fetal heartbeat. At the 11th week of gestation, the acardiac twin continued growing despite the absence of the fetal heart beat and fetal extremities. The cranium could not be evaluated clearly. The diagnosis of TRAP sequence was confirmed by the reversed direction of flow observed in the umbilical artery. Since the patient and her husband did not want any intervention, no interventional diagnostic and treatment modalities were applied. Preterm labor started at the 32th week. Because the presentations were transverse and breech, pump and acardiac fetus, respectively, a cesarean delivery was performed. A healthy female baby, weighing 1650 gr with APGAR scores of 9-10, first and fifth minutes, respectively, was delivered along with the acardiac fetus which was 1550 gram in weight, fetal heart beat negative, with upper and lower extremity deformities. The uniqueness of the present case is that there was no significant difference in the weight of both twins. The acardiac twin was as large as the pump twin. Except for twenty days hospitalization because of neonatal respiratory distress syndrome, which was a consequence of preterm labor, there were no problems with the pump twin even though managed conservatively. In monochorionic twin pregnancies, when one of the twins is found to be fetal heartbeat negative and it continues to grow with concomitant structural abnormalities, the TRAP sequence should come to mind. If the acardiac fetus is small and the pump fetus has no complications, the conservative approach can be considered. Our goal should be to deliver the pump twin with minimal complications. To achieve this, follow-ups and treatment should be individualized for each patient, the pump fetus should be monitored closely.

A case of a surviving co-twin diagnosed with porencephaly and renal hypoplasia after a single intrauterine fetal death at 21 weeks of gestation in a monochorionic monoamniotic twin pregnancy

Monochorionic monoamniotic (MM) twin pregnancy carries a high risk of intrauterine fetal death (IUFD). Single IUFD in an MM twin pregnancy prior to 22 weeks of gestation has been reported to be strongly correlated with double twin demise. To our knowledge, there are no case reports on the natural course of a surviving co-twin in an MM twin pregnancy resulting in live birth after a single IUFD prior to 22 weeks of gestation. Here, we report a case of a surviving co-twin, after a single IUFD at 21 weeks of gestation in a MM twin pregnancy, with an antenatal diagnosis of renal hypoplasia and severe neurological damage leading to porencephaly, and live birth at 36 weeks of gestation.

Twin reversed arterial perfusion syndrome in a monochorionic monoamniotic twin pregnancy.

Yapıcıoğlu-Yıldızdaş H, Ece Ü, Sucu M, Yurdakul G, Şimşek H, Özlü F. Twin reversed arterial perfusion syndrome in a monochorionic monoamniotic twin pregnancy. Turk J Pediatr 2017; 59: 724-727. Twin reversed arterial perfusion syndrome is mostly seen in monochorionic diamniotic twin pregnancies with an estimated incidence of 1/9500-11000 pregnancies. One of the twins is acardiac with various abnormalities especially with upper part of the body, and mortality is 100%. The other twin functions as a pump twin and mostly has polyhydramnios and heart failure; and mortality rate is high due to prematurity and heart failure. Herein we report a TRAP syndrome and the prognosis of pump twin who was born at 30 weeks gestational age.

ISUOG Practice Guidelines: role of ultrasound in twin pregnancy.

ISUOG Practice Guidelines: role of ultrasound in twin pregnancy.

A Monoamniotic Pregnancy Discordant for Limb Body Wall Complex and Complicated by Acute TTTS

We are reporting a case of monoamniotic twin pregnancy discordant for Limb Body Wall Complex (LBWC), complicated by acute twinto-twin transfusion syndrome. The twins were delivered by an emergency cesarean section at 29+6 weeks’ gestation because of persistent fetal tachycardia of the unaffected twin. The phenotipically normal twin was anemic at birth (donor twin), while postmortem examination revealed a condition of overloaded fetal circulation of the LBWC twin (recipient twin). This is, to our knowledge, the first case of acute TTTS in a monoamniotic pregnancy reported in Literature. In monoamniotic pregnancies discordant for LBWC careful fetal monitoring should be granted, as the presence of the malformation masks the classic signs of twin-to-twin transfusion syndrome.

Uterine necrosis and hysterectomy in a postpartum hemorrhage patient who underwent repeated uterine artery embolization

A 19-year-old nulliparous female in the 28th week of her first pregnancy, a monoamniotic monochorial twin pregnancy, was transferred to our hospital after she presented with watery vaginal discharge and lower abdominal pain. Soon after admission to our hospital, the patient was managed conservatively; her condition stabilized without significant clinical events. Approximately 1 month later, she developed vaginal bleeding with fresh blood, suggesting premature membrane rupture requiring emergency cesarean delivery. The estimated blood loss during cesarean delivery was approximately 1000 mL. The patient showed continued vaginal bleeding after cesarean delivery in the operating room. Vital signs and laboratory data were: blood pressure 1⁄4 122/ 73 mmHg, pulse rate 1⁄4 111 times/minute, hemoglobin 1⁄4 8.5 g/dL, and hematocrit 1⁄4 25.3%. The patient was managed by conservative methods including uterine massage, fluid loading, intravenous administration of oxytocin, and vaginal packing. Uterine atony was considered as the cause of postpartum bleeding because the patient had no abnormal findings of the placenta and no particular event occurred during cesarean delivery. Emergency uterine artery embolization (UAE) was performed for massive postpartum hemorrhage (PPH). The anterior divisions of both the right and left internal iliac arteries were embolized using gelfoam particles (Cutanplast, Mascia Brunelli, Milan, Italy). The next morning, massive vaginal bleeding was again evident. The vital signs were blood pressure 1⁄4 80/60 mmHg and pulse rate 1⁄4 125 times/minute. The hemoglobin level was 6.6 g/dL. Emergency UAE was performed once more. A pelvic angiogram showed active bleeding in the

Continued pregnancy and vaginal delivery after 32 weeks of gestation for monoamniotic twins

ObjectiveTo report the outcomes of 38 monoamniotic twin pregnancies managed homogeneously to assess whether continuing the pregnancy past 32 weeks of gestation and vaginal delivery are reasonable options. Study designSingle-centre retrospective study including all monoamniotic pregnancies managed over a 20-year period at Port-Royal Obstetrics Department, Paris, France. MethodsIn the study department, both continuation of the pregnancy up to 36 weeks of gestation and vaginal delivery are allowed for monoamniotic pregnancies in some conditions. Perinatal outcomes are described and then compared according to mode of delivery for patients who gave birth at or after 32 weeks of gestation. ResultsThree of the 38 pregnancies included fetal malformations; in two of these cases, both fetuses died in utero at 26 weeks of gestation. In cases without malformations, one twin died in utero in two women at 28.0 and 29.2 weeks of gestation, and both fetuses died in two other women at 24.0 and 24.5 weeks of gestation. Mean gestational age at delivery was 32.9 weeks (range 24.0–36.3). Five women gave birth between 22 and 26 weeks of gestation, six women gave birth between 27 and 31 weeks of gestation, and 27 women gave birth at or after 32 weeks of gestation (26 after excluding those with fetal malformations). No intrauterine or neonatal deaths were observed at or after 32 weeks of gestation. The 28 infants delivered vaginally did not differ significantly from the 22 infants born by caesarean section in terms of umbilical artery pH or 5-min Apgar scores. ConclusionContinuation of monoamniotic pregnancies beyond 32 weeks of gestation and trial of vaginal delivery are both reasonable options if the parents agree, and optimal surveillance is provided.

EP07.06: Obstetric and perinatal outcomes in monochorionic twin pregnancies conceived by in vitro fertilisation

To investigate obstetric and perinatal outcomes in monochorionic(MC) twin pregnancies conceived by in vitro fertilisation(IVF) or spontaneously. The retrospective cohort study was conducted in 384 women with MC twin pregnancies delivered in Seoul National University Hospital between Jan. 2004 and Dec. 2014. Patients with monoamniotic twin pregnancy and with delayed interval delivery of a second twin were excluded in this study. Patients whose data on the methods for conception and chorionicity were also excluded. Study population was divided into 2 groups according to the methods for conception: IVF versus spontaneous conception (SC). Obstetric and perinatal outcomes were evaluated. This study consisted of 47 twin pregnancies conceived by IVF and 337 twin pregnancies conceived spontaneously. IVF group had a higher median maternal age and higher rate of overweight or obesity than SC group (p < 0.05, for each). The rates of gestational diabetes mellitus (GDM)(OR 2.53, 95% CI 1.03–6.23) and preterm labour (OR 1.88, 95% CI 1.07–3.32) were significantly higher in IVF group than in SC group after adjusting for maternal age and body mass index (p < 0.05, respectively). Other obstetric and perinatal outcomes were not different between the two groups, although congenital anomalies were found more frequently in SC group than in IVF group (p < 0.05). We found that the rates of GDM, preterm labour and congenital anomaly were different in MC twin pregnancies according to the methods for conception. No significant differences in other obstetric and perinatal outcomes were found between both groups.

Managing Monoamniotic Twin Pregnancies

Monoamniotic twins comprise a rare but important subset of twins at risk of unique and serious complications, placing them at the highest risk of perinatal mortality of all twin gestations. In addition to risks faced by all twins (prematurity, selective growth restriction), all monochorionic twins (twin-twin transfusion syndrome), and all monozygotic twins (congenital anomalies), monoamniotic twins face the unique risk of cord entanglement. Accordingly, early diagnosis, screening for fetal anomalies, surveillance for twin-twin transfusion syndrome, decisions related to monitoring after viability, and timing and route of delivery are all critical. Herein, we present recommendations for optimal management.

The psychosocial impact of inpatient management of monoamniotic twin gestations

Objective: Monoamniotic twins require unique considerations in clinical management that challenge both clinicians and patients. The aim of this study was to assess the psychosocial impact of inpatient antepartum versus outpatient management for these patients.Methods: Women with a history of a monoamniotic twin pregnancy between 2002 and 2012 were identified through a social media group and invited to participate in an original survey regarding their clinical management and psychological well-being during gestation. Results between patients managed with inpatient versus outpatient protocols were compared using the Fisher exact test.Results: Participants (n = 197) were multinational. Planned inpatient management after 23 weeks gestation was reported in 76.2% of respondents. Participants in both groups endorsed persistent feelings of hopelessness or despair related to their pregnancies (42.4% of inpatients versus 24.1% of outpatients, p = 0.089). Relationship strain between participants and their partners was similar in both the groups. Participants in the outpatient group were more likely to report feelings of guilt related to their infrequent monitoring (p = 0.01). Patient satisfaction with care was higher in the inpatient group.Conclusions: Inpatient management did not significantly increase measures of psychosocial stress as compared to outpatient management. Participants in the outpatient group reported feelings of guilt about their infrequent monitoring. Our findings provide increased understanding of the patient experience in these rare and challenging clinical circumstances.

Planned early delivery versus expectant management for monoamniotic twins.

Monoamniotic twin pregnancies are formed when a single egg is fertilised and the resulting inner cell mass splits to form twins sharing the same amniotic sac. This condition is rare and affects about one in 10,000 pregnancies overall. Monoamniotic twin pregnancies are susceptible to complications including cord entanglement, increased congenital anomalies, intrauterine growth restriction, twin-to-twin transfusion syndrome and increased perinatal mortality. All twin pregnancies also carry additional maternal risks including pre-eclampsia, anaemia, antepartum haemorrhage, postpartum haemorrhage and operative delivery.The optimal timing for the delivery of monoamniotic twins is not known. The options include 'planned early delivery' between 32 and 34 weeks, or alternatively awaiting spontaneous labour at least up until the usual time of planned delivery for other monochorionic twins (approximately 36 to 38 weeks' gestation), unless there is a specific indication for earlier delivery. To assess whether routine early delivery in monoamniotic twin pregnancies improves fetal, neonatal or maternal outcomes compared with 'expectant management'. Expectant management means awaiting spontaneous labour at least up until the usual time of planned delivery for other monochorionic twins (approximately 36 to 38 weeks' gestation in many centres), unless a specific indication for delivery occurs in the meantime, e.g. for non-reassuring antenatal testing. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 March 2015). Published and unpublished randomised controlled trials (including cluster-randomised trials) comparing outcomes for women and infants who were randomised to planned early delivery of a monoamniotic twin pregnancy with outcomes for women and infants who were randomised to either planned term delivery or expectant management. However, we did not identify any trials for inclusion in this review.Quasi-randomised controlled trials, trials published in abstract form only, and trials using a cross-over design are not eligible for inclusion in this review. No trials were identified by the search strategy. No trials were identified by the search strategy. Monoamniotic twins are rare, and there is insufficient randomised controlled evidence on which to draw strong conclusions about the best management. In their absence, we can refer to historical case series and expert consensus. Management plans should take into consideration the availability of high-quality neonatal care if early delivery is chosen. Women and their families should be involved in the decision making about these high-risk pregnancies.Ongoing, multicentre audits of maternal and perinatal outcomes for monoamniotic twins are needed in order to inform families and clinicians about up-to-date perinatal outcomes with contemporary obstetric practice. Research should consider the social and economic implications of planned interventions, as well as the perinatal outcomes.

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.

The natural history of monoamniotic twin pregnancies: a case series and systematic review of the literature.

To describe the natural history of monoamniotic twin pregnancies in contemporary practice. Cohort study of monochorionic monoamniotic twin pregnancies with two live fetuses diagnosed at less than 16 weeks and prospectively followed up between 2004 and 2013. A systematic review of the literature using Medline, Embase and Scopus to determine the perinatal mortality rate after 24 weeks of gestation in monoamniotic twins was also performed. Twenty pregnancies were analyzed. Four were terminated (in three cases as a result of fetal abnormalities). Another six miscarried spontaneously. Among ten pregnancies reaching viability, there was double intrauterine death in one, and both fetuses were alive at delivery in the other nine. There were no neonatal deaths. Overall survival for fetuses alive at the initial scan was 18/40 (45%; 95% CI 29 to 62%). At meta-analysis of 13 studies (including the current series), the perinatal mortality rate after 24 weeks was 4.5% (95% CI 3.3 to 5.8%). Despite early diagnosis and intensive monitoring, of those fetuses alive before 16 weeks less than half survive until the neonatal period. Most losses are attributable to fetal abnormalities and spontaneous miscarriage and are therefore unlikely to be reduced by further improvements in fetal assessment and monitoring. © 2014 John Wiley & Sons, Ltd.

Monochorionic monoamniotic twin pregnancy: a review of 17 cases

Objective To review the diagnosis,monitoring,management and perinatal outcomes of monochorionic monoamniotic (MCMA) twin pregnancy.Methods From July 2010 to August 2013,there were 17 MCMA twin pregnancies diagnosed and delivered in Shanghai First Maternity and Infant Hospital.According to the MCMA management protocol,induced abortion,elective fetal reduction,and anticipant pregnancy were optional.For those anticipant pregnancies,fetal lung underwent maturation promotion at gestational weeks 28; hospitalization with 40 min/day continual fetal electronic monitoring and umbilical blood monitoring twice weekly at gestational weeks 28-30; 40 min continual fetal electronic monitoring twice daily and umbilical blood monitoring once every other day at gestational weeks 30-32; and 40 min continual fetal electronic monitoring three times daily and umbilical blood monitoring once daily at gestational weeks 32-34; and pregnancy ended on time.The presence of umbilical cord entanglement,congenital malformation,intrauterine fetal death,complications exclusive to monochorionic twins (e.g.selective fetal growth restriction,twin reversed arterial perfusion sequence and twin-twin transfusion syndrome) and the perinatal outcomes were retrospectively analyzed.Results Average maternal age of women with 17 MCMA twins was (29.0±2.7) years,and all were primiparas.They were diagnosed at (18.6± 5.5) weeks on average (11 +5-28+1 weeks).Umbilical cord entanglements were detected in all cases by ultrasonography and confirmed postnatally.There were three cases of complications specific to monochorionic twins,including two with selective fetal growth restriction and one with twin reversed arterial perfusion sequence.There were seven women with fetal congenital malformation; four of whom chose induced abortion; one case of anencephaly chose radiofrequency ablation fetal reduction,and the remaining two cases with congenital malformation and ten cases without chose anticipant pregnancy,and there were no abnormal ultrasonography signs during pregnancy.Among these 12 cases,intrauterine fetal death of both fetuses occurred in two cases at 16 and 21+1 weeks gestation and they were aborted.Intrauterine fetal death of a single fetus occurred in one case at 30+2 weeks gestation (another fetus was delivered by emergency cesarean section).There were a total of eleven live births delivered by cesarean section (four by emergency cesarean section) at a median gestational age of (32.7± 1.6) weeks.There were 20 live neonates with a mean birth weight of (1 850±496) g.Sixteen neonates were transferred to the neonatal intensive care unit and hospitalized for (37.9± 16.4) days.Nine neonates suffered from respiratory distress syndrome but were eventually cured.Conclusions MCMA twin pregnancy has high morbidity and mortality.Early ultrasonography helps to clarify the diagnosis and enhance the monitoring,thus improving the perinatal outcomes. Key words: Twin, monochorionic; Ultrasonography, prenatal; Fetal monitoring; Pregnancy outcome

Prenatal management of monoamniotic twin pregnancies.

To evaluate antenatal surveillance strategies and the optimal timing of delivery for monoamniotic twin pregnancies. Obstetric and perinatal outcomes were retrospectively retrieved for 193 monoamniotic twin pregnancies. Fetal and neonatal outcomes were compared between fetuses followed in an inpatient setting and those undergoing intensive outpatient follow-up from 26 to 28 weeks of gestation until planned cesarean delivery between 32 and 35 weeks of gestation. The risk of fetal death was compared with the risk of neonatal complications. Fetal deaths occurred in 18.1% of fetuses (70/386). Two hundred ninety-five neonates from 153 pregnancies were born alive after 23 weeks of gestation. There were 17 neonatal deaths (5.8%), five of whom had major congenital anomalies. The prospective risk of a nonrespiratory neonatal complication was lower than the prospective risk of fetal death after 32 4/7 weeks of gestation (95% confidence interval 32 0/7-33 4/7). The incidence of death or a nonrespiratory neonatal complication was not significantly different between fetuses managed as outpatients (14/106 [13.2%]) or inpatients (15/142 [10.5%]; P=.55). Our statistical power to detect a difference in outcomes between these groups was low. The in utero risk of a monoamniotic twin fetus exceeds the risk of a postnatal nonrespiratory complication at 32 4/7 weeks of gestation. If close fetal surveillance is instituted after 26-28 weeks of gestation and delivery takes place at approximately 33 weeks of gestation, the risk of fetal or neonatal death is low, no matter the surveillance setting. II.

P19.12: The natural history of monoamniotic twin pregnancies

<scp>P</scp>19.12: The natural history of monoamniotic twin pregnancies