Single fetal death during the late second and early third trimesters presents the greatest risk to the surviving twin. Although the risks of subsequent death or neurological damage to the survivor are comparatively higher for monochorionic twins at this gestational age, the risk of preterm birth is equally increased in mono-and dichorionic twins (Ong, 2006). Delivery generally occurs within 3 weeks of diagnosis of fetal demise, thus antenatal corticosteroids for survivor lung maturity should be considered (Blickstein, 2013). Regardless, unless the intrauterine environment is hostile, the goal is to prolong the preterm pregnancy.
Timing of elective delivery after conservative management of a late second-or early third-trimester single fetal death is debatable. Dichorionic twins can probably be safely delivered at term. Monochorionic twin gestations are more diicult to manage and are often delivered between 34 and 37 weeks' gestation (Blickstein, 2013). In cases of single fetal death at term, especially when the etiology is unclear, most opt for delivery instead of expectant management. The American College of Obstetricians and Gynecologists (2016) also endorse an individualized approach to such cases.
• Impending Death of One Fetus
During antepartum surveillance tests of well-being, abnormal results in one twin, but not the other, pose a particular dilemma. Delivery may be the best option for the compromised fetus yet may result in death from immaturity of the cotwin. If fetal lung maturity is conirmed, salvage of both the healthy fetus and its jeopardized sibling is possible. Unfortunately, ideal management if twins are immature is problematic but should be based on the chances of intact survival for both fetuses. Often the compromised fetus is severely growth restricted or anomalous. Thus, performing amniocentesis for fetal chromosomal analysis in women of advanced maternal age carrying twin pregnancies is advantageous, even for those who would continue their pregnancies regardless of the diagnosis. Chromosomal abnormality identification in one fetus allows rational decisions regarding interventions.
With prenatal management of multifetal pregnancy, primary goals aim to prevent or interdict complications as they develop. A major imperative is to prevent preterm delivery of markedly immature neonates. At Parkland Hospital, women with multifetal gestations are seen every 2 weeks beginning at 22 weeks' gestation. A digital cervical examination is performed at each visit to screen for cervical shortening or dilation. Identification of other unique complications discussed earlier may also lead to interventions including admission or early delivery.
long with more frequent prenatal VISItS, the maternal diet should provide additional requirements for calories, protein, minerals, vitamins, and essential fatty acids. he Institute of Medicine (2009) recommends a 37-to 54-lb weight gain for women with twins and a normal BMI. In their review, Goodnight and Newman (2009) endorse supplementation of micronutrients such as calcium, magnesium, zinc, and vitamins C, D, and E. his is based on upper intake levels from the Food and Nutrition Board of the Institute of Medicine. he daily recommended augmented caloric intake for women with twins is 40 to 45 kcal/kg/d. Diets contain 20 percent protein, 40 percent carbohydrate, and 40 percent fat divided into three meals and three snacks daily.