Acute transfusion

When one MC twin dies in utero, there is an empiric 25% risk of ischaemic, neurological or renal lesions in the survivor [40]. The mechanism is now known to be acute transfusion from the healthy twin's circulation into the hypotensive dying twin's circulation. There is also a comparable risk of the initially healthy twin exsanguinating into the dying twin's circulation, resulting in double intrauterine death. These risks appear greater in the presence of an arterio-arterial anastomosis [41,42].

Unlike DC twins discordant for fetal compromise, where the risks of intrauterine demise in one are balanced against those of iatrogenic prematurity in the other, delivery needs to be expedited in MC twins discordant for fetal compromise, not only to prevent intrauterine death in the compromised twin but also to prevent sequelae in the co-twin. Where this occurs prior to viability ultrasound-guided bipolar cord occlusion is an alternative to expectant management, whereby the dying twin's cord is intentionally blocked prior to its demise to protect the co-twin from acute transfusional sequelae.

If one twin is found dead in utero, delivery is rarely indicated except near term. Instead middle cerebral artery Doppler helps identify surviving fetuses with anaemia [43], and they should all undergo neuro-imaging by MR or ultrasound to exclude transfusional brain injury. If abnormal, handicap is likely and termination of pregnancy maybe offered where allowed, even in late pregnancy.

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