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|Foetus Papyraceous : A Challenge to Obstetricians
Ashok Kumar Shukla*, Asha R Dalal**
|Enbom has reported that the incidence of
twin pregnancy with a single intrauterine death ranges from 0.5%
to 6.8%. The vanishing twin phenomenon is relatively common, and
the prognosis for the surviving foetus is good. In contrast single
foetal death in the second or third trimester is uncommon and
has been shown to be associated with increased risk of mortality
and morbidity for the surviving twin.
Mrs. XYZ Primigravida unregistered uninvestigated woman came with
complaints of 8 months pregnancy and preterm labour pains. She
was admitted and started on IV tocolytics and steroids. She complained
of pain in abdomen after 2 days with leak per vaginum. She delivered
2.2 kg Nearterm baby cried immediately afterbirth apgar 8,9,9.
Placenta got expelled after 5 mins and methergin was administered
On examination of the placenta there were two cords and the other
cord was connected to paper like thin baby which was the foetus
papyraceous or vanishing twin.
XYZ Primigravida unregistered uninvestigated women came
with complaints of 8 months pregnancy and preterm labour
pains. On Examination, General condition was fair, per
abdomen 34 wks cephalic presentation, FHS 160 beats/min
regular, uterine activity 1-2/10/10. She was admitted
and started on IV tocolytics and steroids. Her routine
investigations were send which came in normal limits.
Her USG obstetrics showed single live foetus average gestational
age 35 wks 4 days. She complained of pain in abdomen after
2 days with leak per vaginum. On Examination : she was
getting good uterine contraction of 2-3/10/20 and pervaginum
examination : cervix was 2.5 cms dilated with membranes
absent, vertex presentation, st at 0. Labour was allowed
to progress she delivered 2.2 kgs Nearterm baby cried
immediately afterbirth apgar 8,9,9. Placenta got expelled
after 5 mins and methergin was administered to her.
On examination of the placenta there were two cords and
the other cord was connected to paper like thin baby which
was the foetus papyraceous or vanishing twin (Fig. 1).
Mother and baby otherwise didn’t had any other
complication and she was discharged after 2 days.
Enbom1 has reported that the incidence of twin pregnancy
with a single intrauterine death ranges from 0.5% to 6.8%.
An incidence of 3.7% was reported in a prospective study
of 188 monozygotic twins in the National Collaborative
Perinatal Project figures. However, are overestimates
owing to biases in case selection and reported gestation.
“Vanishing twin syndrome” is described as
a twin pregnancy that was diagnosed at one time, but with
just one baby being eventually delivered. Even when there
are two viable foetuses identified in the first trimester,
the disappearance rate for one of them can reach 29%.2
The vanishing twin phenomenon is relatively common, and
the prognosis for the surviving foetus is good.2 In contrast
single foetal death in the second or third trimester is
uncommon and has been shown to be associated with increased
risk of mortality and morbidity for the surviving twin.3
In general, chorionicity rather than zygosity determines
the risk of mortality and morbidity. Hence, it is important
to determine the type of placentation by ultrasonography.
The perinatal mortality of monochorionic twin pregnancies
is double that of dichorionic twin pregnancies.4
Aetiology : Causes usually include twin-to-twin
transfusion syndrome, velementous insertion of the cord.
Maternal Complications : The association between
retention of dead foetus of twins in utero and maternal
disseminated intravascular coagulation was first noted
in 1950. The principal defect as a gradual reduction in
fibrinogen level. This complication usually occurs 3 or
more weeks after the foetal demise.
|Effects of Foetal Death on the Surviving Twin
|A foetal demise before 14 weeks places no increased risk
on the survivor. However after 14 wks, death or severe morbidity
in the remaining twin may ensue. The most feared sequelae
is neurological damage to the survivor.
The traditional approach to the demise of a twin has been
deliver the survivor to avoid embolization. Cattanach et
al favour conservative management until 37 weeks gestation.
If foetal movements, cardiotocography, and ultrasonography
show no abnormalities.5 Santema et al have advocated treating
impending preterm labour before 34 weeks with intravenous
tocolytics.6 Carlson and Towers have recommended that delivery
should be considered after 32 weeks if lung maturity is
documented; if the lungs are immature, steroids could be
given and maturity re-evaluated afterwards.7 It has been
suggested that after 37 weeks pregnancy should be terminated.
The sequelae of a single foetal death in twin pregnancy
depend on the gestation and in the second and in the late
third trimester there is increase in mortality or morbidity
in the surviving twin. Antenatal evaluation periodically
by ultrasonography is important to reduce the potential
risk. Conservative management remains the main stay but
the risk of keeping the alive foetus in the hostile intrauterine
environment has to be weighed against the risk of preterm
||Enbom JA. Twin pregnancy
with intrauterine single foetal demise. Am J Obstet
Gynaecol 1985; 152 : 424-9.
|| Landy HJ, Weiner S, Corson SL, et
al. The ultrasonographic assessment of foetal
twins in trimester. Am J Obstet Gynaecol 1986.
|| Landy HJ, Weingord AB. Management
of twins complicated by an antepartum fetal demise.
Survey 1989; 44 : 171-6.
|| Nylander PP. Perinatal mortality in
twins : Gemellol (Roma) 1979; 28 : 363-8.
||Cattanch SA, Wedel M, White S. Your
experience of intrauterine fetal death in a suspected
monozygous twins. Aust NZ J Obstet Gynaecol
1990; 30 : 13.
||Santema JG, Swaak AM, Wallenburg H.
Management of twin pregnancy with single foetal demise.
Gynaecol 1995; 102 : 26-30.
||Carlson NJ, Towers CV. Multiple gestation
with death of one fetus. Obstet Gynaecol