A C TA Obstetricia et Gynecologica

MAIN RESEARCH ARTICLE

Fetal death in twins

RHONA MAHONY1 , CELIA MULCAHY1 , FIONNUALA MCAULIFFE2 , COLM O HERLIHY2 , STEPHEN
CARROLL1 & MICHAEL E. FOLEY2
1
Department of Obstetrics and Gynaecology, National Maternity Hospital and 2 Department of Obstetrics and Gynaecology,
University College Dublin, Dublin, Ireland

Key words
Twin pregnancy, fetal death, chorionicity,
intrauterine growth restriction, twin-twin
transfusion syndrome
Correspondence
Rhona Mahony MD, Consultant Obstetrician,
National Maternity Hospital,
Holles St, Dublin 2, Ireland.
E-mail: rhonamahony@hotmail.com
Conflict of interest
The authors have stated explicitly that there
are no conflicts of interest in connection with
this article.
Received: 24 January 2011
Accepted: 7 July 2011
DOI: 10.1111/j.1600-0412.2011.01239.x

Abstract
Objective. To examine the pattern and prospective risk of intrauterine fetal death
(IUFD) in twin pregnancy by chorionicity. Design. Retrospective cohort analysis.
Setting. Large national tertiary referral center. Population. All consecutive twin deliveries (19972006) 24 weeks. Methods. Retrospective review of all consecutive
twin deliveries over 10 years to identify patterns of IUFD in twins and calculate
gestation-specific prospective risks of IUFD. Fetal death was defined as intrauterine
demise of a fetus 24weeks, intertwin birthweight discordance as 20% difference
and growth restriction as birthweight <5th centile. Chorionicity was confirmed by
postnatal placental examination. Main outcome measures. Fetal death. Results. 1094
twin pairs including 276 monochorionic-diamniotic (MCDA) (25.3%) and 818
dichorionic-diamniotic (DCDA) twin pregnancies (74.7%) were studied. Twentynine fetal deaths occurred affecting 22 twin pregnancies. The incidence of IUFD
(death of one or both fetuses) in MCDA twin pregnancies was three times that
in DCDA pregnancies [11/276 (3.9)% vs. 11/818 (1.3%) p<0.001]. The majority
of deaths in MCDA twins were associated with twintwin transfusion syndrome
(TTTS) prior to 30 weeks. In normally grown twins the prospective risk of IUFD
was similarly low in MCDA and DCDA pregnancies after 34 weeks but in pregnancies complicated by abnormal growth, the prospective risk of IUFD was 3.4 in
MCDA and 2.0 in DCDA pregnancies. Conclusion. Twin pregnancies complicated
by growth restriction or growth discordance were associated with a high risk of
IUFD, particularly in affected MCDA twins. Conversely, in normally grown twins
the risk was similarly low in MCDA and DCDA pregnancies after 34 weeks.
Abbreviations: DCDA, dichoriotic-diamniotic; IUFD, intrauterine fetal death;
MCDA, monochorionic-diamniotic; TTTS, twin twin transfusion syndrome.

Introduction
Perinatal mortality is increased in twin compared with singleton pregnancies, and is greater in monochorionic diamniotic
(MCDA) compared with dichorionic diamniotic (DCDA)
twins (1,2). Much of the excess fetal loss in twin pregnancies can be attributed to preterm birth, intrauterine growth
restriction, and twin-to-twin transfusion in MCDA pregnancies (3). Intrauterine fetal death (IUFD) is particularly
devastating in monochorionic pregnancies because of the elevated risk of co-twin demise and the high risk of adverse
neurological outcome if the co-twin survives (4).
It has been shown that perinatal mortality in twin pregnancy reaches a nadir at around 38 weeks gestation and

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rises thereafter (5), indicating that it may be unwise to prolong twin pregnancy much beyond 38 weeks. Indeed, some
authors suggest delivery of MCDA twins before 38 weeks
and the optimal timing of MCDA twins remains controversial. Concern has been expressed that IUFD in MCDA
twins is increased and unpredictable (6). The inability to
identify the at risk fetus has prompted a call for the evaluation of elective preterm delivery in apparently uncomplicated
MCDA twins at around 36 weeks in an effort to reduce the
risk of unexpected stillbirth (7,8). It has been shown that
even when MCDA twin pregnancies affected by growth disorders and twin-twin transfusion syndrome are excluded,
the excess risk of IUFD is maintained in apparently normal MCDA twin pregnancies, although a relatively small


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R. Mahony et al.

proportion of the MCDA cohort in this study proceeded

beyond 35 weeks (3).
Optimal management involves a balance of risk, as even late
preterm delivery is not without morbidity and even mortality
(9). Like perinatal mortality, perinatal morbidity has been
shown to be lowest for twins born at 3738 weeks (9). Our
aim was to perform a retrospective cohort analysis of all
twin deliveries at a single tertiary care center over 10 years
to determine the pattern of fetal death in twin pregnancy
according to chorionicity. We placed particular emphasis on
fetal deaths at or after 34 weeks gestation (elective routine
delivery is unlikely to be considered before this gestation).
In addition, in keeping with previous published data (3), we
have presented the prospective risk of fetal in death in both
MCDA and DCDA twins to facilitate comparison, as during
the course of this study we did not electively deliver twin
pregnancies prior to 38 weeks.

Material and methods

All consecutive twin gestations delivered at the National Maternity Hospital Dublin from 1st January 1997 to 31st December 2006 were identified from the hospital perinatal database.
Inclusion criteria were twins with two viable fetuses at 23+6
and delivery at 24+0 weeks or later. We excluded pregnancies
with fetal malformation, unknown chorionicity, monoamniocity and twin sets within triplets and higher order multiples. Chorionicity was determined by placental histopathologic examination rather than by ultrasound alone (10). Fetal
death was defined as intrauterine demise of a fetus 24 weeks
gestation and the stillbirth rate was calculated as the incidence
of stillbirth per pregnancy. Growth restriction was defined as
birthweight <5th percentile for gestational age on a standardized growth chart (11). Birthweight discordance was calculated by subtracting the weight of the smaller twin from that
of the larger twin and dividing the difference by the weight
of the larger twin and expressed it as a percentage. Significant intertwin discordance was defined as 20% or greater (3).
Twintwin transfusion syndrome (TTTS) was diagnosed according to the internationally accepted sonographic criteria
adopted by the Eurofetus project (www.eurofetus.org): maximum vertical pocket of amniotic fluid (MVP) <2cm in the
donors gestational sac and an MVP 8cm in the recipients
sac (10cm in the recipients sac after 20 weeks gestation),
with distended bladder in the recipient and collapsed bladder
in the donor in most of the examinations (12).
Gestational age-specific stillbirth rates per twin pregnancy
were calculated as the incidence of fetal death per pregnancy
(whether single or double) during or after a given two-week
gestational period divided by the total number of ongoing
pregnancies at the start of the period (3). In concordance with
a previous study, twins were classified as apparently normal
growth in the absence of IUGR, significant inter-twin dis-

Fetal death in twins

cordance and TTTS (3). Conversely, abnormal growth twins

were defined as twin pregnancies complicated by IUGR or
significant growth discordance excluding TTTS.
Statistical analysis was performed using the spss statistical
package (SPSS Inc., Chicago, IL, USA). Differences between
categorical variables were analyzed using the chi-squared test
and differences between continuous variables were summarized as means and standard deviations. Groups were compared using Students t-test. All hypothesis tests were twosided and significance was set at <0.05. As this study conformed to the standards established by the National Health
and Research Council for ethical quality review, specific ethical approval was not required because all of the data obtained
retrospectively were in the public domain and published annually in the hospital clinical reports.

Results
During the 10-year study period, 1 178 twin pairs were delivered at NMH. Ten twin pairs were excluded because of inadequate data. Data on placental chorionicity were not available
in 74 twin pairs (6.3%) leaving 1 094 twin pregnancies as
the subject of this study, including 276 monochorionic twin
pairs (25.3%) and 818 dichorionic twin pairs (74.7%).
Monochorionic twins were delivered significantly earlier
than dichorionic twins, although there was no difference in
the incidence of growth discordance or IUGR between the
two groups (Table 1); 164/276 (59.4%) of MCDA twins delivered at or after 36 weeks gestation compared with 626/818
(76.5%) of DCDA twins (p<0.001). Of the 112 MCDA and
192 DCDA twin pairs who were delivered before 36 weeks
gestation, 63.6% of the MCDA twins and 71.6% of the DCDA
twins were delivered following spontaneous preterm labor.
Conversely, 36.4% of MCDA and 28.4% of DCDA twins were
delivered prelabor in the fetal or maternal interest. Overall,

Table 1. Characteristics of 1 094 twin pregnancies in NMH in 1997

2006 analyzed by chorionicity.
Monochorionic
n = 276
Mean gestation/(weeks) at
delivery
Mean birth weight/g
Birthweight < 5th
percentile/pregnancy
Growth discordance
>20%/pregnancy
Stillbirth/pregnancy
Stillbirth/normal growth
pregnancy (IUGR,
growth discordance,
TTTS excluded)

Dichorionic
n = 818

35 3.7

36 2.88

<0.001

2319 36
46 (16.6%)

2584 615
159 (19.4%)

<0.001
0.35

54 (19.6%)

144 (17.6%)

0.52

11 (3.9%)
1/194 (0.5%)

11 (1. 34%)
6/575 (0.87%)

0.01
1

Data are expressed as n, n (%) or mean (SD).


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Fetal death in twins

R. Mahony et al.

the incidence of intrauterine fetal death (IUFD) per pregnancy (whether single or double) in MCDA twins was three
times that in DC twins [11/276 (3.9)% vs. 11/818 (1.3%)
p<0.001) (Table 1). When pregnancies complicated by TTTS,
growth discordance and/or IUGR were excluded (normal
growth pregnancies), the overall incidence of IUFD was similar in MCDA and DCDA pregnancies [(1/194 (0.5%) vs.
6/575 (0.87%); p=1.0] (Table 1).
The number of fetal deaths by gestational week and the
prospective risk of IUFD with increasing gestation is shown
for all twins studied in Table 2. The prospective risk of IUFD
in all twins was greater in MCDA than DCDA twins at all gestations after 24 weeks with the risk being greatest between 24
and 27 weeks in MCDA twins (Table 2). After 34 weeks gestation, the incidence of IUFD was 2/205 (0.97%) in MCDA
twins vs. 6/708 in DCDA twins (0.85%) (p=1.0). In apparently normal growth twins, there was only one IUFD
at 26 weeks gestation in MCDA twins compared with six
antepartum deaths in 575 DCDA pregnancies. At or after
34 weeks, there were two deaths of 489 ongoing pregnancies
in normally grown DCDA twins and no deaths in normally
grown MCDA twins (Table 3). In twin pregnancies affected
by growth discordance or IUGR (but TTTS excluded), i.e.
abnormally grown twin pregnancies, the prospective risk
of IUFD in MCDA twins was greater at all gestations. At
34 weeks gestation the prospective risk of IUFD was 3.4 in
MCDA pregnancies and 1.8 in DCDA pregnancies, rising
to 4.3 and 2.0, respectively, at 36 weeks gestation (p=0.33)
(Table 4).
Of 11 instances of IUFD in MCDA twin pregnancies, five
(45.4%) were double deaths and of 11 IUFDs in DCDA pregnancies, two (18.1%) were double deaths. The individual
causes of IUFD are detailed in Table 5. The majority of deaths
in MCDA twins, 8/11 (72.7%), were related to TTTS, with
two cases of IUFD related to placental abruption at 37 weeks
gestation. In one of these cases, the fetuses were discordant for
growth and in the other, both fetuses were growth-restricted.
Seven of 13 deaths in DCDA twins were related to IUGR or
growth discordance (Table 5). Overall, six of eight cases (75%)
of IUFD in all twin pregnancies at or after 34 weeks gestation
(2/2 MCDA and 4/6 DCDA pregnancies) were associated with
either growth discordance or IUGR. After 34 weeks the interval between last scan and diagnosis of IUFD was one week or
less in all cases, except one case of DCDA twins where there
had been a four-week interval between scan and diagnosis
of IUFD. In the MCDA group, a late double fetal death occurred at 37 weeks. In this case, amniotomy was performed
to induce labor because of IUGR. Amniotomy was followed
by placental abruption and the demise of both fetuses. In the
DCDA group of twins, three pregnancies were affected by late
IUFD (including one double death) at 38 weeks gestation.
In total, there were 16 stillbirths and 14 neonatal deaths in
the MCDA twins and 13 stillbirths and 22 neonatal deaths

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in the DCDA twins. This gives a perinatal mortality rate of

54/1 000 in the MCDA twins and 21/1 000 in the DCDA
twins (p<0.001). In MCDA twins 13/14 neonatal deaths and
in DCDA twins 16/22 deaths occurred before 26 weeks gestation and were related to prematurity.

Discussion
This was a large retrospective study of IUFD in over 1 000 twin
pregnancies in which the majority delivered after 36 weeks
gestation (59% in MCDA twins and 76% in DCDA twins).
The overall risk of IUFD was threefold greater in MCDA than
DCDA twins and the prospective risk of IUFD was greater in
MCDA twin pregnancies at all gestations after 24 weeks, consistent with previous studies (2). In addition, the proportion
of twin pregnancies affected by double fetal death was greater
in MCDA twin pregnancies, consistent with the elevated risk
of co-twin death in MCDA pregnancies because of placenta
vascular anastomoses. Almost three-quarters of all deaths
in MCDA twins occurred before 30 weeks gestation and
were related to TTTS. In apparently normally grown twins,
the risk of IUFD was similarly low in MCDA and DCDA
twin pregnancies. In contrast, in twin pregnancies complicated by IUGR, growth discordance or both, the prospective
risk of IUFD was higher than in apparently normal grown
twins, with the highest prospective risk of IUFD occurring
in abnormally grown MCDA twins. After 34 weeks gestation, three-quarters of deaths were associated with IUGR or
growth discordance with a prospective risk of 3.4% in abnormally grown MCDA twins vs. 2.0% in abnormally grown
DCDA twins. These data are consistent with recently published information (13).
When TTTS is excluded, the majority of deaths in MCDA
twins and almost half the deaths in DCDA twins were associated with IUGR and/or growth discordance. We were
only able to identify one IUFD in MCDA twins with apparently normal growth and this was associated with vasa
previa. At or after 34 weeks gestation, the two of two cases
of IUFD in MCDA twins were associated with abnormal
growth, while four of six cases of IUFD in DCDA twins at
or after 34 weeks gestation were associated with growth discordance or IUGR. Birthweight discordance affects up to
30% of twin pregnancies and has long been associated with
adverse perinatal outcome (14,15,16). Different genetic potential, crowding in utero, and placental insufficiency have
been postulated to cause discordant growth in dichorionic
twins, whereas unequal sharing of placental mass and hemodynamic imbalance caused by placental vascular anastomoses
is commonly cited as the etiology of growth discordance in
monochorionic twins (17,18). The risk of adverse perinatal
outcome has been shown to increase when growth discordance in twins is associated with IUGR (1921). Our results
are consistent with this finding, showing that even when


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Fetal death in twins

Table 2. Prospective risk of IUFD per ongoing pregnancy in all twins by gestational age.
Monochorionic
Ongoing
pregnancies
Week of gestation
2425
2627
2829
3031
3233
3435
3637
38

Dichorionic
Ongoing
pregnancies

Percentage

IUFD (n)

Prospective risk
of IUFD (%)

Percentage

IUFD (n)

Prospective risk
of IUFD (%)

276
268
255
245
231
205
164
84

100
97.1
92.4
88.8
83.6
74.2
59.4
30.4

2
4
2
0
1
0
2
0

3.9
3.4
1.9
1.2
1.3
1.0
1.2
-

818
810
800
786
754
708
626
241

100
99.0
97.8
96.0
92.2
86.5
76.5
29.4

1
0
1
1
2
1
2
3

1.34
1.23
1.25
1.0
1.1
0.8
0.79
1.2

IUFD, in utero fetal death.

Prospective risk of IUFD was calculated as the incidence of stillbirths per pregnancy (whether single or double) during or after a given two-week
gestational period divided by the total number of ongoing pregnancies at the start of the time period.
Table 3. Prospective risk of IUFD per ongoing pregnancy in apparently normally grown twins by gestational age.
Monochorionic
Ongoing
pregnancies
Week of gestation
2425
2627
2829
3031
3233
3435
3637
38

Dichorionic
Ongoing
pregnancies

Percentage

IUFD (n)

Prospective risk
of IUFD (%)

Percentage

IUFD (n)

Prospective risk
of IUFD (%)

194
190
180
175
164
146
118
67

100
97.9
92.7
90.2
84.5
75.3
60.8
34.5

0
1
0
0
0
0
0
0

1.03
1.05
0.55
-

575
569
560
546
521
489
426
240

100
98.9
97.3
94.9
90.4
85.0
74.1
41.7

1
0
1
1
1
1
0
1

1.04
0.87
0.89
0.73
0.57
0.40
0.23
0.41

IUFD, in utero fetal death.

Prospective risk of IUFD was calculated as the number of stillbirths per pregnancy during or after a given two-week gestational period divided by the
total number of ongoing pregnancies at the start of the time period.
Table 4. Prospective risk of IUFD per ongoing pregnancy in abnormally grown twins by gestational age (TTTS excluded).
Monochorionic
Ongoing
pregnancies
Week of gestation

Percentage

IUFD (n)

2425
2627
2829
3031
3233
3435
3637
38

80
75
73
70
66
59
46
17

100
95.1
91.5
85.4
81.7
71.9
56.0
20.7

0
0
0
0
0
0
2
0

Dichorionic

Prospective risk
of IUFD (%)
2.5
2.6
2.7
2.8
3.0
3.4
4.3

Ongoing
pregnancies
n

Percentage

IUFD (n)

243
241
240
240
233
219
200
2

100
99.2
98.7
98.7
95.8
90.1
82.3
0.8

0
0
0
0
1
0
2
2

Prospective risk
of IUFD (%)
2.0
2.2
2.0
2.0
2.1
1.8
2.0

IUFD, in utero fetal death.

Prospective risk of IUFD was calculated as the number of stillbirths per pregnancy during or after a given two-week gestational period divided by the
total number of ongoing pregnancies at the start of the time period.


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Table 5. Intrauterine fetal death cases.

Gestation

Cause

Birthweight

Interval scan IUFD

Monochorionic twin pregnancy

25,
1 (2)
25
1 (2)
26
1
26
1
26
1 (2)
27
1
28
1 (2)
29
1
33
1
37
1
37
1 (2)

TTTS
TTTS
TTTS
Unexplained
TTTS
TTTS
TTTS
TTTS
TTTS
Abruption
Abruption

880g, 720g
445g, 505g
585g, 2 500g (at 38/40 weeks).
830g, 740g
770g, 900g
800g, 1 080g
645g, 880g
1 125g, 1230g
3 430g,1730g
3 520g, 2740g
2 205g, 1950g

1 week
1 week
2 weeks
<1 week
2 weeks
1 week
2 weeks
1 week
4 weeks
<1 week
<1 week

Dichorionic twin pregnancy

25
1 (2)
28
1
30
1
33
1
33
1
35
1
36
1
37
1
38
1 (2)
38
1
40
1

Fetomaternal hemorrhage
Pre-eclampsia
Cholestasis
Vasa previa
Growth discordance
Unexplained
IUGR
IUGR
IUGR
IUGR
Unexplained

920g, 790g
1 020g, 1 140g
1 885g, 1 780g
1 700g, 2 130g
1 580g, 2 260g
2 485g, 2 175g
2 140g, 1 675g
2 980g, 1 430g
3 530g, 2 100g
2 495g, 2 420g
3 260g, 2 700g

<1 week
<1 week
Ext Ref (external referral)
1 week
<1 week
1 week
<1 week
4 weeks
1 week
1 week
1 week

Growth discordance >20% or IUGR.

n represents the number of twin pregnancies affected by stillbirth. (2) signifies death of both fetuses.

TTTS is excluded, three-quarters of IUFDs in all twins are

associated with growth restriction or growth discordance at
or after 34 weeks gestation. Ideally, twins with growth discordance or IUGR should be identified by antenatal fetal
surveillance but it is widely acknowledged that the estimation
of fetal weight by ultrasound can vary within a range of up to
20% of the actual birthweight and is less accurate in multiple
pregnancies (22,23). In contrast, in normally grown twins,
there was only one death in MCDA twins at 26/40 weeks
gestation, a finding consistent with previous studies (23,24).
It is noteworthy that more than half of all deaths (6/11) in
DCDA twins occurred in apparently normally grown DCDA
twins, with two of these deaths occurring after 34 weeks.
The greatest prospective risk of IUFD in MCDA twins occurs between 24 and 27 weeks gestation, coinciding with
the greatest incidence of TTTS, which accounted for almost
three-quarters of all deaths in MCDA twins. Approximately
1015% of monochorionic twin pregnancies are complicated
by TTTS and before 26 weeks of gestation this is associated
with a high risk of fetal loss, perinatal death and subsequent
handicap in survivors (25). Over the 10-year course of this
study, there have been many advances in the management
of TTTS which are likely to improve outcomes in MCDA
twins. At present, fetoscopic laser ablation of placental vas-

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cular anastomoses appears to be the best first line treatment,

maximizing perinatal survival and minimizing long-term
neurodevelopment morbidity (26,27,28). One of the limitations of this study is the lack of prospectively recorded data
regarding the treatment of identified cases of TTTS. This 10year study began with the year 1997, a time when fetoscopic
laser coagulation was a new procedure restricted to a minority of centers. Although several affected pregnancies were
treated with amniodrainage, the data were not reliable and
were therefore omitted from this study.
Another limitation of this study is that it spanned 10 years
(19972006) during which there were significant advances in
the understanding of the particular challenges faced in the
management of twin pregnancy. Nonetheless, the data relate
to a very large cohort of twin pregnancies in whom the majority were delivered after 36 weeks. The findings have led
to a change in practice in keeping with current international
norms (22). It is now our policy to routinely deliver all MCDA
twins at 37 weeks and all DCDA twins at 38 weeks or earlier if indicated. In addition, during this study, surveillance
of twin pregnancies has changed. Prior to 2002, chorionicity
was not routinely assigned and all twins were scanned every
four weeks. Ongoing audits prompted our unit to increase
fetal surveillance so that, at present, chorionicity is assigned


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ultrasonically at 12 weeks gestation in all twin pregnancies.

MCDA twins are routinely scanned at least every two weeks
and DCDA twins every four weeks until 28 weeks gestation
and every two weeks after that. Each ultrasonic assessment
includes estimated fetal weight, biophysical score and umbilical artery Doppler studies. It is possible that some of the late
fetal deaths highlighted in growth-restricted fetuses could
have been avoided with more intensive fetal monitoring.
A further limitation in this study was the inability to determine exactly the timing of intrauterine death and the effect of
maceration on fetal weight (23). However, in the majority of
fetal deaths studied, we can reasonably exclude a prolonged
interval between intrauterine death and delivery so that it is
unlikely that intrauterine death could entirely account for the
birthweight discordance observed.
In conclusion, the majority of deaths in MCDA twins were
associated with TTTS. In the absence of TTTS, twin pregnancies complicated by growth restriction or growth discordance
were associated with a high prospective risk of IUFD, with
the highest risk occurring in MCDA twins. Conversely, in
normally grown twins, the risk of IUFD was similarly low in
MCDA and DCDA pregnancies after 34 weeks.

Funding
No specific funding.
References
1. Sherer DM. Adverse perinatal outcome of twin pregnancies
according to chorionicity: review of the literature. Am J
Perinatol. 2001;18:2337.
2. Simoes T, Amaral N, Lerman R, Ribiero F, Dias E, Blickstein
I. Prospective risk of intrauterine death of monochorionic
diamniotic twins. Am J Obstet Gynecol. 2006;195:1349.
3. Lee YM, Wylie JB, Simpson LL, DAlton ME. Twin
chorionicity and risk of stillbirth. Obstet Gynecol.
2008;111:3018.
4. Ong SS, Zamora J, Khan KS, Kilby MD. Prognosis for the
co-twin following single twin death: a systematic review. Br J
Obstet Gynaecol. 2006;113:9928.
5. Hartley RS, Emanuel I, Hitti J. Perinatal mortality and
neonatal morbidity rates among twin pairs at different
gestational ages: optimal delivery timing at 37 to 38 weeks
gestation. Am J Obstet Gynecol. 2001;184:4518.
6. Barigye O, Pasquini L, Galea P, Chambers H, Chappell L,
Fisk NM. High risk of unexpected late fetal death in
monochorionic twins despite intensive ultrasound
surveillance: a cohort study. PLoS Medicine 2005;2e172.
7. Hack K, Derks JB, Elias SG, Franx A, Roos EJ, Voerman SK,
et al. Increased perinatal mortality and morbidity in
monochorionic versus dichorionic twin pregnancies: clinical
implications of a large Dutch cohort study. Br J Obstet
Gynaecol. 2008;115:5867.

Fetal death in twins

8. Cleary-Goldman J, DAlton ME. Uncomplicated

monochorionic diamniotic twins and the timing of delivery.
PLoS Med. 2005;2e180. Epub 2005 Jun 28.
9. McIntire DD, Leveno KJ. Neonatal mortality and morbidity
rates in late preterm births compared with births at term.
Obstet Gynecol 2008;111:3541.
10. Carroll SG, Soothill PW, Abdel-Fattah SA, Porter H,
Montague I, Kyle PM. Prediction of chorionocity in twin
pregnancies at 1014 week of gestation. Br J Obstet Gynaecol.
2002;109:1826.
11. Yudkin PL, Aboufa M, Eyre JA, Redman CWG, Wilkonson
AR. New birth weight and head circumference centiles for
gestational ages 2442 weeks. Early Hum Develop
1987;15:4552.
12. Senat MV, Deprest J, Boulvain M, Paupe A, Winer N, Ville Y.
Endoscopic laser surgery versus serial amnioreduction for
severe twin-to-twin transfusion syndrome. N Engl J Med.
2004;351:13644.
13. Smith NA, Wilkins-Haug L, Santolaya-Forgas J, Acker D,
Economy KE, Benson CB, et al. Contemporary management
of monochorionic diamniotic twins: outcomes and delivery
recommendations revisited. Am J Obstet Gynecol.
2010;203:133.e16.
14. Demissie K, Ananth CV, Martin J, Hanley ML,
MacDornan MF, Rhoads GG. Fetal and neonatal mortality
among twin gestations in the United States: the role of
intrapair birth weight discordance. Obstet Gynecol.
2002;100:47480.
15. Branum AM, Schoendorf KC. The effect of birth weight
discordance on twin neonatal mortality. Obstet Gynecol.
2003;101:5704.
16. Hollier LM, McIntire DD, Leveno KJ. Outcome of twin
pregnancies according to intrapair birth weight differences.
Obstet Gynecol. 1999;94:100610.
17. Victoria A, Mora G, Arias F. Perinatal outcome, placental
pathology, and severity of discordance in monochorionic and
dichorionic twins. Obstet Gynecol. 2001;97:3105.
18. Eberle AM, Levesque D, Vintzileos AM, Egan JF, Tsapanos V,
Salafia CM. Placental pathology in discordant twins. Am J
Obstet Gynecol. 1993;169;9315.
19. Fick L, Feldstein VA, Norton ME, Wassel Fyr C, Caughey AB,
Machin GA. Unequal placental sharing and birth weight
discordance in monochorionic diamniotic twins. Am J
Obstet Gynecol. 2006;195:17883.
20. Garite TJ, Clark RH, Elliott JP, Thorp JA. Twins and triplets:
The effect of plurality and growth on neonatal outcome
compared with singleton infants. Am J Obstet Gynecol.
2004;191:7007.
21. OBrien WF, Knuppel RA, Scerbo JC, Rattan PK. Birth
weight in twins: An analysis of discordancy and growth
retardation. Obstet Gynecol. 1986;67:4836.
22. Vayssiere C, Benoist G, Blondel B, Dereulle P, Favre R, Gallot
D, et al. Guidelines for clinical practice from the French
College of Gynaecologists and Obstetricians (CNGOF). Eur J


C 2011 The Authors
C 2011 Nordic Federation of Societies of Obstetrics and Gynecology 90 (2011) 12741280
Acta Obstetricia et Gynecologica Scandinavica 

1279

Fetal death in twins

R. Mahony et al.

Obstet Gynecol Reprod Biol. 2011;Feb 1. Epub ahead of

print.
23. Tan H, Wen SW, Fung Kee, Fung K, Walker M, Demissie K.
The distribution of intra-twin birth weight discordance and
its association with total twin birth weight, gestational age,
and neonatal mortality. Eur J Obstet Gynaecol.
2005:121;2733.
24. Cordera L, Franco A, Joy SD, OShaughnessy RW.
Monochorionic diamniotic infants without
twin-to-twin transfusion syndrome. J Perinatol.
2005;25:7538.
25. Acosta-Rojas R, Becker J, Munoz-Abellana B, Ruiz C,
Carreras E, Gratacos E. Twin chorionicity and the risk of

1280

adverse perinatal outcome. Int J Gynaecol. Obstet

2007;96:98102.
26. Hecher K, Plath H, Bregenzer T, Hansmann M, Hackeloer BJ.
Endoscopic laser surgery versus serial amniocenteses in the
treatment of severe twin-twin transfusion syndrome. Am J
Obstet Gynecol. 1999;180:71724.
27. Senat MV, Deprest J, Boulvain M, Paube A, Winer N, Ville Y.
Endoscopic laser surgery versus serial amnioreduction for
severe twin-to-twin transfusion syndrome. N Engl J Med.
2004;35:13644.
28. Roberts D, Neilson JP, Kilby M, Gates S. Interventions for the
treatment of twin-twin transfusion syndrome. Cochrane
Database Syst Rev. 2008;1:CD002073.


C 2011 The Authors
C 2011 Nordic Federation of Societies of Obstetrics and Gynecology 90 (2011) 12741280
Acta Obstetricia et Gynecologica Scandinavica