Expectant management in twin pregnancies with discordant structural fetal anomalies

Routine obstetric ultrasound increasingly leads to the detection of structural fetal anomalies. In twin pregnancies with one anomalous twin, counseling on management strategies is complicated.

Twin pregnancies (n = 212) were referred to a tertiary center between January 2007 and July 2009. In a retrospective analysis, twins discordant for a structural fetal anomaly were compared to twins without anomalies in the prenatal ultrasound. Outcome parameters were survival and gestational age at birth.

Anomalies were seen in at least one fetus of 30 twin pairs. The two pregnancies in which the anomalies were concordant were terminated. Selective feticide was performed in three cases of major but non-lethal anomalies in dichorionic twins. The remaining 25 cases were managed expectantly. In three of these cases, spontaneous fetal demise of the affected fetus was observed. In five cases with major (lethal) anomalies, the pregnant women and their partners opted for non-intervention comfort care after birth for the affected fetus. Median gestational age at delivery was 257 days for twins without structural anomalies and was 254 days (n = 22) for twins with one anomalous fetus. This was not significantly different (Mann Whitney U, p = .69). Again, no difference was found for median gestational age at delivery in normal vs. discordant anomalous dichorionic twins if subdivided for chorionicity (Mann Whitney U, p = .68).

In this cohort we describe the request for expectant management by pregnant women and their partners of those twins discordant for major (lethal) anomalies. Expectant management was not associated with increased risk of premature delivery. Fetocide was only opted for in a small number of cases with severe but non-lethal anomalies in dichorionic twins.