Background: The advancement of fertility medicine and the increasing age of many parturients has contributed to the overall increased frequency of multiple pregnancies since the 1970s. Since that time the number of twins has doubled and the rate of twins has risen from 18.9 to 33.2 per 1,000 births in the U.S. Sadly, single intrauterine fetal demise (IUFD) in twin pregnancies is not rare, occurring in 0.7 percent of dichorionic twin pregnancies before 22 weeks gestation. These patients present a unique and challenging set of considerations for the obstetric anesthesiologists, as outlined below.
Case Description: We present a 35-year-old G2P0 who presented at 24 weeks gestation for preterm labour in the setting of dichorionic-diamniotic twin pregnancy. Her past medical history was significant for back pain following a MVA in the past for which she underwent six different spinal cord stimulator surgeries for placement and removal, which resulted in keloid scars in mid thoracic and upper lumbar distributions. She had known demise of Twin A approximately 4 weeks prior to arrival for which she had been expectantly managed without complication. On admission she was found to have a bulging amniotic sac with A’s fetal parts visible at the cervical os. The plan was for administration of betamethasone for Twin B and expectant management. After lengthy discussions with both the obstetrics team and patient, and baseline coagulation panel was confirmed normal, an epidural was placed with minimal difficulty despite her previous back procedures. On hospital day 2, Twin A was delivered vaginally at 24w1d. Her epidural was maintained until the day following delivery as she was closely monitored to ensure Twin B stability. The patient stabilized and did not continue to labour. After counseling on options, the decision was made to attempt interval delivery of Twin B. On hospital day 5, the patient began to experience painful contractions and it was decided to place another epidural in anticipation of possible delivery. Twin B’s fetal heart rate tracing indicated significant fetal distress and the decision was made to proceed with urgent delivery. Twin B was delivered via uncomplicated c-section under neuraxial anesthesia and taken to the NICU.
Discussion: This case report contains several interesting educational aspects. The management of an IUFD in the setting of di/di twins with a borderline gestational age created a unique patient demographic. Close collaboration with all care teams, the patient and her spouse allowed careful consideration of when to place and duration of epidural through her multiple stages of labour. The placement and management of the epidural during both scenarios required a thorough evaluation. All usual modalities, including regional anesthesia, should be available and reviewed with the patient. It is particularly important for women with IUFD, as they may find labour and delivery physically insufferably harder.
