Research www. AJOG.

org

OBSTETRICS
Impact of chorionicity on risk and timing of intrauterine
fetal demise in twin pregnancies
Jessica A. McPherson, MD; Anthony O. Odibo, MD, MSCE; Anthony L. Shanks, MD;
Kimberly A. Roehl, MPH; George A. Macones, MD, MSCE; Alison G. Cahill, MD, MSCI

OBJECTIVE: We sought to estimate the association between chorionic-
ity and intrauterine fetal demise (IUFD) of one or both fetuses in twin
pregnancies.
STUDY DESIGN: In a retrospective cohort of twins undergoing ana-
tomic survey, risk of IUFD in monochorionic and dichorionic twins was
compared. The primary outcome was IUFD of one or both fetuses; sec-
ondary outcomes included nonanomalous fetal deaths.
RESULTS: Of 2161 twin pregnancies meeting inclusion criteria, 86 had
at least 1 IUFD and 32 experienced a double fetal loss. Monochorionic
pregnancies had an increased risk of a single demise (adjusted odds
ratio, 1.69; 95% confidence interval, 1.04 2.75) and a double demise
(adjusted odds ratio, 2.11; 95% confidence interval, 1.02 4.37). Of all
double demises, 70% occurred 24 weeks.
CONCLUSION: Monochorionic twins carry an increased risk of fetal
death compared to dichorionic twins. Double demise occurs primarily
24 weeks, regardless of chorionicity.
Key words: intrauterine fetal demise, multiple gestation

Cite this article as: McPherson JA, Odibo AO, Shanks AL, et al. Impact of chorionicity on risk and timing of intrauterine fetal demise in twin pregnancies. Am J
Obstet Gynecol 2012;207:190.e1-6.

S ince 1980, there has been a 70% in-

crease in the number of twin preg-
nancies, attributable to delayed child-
bearing and use of assisted-reproductive
therapies.1,2 It is known that twins carry
a high burden of morbidity and mortal-
ity, with the published risk of intrauter-
ine fetal demise (IUFD) ranging from
2.6 5.8%.3-6 Available data on the com-
parative rates of demise by chorionicity
are limited, predominantly by sample
size and assessment of chorionicity.3,6,7
The largest published studies have ap-
proximately 1000 twin pregnancies and
assessment of chorionicity is often in-
From the Department of Obstetrics and
Gynecology, Washington University in St. Louis
School of Medicine, St. Louis, MO.
Received May 23, 2012; revised May 25, 2012;
accepted July 21, 2012.
A.G.C. is a Physician Faculty Scholar, Robert
Wood Johnson Foundation, which partially
supports this work.
The authors report no conflict of interest.
Reprints: Jessica A. McPherson, MD,
Department of Obstetrics and Gynecology,
Washington University School of Medicine, 660
S. Euclid, Campus Box 8064, St. Louis, MO
63110. mcphersonj@wudosis.wustl.edu.
0002-9378/$36.00
2012 Mosby, Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajog.2012.07.031
complete, or a surrogate such as gender
is used.3,6,7
Additionally, there is little evidence
available to manage women after a twin
pregnancy is complicated by the death of
1 fetus, limiting much of counseling and
management to expert opinion.2,6,7 The
recent systematic review and metaanaly-
sis by Hillman et al8 confirms the need
for additional data on the risk of IUFD of
one or both fetuses in twin pregnancies.
The aims of our study were to estimate
the association between chorionicity and
the risk of IUFD of one or both fetuses
and, further, to describe the effect of
chorionicity on the risk and timing of the
second twin death, in those pregnancies
complicated by a double fetal loss.
M ATERIALS AND M ETHODS
We performed a retrospective cohort
study of all consecutive twin pregnancies
undergoing routine sonographic ana-
tomic survey at 17-22 weeks from 1990
through 2008 at Washington University
Medical Center. The Washington Uni-
versity School of Medicine Human
Studies Review Board approved the
study prior to initiation. Obstetric
sonographers performed all standard-
ized examinations with review and fi-
nal interpretation by maternalfetal
medicine physicians.
Dedicated research nurses collected
the data prospectively. The data were
primarily extracted from medical re-
cords, and then secondarily by the pa-
tient. Each patient provided detailed in-
formation regarding medical history,
obstetrical history, and social history at
the time of the second-trimester ultra-
sound. Each patient was also given a
form to be completed after delivery re-
flecting pregnancy outcomes including
antenatal complications, delivery com-
plications, and neonatal outcomes. If the
form was not completed and received
within 4 weeks of the expected date of
delivery, a research coordinator called
the patient to obtain the information.
The majority of patients (92%) delivered
at our institution; if the patient could not
be reached and delivered at an outside
facility, the coordinator contacted the
referring physician to obtain outcome
data. For twin pregnancies discordant
for outcomes, the details and outcomes
regarding each twin were obtained. Only
twin pregnancies with complete out-
come information were included in this
study.
Study groups were defined by chorio-
nicity, which is a standard component of

190.e1 American Journal of Obstetrics & Gynecology SEPTEMBER 2012

www.AJOG.org
twin pregnancy sonographic examina-
tions.9,10 Final chorionicity designation
was made by the earliest available ultra-
sound and confirmed by pathology spec-
imens in 71% of the pregnancies. Gesta-
tional age was assigned based on the first
day of a womans last menstrual period.
If this dating was not consistent with dat-
ing based on the earliest ultrasound (7
days in the first trimester or 10 days in
the second trimester), the gestational age
was reassigned.11 In twin pairs that were
discordant in size at the time of a dating
ultrasound, the biometry of the larger
twin was used to date the pregnancy as to
err on the side of safety by maximizing
sensitivity for abnormal growth. At the
discretion of the providers but in accor-
dance with typical practice at our insti-
tution, ultrasounds were performed ev-
ery 2 weeks for monochorionic twins to
assess for evidence of twin-to-twin trans-
fusion syndrome (TTTS),12 and every
3-4 weeks for all twins to assess growth.
Antenatal testing with twice-weekly
nonstress tests or biophysical profiles
was initiated at 32 weeks unless there was
a clinical indication for earlier testing.
Dichorionic diamniotic pregnancies
were compared to monochorionic diam-
niotic pregnancies. Monoamniotic preg-
nancies, pregnancies affected by TTTS,
singleton gestations, and higher-order
multiple gestations were excluded from
the study. The primary outcome was
IUFD of one or both fetuses defined as
fetal death 20 weeks and confirmed by
ultrasound examination at our institu-
tion.9 If a fetal death occurred 20
weeks, the pregnancy was not included
in the analysis. Risk of IUFD of either
twin was estimated, as well as the risk of
IUFD of either twin by week of continu-
ing gestation. In the subanalysis of
women who experienced an IUFD of at
least 1 fetus, the effect of chorionicity on
timing of IUFD of the second twin was
described.
Baseline characteristics of women by
chorionicity were compared. The Stu-
dent t test or Mann-Whitney U test was
used for continuous variables and the 2
or Fisher exact test was used for categor-
ical variables as appropriate. The relative
risk of IUFD within the pregnancy and
the 95% confidence interval (CI) were
estimated and compared by chorionic-
ity. Stratified analyses were performed to
identify potentially confounding factors.
Logistic regression analyses were used to
refine the risk estimate by chorionicity
for any IUFD in the pregnancy by adjust-
ing for confounding factors that were
identified by unadjusted and stratified
analyses, as well as those factors histori-
cally reported to be associated with
IUFD. Backward stepwise selection was
used to reduce the number of variables in
the model by assessing the magnitude of
change in the effect size of remaining co-
variates. Differences in the explanatory
model were tested using the likelihood
ratio test or Wald test.13 Statistically
significant variables were included in
the final models. To estimate the risk of
stillbirth of either twin by chorionicity,
conditional logistic regression adjust-
ing for twin clusters was used to ac-
count for nonindependence of twin
pairs and adjust for prior fetal death. A
subanalysis excluding pregnancies af-
fected by known major congenital
anomalies and known chromosomal
abnormalities was performed.
Next, the prospective risk of any
IUFD by chorionicity was calculated
for each week of continuing gestation
using the number of ongoing pregnan-
cies as the denominator. In a subanaly-
sis of women who experienced IUFD of
both twins, gestational age at loss of the
second twin was described by chorio-
nicity. Presence of intrauterine growth
restriction (IUGR), defined as birth-
weight 10th percentile by the Alexan-
der growth standard,14 was described
within pregnancies experiencing single
or double fetal loss. Finally, women who
experienced a double fetal demise were
compared to those who lost 1 twin to
identify possible factors, besides chorio-
nicity, associated with risk of a second
twin loss. Statistical analyses were per-
formed using STATA 10.0, special edi-
tion (StataCorp, College Station, TX).
R ESULTS
Of 2445 twin intrauterine pregnancies,
2333 met inclusion criteria. Of those,
2161 (92.6%) had complete outcome
data and were included in the analysis;
SEPTEMBER 2012 American Journal of Obstetrics & Gynecology
Obstetrics Research
496 (23%) were monochorionic and
1665 (77%) were dichorionic pregnan-
cies (Figure).
The 2 groups were similar in terms of
gravidity, nulliparity, rates of pre-
eclampsia, pregestational diabetes, ges-
tational diabetes, history of preterm de-
livery including spontaneous preterm
delivery, IUGR, and having any major
congenital anomaly diagnosed during
the pregnancy (Table 1). Women carry-
ing monochorionic twins on average
were younger, delivered at an earlier ges-
tational age, were more likely to be
smokers, and were more likely to report
alcohol exposure during the pregnancy.
Women carrying dichorionic twins were
more likely to have a body mass index
30 kg/m2, be of African American race,
have chronic hypertension, and have a
history of an IUFD. Women excluded
for lack of follow-up were generally sta-
tistically similar, although less advanced
maternal age, and they were more likely
to be African American, be obese, and
use tobacco.
Monochorionic pregnancies were at
increased risk of at least 1 fetal demise
(adjusted odds ratio [OR], 1.69; 95% CI,
1.04 2.75) as well as an increased risk of
a double fetal demise (adjusted OR, 2.11;
95% CI, 1.02 4.37) when compared to
dichorionic pregnancies (Table 2). Risk
of IUFD of either twin within a mono-
chorionic compared to a dichorionic
pregnancy was also significantly in-
creased and remained increased after ad-
justing for fetal demise in a prior preg-
nancy (adjusted OR, 1.74; 95% CI, 1.10
2.78). When excluding pregnancies
complicated by any major congenital
anomaly, monochorionic pregnancies
remained at increased risk of a single
IUFD; the increased risk of a double fetal
demise did not reach statistical signifi-
cance. The prospective risk of IUFD
within the pregnancy for ongoing preg-
nancies by week of gestation starting at
20 weeks is presented in Table 3. A
greater risk for any IUFD was observed
in women with monochorionic com-
pared to dichorionic twins throughout
gestation, particularly in the second tri-
mester. The risk for any IUFD decreased
as pregnancy progressed.
190.e2
Research Obstetrics
FIGURE
Flow diagram of study participants
496 monochorionic
diamnio
c twins (22.9%)
30 cases of single 12 cases of double
fetal demise
(6.0% of MC twins) (2.4% of MC twins)
DC, dichorionic diamniotic; MC, monochorionic diamniotic; TTTS, twin-to-twin transfusion syndrome.
McPherson. Fetal death in twin pregnancies. Am J Obstet Gynecol 2012.
Within the 86 pregnancies that expe-
rienced at least 1 fetal death, 32 subse-
quently had a second demise; 12 were
monochorionic and 20 were dichori-
onic. Table 4 presents the timing of diag-
nosis of the second demise by chorionic-
ity. Seven of 12 monochorionic and 15 of
20 dichorionic pregnancies had the sec-
ond demise diagnosed 24 weeks
(58.3% vs 75.0%, Fisher exact P .81).
Double demises were diagnosed at the
same examination in 23 cases: 8 of the
monochorionic and 15 of the dichori-
onic pregnancies. The majority were si-
multaneously diagnosed 24 weeks (17/
190.e3 American Journal of Obstetrics & Gynecology SEPTEMBER 2012
www.AJOG.org
were assessed, African American race
(OR, 4.65; 95% CI, 1.6113.47) was as-
sociated with an increase in risk, but pre-
eclampsia, chronic hypertension, and di-
2445 live twins >20 weeks
abetes were not.
C OMMENT
Exclusion (n = 112): In our cohort, we found the risk of IUFD
- Monoamnio
c twins
to be significantly increased in mono-
- TTTS
- Higher order mul
ples chorionic pregnancies. Second twin loss
after IUFD of the first twin occurred pre-
dominantly 24 weeks gestation, re-
gardless of chorionicity.
2333 twins mee
ng inclusion There is a paucity of published data on
criteria (95.4%)
the rare, but clinically important occur-
rence of stillbirth in twin pregnancies. In
a retrospective cohort study by Lee et al3
looking at 1000 twin pregnancies, they
Lost to follow-up (n = 172)
found a nearly 4-fold increase in IUFD in
monochorionic twin pregnancies when
compared to dichorionic pregnancies.
This is greater than the risk that we
found; however, in the initial analysis by
2161 twins with complete
follow-up (92.6%) Lee et al,3 pregnancies affected by TTTS,
growth discordance, IUGR, and major
anomalies were not excluded. When
those pregnancies were excluded, there
was no evidence for increased risk of fetal
1665 dichorionic
diamnio
c twins (77.1%) death in monochorionic pregnancies.
The authors did acknowledge that sam-
ple size was a possible limitation and
thus the lack of statistically significant
findings may represent a type II error.
fetal demise
56 cases of single 20 cases of double The authors did not evaluate those preg-
fetal demise fetal demise
(3.4% of DC twins) (1.2% of DC twins) nancies suffering a second demise sepa-
rately and, therefore, did not comment
on temporal risk of suffering a second
loss after an initial demise.
Ong et al7 completed a systematic re-
view to evaluate morbidity and mortality
23, 70%). Only 10 patients with a double of a surviving twin after a single demise.
demise experienced death of the second The review included 19 studies and a to-
twin after viability; 5 were monochori- tal of 904 twin pregnancies with at least a
onic and 5 were dichorionic. single demise. Nineteen of the 904 preg-
There was no difference by chorionicity nancies progressed to complete preg-
in rate of growth restriction among the 118 nancy loss (2.1%), which was similar to
fetal deaths (86 pregnancies with at least a our study. They cited a 6-fold increased
single demise and 32 with a double de- risk for complete pregnancy loss in
mise). Growth restriction was present in 13 monochorionic pregnancies, which was
of 76 (17.1%) fetuses in dichorionic and 10 higher than our findings. However, cho-
of 42 (23.8%) fetuses in monochorionic rionicity data were missing on 18%
pregnancies (Fisher exact P .62) expe- of the pregnancies and gestational age of
riencing an intrauterine death. Finally, the initial demise was missing in 36% of
when additional risk factors for IUFD of the pregnancies. A subset of the studies
the second twin besides chorionicity included was lacking information on
www.AJOG.org Obstetrics Research

TABLE 1
Characteristics of women with monochorionic compared to dichorionic
twins, and those excluded for lack of follow-up
Monochorionic Dichorionic No outcome
Characteristics n 496 n 1665 P valuea n 172
Age, y 29.8 6.2 31.4 5.9 .01 29.1 6.0
................................................................................................................................................................................................................................................................................................................................................................................
Age 35 y 23.2 29.3 .01 6.3
................................................................................................................................................................................................................................................................................................................................................................................
Gravidity 2.6 1.5 2.6 1.6 .78 3.1 2.2
................................................................................................................................................................................................................................................................................................................................................................................
Nulliparity 27.0 27.3 .91 27.8
................................................................................................................................................................................................................................................................................................................................................................................
Gestational age at delivery, wk 33.9 4.8 34.8 4.2 .01 N/A
................................................................................................................................................................................................................................................................................................................................................................................
BMI, kg/m 2
25.1 6.4 26.0 7.0 .01 27.04 7.5
................................................................................................................................................................................................................................................................................................................................................................................
BMI 30 kg/m 2
16.6 22.0 .01 22.8
................................................................................................................................................................................................................................................................................................................................................................................
African American 17.1 21.7 .03 46.2
................................................................................................................................................................................................................................................................................................................................................................................
Tobacco use 13.1 9.1 .01 14.6
................................................................................................................................................................................................................................................................................................................................................................................
Alcohol use 16.2 11.7 .01 10.3
................................................................................................................................................................................................................................................................................................................................................................................
Chronic hypertension 1.4 3.3 .03 2.1
................................................................................................................................................................................................................................................................................................................................................................................
Preeclampsia 17.9 20.9 .13 10.8
................................................................................................................................................................................................................................................................................................................................................................................
Pregestational diabetes 0.6 1.2 .26 1.9
................................................................................................................................................................................................................................................................................................................................................................................
Gestational diabetes 6.5 6.2 .82 8.1
................................................................................................................................................................................................................................................................................................................................................................................
History of IUFD 1.8 3.0 .15 1.9
................................................................................................................................................................................................................................................................................................................................................................................
History of preterm delivery 5.2 6.7 .25 7.1
................................................................................................................................................................................................................................................................................................................................................................................
Birthweight 10th percentile b
25.1 21.0 .32 N/A
................................................................................................................................................................................................................................................................................................................................................................................
c
Any anomaly 1.6 2.3 .33 2.5
................................................................................................................................................................................................................................................................................................................................................................................
Data are mean SD or percent unless otherwise specified.
BMI, body mass index; IUFD, intrauterine fetal demise; N/A, not applicable.
a
Comparing monochorionic and dichorionic groups only; b Based on Alexander birth standard; c Includes any major congenital anomaly identified in either twin.
McPherson. Fetal death in twin pregnancies. Am J Obstet Gynecol 2012.

TTTS, anomalies, and maternal illness. despite a robust literature search sum- Johnson and Zhang6 examined the
In a more recent review by Hillman et marizing 16 articles, this estimate was risk of IUFD in twin pregnancies and
al,8 summary statistics were provided based on only 17 pregnancies compli- survival of the remaining twin after a sin-
and were similar to those of Ong et al,7 cated by double fetal demise. Both the gle demise. A single fetal demise occurred
citing a 5-fold increased risk of complete small sample size and significant hetero- in 2.6% of twin pregnancies included in
pregnancy loss in monochorionic com- geneity make interpretation of these risk their study. They found that same sex
pared to dichorionic twins. However, estimates challenging. twins were 2 times more likely than oppo-

TABLE 2
Risk of intrauterine fetal demise in monochorionic compared to dichorionic twin pregnancies
Monochorionic Dichorionic Unadjusted RR Adjusted OR
Outcome n 496 n 1665 (95% CI) (95% CI) P value
Any IUFD (n 86) 6.0% (n 30) 3.4% (n 56) 1.76 (1.152.72) 1.69a (1.042.75) .03
................................................................................................................................................................................................................................................................................................................................................................................
IUFD of both (n 32) 2.4% (n 12) 1.2% (n 20) 1.65 (1.052.60) b
2.11 (1.024.37) .04
................................................................................................................................................................................................................................................................................................................................................................................
Any nonanomalous IUFD 5.7% (n 28) 3.0% (n 49) 1.61 (1.192.19) a
1.87 (1.123.10) .02
(n 77)
................................................................................................................................................................................................................................................................................................................................................................................
Nonanomalous IUFD of both 2.3% (n 11) 1.2% (n 19) 1.60 (0.992.58) b
2.02 (0.954.30) .07
(n 30)
................................................................................................................................................................................................................................................................................................................................................................................
CI, confidence interval; IUFD, intrauterine fetal demise; OR, odds ratio; RR, relative risk.
a
Adjusted for gestational age at delivery, history of IUFD; b Adjusted for history of IUFD.
McPherson. Fetal death in twin pregnancies. Am J Obstet Gynecol 2012.

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Research Obstetrics www.AJOG.org

founders may remain. Chorionicity was

TABLE 3 diagnosed by ultrasound and confirmed
Risk of any intrauterine fetal demise in by pathology in most, but not all preg-
pregnancy >20 weeks by chorionicity nancies, which inherently introduces the
Monochorionic Dichorionic potential for misclassification bias. We
would offer that this misclassification was
Ongoing Ongoing
pregnancies, IUFD, Prospective risk pregnancies, IUFD, Prospective risk nondifferential with respect to the out-
wk n n of IUFD, % n n of IUFD, % come of interest given that the timing of
20-21 496 12 6.0 1665 15 3.4 chorionicity determination was weeks to
..............................................................................................................................................................................................................................................
months before fetal death, and thus would
22-23 483 4 3.7 1644 12 2.5
.............................................................................................................................................................................................................................................. bias our results toward the null. The pre-
24-25 477 2 2.9 1633 4 1.8 cise timing of demise is typically indeter-
..............................................................................................................................................................................................................................................
26-27 471 6 2.5 1619 2 1.5 minable, but ultrasound diagnosis is what
..............................................................................................................................................................................................................................................
28-29 452 2 1.3 1595 6 1.4 is available to clinicians, which increases
..............................................................................................................................................................................................................................................
the clinical generalizability and applicabil-
30-31 430 2 0.9 1561 3 1.1
.............................................................................................................................................................................................................................................. ity of our study. It remains important,
32-33 401 0 0.5 1470 3 1.0 however, to consider our results within
..............................................................................................................................................................................................................................................
34-35 349 2 0.1 1300 5 0.8 the framework of ultrasound diagnosis.
..............................................................................................................................................................................................................................................
36-37 225 0 881 6 0.7 While this is one of the largest samples of
..............................................................................................................................................................................................................................................
twins with robust follow-up data and
38 67 0 254 0
.............................................................................................................................................................................................................................................. chorionicity determinations to study
Total 496 30 1665 56 IUFD in twin pregnancies, the absolute
..............................................................................................................................................................................................................................................
IUFD, intrauterine fetal demise. number of events limits precision of risk
McPherson. Fetal death in twin pregnancies. Am J Obstet Gynecol 2012. estimates. Also, generalizability is lim-
ited to women presenting to anatomic
survey with 2 live fetuses, as those with
site sex twins to suffer a second death after used. Our robust database allowed us to an earlier demise were excluded. Lastly,
a single demise between 25-32 weeks and 3 estimate the effect of chorionicity on fe- given that our institution is a tertiary
times more likely 33 weeks. Overall, the tal death without using surrogate mark- care referral center with high-risk preg-
risk of complete pregnancy loss after a sin- ers such as fetal gender, and to further nancies, reflected by the rates of pre-
gle demise was inversely related to gesta- address the clinically relevant questions eclampsia and preterm birth in the co-
tional age at the time of death, similar to of timing of IUFD of both a single fetus hort, the results of the study may not be
our findings. The authors of the study did and a subsequent fetus when applicable. applicable to all populations.
not have chorionicity information avail- The information in the database was col- In our cohort, we observed that
able. While clearly recognizing the im- lected prospectively and complete fol- monochorionic twin pregnancies are at
portance of this information by using low-up was available in 90% of an approximately 2-fold increased risk of
gender as a surrogate marker, gender dif- women, which allowed us to evaluate the single and double fetal demise as com-
ference remains only a surrogate, and effects of confounding factors and lim- pared to dichorionic twin pregnancies.
thus limits the conclusions that can be ited the potential for selection bias. Although the risk of IUFD is lower in di-
drawn from these results. Our study does have limitations that chorionic twin pregnancies, there re-
A major strength of our study is the are important to consider when inter- mains a clinically significant absolute
relatively large sample size of twin preg- preting our results. The observational risk. Our study does not allow us to com-
nancies that allowed us to study a rare nature of the study is a potential limita- ment on etiology, however, previous
but clinically important outcome, IUFD. tion. While multivariable regression data have described vascular accidents
An additional strength is the compre- analyses were used to adjust for group occurring after a single demise in mono-
hensive ultrasound database that was differences, unmeasured potential con- chorionic pregnancies that lead to mor-
bidity and mortality for the surviving
TABLE 4 twin.5 This has not been described in di-
Gestational age of intrauterine fetal demise of second twin chorionic pregnancies, and mechanisms
after intrauterine fetal demise of first by chorionicity for the increased risk of fetal death in di-
chorionic pregnancies remains to be
Variable <24 wk 24-28 wk 28-34 wk >34 wk elucidated.
Monochorionic (n 12) 7 (58.3%) 3 (25.0%) 2 (16.7%) 0 The information from this study can
..............................................................................................................................................................................................................................................
Dichorionic (n 20) 15 (75.0%) 3 (15.0%) 0 2 (10.0%) be used to counsel women regarding in-
..............................................................................................................................................................................................................................................
McPherson. Fetal death in twin pregnancies. Am J Obstet Gynecol 2012.
crease in risk of fetal death in monocho-
rionic twin pregnancies. These data can

190.e5 American Journal of Obstetrics & Gynecology SEPTEMBER 2012

www.AJOG.org
also provide some guidance in the rare
circumstance of a single IUFD in an on-
going twin pregnancy, particularly given
that death of the second twin occurs
rarely after viability is reached, regardless
of chorionicity. f Semin Perinatol 1995;19:375-86.
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