Objective: To evaluate the incidence, type and severity of cerebral injury in the surviving monochorionic (MC) cotwin after single fetal demise in twin pregnancies.Methods: All MC pregnancies with single fetal demise that were evaluated at the Leiden University Medical Center between 2002 and 2013 were included. Perinatal characteristics, neonatal outcome and the presence of cerebral injury, observed on neuroimaging, were recorded for all cotwin survivors.Results: A total of 49 MC pregnancies with single fetal demise, including one MC triplet, were included in the study (n = 50 cotwins). Median gestational age at occurrence of single fetal demise was 25 weeks and median interval between single fetal demise and live birth was 61 days, with a median gestational age at birth of 36 weeks. Severe cerebral injury was diagnosed in 13 (26%) of the 50 cotwins and was detected antenatally in 4/50 (8%) and postnatally in 9/50 (18%) cases. Cerebral injury was mostly due to hypoxic‐ischemic injury resulting in cystic periventricular leukomalacia, middle cerebral artery infarction or injury to basal ganglia, thalamus and/or cortex. Risk factors associated with severe cerebral injury were advanced gestational age at the occurrence of single fetal demise (odds ratio (OR), 1.14 (95% CI, 1.01–1.29) for each week of gestation; P = 0.03), twin–twin transfusion syndrome developing prior to single fetal demise (OR, 5.0 (95% CI, 1.30–19.13); P = 0.02) and a lower gestational age at birth (OR, 0.83 (95% CI, 0.69–0.99) for each week of gestation; P = 0.04).Conclusions: Single fetal demise in MC pregnancies is associated with severe cerebral injury occurring in 1 in 4 surviving cotwins. Routine antenatal and postnatal neuroimaging, followed by standardized long‐term follow‐up, is mandatory. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd.

Objective: To estimate the odds of severe cerebral injury and long-term neurodevelopmental impairment in monochorionic twins treated with amnioreduction versus laser surgery for twin-twin transfusion syndrome. Methods: A systematic review and meta-analysis of studies on cerebral injury and long-term impairment after amnioreduction versus laser surgery were conducted. Odds ratios (OR) with their 95% confidence interval (CI) were computed. Results: Electronic and manual search identified 63 references. Five studies were included for analysis. We found an ample seven-fold higher risk of severe cerebral injury in live-born children treated with amnioreduction compared to laser (OR 7.69, 95% CI 2.78-20.0, p = 0.00). In children surviving the neonatal period, the odds were three-times higher following amnioreduction (OR 3.23, 95% CI 1.45-7.14, p = 0.00). Although not significant, monochorionic twins treated with amnioreduction had higher odds of periventricular leukomalacia and intraventricular hemorrhage (OR 2.08, 95% CI 0.86-5.00, p = 0.10 and OR 3.56, 95% CI 0.82-14.29, p = 0.09). Unfortunately, there were insufficient long-term outcome data available to estimate the odds of neurodevelopmental impairment. Conclusion: Amnioreduction is associated with an increased risk of severe cerebral injury compared to laser surgery in twin-twin transfusion syndrome. Our study highlights a lack of studies focusing on long-term neurodevelopmental outcome. Follow-up into childhood is indispensable to determine outcome in terms of motor, cognitive and socioemotional development.

Twin–twin transfusion syndrome (TTTS) is a severe complication of monochorionic (MC) twin pregnancies associated with high perinatal mortality and morbidity rates. Management in TTTS is a major challenge for obstetricians and neonatologists. Twins with TTTS are often born prematurely after an extremely distressing and highly hazardous fetal period. Follow-up studies report varying rates of cerebral palsy (CP) and long-term neurodevelopmental impairment (NDI). This review discusses the latest findings on the long-term outcome of TTTS survivors, possible risk factors for long-term impairment, and provides recommendations for future research.