General approach to minimizing perinatal mortality in monoamniotic twin pregnancies

FGR: fetal growth restriction; FHR: fetal heart rate; NST: nonstress test; TAPS: twin anemia polycythemia sequence; TTTS: twin-twin transfusion syndrome.

* Refer to UpToDate table on ultrasound screening protocol for monitoring monochorionic multifetal pregnancies.

¶ The frequency and duration of FHR monitoring varies among providers. Outpatients are typically monitored for 60 minutes two to three times per week. Inpatients may be monitored for 60 minutes or just until an NST is reactive; in either case, monitoring is performed two to three times per day.

Δ A rescue course of antenatal corticosteroids may be administered to patients who remain undelivered after three weeks. Refer to UpToDate content on antenatal corticosteroids.

◊ Guidelines consistently suggest cesarean birth for monoamniotic twin pregnancies to avoid intrapartum complications from cord entanglement and this is our preferred route of birth. This cautionary approach is based on expert opinion; no randomized trials or large cohort studies have been performed. Some providers, however, have offered a trial of labor and had good outcomes if the first twin is cephalic, the twins are concordant in size, and a well-informed patient chooses this approach.