Mechanisms of fetal death in 783 twin pregnancies from 22 weeks at a level3 perinatal center, 1993-98: a quality analysis

Objective To analyze critically the fetal deaths in twin pregnancies follow ed since the beginning of pregnancy and delivered at the same institution a nd to assess the extent to which the goals defined for the prenatal care of twin pregnancies had been met. Those goals included reducing the number of fetal deaths related to fetal intrauterine growth restriction and of unexp lained fetal deaths in late pregnancy. Design This retrospective observational study examined all twin deliveries from 22 weeks of gestation onward in a level 3 referral center from 1 Janua ry 1993 to 31 December 1998. Charts of all fetal deaths were reviewed by a single observer. The major categories of causes of death were twin-twin tra nsfusion syndrome (TTTS), malformations and fetal intrauterine growth restr iction. Methods In the Port Royal Maternity Hospital in Paris, every fetal death wa s classified according to the mechanism: malformation, TTTS, fetal intraute rine growth restriction, unexplained fetal death near term, or ascending in fection. Fetal intrauterine growth restriction was defined according to the French standards for birth weight by weeks of gestation. Population or sample All twin pregnancies delivered at this institution dur ing the study period were included (783 twin pregnancies and 1566 births); they were divided into three categories based on their prenatal care. The f irst group included 610 'early-followed' women, i.e. those receiving prenat al care from early pregnancy at the outpatient clinic at Port Royal Materni ty Hospital. The quality assessment concerns only this group. Two other gro ups of women gave birth to twins in this department: 54 mothers referred at various times of their pregnancy to our prenatal clinic for advice and fol lowed thereafter at this outpatient clinic, and 119 mothers transferred fro m another institution at which they had been hospitalized for a severe comp lication. Results Of the 1220 births to the 610 mothers of the group follow ed from early pregnancy, 11 suffered fetal death (7 per 1000 births), none related to fetal intrauterine growth restriction. No deaths were due to fet al distress during labor. Two cases with fetal infection were considered po tentially avoidable. The mechanisms of fetal death were very different in t he other two groups. Of the 108 births in the group of 54 referred mothers, there were 13 fetal deaths: three acardiac fetuses, three complications of TTTS, and seven different malformations. Of the 238 births in the group of 119 transferred mothers, there were 11 fetal deaths: three related to chor ioamnionitis, six to a complication of ms and two to very severe fetal intr auterine growth restriction. Few were considered avoidable, except that ear lier intervention in some cases of TTTS might have been possible and helpfu l. Conclusions The quality of prenatal to peripartum obstetric care offered in an institution, here a level 3 referral center, can be analyzed only on th e basis of the cases followed from early pregnancy; their results can be co mpared with proposed goals. This analysis showed that the goal of minimizin g fetal deaths related to fetal intrauterine growth restriction was met, as was the goal of minimizing the number of unexplained fetal death near term among twins.