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      To the Editors:

      Because we imagined a situation in which one twin is found to be dead in the vagina while the sibling is alive in utero, we stated that a policy to prolong the gestation of a second twin after the delivery of its sibling may not be justified in monochorinic twins. Actually, in case 1 the first twin was found to be dead in the vagina at arrival at our hospital, and there was a dichorionic placenta.
      The shared placental circulation of monochorionic twins predisposes a surviving twin to devastating neurologic injury in the event of cotwin death.
      • Fusi L
      • Gordon H
      Twin pregnancy complicated by single intrauterine death: problem and outcome with conservative management.
      Hypotensive ischemia of the brain from hemorrhage, from the surviving twin to the dead twin, through placental anastomoses has been suggested as a cause of neurologic injury.
      • Okamura K
      • Murotsuki J
      • Tanigawara S
      • Uehara S
      • Yajima A
      Funipuncture for evaluation of hematologic and coagulation indices in the surviving twin following co-twin death.
      The comparative rarity of this disorder and the absence of any large study make it difficult to advise patients on the outlook; the optimum management of such patients is not fully established. It is not known whether early or delayed delivery of the second twin is better in such cases.
      In the case presented by Beinder and Lang the first twin was liveborn. In such a case a policy to prolong the gestation of the remaining twin is justified if the first twin is born long before term. Cord ligation of the living twin may not be harmful for the cotwin even in monochorionic twins.
      • Crombleholme TM
      • Robertson F
      • Marx G
      • Yarnell R
      • D'Alton ME
      Fetoscopic cord ligation to prevent neurological injury in monozygous twins.

      References

        • Fusi L
        • Gordon H
        Twin pregnancy complicated by single intrauterine death: problem and outcome with conservative management.
        Br J Obstet Gynaecol. 1990; 97: 511-516
        • Okamura K
        • Murotsuki J
        • Tanigawara S
        • Uehara S
        • Yajima A
        Funipuncture for evaluation of hematologic and coagulation indices in the surviving twin following co-twin death.
        Obstet Gynecol. 1994; 83: 975-978
        • Crombleholme TM
        • Robertson F
        • Marx G
        • Yarnell R
        • D'Alton ME
        Fetoscopic cord ligation to prevent neurological injury in monozygous twins.
        Lancet. 1996; 348: 191