Percutaneous legation and transection of the umbilical cord in complicated monoamniotic twin gestations via operative fetoscopy

R. A. Quintero, J. Lanouette, C. A. Carreño, M. King, M. P. Johnson, C. Sudz, R. Romero, M. I. Evans

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OBJECTIVE: Monoamniotic twin gestations with a non-viable fetus represent an inordinately high therapeutic challenge. Cord entanglement or spontaneous fetal demise of one of the fetuses may result in loss of the pregnancy Since vascular communications are present in virtually all cases, KCI selective feticide cannot he performed, and other intravascular methods are unreliable. We report our experience with ligation and transection of the umbilical cord (L&T U-C) to manage these patients. STUDY DESIGN: Four patients with pre-viable monoamniotic twin gestations in which one fetus was considered non-viable were assessed. L&T U-C was offered if the abnormal twin was non-viable or if cord entanglement with obvious hemodynamic compromise of one of the fetuses was present. A normal karyotype was required. Percutaneous L&T U-C was performed under general anesthesia with combined endoscopic and sonographic guidance using 2-3 mm custom-designed ports. Perioperative intravenous tocolysis and antibiotics were given. RESULTS: The mean gestational age at the time of the procedure was 17.5 weeks (range 16-19). Two patients had an acardiac twin with a normal co-twin, 1 patient had a discordant twin with cystic hygroma and dysplastic kidneys, and 1 patient had cord entanglement with pericardial effusion and evidence of hemodynamic decompensation of one of the fetuses by pulsed Doppler. L&T U-C was successfully performed in all cases. When possible, two knots were placed around the umbilical cord, and the transection was performed between the sutures; otherwise, the cord was transected proximal to the anomalous fetus. Post-operative disentanglement of the umbilical cords was documented with ultrasound. The average time gained after L&T U-C was 17 weeks (range 11-21), and all patients delivered after 30 weeks. Premature rupture of membranes (PROM) within three weeks of the procedure occurred in 1/4 (25%) cases, but was sealed with a percutaneous amniopatch and the pregnancy progressed to term. Two patients (50%) were electively delivered at term. One patient developed oligohydramnios and placental insufficiency at 30 weeks, and the other delivered prematurely at 34 weeks. Neonatal outcomes were unremarkable. CONCLUSIONS: L&T U-C is a reliable technique for the management of complicated monoamniotic twin gestations. Transection of the cord effectively avoids the possibility of cord entanglement and subsequent death of the remaining twin. L&T U-C may also be used prior to spontaneous death of a non-viable twin to prevent neurologic and other complications in the survivor. L&T U-C probably should not be offered to otherwise uncomplicated monoamniotic twins. Transection of the umbilical cord may also improve the outcome of complicated diamniotic monochorionic gestations in which the dividing membrane has been breached during ligation of the umbilical cord.

Original languageEnglish
Pages (from-to)S19
JournalActa Diabetologica Latina
Issue number1 PART II
StatePublished - 1997
Externally publishedYes


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