PP-010 A Case of monochorionic monoamniotic twins with cord entanglement and its outcome

Monoamniotic twin gestations are rare occurring 1 in 12500 births making up <1% of all twin pregnancies.The outcome of monozygotic twinning depends on when division occurs. If it occurs after 8 days of fertilization as chorion and amnion are already differentiated.  The main factor associated with perinatal mortality of Monochorionic  monoamniotic  twins are umbilical cord entanglement, cord accidents, congenital malformations, preterm delivery, fetal loss, TTTS, congenital anomalies. We present a peculiar case of cord entanglement in monochorionic monoamniotic twins who presented to us at 34 weeks gestation with follow up had positive outcome

G2P1L1 with monochorionic monoamniotic twin gestation who was under regular follow up presented to us at 34 weeks gestation in labor with scan showing Monochorionic monoamniotic twins with twin 1 in cephalic and twin 2 in breech presentation with normal interval growth scan and doppler. NST was reactive. She underwent emergency section, revealing intraoperative findings consistent with cord entanglement. Subsequent follow-up confirmed a positive perinatal outcome.

Patient was admitted at 31 weeks for prophylactic steroid administration (4 doses dexamethasone 6mg im given 12 hours apart). Routine investigations with obstetric ultrasound done found to be within normal limits. Intraoperative findings ; lower uterine segment was well formed with clear and adequate liquor drained. Twin 1 extracted by vertex, twin 2 extracted by breech. One loop of cord was present around neck of twin 2. Hyper coiling of the cord present of about 30cm with cord entanglement with multiple true knots. Total length of the cord was about 50 cm.Figure-1. Both babies cried immediately after birth. Placenta was monochorionic monoamniotic type weighing 1 kilogram. Both babies  were transferred to the Neonatal Intensive Care Unit and underwent continuous monitoring Figure-2.They demonstrated gradual improvement, eventually being successfully weaned off respiratory support and initiated on feeding. On Day 13, they were shifted to ward fFigure-3. and were discharged on day 19.

Monoamniotic twins are admitted at 24-28 weeks for daily fetal heart rate monitoring. The optimal surveillance strategy remains uncertain but may involve non-stress testing (NST) or assessment of biophysical profiles. Betamethasone is administered for pulmonary maturation. If fetal testing remains reassuring and no other concerns arise, delivery via cesarean section is typically scheduled between 32-34 weeks to prevent umbilical cord accidents.