1. Case Presentation Maryam Al-Shabibi OMSB Resident Obstetrics & Gynaecology

2. History 7/9/2009 Mrs. A, 23 years old lady Primigravida at 23 weeks of gestation Referred from Private clinic Monochorionic monoamniotic spontaneous twin pregnancy with one twin fetal demise. Blood group A negative Antenatal period uneventful

3. History ….cont 2 weeks history of low back and abdominal pain and vaginal discharge. Appreciating good fetal movements. No history of vaginal bleeding or draining liqour. No past medical or surgical history.

4. Physical Examination Comfortable Not in pain Vitals normal, afebrile Abdominal examination: uterus relaxed 36 weeks size

5. Physical Examination ….cont Speculom: minimal vaginal discharge seen cervix and vagina look healthy Vaginal exam: cervix 2 cm long, os 1 cm dilated membranes present.

6. Trans abdominal scan done: Monochorionic diamniotic twin pregnancy Twin I : cephalic presentation, no cardiac activity seen, polyhydramnios. Twin II: breech presentation, stuck to the right uterine wall, no cardiac activity seen. Impression: Monochorionic diamniotic twin pregnancy. Both fetal demise. Twin – To – Twin Transfusion Syndrome.

7. Investigations Full blood count Coagulation profile Indirect Coomb Test ( ICT ) : negative

8. Management Explained to the patient. Counseled regarding the need for induction. Booked for induction of labour Readmitted on 12/9/2009 labour induced with 2 doses of prostin.

9. Delivered on 14/9/2009 Outcome: **Twin I : macerated, girl, 520 g with fronto – parietal swelling ** Twin II: macerated, girl, 510 g

10. Received anti D immunoglobulin Uneventful post natal stay Discharged on 15/9/2009