Laboratory Studies

Recent vanishing twin has been shown to increase levels of pregnancy-associated plasma protein-A (PAPP-A) and free beta-human chorionic gonadotropin (beta-hCG). This may affect risk assessment for aneuploidy in the surviving fetus.^[31]

Alpha-fetoprotein levels are elevated compared with values at similar junctures in both a singleton pregnancy and a normal twin pregnancy.^[4]

The rate of rise of beta-hCG is slower than in a normal twin pregnancy.^[32]

If vanishing twin syndrome is diagnosed at the time of nuchal translucency ultrasound, biochemical screening markers may not be as precise as in singleton assisted-reproductive technique pregnancies.^[33]

The use of biochemical markers may be indicated if, at the time of nuchal translucency, a vanishing twin is confirmed to have an empty gestational sac; however, if a dead fetus remains, biochemical markers are not accurate for screening.^[34]

Other tests

Amniocentesis after diagnosis of a vanishing twin by prior ultrasonography has been reported to detect an XY cell by both FISH and real-time PCR in the sustained XX 20 weeks' gestation pregnancy. Take caution about interpretation of amniocentesis results because a vanishing twin fetus could lead to false-positive results.^[27]

Imaging studies

Ultrasonography is used to confirm the diagnosis of early twin pregnancy. Follow-up ultrasonography reveals the pregnancy loss (vanishing twin).^{[13, 35]} In addition, after diagnosing first-trimester bleeding, using ultrasonography before dilation and curettage is important. This ensures that bleeding does not signal the loss of just one fetus.

Chorionic villus sampling

Chorionic villus sampling may be helpful if the placenta has a mosaic makeup and there is a singleton at birth.

Histologic findings

Obtain histologic samples of the placenta at birth, because they may be the only evidence of vanishing twin syndrome with a reabsorbed fetus.^{[3, 9, 12]}

Treatment & Management

Landy HJ, Weiner S, Corson SL, et al. The "vanishing twin": ultrasonographic assessment of fetal disappearance in the first trimester. Am J Obstet Gynecol. 1986 Jul. 155(1):14-9. [QxMD MEDLINE Link].
Saidi MH. First-trimester bleeding and the vanishing twin. A report of three cases. J Reprod Med. 1988 Oct. 33(10):831-4. [QxMD MEDLINE Link].
Sulak LE, Dodson MG. The vanishing twin: pathologic confirmation of an ultrasonographic phenomenon. Obstet Gynecol. 1986 Dec. 68(6):811-5. [QxMD MEDLINE Link].
Abbas A, Johnson M, Bersinger N, Nicolaides K. Maternal alpha-fetoprotein levels in multiple pregnancies. Br J Obstet Gynaecol. 1994 Feb. 101(2):156-8. [QxMD MEDLINE Link].
Sampson A, de Crespigny LC. Vanishing twins: the frequency of spontaneous fetal reduction of a twin pregnancy. Ultrasound Obstet Gynecol. 1992 Mar 1. 2(2):107-9. [QxMD MEDLINE Link].
Landy HJ, Keith LG. The vanishing twin: a review. Hum Reprod Update. 1998 Mar-Apr. 4(2):177-83. [QxMD MEDLINE Link].
Yoshida K, Soma H. Outcome of the surviving cotwin of a fetus papyraceus or of a dead fetus. Acta Genet Med Gemellol (Roma). 1986. 35(1-2):91-8. [QxMD MEDLINE Link].
Yoshida K, Matayoshi K. A study on prognosis of surviving cotwin. Acta Genet Med Gemellol (Roma). 1990. 39(3):383-8. [QxMD MEDLINE Link].
Callen DF, Fernandez H, Hull YJ, Svigos JM, Chambers HM, Sutherland GR. A normal 46,XX infant with a 46,XX/69,XXY placenta: a major contribution to the placenta is from a resorbed twin. Prenat Diagn. 1991 Jul. 11(7):437-42. [QxMD MEDLINE Link].
Reddy KS, Petersen MB, Antonarakis SE, Blakemore KJ. The vanishing twin: an explanation for discordance between chorionic villus karyotype and fetal phenotype. Prenat Diagn. 1991 Sep. 11(9):679-84. [QxMD MEDLINE Link].
Lloveras E, Lecumberri JM, Perez C, et al. A female infant with a 46,XX/48,XY, +8, +10 karyotype in prenatal diagnosis: a 'vanishing twin' phenomenon?. Prenat Diagn. 2001 Oct. 21(10):896-7. [QxMD MEDLINE Link].
Verstraete L, Costa JM, Chantot-Bastaraud S, Siffroi JP, Fiori O, Uzan S. Finding a single XY cell among XX cells in amniotic fluid by FISH: a possible consequence of a vanishing male twin?. Prenat Diagn. 2007 Jan. 27(1):85-6. [QxMD MEDLINE Link].
Pharoah PO, Cooke RW. A hypothesis for the aetiology of spastic cerebral palsy--the vanishing twin. Dev Med Child Neurol. 1997 May. 39(5):292-6. [QxMD MEDLINE Link].
Classen DA. Aplasia cutis congenita associated with fetus papyraceous. Cutis. 1999 Aug. 64(2):104-6. [QxMD MEDLINE Link].
Almog B, Levin I, Wagman I, Kapustiansky R, Lessing JB, Amit A, et al. Adverse obstetric outcome for the vanishing twin syndrome. Reprod Biomed Online. 2010 Feb. 20(2):256-260. [QxMD MEDLINE Link].
Sazonova A, Kallen K, Thurin-Kjellberg A, Wennerholm UB, Bergh C. Factors affecting obstetric outcome of singletons born after IVF. Hum Reprod. 2011 Oct. 26(10):2878-86. [QxMD MEDLINE Link].
Shebl O, Ebner T, Sommergruber M, Sir A, Tews G. Birth weight is lower for survivors of the vanishing twin syndrome: a case-control study. Fertil Steril. 2008 Aug. 90(2):310-4. [QxMD MEDLINE Link].
Benirschke K. Intrauterine death of a twin: mechanisms, implications for surviving twin, and placental pathology. Semin Diagn Pathol. 1993 Aug. 10(3):222-31. [QxMD MEDLINE Link].
Anand D, Platt MJ, Pharoah PO. Vanishing twin: a possible cause of cerebral impairment. Twin Res Hum Genet. 2007 Feb. 10(1):202-9. [QxMD MEDLINE Link].
Pharoah PO. Prevalence and pathogenesis of congenital anomalies in cerebral palsy. Arch Dis Child Fetal Neonatal Ed. 2007 Nov. 92(6):F489-93. [QxMD MEDLINE Link].
Maccario S, Fasolato V, Brunelli A, Martinelli S. Aplasia cutis congenita: an association with vanishing twin syndrome. Eur J Dermatol. 2009 Jul-Aug. 19(4):372-4. [QxMD MEDLINE Link].
Pinborg A, Lidegaard O, Andersen AN. The vanishing twin: a major determinant of infant outcome in IVF singleton births. Br J Hosp Med (Lond). 2006 Aug. 67(8):417-20. [QxMD MEDLINE Link].
Evron E, Sheiner E, Friger M, Sergienko R, Harlev A. Vanishing twin syndrome: is it associated with adverse perinatal outcome?. Fertil Steril. 2015 May. 103 (5):1209-14. [QxMD MEDLINE Link].
Sarhan A, Beydoun H, Jones HW Jr, Bocca S, Oehninger S, Stadtmauer L. Gonadotrophin ovulation induction and enhancement outcomes: analysis of more than 1400 cycles. Reprod Biomed Online. 2011 Aug. 23(2):220-6. [QxMD MEDLINE Link].
Harris AL, Sacha CR, Basnet KM, et al. Vanishing twins conceived through fresh in vitro fertilization: obstetric outcomes and placental pathology. Obstet Gynecol. 2020 Jun. 135 (6):1426-33. [QxMD MEDLINE Link].
Jauniaux E, Elkazen N, Leroy F, et al. Clinical and morphologic aspects of the vanishing twin phenomenon. Obstet Gynecol. 1988 Oct. 72(4):577-81. [QxMD MEDLINE Link].
Rudnicki M, Vejerslev LO, Junge J. The vanishing twin: morphologic and cytogenetic evaluation of an ultrasonographic phenomenon. Gynecol Obstet Invest. 1991. 31(3):141-5. [QxMD MEDLINE Link].
Pinborg A. IVF/ICSI twin pregnancies: risks and prevention. Hum Reprod Update. 2005 Nov-Dec. 11(6):575-93. [QxMD MEDLINE Link].
Bryan E. Loss in higher multiple pregnancy and multifetal pregnancy reduction. Twin Res. 2002 Jun. 5(3):169-74. [QxMD MEDLINE Link].
De Pascalis L, Monti F, Agostini F, Fagandini P, La Sala GB, Blickstein I. Psychological vulnerability of Singleton children after the 'vanishing' of a co-twin following assisted reproduction. Twin Res Hum Genet. 2008 Feb. 11(1):93-8. [QxMD MEDLINE Link].
Chasen ST, Perni SC, Predanic M, Kalish RB, Chervenak FA. Does a "vanishing twin" affect first-trimester biochemistry in Down syndrome risk assessment?. Am J Obstet Gynecol. 2006 Jul. 195(1):236-9. [QxMD MEDLINE Link].
Kelly MP, Molo MW, Maclin VM, Binor Z, Rawlins RG, Radwanska E. Human chorionic gonadotropin rise in normal and vanishing twin pregnancies. Fertil Steril. 1991 Aug. 56(2):221-4. [QxMD MEDLINE Link].
Gjerris AC, Loft A, Pinborg A, Christiansen M, Tabor A. The effect of a 'vanishing twin' on biochemical and ultrasound first trimester screening markers for Down's syndrome in pregnancies conceived by assisted reproductive technology. Hum Reprod. 2009 Jan. 24(1):55-62. [QxMD MEDLINE Link].
Gjerris AC, Tabor A, Loft A, Christiansen M, Pinborg A. First trimester prenatal screening among women pregnant after IVF/ICSI. Hum Reprod Update. 2012 Jul. 18(4):350-9. [QxMD MEDLINE Link].
Blumenfeld Z, Dirnfeld M, Abramovici H, et al. Spontaneous fetal reduction in multiple gestations assessed by transvaginal ultrasound. Br J Obstet Gynaecol. 1992 Apr. 99(4):333-7. [QxMD MEDLINE Link].
Lau WC, Rogers MS. Fetus papyraceous: an unusual cause of obstructed labour. Eur J Obstet Gynecol Reprod Biol. 1999 Sep. 86(1):109-11. [QxMD MEDLINE Link].
Pinborg A, Lidegaard O, Freiesleben NC, Andersen AN. Vanishing twins: a predictor of small-for-gestational age in IVF singletons. Hum Reprod. 2007 Oct. 22(10):2707-14. [QxMD MEDLINE Link].
Shebl O, Ebner T, Sommergruber M, Sir A, Tews G. Birth weight is lower for survivors of the vanishing twin syndrome: a case-control study. Fertil Steril. 2008 Aug. 90 (2):310-4. [QxMD MEDLINE Link].
Anand D, Platt MJ, Pharoah PO. Comparative development of surviving co-twins of vanishing twin conceptions, twins and singletons. Twin Res Hum Genet. 2007 Feb. 10(1):210-5. [QxMD MEDLINE Link].
Pharoah PO. Neurological outcome in twins. Semin Neonatol. 2002 Jun. 7(3):223-30. [QxMD MEDLINE Link].
Pinborg A, Lidegaard O, la Cour Freiesleben N, Andersen AN. Consequences of vanishing twins in IVF/ICSI pregnancies. Hum Reprod. Oct 2005. 20(10):2821-9. [QxMD MEDLINE Link].

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Author

Ann L Anderson-Berry, MD, PhD Associate Professor of Pediatrics, Section of Newborn Medicine, University of Nebraska Medical Center, Creighton University School of Medicine; Medical Director, NICU, Nebraska Medical Center

Ann L Anderson-Berry, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, Nebraska Medical Association, Society for Pediatric Research

Disclosure: Nothing to disclose.

Coauthor(s)

Terence Zach, MD Professor, Department Chair, Department of Pediatrics, Section of Newborn Medicine, Creighton University School of Medicine

Terence Zach, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Richard S Legro, MD Professor, Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology, Pennsylvania State University College of Medicine; Consulting Staff, Milton S Hershey Medical Center

Richard S Legro, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, Society of Reproductive Surgeons, American Society for Reproductive Medicine, Endocrine Society, Phi Beta Kappa

Disclosure: Received honoraria from Korea National Institute of Health and National Institute of Health (Bethesda, MD) for speaking and teaching; Received honoraria from Greater Toronto Area Reproductive Medicine Society (Toronto, ON, CA) for speaking and teaching; Received honoraria from American College of Obstetrics and Gynecologists (Washington, DC) for speaking and teaching; Received honoraria from National Institute of Child Health and Human Development Pediatric and Adolescent Gynecology Research Thi.

Chief Editor

Christine Isaacs, MD Associate Professor, Department of Obstetrics and Gynecology, Division Head, General Obstetrics and Gynecology, Medical Director of Midwifery Services, Virginia Commonwealth University School of Medicine

Christine Isaacs, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists

Disclosure: Nothing to disclose.

Vanishing Twin Syndrome Workup