Spontaneous Resolution of Hypofibrinogenemia in a Triplet Gestation Associated with Second Trimester in Utero Death of Two Fetuses

ABSTRACT

Multiple gestations are increasing in frequency secondary to assisted reproductive technologies; therefore, it will become increasingly important to know how to manage a multiple pregnancy in which an in utero fetal death has occurred. This case report describes the spontaneous resolution of maternal hypofibrinogenemia associated with the deaths of two fetuses in a triplet gestation. A 29-year-old woman with a triplet gestation had in utero death of two monoamniotic fetuses between 15 and 17 weeks' gestation. Maternal plasma fibrinogen levels were obtained weekly and were initially in the normal range for pregnancy. At 31 weeks' gestation, the fibrinogen level decreased to 239 mg/dl and reached a nadir of 150 mg/dl 11 days later. Although the patient received no treatment, her fibrinogen level increased to 307 mg/dl over the next 4 days and then remained above 260 mg/dl for the rest of her pregnancy. At 35 weeks' gestation, a healthy 2090 gm female was delivered. The infant is alive and well and developing normally. When there is an in utero death of one fetus of a multiple gestation in the second or early third trimester, some authors advocate heparinization to reverse maternal coagulopathy; others describe spontaneous resolution of hypofibrinogenemia. The role of heparin in treating hypofibrinogenemia remains unclear. Hypofibrinogenemia may resolve spontaneously without exposing the patient to the potentially serious risks associated with heparin therapy.