TWIN PREGNANCY

Dr. Girishankar Samarasam

Supervised by :
Dr Rathimalar
Dr Mohd Faizal Bin Nor Azmi
 INTRODUCTION
• 1% of all pregnancies

• Associated with increased perinatal mortality & morbidity

• Results from ovulation & fertilization of > 1 oocyte

OR splitting of 1 embryonic mass to form 2
genetically identical fetus

• Since 1970, the prevalence of multiple births has been

increasing because of more widespread use of ART.
INCIDENCE
Hellin’s law
 Twin 1 : 80
 Triplets 1 : 802
 Quadruplets 1:803
 Quniplets 1:804
Frequency of twins : highest – black race,
lowest – orientals
Increase with maternal age and
parity
The chances to get twin 2x  if conception <1
month after discontinuation of oral
contraceptives
 TERMS
Zygosity refers to the type of conception
 Two thirds of all twins are dizygotic.

Chorionicity denotes the type of

placentation.

*Chorionicity rather than zygosity

determines outcome.
 TWINS

MONOZYGOTIC DIZYGOTIC
1/3 2/3

Monochorionic monoamniotic <1%

Dichorionic
Monochorionic diamniotic -75%
Diamniotic
Dichorionic diamniotic -25%
 DIZYGOTIC
• Fertilization of 2 separate ova
 DIZYGOTI
• C twins varies with
incidence of dizygotic
– ethnic group - up to 5 times higher in
certain parts of Africa and half as high
in parts of Asia
– maternal age - 3 in 1000 births in
women younger than 20,14 in 1000
births in women aged 35-40 y
– Parity - 2% after four pregnancies
– method of conception - 20% with
ovulation induction.
 MONOZYGOTIC
• Also known as identical twins.
• 1/3 of twin.
• Fertilization of single ovum
• Similar sex
• Identical in every way including HLA genes
• Not genetically determined
• Its prevalence 1/250
THE OUTCOME OF TWINNING PROCESS
DEPENDS ON WHEN THE DIVISIONS OCCUR
Dichorionic Diamniotic Monochorionic Monochorionic
(DCDA) Diamniotic (MCDA) Monoamniotic
(MCMA)

0-3 days 4-8 days 9-12 days

Before amnion and After chorion formed After amnion and

chorion are formed Before amnion formed chorion are formed

* Division after 13 days > Conjoined twins

 ZYGOSITY AND
•
CHORIONICITY
Zygosity - determined by DNA fingerprinting.
– require an invasive procedure –
amniocentesis, chorionic villus sampling or
cordocentesis

• Chorionicity - determined by USS (fetal gender, number of

placentas and characteristics of the membrane between
the two amniotic sacs).
– Different-sex twins =dizygotic and dichorionic,
– but in 2/3 of twin pregnancies the fetuses same sex
and these may be either monozygotic or dizygotic.
– Two separate placentas=dichorionic
– but, iftwo placentas are adjacent to each other and
therefore difficult to distinguish between
dichorionic- fused and monochorionic placentas.
 ZYGOSITY AND
• CHORIONICITY
The best way to determine chorionicity
 ultrasound examination at 10-14 weeks
of gestation

• Lambda sign-Dichorionic
• T-sign - Monochorionic
DIAGNOSIS OF MULTIPLE PREGNANCY
History : h/o IVF, taking ovulation inducing drugs
Symptoms
 Early pregnancy : excessive nausea, vomiting, Abnormal
bleeding
 Mid pregnancy : excessive weight gain, uterus larger
than date
 Late pregnancy : pressure symptoms – dyspnea,
dyspepsia
Signs :
 Anemia, edema, high BP, abnormal weight gain
 Uterus larger than date
 Multiple fetal poles felt
 2 distinct FH heard
Ix : confirm by Ultrasound
Detect 99% of multiple gestation before 26 weeks
Confirms fetal viability
Diagnose type
 Patient
Dichorionic twins Monochorionic
•twins care
Ultrasound at 10–14 weeks: (a)
•
viability; (b) chorionicity; (c) Ultrasound at 10–14 weeks: (a)
NT: aneuploidy viability; (b) chorionicity; (c)
NT: aneuploidy/TTTS
• Structural anomaly scan at 20– • Ultrasound surveillance for
22 TTTS and discordant growth: at
weeks. 16 weeks and then two-
• Serial fetal growth scans e.g weekly.
24, 28, 32 and then two- to • Structural anomaly scan at 20–
four- weekly. 22 weeks (including fetal
• ECHO).
34–36 weeks: discussion of • Fetal growth scans at two-
mode
weekly
of delivery and intrapartum intervals until delivery.
care. • 32–34 weeks: discussion of
• Elective delivery at 37–38 mode of delivery and
completed weeks. Some intrapartum care.
by 40weeks • Elective delivery at 36–
• Postnatal advice and support 37 completed weeks (if
(hospital- and community- uncomplicated).
•
METHODS AVAILABLE FOR GENETIC
SCREENING IN TWIN PREGNANCIES
• Biochemical screening for aneuploidy is not
recommended in twins.
• Maternal serum alpha fetoprotein (MS-AFP) is
useful for detection of open neural tube and other
birth defects.
• Evidence is promising that nuchal translucency
(NT) screening is useful for identifying twin
pregnancies at high risk of aneuploidy.
• The fetal loss rates with invasive testing
(amniocentesis and chorionic villus sampling
(CVS)) in twins are unclear.
• Invasive testing should be offered to twins according
to the usual standard of care.
 MORTALITY AND MORBIDITY
• Multifetal pregnancies are high-risk pregnancies.

• fetal mortality rate for twins is 4 x the fetal mortality rate

for single births.

• neonatal mortality rate for twins is more than 5 x greater

than the neonatal mortality rate for single births.

• A high prevalence of low birth weight infants, due to

prematurity and intrauterine growth retardation (IUGR)
and their associated complications, contribute to this
problem.
 Complications of Multiple
Pregnancy
• preterm labor and birth

• pregnancy-induced hypertension/PE
– Women with multiple fetuses are more than three times as likely to
develop high blood pressure of pregnancy.
– This condition often develops earlier and is more severe
than pregnancy with one baby.
– It can also increase the chance of placental abruption
(early detachment of the placenta).

• anemia
– Anemia is more than twice as common in multiple pregnancies as in
a single birth.

• birth defects
– Multiple birth babies have about twice the risk of congenital
(present at birth) abnormalities including neural tube defects (such
as spina bifida), gastrointestinal, and heart abnormalities.
FETAL COMPLICATIONS
MATERNAL COMPLICATION
UNIQUE COMPLICATIONS
• Problems related to vascular
anastomosis between twins

• Single intrauterine demise

• Discordant twins

• Conjoined twins

• Cord entanglement
1. VASCULAR ANASTOMOSIS
Present only in monochorionic twin placentas.
Nearly 100% of monochorionic twin placentas have vascular
anastomoses,but there are marked variations in the
number ,size, and direction.

2 patterns of vascular anastomosis

• twin-to-twin transfusionsyndrome (TTTS)
• acardiac twinning or twin reversed arterial perfusion
(TRAPS)
 Twin-to-twin transfusion syndrome
(TTTS)
• Features of TTTS are the result of
hypoperfusion of the donor twin and
hyperperfusion of the recipient twin.
• twin becomes hypovolemic and oliguric or
anuric.
• Oligohydramnios develops in the amniotic sac
of the donor twin.
• Profound oligohydramnios can result in the
stuck twin phenomenon in which the twin
appears in a fixed position against the uterine
wall.
• Ultrasonography may fail to visualize the
fetal bladder because of absent urine.
• Either twin can develop hydrops fetalis.
– The donor twin can become hydropic because
of anemia and high-output heart failure.
– The recipient twin can become hydropic
because of hypervolemia.
• The recipient twin can also develop
hypertension, hypertrophic
cardiomegaly, disseminated intravascular
coagulation, and hyperbilirubinemia
after birth.
 Twin-to-twin transfusion syndrome
(TTTS)
• Severe TTTS has a 60-100% fetal or
neonatal mortality rate.
• Mild-to-moderate TTTS is
frequently associated with
premature delivery.
• Fetal demise of one twin is associated with
neurologic sequelae in 25% of surviving
twins.
• The more premature the twins are at
birth, the higher the incidence of
postnatal morbidity and mortality
TWIN REVERSED ARTERIAL PERFUSION
SEQUENCE (TRAPS)
• 1:35,000 pregnancies, 1% of monochorionic
• Large arterio-arterial anastomosis
• Perinatal mortality in the pump twin is 55%, due
to polyhydramnios and high-output cardiac failure
• An acardiac twin which received its blood supply
large
via a arterio-arterial anastomosis from a normal
co-twin
• ‘pump’ in absent or rudimentary development of the
~>result
• upper body structures
• Not all pregnancies with TRAP sequence require
invasive treatment and this appears to be dependent
on:
• twini) the relative size of the ‘acardiac’ twin to the pump
and ii) the presence of any cardiovascular impairment
• thein‘pump’
Careful monitoring and ultrasound surveillance
twin.
• require
is
d
SUGGESTED TREATMENT IN
VASCULAR ANASTOMOSIS

• Amniotic septostomy

• Laser ablation

• Selective fetocide

• Serial amnioreduction
Treatment for established TTTS:
The frequency of ultrasound surveillance of fetal
health in severe cases of TTTS will depend on the
severity and intervention strategy.
Therapeutic options: These include:
i) no intervention ( survival 0—30%),
ii) amnioreduction 64 percent ( survival 64% overall,
74%
of at least one twin),
iii) laser photocoagulation (55% overall survival—73%
of
at least one twin),
iv)amniotic septostomy, 83 percent survival (12 cases
only).
SERIAL AMNIOREDUCTION
LASER ABLATION
-Laser photocoagulation of placental vascular
anastomosis
2. SINGLE INTRAUTERINE DEMISE
• 2-6% of twins pregnancies

• Up to 25% in MC twin pregnancy

• Perinatal morbidity and mortality of the surviving co-

twin
 19% perinatal death
 24% having serious longterm sequelae

• Morbidity of surviving fetus depend on chorionicity

and consequences of prematurity
 SINGLE FETAL DEATH
• After the single fetal death in a monochorionic pregnancy, the
risk to the surviving twin of death or neurological abnormality
is of the order of 12% and 18%, respectively.

• Damage to MC twins after the death of a co-twin is now

thought to be caused by acute haemodynamic changes around
the time of death, with the survivor essentially
haemorrhaging part of its circulating volume into the
circulation of the dying twin.

• This may cause transient or persistent hypotension and

low perfusion,leading to the risk of ischaemic organ
damage, notably but not exclusively, to the brain

• Single fetal death in a monochorionic pregnancy should be

referred and assessed in a regional fetal medicine centre.
 3. DISCORDANT FETAL GROWTH
• Fetal growth differs slightly in twin gestations and twin specific charts
may be used to define the normal growth rate. Precision may also be
obtained by using sex and race specific charts.
• In clinical practice, however, these differences are small and singleton
growth curves may be used. Patterns of fetal growth are more important
than absolute measurements. Both must be interpreted in the light of
the clinical history, together with all the genetic and environmental
factors that may affect fetal growth.

The diagnosis of discordance has been based on the following:

• AC difference of 20 mm (sensitivity of 80%, specificity 85%, PPV= 62%)
• EFW based on bi-parietal diameter (BPD) and AC or AC and femur length
(FL) > 20 percent (sensitivity 25-55%)

Fetal weight difference = wt. of the larger - wt.of smaller

wt.of the larger twin
( >15-25% poor
outcome )
• It has been shown that the risk of fetal death
begins to increase progressively when the
weight discordance exceeds 25%.
• Discordant fetal growth can be due to different
genetic growth potentials, structural anomaly of
one fetus, or an unfavourable placental
implantation.
• True discordance is an indicator for an increased
risk of IUGR, morbidity, and mortality for the
smaller twin.
• A risk for aneuploidy, anomaly or viral syndrome
affecting only one fetus must also be considered
when discordant growth is identified.
Management
 US monitoring of growth within a twin pair = mainstay in
management .
 The indication for delivery should take into consideration
of the fetal well-being, the gestational age and serial
growth velocity
 4. CONJOINED TWIN

Rare complication of monoamniotic twining, with

an incidence of around 1: 55 000 pregnancies.
Accurate prenatal diagnosis is possible in the first
trimester and allows better counseling of the
parents regarding the management options.
Types :
 Anterior (thoracopagus)
 Posterior (pygopagus)
 Cephalic (craniopagus)
 Caudal (ischiopagus)
 *diagnosis of conjoined twins can frequently be
made at mid pregnancy using USG - careful
evaluation of the point of connection and
organs involved
 5. CORD ENTANGLEMENT
• Cord entanglement occurs in over 70% of MCMA twins and is
believed to be the major cause for sudden IUFD
• Ultrasound diagnosis of cord entanglement and close fetal
surveillance from 24 weeks onward, may help to improve
perinatal outcome.
• Because of the high perinatal mortality, prophylactic delivery by
caesarean section at 32 to 34 weeks is recommended.
 PRESENTATION
• 40% of twins present as vertex/vertex,
• 35% as vertex/non-vertex,
• remaining 25% of twins present with the
leading twin in a non-vertex presentation
at birth .
 DELIVER
Y
• If the first twin presents as breech - - CS
as being safer for the babies.
• Although many clinicians choose
caesarean section when the first twin
presents as a breech,because of concern
about
‘interlocking’, this complication is
extremely
Rare.
*interlocking only occurs once in 817 twin
pregnancies where the first twin was
 DELIVER
• Y
For twins presenting vertex/vertex, most
clinicians recommend planned VB.
• However, planned CS may benefit twins in which the
first twin is presenting vertex for a number of reasons.
• As many as 20% of vertex presenting second twins will
change presentation spontaneously after the first twin
is delivered.
• A substantial number of those presenting vertex/vertex
will present with serious acute intrapartum problems
following the delivery of the first twin (for example,
conversion to transverse lie, cord prolapse, prolonged
interval to delivery of the second twin), which may lead
to emergency CS, perinatal death, and neonatal morbidity.
 MANAGEMENT DURING LABOR

Basic Principles

 The presence of 2 skilled obstetrics attendants for

labor and delivery
 Anesthesiologist available
 Neonatal care personnel sufficient for resuscitation of
the newborns
 Portable US scanner
 Reliable IV access
CTG with dual monitoring capacity
INTRAPARTUM MANAGEMENT OF TWIN
PREGNANCY
1st stage
 Good intrapartum care : blood, IV access,
continuous FH monitoring, adequate analgesia
and LPC.
 it is also preferable to have an USG in the delivery
suite to detect the FH, fetal lie and presentation
when needed.
 Progress of labour should be closely monitored
with 2-4 hourly VE.
The criteria for diagnosing slow progress are the
same as in singletons.
In case of inefficient uterine contractions,
oxytocin augmentation can be used.
2nd stage
 An experienced obstetrician must be present during the 2nd
stage of labour.
 Following delivery of the first twin, syntometrine must NOT be
given as it might facilitate the premature placental separation
before the delivery of the second twin.
 The cord of the first twin should be clamped and divided as
usual.
 After delivery of the 1st twin, the obstetrician should
ascertain the lie and presentation of the 2nd twin, using USG if
required.
 Once a Cx presentation is confirmed, the decent of the fetal
head is expected with re-establishment of uterine contractions.
 Oxytocin infusion should be commenced if uterine contractions
have failed to resume.
 Fetal heart rate should be continuously monitored.
A twin-to-twin delivery interval of ≤ 30 minutes, after which
delivery should be expedited, since the risks of both acidosis
and second stage Caesarean section increase with the length of
this interval
If the second twin is in non-vertex presentation, the available
options include
 Assisted vaginal breech delivery or breech extraction,
 Internal podalic version following by breech extraction,
 ECV followed by vaginal cephalic delivery,
 Emergency LSCS
3rd
stage
•increased risks of primary PPH.
•delivery of the shoulder of the 2nd twin, active
management of the third stage should ensue.
•Oxytocin infusion in addition is advised.
•The placentas should be examined as a routine to
confirm the chorionicity and amnionicity.
Indications for Caesarean Section
 Elective
 First twin non-cephalic
 Conjoined twin
 Monoamniotic twin
 Placenta previa
 Previous LSCS
 IUGR in dichorionic twin
 Congenital abnormality
 Emergency
 Fetal distress
 Cord prolapse of 1st twin
Non progress of labor
Collision of both twins
 2nd twin transverse after
delivery of 1st twin
SPECIALIZED TWIN CLINICS/PREVENTION
PROGRAMMES
Multi-intervention preterm birth prevention
programmes for twin pregnancies have been
evaluated in several observational studies with
contemporary and/or historical controls. All studies
reviewed suggest reduction in preterm birth
rate, decreased perinatal mortality, and overall
improvement in perinatal outcome.
The evidence to support specialized clinics is of
insufficient quality to recommend that they be
part of routine clinical practice. Further
randomized controlled studies are needed to
validate the improved outcomes that have been
demonstrated in cohort studies.
THANK
YOU