DR.

SHAMIM
[Link]
RIMA
MBBS,DMU,FCGP
MBBS,DMU,FCGP
[Link]
[Link]
RADIOLOGY
RADIOLOGY&&IMAGING
IMAGING
 Multiple Pregnancy

More
Morethan
thanone
onefetus
fetussimultaneously
simultaneouslydevelops
developsininthe
theuterus.
uterus.

Two
Twofetus
fetus: : Twin
Twin
Three
Threefetus
fetus: :triplets
triplets
Four
Fourfetus
fetus: :quadruplets
quadruplets
Five
Fivefetus
fetus: :quintuplets
quintuplets
Six
Sixfetus
fetus: :sextuplets
sextuplets
 Twins
Twins
Types :
Binovular
Binovular(fraternal/
(fraternal/dizygotic):
dizygotic):
Commonest 2/3 rd
Result from fertilization of
two ova
Uniovular
Uniovular( (identical
identical/ /monozygotic
monozygotic):):
1/3 rd
Result from fertilization of
single ova
Conjoint
Conjointtwins
twins: :
Thoracopagus Craniopagus

Pyopagus Ischiopagus
 Placentation
Placentation

Dyzigotic
Dyzigotictwins:
twins:

dichorionic
dichorionicdiamniotic
diamniotic

Monozygotic
Monozygotictwins:
twins:

dichorionic
dichorionicdiamniotic
diamniotic
monochorionic
monochorionicdiamniotic
diamniotic
monochorionic
monochorionicmonoamniotic
monoamniotic
Sonographic
Sonographicdetermination
determinationof
ofamniocity
amniocityand
andchorionicity
chorionicity

InInfirst
firsttrimester
trimester

Intradecidual sign :

4.5
4.5––5.5
5.5wks
wkschorion
chorionseen
seenas
asechogenic
echogenicring
ringwithin
withinthe
the
thickened
thickeneddecidua.
decidua.

Double decidual sign:

After
After5.5
5.5wks
wkschorion
chorionlaeve
laeve/ /decidua
deciduacapsularis
capsularisisisseen
seenasas
thick-walled,
thick-walled,echogenic
echogenicring
ringsituated
situatedeccentrically
eccentricallywithin
withinthe
the
thick
thickring
ringofofdecidua
deciduavera.
vera.
Sonographic
Sonographicdetermination
determinationof
ofamniocity
amniocityand
andchorionicity
chorionicity

In first trimester

The
Theamnion
amnionthin
thinand
andfilamentous.
filamentous.
The
The amnion
amnioncancanbe
beseen
seenas
as2mm
2mmbleb
blebadjacent
adjacent totoyolk
yolk sac
sac atat
about
about5.5
5.5wks.
wks.
The
Theamnion
amnionthen
thenbecomes
becomesdifficult
difficultuntil
untilthe
theCRL
CRL8-12mm
8-12mm&&seen
seen
as thin filamentous, rounded membrane surrounding the embryo.
as thin filamentous, rounded membrane surrounding the embryo.
AtAt10
10wks
wksthetheamnion
amniongrown
grownenough
enoughcontact
contacteach
eachother,
other,appear
appearas
as
aasingle, thin membrane separating two fetus.
single, thin membrane separating two fetus.
After the first trimester

Determination
Determinationofofchorionicity
chorionicityand
andamniocity
amniocityisismore
moredifficult.
difficult.
Intradecidual sign
Figure
Figure..   Double
..   Doubledecidual
decidualsac
sacsign.
[Link]
USimage
imageofofan
anearly
earlyIUP
IUP
demonstrates two hyperechoic rings (arrows). The
demonstrates two hyperechoic rings (arrows). The inner ringinner ring
represents
represents the the combined
combined chorion-decidua
chorion-decidua capsularis,
capsularis, and
and the
the
outer ring represents the decidua parietalis.
outer ring represents the decidua parietalis.
Maternal
Maternalrisks
risksassociated
associatedwith
withmultiple
multiplepregnancy
pregnancy

Miscarriage
Hemorrhage
Pregnancy induced high blood pressure
Malpresentation
Pre-eclampsia occurs three to five times more frequently
Diabetes
Anemia
Polyhydramnios
Caesarean section is often needed in twin pregnancy, and
almost always required for triplets or more
Prolonged hospitalization resulting in higher cost of medical
care
Fetal
Fetalcomplications
complicationsassociated
associatedwith
withmultiple
multiplepregnancy
pregnancy
Preterm delivery. The average length of a pregnancy is 39 weeks
for a single pregnancy, 35 weeks for twins and 33 for triplets.
Preterm delivery occurs over 50% in twin pregnancy and in 90%
of triplets. The proportion of twins and triplets delivering before
30 weeks pregnancy is around 7% and 15% respectively.

Multiple pregnancies have a four-fold increase in the rate of low

birth weight compared to single pregnancy. The risk of lifelong
disability is over 25% for babies weighing less than 1 Kg.

Stillbirth rates and neonatal death rates are higher for multiple
pregnancies compared to singletons. For example, for a single
birth the incidence is less than 1%, for twins 4.7% and for triplets
8.3%.

Birth defects are twice as common as in single birth.

Fraternal
Fraternal twins
twins
Two different sperm fertilize two different eggs .
Each twin has its own sac of amniotic fluid and its own placenta. 
Have two sets of membranes surrounding their amniotic fluid sacs known
as diamniotic, dichorionic.  
 Fraternal
Fraternaltwins
twins

yolk
yolksacs
sacsand
andfetal
fetalpoles
poles(the
(theearly
earlyfetus)
fetus)are
areseen
seeninin22
completely
completelyseparate
separatesacs.
sacs.
Dichorionic-diamniotic
Dichorionic-diamniotictwin
twinpregnancy
pregnancyininthe
the13th
13thweek
weekofofgestation
gestation
Dichorionic/Diamniotic
Dichorionic/DiamnioticTwins
Twins
Dichorionic/Diamniotic
Dichorionic/Diamniotic Twins
Twins
IDENTICAL
IDENTICALTWIN
TWIN
One
Onesperm
spermfertilizes
fertilizesone
oneegg
eggbut
butthis
thissplits
splitsinto
intotwo
twoembryos
embryos. .   
They
Theyhave
havethe
thesame
samegenetic
geneticmaterial.
material.   
There
Thereare
aretwo
twoseparate
separateamniotic
amnioticsacs
sacsand
andtwo
twoseparate
separateplacentas.
placentas.   
2/3’s,
2/3’s,each
eachtwin
twinhas
hasits
itsown
ownamniotic
amnioticsac
sacbut
butshare
shareaacommon
commonplacenta
placentacalled
called
monochorionic, diamniotic.
monochorionic, diamniotic.
Monochorionic
Monochorionictwins
twinsare
areatathigher
higherrisk
riskfor
forcomplications
complicationssince
sincethey
theyshare
shareaa
common
commonplacenta.
placenta.    
Monozygotic
Monozygotictwins
twinswith
with Monozygotic
Monozygotic twins
twins with
with
monochorionic, diamniotic
monochorionic, diamniotic monochorionic,
monochorionic,
placentation.
placentation. monoamniotic
monoamnioticplacentation
placentation
 Identical
Identical(monozygotic)
(monozygotic)twins
twins

One
Onegestational
gestationalsac
sacisisseen
seenwith
with22yolk
yolksacs
sacsvisible 
visible 
Monozygotic
Monozygotictwins
twinsin
inaasingle
singleamniotic
amnioticsac
sac
Monochorionic/Diamniotic
Monochorionic/Diamniotic
are
are
Identical
Identical
 Dichorionic-Diamniotic
Dichorionic-Diamniotic
can
canbebe
Fraternal
Fraternalor
orIdentical
Identical

 The twin peak sign indicates the presence of a dichorionic-

The twin peak sign indicates the presence of a dichorionic-
diamniotic twin
diamniotic twingestation.
gestation.
 It forms where two separate placentas grow contiguously and
It forms where two separate placentas grow contiguously and
appear
appearfused.
[Link]
Thetwin
twinpeak
peakcan
canbe
beofofvariable size,
variable size,and
andonly
onlyits
its
presence
presenceisisrequired
requiredtotosuggest
suggestthat
thatthe pregnancy
the pregnancyisisdichorionic-
dichorionic-
diamniotic.
diamniotic.
 This sign is most useful in assessing the chorionicity of
This sign is most useful in assessing the chorionicity of
pregnancies
pregnanciesafter
after10
10weeks.
weeks.
Monochorionic/Diamniotic
Monochorionic/DiamnioticTwins
Twins(mono/di)
(mono/di)
 Twin-Twin
Twin-TwinTransfusion
TransfusionSyndrome
Syndrome(TTTS) 
(TTTS) 

This
Thiscondition
conditionoccurs
occursonly
onlyininthose
thoseidentical
identicaltwins
twinsthat
thatare
are
monochorionic,
monochorionic,diamniotic
diamniotic(1/3
(1/3ofofall
allidentical
identicalor
or
monozygotic
monozygotictwins).
twins).
InInalmost
almostall
allofofthese
thesepregnancies,
pregnancies,the
thesingle
singleplacenta
placenta
contains
containsblood
bloodvessel
vesselconnections
connectionsbetween
betweenthe
thetwins.
twins.

 For
 Forreasons
reasonsthat
thatare
arenot
notclear,
clear,inin15-20%
15-20%ofofmonochorionic,
monochorionic,
diamniotic
diamniotictwins,
twins,the
theblood
bloodflow
flowthrough
throughthese
theseblood
bloodvessel
vessel
connections
connectionsbecomes
becomesunbalanced
unbalancedresulting
resultingininaacondition
condition
known
knownas
astwin-twin
twin-twintransfusion
transfusionsyndrome
syndrome(TTTS).
(TTTS).   
InInTTTS,
TTTS,the
thesmaller
smallertwin
twin(donor twin)
(donor twin)does
doesnot
notget
getenough
enoughblood
bloodwhile
while
the larger twin ( recipient twin) becomes overloaded with too
the larger twin ( recipient twin) becomes overloaded with too much much
blood. 
blood. 

InIn an
an attempt
attempt toto reduce
reduce itsits blood
blood volume,
volume, the
the recipient
recipient twin
twin will
will
increase the urine it makes.  This will eventually result in
increase the urine it makes.  This will eventually result in the twin the twin
having
havingaavery
verylarge
largebladder
bladderononultrasound
ultrasoundasaswell
wellas
astoo
toomuch
muchamniotic
amniotic
fluid around this twin.  This known as polyhydramnios.
fluid around this twin.  This known as polyhydramnios.    

At
At the
the same
same time,
time, the
the donor
donor twin
twin will
will produce
produce less
less than
than the
the usual
usual
amount of urine.  The amniotic fluid around the donor twin will
amount of urine.  The amniotic fluid around the donor twin will becomebecome
very
verylow
lowor
orabsent.
[Link]
Thisisisknown
knownas oligohydramnios.
as oligohydramnios.   

 As
 Asthe
thedisease
diseaseprogresses,
progresses,the
thedonor
donorwill
willproduce
producesosolittle
littleurine
urinethat
that
its bladder may not be seen on ultrasound.  The twin will
its bladder may not be seen on ultrasound.  The twin will become become
wrapped
wrappedbybyits
itsamniotic
amnioticmembrane
membrane(known
(knownas asaa“stuck”
“stuck”twin).
twin).   
Acardiac
Acardiactwin
twinor
ortwin
twinreversed
reversedarterial
arterialperfusion
perfusion(TRAP)
(TRAP)syndrome
syndrome

AnAnusual
usualform
formofofTTTS
TTTSoccurs
occursininabout
about11inin15,000
15,000pregnancies.
pregnancies.
InInthese
thesemonochorionic
monochorionictwins, twins,one
onetwin
twindevelops
developsnormally
normallywhile
whilethe
the
other twin fails to develop a heart as well as other body structures.
other twin fails to develop a heart as well as other body structures.
 The
 Theabnormal
abnormaltwintwinisiscalled
calledan acardiac
an acardiactwin
twin

InIn these
these pregnancies,
pregnancies, the the umbilical
umbilical cord
cord from
from the
the acardiac
acardiac twin
twin
branches directly from the umbilical cord of the normal twin.
branches directly from the umbilical cord of the normal twin.  Blood  Blood
flow
flowtotothe
theacardiac
acardiactwin
twincomes
comesfrom
fromthethenormal
normaltwin
twinwhich
whichisisalso
also
known as apump twin.
known as apump twin.    
This
Thisblood
bloodflow
flowisisreversed
reversedfrom
fromthe
thenormal
normaldirection
directionleading
leadingtotothe
the
name
namefor
forthis
thiscondition
condition- twin
- twinreversed
reversedarterial
arterialperfusion
perfusionsyndrome;
syndrome;
TRAP. 
TRAP. 
Figure
Figure : Acardiac
: Acardiac twin
twin with
with absence
absence ofof formed
formed cranium.
cranium. Diffuse
Diffuse
anasarca is seen with a focal cystic hygroma
anasarca is seen with a focal cystic hygroma
 Conjoined
Conjoined or
orSiamese
Siamese twins
twins

Conjoined
Conjoinedtwins or
twins orSiamese
SiameseTwins
Twinsare
arethe
theresult
result
ofofincomplete division of the embryonic disc.
incomplete division of the embryonic disc.

The
Thetwins
twinshere
hereare
arepartially
partiallyjoint
jointatateither
eitherofofthe
the
following
followingpoints:
points:

Head-
Head-craniopagus
craniopagus
chest- thoracopagus
chest- thoracopagus
abdomen-
abdomen-omphalopagus
omphalopagus
pelvis-
pelvis-ischiopagus
ischiopagus
 Conjoined
Conjoined Twins
Twins
Division
Divisionoccurs
occursafter
afterthe
thedevelopment
developmentof
ofembryonic
embryonicdisc.
disc.

Figure : Dicephalus-conjoined twins seen on an 11-week ultrasound.

Two fetal heads (arrows) and a single thorax and abdomen are seen.
Figure
Figure : Fetal
: Fetaldemise
demiseofofone
onetwin
twinwith
withaasurviving
survivingco-twin
co-twinatat21
21weeks'
weeks'
gestation. A. The collapsed cranium of the twin with the fetal
gestation. A. The collapsed cranium of the twin with the fetal demise demise
compared
compared withwith the
the surviving
surviving twin's
twin's cranium. B.
cranium. B. The
The abdominal
abdominal
circumference
circumference ofof the
the fetal
fetal demise
demise isis compared
compared with
with that
that ofof the
the
surviving twin.
surviving twin.
 Thoracopagus
 Thoracopagustwins
twinsshared
sharedgreat
greatvessels
vessels
Triplets
QUADRUPLETS
Abdominal
Abdominal Defects
Defects

Gastroschisis 
Gastroschisis 
Omphalocele
Omphalocele
Esophageal
EsophagealAtresia 
Atresia 
Duodenal
DuodenalAtresia
Atresia
Gastroschisis 
Gastroschisis 
 Gastroschisis
Gastroschisis

Gastroschisis
Gastroschisisrefers
refersto
toaa(full
(fullthickness)
thickness)defect
defectininthe
the
abdominal
abdominalwall,
wall,adjacent
adjacenttotothe
theumbilical
umbilicalcord
cordinsertion,
insertion,
through
throughwhich
whichextrusion
extrusionof
ofthe
thefetal
fetalbowel
bowelhas
hasoccurred.
occurred.

The
Thedefect
defectusually
usuallyarises
arisesto
tothe
theright
rightof
ofthe
theumbilicus
umbilicusand
andisis
generally
generallysmall
small(less
(lessthan
than22cm).
cm).

ItItisismost
mostcommonly
commonlyfound
foundon
onthe
theright
rightside
sideof
ofthe
theumbilical
umbilical
cord.
cord.
 Etiology
Etiology

Gastroschisis
Gastroschisis occurs
occurs inin about
about 11 inin 55 -10,000
-10,000 live
live births.
births. ItIt
appears
appearstotooccur
occurmore
morefrequently
frequentlyininwomen
womenwho whoare
areless
lessthan
than2020
years of age. It may also be more common in women
years of age. It may also be more common in women who smoke who smoke
and
and use
use drugs
drugs such
such as
as cocaine.
cocaine.
During
During thethe 4th
4th toto 5th
5th week
week ofof embryonic
embryonic development
development the the
embryo,
embryo,which
whichhas
hasbeen
beenaaflatflatdisk,
disk,folds
foldsininfour
fourdirections:
directions:upup
and down and right and left sides. Each fold converges
and down and right and left sides. Each fold converges at the at the
site
siteofofthe
theumbilicus
umbilicuswithwiththe
theside
sidefolds
foldsforming
formingthethesides
sidesofofthe
the
abdominal
abdominal wall.
wall.
Gastroschisis
Gastroschisisisisthought
thoughttotooccur
occurbecause
becauseofofinterruptions
interruptionstoto
the
theblood
bloodsupply
supplyororblood
bloodvessels
vesselswhich
whichsupply
supplythe
themuscles
musclesofof
the
the abdominal
abdominal wall
wall during
during the
the period
period ofof abdominal
abdominal wall
wall
development.
development.
 Diagnosis
Diagnosis

The
Thefetal
fetalabdominal
abdominalwall
wallcan
canbe
beseen
seenbybyultrasound
ultrasoundfrom
from99
postmenstrual
postmenstrualweeks
weeksalthough
althoughthethedefect
defectcannot
cannotnot
notbeen
been
confidently diagnosed until after the 12th week of pregnancy.
confidently diagnosed until after the 12th week of pregnancy.
The
Theultrasound
ultrasoundappearance
appearanceofofgastroschisis
gastroschisisisisofofaanormally
normally
positioned
positioned umbilical cord with a mass of bowel, whichlacks
umbilical cord with a mass of bowel, which lacksaa
membrane
membranecover,
cover,totothe
theright
[Link]
Thebowel
boweloutside
outsidethe
theabdominal
abdominal
cavity may be small or large bowel and occasionally
cavity may be small or large bowel and occasionally also the also the
stomach
stomachandandhas
hasthe
theappearance
appearanceofofaacauliflower.
cauliflower.
Late
Lateininpregnancy,
pregnancy,the
theexternalized
externalizedbowel
boweloften
oftenappears
appearsthickened,
thickened,
matted,
matted,andandmildly
mildlydilated
dilateddue
duetotochronic
chronicexposure
exposuretotoamniotic
amnioticfluid.
fluid.
Both the bowel which remains inside the fetal abdomen and
Both the bowel which remains inside the fetal abdomen and the the
external
externalbowel
bowelmay
maybecome
becomedilated
dilatedduring
duringthe
thepregnancy.
pregnancy.
Indian
IndianMan
ManGives
GivesBirth
BirthTo
ToHis
HisTwin
Twin
OMPHALOCELE
OMPHALOCELE
 OMPHALOCELE
OMPHALOCELE
An
Anomphalocele
omphaloceleisisaamidline
midlinedefect
defectofofthe
theabdominal
abdominalwall
wallthat
that
results in herniation of the bowel and intrabdominal contents
results in herniation of the bowel and intrabdominal contents
into
intothe
theumbilical
umbilicalcord.
cord.
The
Thedefect
defectmay maybebecategorized
categorizedby
bythe
thepresence
presenceor
orabsence
absenceofof
the
the liver
liverininthe
theomphalocele
omphalocelesac.
sac.
The
The bowel
bowel contents
contents are
are covered
covered by
by aa membrane
membrane inin an
an
omphalocele. Often excess fluid will develop within
omphalocele. Often excess fluid will develop within the the
omphalocele
omphalocelesac.
sac.
An
Anomphalocele
omphalocelecan
canvary
varyininsize
sizeand
andmay
maycontain
containany
anyor
orall
allofof
the
thefollowing
followingstructures:
structures:

Small Spleen
Smalland
andlarge
largeintestine
intestine
Stomach Bladder
Stomach
Liver Uterus
Liver
Ovaries
Approximately
Approximately 30%
30% ofof fetuses
fetuses with
with an
an omphalocele
omphalocele have
have aa
chromosome
chromosomeabnormality 
abnormality 
The
Themost
mostcommon
commonchromosome
chromosomeabnormalities
abnormalitiesare
aretrisomy 18,
trisomy 18,
13 and
13 and21
21(Down
(Downsyndrome),
syndrome),Turner
Turnersyndrome
syndrome(45,X),
(45,X),and
andtriploidy.
triploidy.

Another
Anothersyndrome
syndromethat
thatmay
maybe
beassociated
associatedwith
withan
anomphalocele
omphalocele
is beckwith wiedemann syndrome.
is beckwith wiedemann syndrome.

Other
Other abnormalities,
abnormalities, such
such as as heart
heart defects,
defects, are
are identified
identified inin
approximately
approximately67
67toto88%
88%ofoffetuses
fetuseswith
withan
anomphalocele.
omphalocele.
The
The prognosis
prognosis ofof the
the fetus
fetus often
often depends
depends on
on the
the presence
presence ofof
associated
associatedabnormalities.
abnormalities.
 Esophageal
EsophagealAtresia 
Atresia 

AA sporadic
sporadic defect
defect ofof the
the gastrointestinal
gastrointestinal system
system that
that results
results from
from
incomplete
incomplete division of the foregut into the trachea and the
division of the foregut into the trachea and the
esophagus.
esophagus.
Esophageal
Esophagealatresia
atresiaisisoften
oftendifficult
difficulttotoidentify
identifyprior
priortoto24
24weeks
weeks
gestation. 
gestation. 

Ultrasound Findings
Polyhydramnios,
Polyhydramnios,
Non-visualization
Non-visualizationofofthe
thefetal
fetalstomach,
stomach,and
and
Visualization
Visualizationofofregurgitation
regurgitationafter
afterfetal
fetalswallowing.
swallowing.

Approximately
Approximately 50
50 toto 70%
70% ofof fetuses
fetuses with
with esophageal
esophageal atresia
atresia have
have
another associated defect, such as a heart defect. 
another associated defect, such as a heart defect. 
Esophageal atresia with
Esophageal atresia withdistal tracheo-esophageal
distal tracheo-esophagealfistula
fistula

Polyhydramnios small
smallstomach
stomach(microgastria)
(microgastria)
Polyhydramnios
Esophageal atresia with
Esophageal atresia withno
nodistal
distalfistula 
fistula 

Severe
SevereMicrogastia –
Microgastia –
Almost
Almost non-visualizationofofthe
non-visualization thestomach.
stomach.
Polyhydramnios.
Polyhydramnios.
 Duodenal
DuodenalAtresia 
Atresia 

Duodenal atresia is a condition in which the first part of the small

bowel (the duodenum) has not developed properly resulting in a
blockage between the stomach and the bowel.

Ultrasound Findings

Polyhydramnios
Polyhydramnios
The
The"double-bubble"
"double-bubble"(fluid-filled
(fluid-filledstomach
stomachand
andduodenum).
duodenum).
Duodenal
Duodenal obstruction
obstruction has
has been
been reported
reported as
as early
early as
as 14
14 weeks
weeks
gestation but is rarely evident before 20 weeks gestation.  
gestation but is rarely evident before 20 weeks gestation.  
There
Thereisisan
anassociation
associationwith Trisomy
with Trisomy21.
21.
Double
Doublebubble"
bubble" && Moderate
Moderatepolyhydramnios
polyhydramnios