TWIN PREGNANCY

DEFINITION:
• When more than one fetus develops simultaneously in the
uterus, it is called as multiple pregnancy.
• According to Hellin’s rule, twins were found to occur 1 in
80 pregnancies, triplets in 1 in 80², quadraplets in 1 in 80³
and so on.
• TWINS: Simultaneous development of two fetuses in the
uterus is called Twin pregnancy. It is the most common
variety.
Based on zygosity:
• Dizygotic twins(non identical or binovular twins):
Most common, seen in 80%. Results from fertilisation
of two separate ova.
• Monozygotic twins(identical or uniovular twins): seen
in 20%. Results from division of one fertilised ovum
into two separate embryos.
Types of twins:
Types of monozygotic twins
• Diamniotic dichorionic twins
• Diamniotic monochorionic twins
• Monoamniotic monochorionic twins
• Conjoined twins
Types of monozygotic twins
Diamniotic dichorionic twins: Results if the division
takes place within 72hrs after fertilization
• The embryos have two separate placenta, chorions
and amnions.
• Difficult to differentiate from dizygotic twins.
• Both babies have same sex.
Types of monozygotic twins
• Diamniotic monochorionic twins: Results if the
division takes place between 4th and 8th day after
fertilisation.
• Monoamniotic monochorionic twins: Results if the
division occurs after 8th day of fertilisation.
• Conjoined twins(<1%): Results if the division occurs
after 2wks. These twins share a particular body part
with each other.
Types of monozygotic twins
Etiology:
1.Race: natural incidence is 1 in 80 pregnancies.
2.Age and Parity- elderly and multi parous women.
3.Heredity.
4.Iatrogenic factors: Use of oral contraceptives.
5.Infertility therapy: Increasing use of fertility
enhancing drugs and assisted reproductive techniques
like IVF.
Diagnosis:
• Clinical evaluation:
• Fundal height is always more than period of gestation.
• Palpation of too many fetal parts.
• Finding of two fetal heads or three fetal poles makes
the diagnosis almost certain.
• Simultaneous hearing of two distinct fetal heart
sounds located at separate spots by two observers.
Diagnosis:
• Ultrasonography:
• Confirmation of diagnosis as early as 10thwk of
pregnancy.
• Two yolk sacs, single or separate placenta can be
diagnosed in first trimester.
• Thick septum between two gestational sacs with
triangular projection at the base, known as Twin-peak
or lambda sign. Presence of it indicates dichorionic.
Dichorionic diamniotic
twins

Thick septum
between two
gestational sacs,
suggesting twin peak
or lambda sign.
Diagnosis:
• Ultrasonography:
• “T” sign: Presence of one
gestational sac with a thin
dividing membrane, and two
foetuses, suggests
monochorionic diamniotic
pregnancy.
Diagnosis:
• Biochemical tests:
• serum and urine levels of β-hcg and maternal serum
alpha-fetoprotein(MSAFP) are higher in twins
compared to singletons.
Maternal complications:
During pregnancy:
• Hyperemesis- More severe than singleton pregnancies
• Anemia
• Pre-eclampsia- Seen in 25%
• Polyhydramnios- 10% and Commonly in monozygotic,
involving the second sac.
• Pressure symptoms- Due to uterine enlargement.
• Antepartum haemorrhage- Due to increased incidence of
placenta previa( bigger placenta)
• Malpresentation
• Preterm labor- Seen in 50%
Maternal complications:
• During labor:
• Early rupture of membranes and cord prolapse.
• Prolonged labor
• Increased operative interference- Due to malpresentation.
• Postpartum haemorrhage- caused by atony of uterine
muscle.
• During puerperium:
• Subinvolution, infection and lactation failure.
Fetal complications:
More common in monochorionic monoamniotic twins.
• Spontaneous abortions
• Congenital malformations- Seen in about 2-4%
• Low birth weight
• Premature birth- 80%
• Intrauterine growth restriction(IUGR)
• Discordant twin growth- 25% of cases
• Asphyxia and still birth
• Vanishing twin- Twins,
diagnosed in the initial USG,
missed in the later scan.
• It is due arrest of development
and subsequent resorption of
the fetus during the first
trimester, called as vanishing
twin syndrome.
• Fetus papyraceous or compressus: One of the fetus
dies early, which is flattened, mummified and
compressed between the membranes of living fetus
and uterine wall.
Unique fetal complications
• These are
1.Conjoined twins
2.Twin reversed arterial perfusion(TRAP) sequence
3.Twin-to-twin transfusion syndrome(TTTS)
Unique fetal complications
1.Conjoined twins:
• Occurs in <1%, also called as Siamese twin.
• Fusion of fetal body parts is seen. Common types are
thoracopagus, omphalopagus and craniopagus.
• Diagnosis is possible by ultrasonography- Bifid
appearance of fetal pole, four vessels in umbilical cord,
no change in fetal positions relative to eachother.
• Lethal forms should be terminated.
Conjoined twins:
2.Twin reversed arterial perfusion(TRAP)
sequence:
• Twin reversed arterial perfusion(TRAP) sequence:
• Seen in 1% of monochorionic twins.
• Characterised by an acardiac perfused twin having blood
supply from a normal co-twin via large arterio-arterial or vein
to vein anastomosis, resulting in reversal of flow in umbilical
cord vessel of recipient twin.
• Arterial blood flow towards affected fetus on color Doppler is
diagnostic of TRAP.
• Treatment is vessel occlusion of acardiac twin by endoscopic
ligation, laser coagulation of umbilical cord, bipolar cord
cauterisation, radiofrequency ablation or with absolute
alcohol.
3.Twin-to-twin transfusion syndrome(TTTS):
• Twin-to-twin transfusion syndrome(TTTS):
• Seen in about 15% of monochorionic diamniotic
pregnancies and severe in about 1%.
• Occurs when there is hemodynamical imbalance due
to unidirectional deep arteriovenous anastomosis
from donor to recipient twin.
• The receptor twin becomes polycythemic, larger with
hydramnios, hypervolemia and volume overload.
• The donor twin becomes anaemic, growth restricted,
hypovolemic and develops oligohydramnios.
• Diagnosis is based on two criteria:
1.Presence of monochorionic diamniotic pregnancy.
2.Presence of oligohydramnios in one sac and
polyhydramnios in other sac.

Antenatal diagnosis is also made by ultrasound with

Doppler blood flow study in the placental vascular bed.
• Management of TTTS:
• Repeated amniocentesis, to control polyhydramnios in
the recipient twin is done.
• Septostomy in the intervening membrane is done to
restore normal volume in both sacs.
• Laser photocoagulation, to interrupt the anastomotic
vessels.
The smaller twin generally has got better outcome.
Perinatal mortality in TTTS is about 70%.
• Single fetal demise:
• Antepartum death of one fetus seen in about 5% of twins.
• Commonly occurs in second trimester, due to twin-twin
transfusion syndrome, severe IUGR, placental insufficiency
and placental abruption.
• Other fetus is unaffected in dichorionic but there is risk of
multi-organ injury in monochorionic twins.
• These pregnancies are to be monitored by non stress test
and biophysical profile.
• Maternal consumptive coagulopathy may occur due to
retention of dead fetus.
Single fetal demise
Antepartum management:
• Early diagnosis of multiple pregnancy is essential for successful
outcome.
• Increase dietary supplement is advised.
• Iron therapy and additional vitamins, calcium and folic acid are to
be given higher than for a singleton pregnancy.
• Antenatal visits should be more frequent after 20wks(once in
2wks).
• Bed rest is advised to prevent preterm deliveries.
• Umbilical artery Doppler is useful, when there are complications
involving placental circulation or fetal haemodynamic physiology.
Antepartum management:
• Ultrasound examination used to detect chorionicity,
amniocity, fetal growth pattern and congenital
malformations.
• Serial ultrasound assessment every 2 to 3wks for
monochorionic pregnancies starting at 16wks and every
3 to 4wks for dichorionic pregnancies from 18-20wks.
• Use of corticosteroids, to accelerate lung maturity in
women with POG less than 34wks. Twins develop
pulmonary maturity 3-4wks earlier than singletons.
Intrapartum management:
Pre-requisites to twin delivery include:
• Intravenous access
• Availability of cross-matched blood
• Sonography machine in labour room to evaluate
presentation and position of fetuses
• Availability of two skilled obstetricians and neonatologists
• An anaesthetist in emergency
• Availability of oxytocics like oxytocin, methylergometrine
and prostaglandins
Route of delivery
• Twin A vertex-twin B vertex:
• Vaginal delivery is recommended.
• Twin A vertex-twin B non-vertex:
• Twin A is delivered by vaginal delivery.
• Twin B: if breech, deliver by breech extraction.
• Both twins non-vertex:
• Caesarean section is the best route of delivery
recommended.
• Third stage of labour:
• Active management is recommended to prevent
postpartum haemorrhage.
• Postpartum haemorrhage can be minimised by giving
oxytocin 10units IM following the delivery of second
baby and to continue oxytocin drip for at least 1 hour.
 EARLY SCAN

MULTIPLE PREGNANCY
DIAGNOSED

TWINS TRIPLETS/MORE

MONOZYGOTIC DIZYGOTIC
Refer to
MAMC MCDA DADC specialist(fetal
medicine unit)
-Screen for
-High risk Downs
-Frequent -Counsel
visits regarding
-USG preterm
-Twin deliveries and
syndrome preeclampsia
Aim to deliver Aim to deliver at
at 35-36wks 36-37wks
INDICATIONS OF CAESAREAN SECTION.
• Obstetric causes:
• Placenta previa .
• Severe pre eclampsia.
• Previous caesarean section.
• Cord prolapse of first baby.
• Abnormal uterine contractions.
• Contracted pelvis.
• For twins:
• First fetus with non cephalic presentation.
• Twins with IUGR.
• Conjoined twins.
• Monoamniotic twins.
• Monochorionic twins with TTTS.
Thank you