Hari Dev

2008 MBBS

MULTIPLE PREGNANCY
Presence of more than one fetus in the gravid
uterus
1% of all pregnancies
Hellins Rule
Twins
: 1 in 80
Triplets
: 1 in 80 80
Quadruplets : 1 in 80 80 80.
Gemellology : Study of twins

 ZYGOSITY - Refers to the Type of Conception.

- only determined by DNA testing

CHORIONICITY - Type of Placentation

- prenatally by ultrasound
- postnatally by examining
membranes.

1. ZYGOSITY
Dizygotic Twins

Monozygotic Twins

1.DIZYGOTIC TWINS/ BINOVULAR

75%
Fertilisation of 2 ova by different spermatozoa.
Each twin has its own placenta, chorion , amnion.

Hence always dichorionic, diamniotic.

Factors affecting - ethnic group
- increasing maternal age
- increasing parity
- Family history of twinning
- ovulation induction with clomiphene citrate/
gonadotrophins resulting in multiple ovulation.

DIZYGOTIC TWINS/ BINOVULAR

2.MONOZYGOTIC / BINOVULAR/ IDENTICAL

25%
Result from splitting of a single fertilized ovum
Always same sex and look alike. [ IDENTICAL ]
Rate of monozygotic twinning is relatively constant , not affected
by any factors.
True etiology unknown.
Type of placentation is determined by the time of splitting

MONOZYGOTIC TWINS

MONOZYGOTIC / BINOVULAR/ IDENTICAL

2.CHORIONICITY
Type of Placentation
Postnatally- Examination of Membranes
Prenatally- By Ultrasound
Ideal time for assesment is before 14 weeks

Which is more important

zygosity or chorionicity??

CHORIONICITYWhy????
Dichorionic twins can be either
mono/dizygotic.
Dichorionic twins develop as two distinct
organs. so no risk.

CHORIONICITYWhy????
Monochorionic twins have increased vascular
anastomoses between the two circulation
so high risk!!

Ultrasound Determination of Chorionicity

Number of sacs. [ before 10 weeks ]
2 sacs dichorionic
Single sac - monochorionic
Placenta
Sex
Intertwin membrane
thicker and more echogenic in dichorionic
.

 Twin peak / Lambda sign

- characteristic of dichorionic pregnancies
- chorionic tissue between 2 layers of
intertwin membrane at the placental origin
T Sign in monochorionic , no chorionic tissue

If no membrane is seen in between

monochorionic monoaniotic

Ultrasound differentiation of chorionicity

Criterion

Monochorionic

Dichorionic

Placenta

Single

Double

Fetal Sex

--------

Discordance

Membrane

<2 mm

>2 mm

No: of layers in
membrane

2 layers

4 layers

Twin peak sign

Absent

Present

Maternal Complications
Antepartum
1.Hyperemesis

Intrapartum
1.Dysfunctional labour

2.Hydramnios

2.Malpresentation

3.Pre-eclampsia

3.Operative delivery

4.Pressure symptoms
5.Anaemia

4.Postpartum
hemorrhage
5.Retained Placenta

6.Antepartum
hemorrhage

6.Premature separation
of placenta

Maternal Complications - Antepartum

Hyperemesis increased - hCG
Hydramnios monoamniotic pregnancies, Twin
transfusion syndrome, major cause of prematurity

Pre- eclampsia 3 times commoner compared to

singleton
Pressure symptoms
Anaemia increased plasma volume expansion ,
fetoplacental demand for iron increased.

APH Placenta praevia , Abruptio placenta.

Fetal Complications
Antepartum
1.Prematurity
2.IUGR
3.Single fetal demise

Intrapartum
1.PROM
2.Cord Prolapse
3.Abruption in second
twin
4.Twin to Twin transfusion 4.Interlocking (rare)
syndrome
5.Vanishing Twin/abortion
6.Cong.anomalies
7.Conjoined twins

FETAL COMPLICATIONS
Perinatal mortality: 6 times
Morbidity: 2- 3 times

Mono chorionic

- morbidity/mortality twice as that of dichorionic.

- additional risk from TTS

Monoamniotic twins - 50% mortality.

Main cause of adverse outcome is
1. Prematurity
2. IUGR

Cerebral palsy, neurodevelopmental impairment, lower IQ scores.

Monochorionic twins:

1. TTTS
2 .Monoamniotic twinning
3. Conjoined twinning
4. Acardiac fetus

1. Prematurity
Single most important cause of perinatal
mortality and morbidity.
Ensure delivery in a tertiary care centre.!!

2. IUGR
Can affect one or both fetuses.
Monochorionic > Dichorionic.
UPTO 30-32 Weeks twins grow with same velocity , after
that reduction in abdominal circumference.
Poor growth poor placentation , unequal placental
sharing, fetal anomalies.

3. SINGLE FETAL DEMISE

Death of one twin

NEUROLOGICAL
DAMAGE
in surviving TWIN

Sudden acute shift

of blood from
surviving twin to
dead fetus

3. SINGLE FETAL DEMISE

Monochorionic - 25% risk of twin death, 25% risk of
neurological damage in surviving twin.
Dilemma exists whether to deliver early or not
Terminated as soon as other twin is capable of extra uterine
survival

Dichorionic no such risk

Conservative management

4.Monochorionic Monoamniotic twinning

Seen in less than 1% of all twin pregnancies
Late intrauterine death due to cord entanglement.
Best diagnosed in 1st trimester absence of intervening membrane.
Colour doppler cord entaglement
Fetal loss 50-70%
Hence elective CS at 36 weeks.

5. Twin twin Transfusion Syndrome

[ TTS]
Occurs in monochorionic placentation due to
AV anastomoses with resultant flow in one
direction.

5. Twin twin Transfusion Syndrome

[ TTS]

Ultrasound in TTS STUCK TWIN SIGN

 Management after delivery

Exchange transfusion
Chronic TTS Serial amnio reduction
- Reduces preterm labour
- Reduce hydrostatic pressure
- improves circulation and urine production.
Fetoscopic laser ablation of anastomoses

 Acute TTS can occur in 3rd trimester or in

labour sudden death of one twin
Overall mortality is 70%
High incidence of CP and neurological
abnormalities in survivors.

6. Vanishing Twin & Abortion

Incidence of abortion more in multiple pregnancy
Spontaneous cessation of cardiac activity in a previously
viable fetus of a multiple gestation. VANISHING TWIN
When fetal death occur after the first trimester, results in
a thin parchment like body called FETUS PAPYRACEOUS
Diagnosis made after delivery
No effect on mother or the viable fetus.

7. Congenital Anomalies
STRUCTURAL MALFORMATIONS

Unique to twins conjoined twins , Acardiac fetus

Non specific but common in twins CHD , Anencephaly
Postural deformities Talipes & Congenital dislocation of
Hip
CHROMOSOMAL ANOMALIES
Dizygotic independent risk, but both will not be involved
Monozygotic same risk as that of singleton, both affected
Downs syndrome

Nuchal Translucency

Mid Trimester
Amniocentesis is
the gold standard

Management of Anomalies

DICHORIONIC
PREGNANCY

If one fetus is
abnormal

Selective
feticide using
KCl

Conjoined Twins
Always monozygotic
Incomplete division occuring after 13 days.

Very rare
Thoraco pagus, craniopagus, omphalopagus, pyopagus, ischiopagus..
Prenatal diagnosis important for termination , for planning operation
Severe cases detected early Termination
Surgical separation only in some cases sharing of brain and heart unsuccessful operation
Caesarean preferred

THORACOPAGUS

OMPHALOPAGUS

CRANIOPAGUS

PYOPAGUS

ISCHIOPAGUS

RACHYPAGUS

Acardiac Foetus
Very rare
Bizarre form of monochorionic twinning

One fetus is normal

The other twin is severely malformed no heart , absent
development of upper part of body

MECHANISM
PUMP TWIN

ACARDIAC TWIN

Twin Reversed Arterial Perfusion

Sequence [ TRAP]
Pump twin high output cardiac failure, hydrops,
poly hydramnios and death
Overall perinatal mortality of pump twin is 50%

ACARDIAC TWIN

PUMP TWIN

THANK YOU