Multiple

pregnancy

HELLINS
RULE
Twins
80
Triplets
80^2
Quadruplets
gemellology
80^3

1 in
1 in
1 in

Types of
twins

DIZYGOTI
C

MONOZYGO
TIC

DIZYGOT
IC

amni
on

Always dichorionic &

2
chorio
ns

amnio
n

Factors affecting
dizygotic twinning
Ethnic
group

Increasing
maternal age

Increasing parity

Family h/o
twinning, esp
maternal

Ovulation
induction

MONOZYGO
TIC

4-7
days

>8day
s

Chorionicity
Type of placentation
Prenatal detection by USS
Clinical implications in antepartum &
intrapartum management
Monochorionic

MZ
Dichorionic+discord
ant sex
DZ
Dichorionic+concor
dant sex
MZ or DZ

USS DETERMINATION OF
CHORIONICITY
Number of sacs
Placenta
Sex
Intertwin membrane
Lambda sign & T sign

Ideal time for assessing of chorionicity is

before 14 weeks

DIZYGOTIC

LAMBDA
SIGN

MONOCHORIONIC &
DIAMNIONIC

T SIGN

MONOCHORIONIC
MONOAMNIOTIC

Importance of
chorionicity ?????

MATERNAL
COMPLICATIONS
Antepartum
hyperemesis

hydramnio
s

Pre eclampsia(3 fold times),eclampsia(6

fold times)
Pressure symptoms
Anaemia
Ante partum hemorrhage-

Placenta preavia

Abruption

Intrapartum
complications
Dysfunctional labour
Malpresentations
Increased chance for operative
delivery
Post partum hemorrhage
Retained placenta

FETAL
COMPLICATIONS
Antepartum complications
I.

Prematurity

2.

IUGR

Poor placentation,unequal placental

sharing,fetal anomalies

3.

Single fetal demise

monochorio
nic
Death of one
twin

Shift of
blood

Norma
twin

25% risk of co-twin death /25% risk of

neurological damage in surviving twin

4. Cord entanglement

5.
TWIN-TWIN TRANSFUSION
SYNDROME

Arterio venous anastomoses

with net flow in one direction..
A/c or C/c
Donor(arterial

Severe IUGR
poor renal
side)
perfusion
Anuria
severe
oligohydramnios

Hypervolemia
recipientPolyuria with
polyhydramnios

Uss of TTS.

STUCK TWIN

Serial amnio reduction,fetoscopic laser

ablation of anastomosis

6. Vanishing twin
Cessation of cardiac
activity in a previously
viable foetus

Fetus
papyraceous

7.

Congenital anomalies

Structural
malformations
Conjoint twins
Acardiac fetus
Anencephaly
Talipes
Dislocation of hip
etc..

Chromosomal
anomalies
Downs syndrome

Conjoint twins
Always monozygotic
classification

Thoracopagus
Craniopagus

omphalopagus

Pygopagus

ischiopagus

Prenatal diagnosis-to counsel the parents for

mtp / to plan site & mode of delivery

Acardiac foetus
A-A
anastamoses
in placenta
De
oxygenated
blood

Umb. A

Um
b.A

Normal fetus/pump
twin

Umb.V V-V
anastomoses
in placenta

Minimal oxy. extracted by

lower part of

fetus

Acardiac

Fully de oxygenated

Upper part of fetus ,no grow

Umb.V

Acardiac twins

Anencephaly

Intrapartum complications
PROM & cord
prolapse
Abruption in the
2nd twin
Interlocking of
twins