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Definition
Presence in Utero or birth of more than one
fetuses.
Twin gestation accounts for 1% of all deliveries
and 10% of perinatal mortality.
Currently the incidence is increasing world wide.
Twins, Triplets, Quadruplicates and so on
incidence is calculated by HELLIN hypothesis.
Vanishing Twin Syndrome :- When one of the
twin does not grow and vanishes in utero
leading to singleton birth.
INCIDENCE
Twins : 1: 80 or 90
Triplets : 1:80 square or 1: 8000
Quadruplet : 1:80 cube or 1: 512 000
Highest in Nigeria
Lowest in japan or east Asia
Spontaneous ovulation twins 1%
Clomiphene induced ovulation 10 %
HMG (gonadotrophins) induced 30%
The incidence of twin and higher-order
multiple gestations has increased
significantly over the past 15 years
primarily because of
The availability and increased use of
ovulation-inducing drugs and assisted
reproductive technology (ART).
(ART)
Multiple gestations now compose 3% of all
pregnancies,
pregnancies and twins compose 2530%
of deliveries resulting from ART.
ART
Associated complications
1. Antenatal
Spontaneous abortion:- Vanishing twin-12%
Hyperemesis gravidarum
Placenta previa
Pressure symptoms
Structural malformation
Teratogenic events, neural tube defect,
conjoined twins
Vascular interchange:- reverse flow acardia
Overcrowding:- congenital hip dislocation
5
IUGR
APH
Anemia
Preterm delivery
Polyhydramnios, oligohydramnios,
TTTS
2. Intrapartum
Malpresentations & malpositions
Permature rupture of membrances
Cord accidents
6
Locked twins
Dysfunctional uterine action
Abruption after delivery of the first
twin
Birth trauma
Cesarean section
3. Postprtum
PPH:- atony, laceration large placental
site
7
Twin pregnancy Types
Monozygotic ("identical Dizygotic ("fraternal twins")
twins") Fertilization of 2 separate ova
Fertilization of a single ovum, Its etiology and prevalence
varies,
varies with racial / hereditary
Have the same sex & BG difference,
Identical in every way including Its actual prevalence is
the HLA genes increasing due to:
Early diagnosis by U/S.
Not genetically determined
Induction of ovulation
Constant in all races; its Change of the ages of women
prevalence: 1/250. experiencing their first
pregnancy and delivery ( > 35
Their fingerprints differ years age).
. Slightly more than 30% of twins are monozygotic; nearly 70% are dizygotic
Approximately 75% of dizygotic twins are the same sex.
Both twins are males in approximately 45% of cases (a lesser
preponderance of males in twins than in singletons) and both
females in approximately 30%.
Dizygotic multiple pregnancy tends to be recurrent.
Women who have borne dizygotic twins have a 10-fold
increased chance of subsequent multiple pregnancy.
Dizygotic twinning probably is inherited via the female
descendants of mothers of twins; the father's genetic
contribution plays little or no part.
White women who are dizygotic twins or who are siblings of
dizygotic twin mothers have a higher twinning rate among
their offspring than do women in the general population.
Parity does not influence the incidence of dizygotic twinning
but aging does.
CLASSIFICATION:-
BY ZYGOSITY (number of ovum) :- Monozygotic:-
Monozygotic 30%.
Dizygotic:-
Dizygotic 70%.
BY CHORIONICITY (Number of placenta):-
Monochorionic (shared placenta),
placenta Dichorionic (two
placentae)
placentae
It could be either Mono or Dizygotic, Placenta fused or
separate, and septum has four layers.
AMNIOCITY Number of amniotic sacs.
BY AMNIOCITY:-
One sac-
sac Monoamnionic (Monozygotic) and increase
chances of TTT Syndrome
Two Sacs-
Sacs Diamnionic,
Diamnionic these could be mono or
dichorionic, if dichorionic then either mono or dizygotic.
dizygotic
TWIN GESTATION TYPE :-
D C D A, M C DA, M C - M A, CONJOINED
Plac No. 2 1 1 1
Amni No. 2 2 1 1
Incidence. 1:300 1:400 1:3000 1:50,000
Time of Cleav. 0-72 hrs 4 to 8days 912 days > 12 days.
Zygosity. Diz or Mo Monozy Monozy Monozy
Rela to Ferti Rx. Yes No No No
Risk of TTTS. X Yes Yes NA
Cord Entangle X X Yes NA
Cong Anomaly Low Medium High NA
Vasa Previa Low High High NA
Placenta Previa High High High High
Preterm Delivery High High High High
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Notes:- DC (Dichorionic), DA(Diamnionic), MC(Monochorionic),
MA(Monoamnionic),
DC- DA :- may be Dizygo if diff gender; Same gender Di or Monozygo
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MZ twins (30%) a single fertilized ovum splits
into two distinct individual after a variable
number of division
Timing of egg division Determines placentation
in twins
DC DA placentation occurs with division prior
to the morula stage (within 3 days post
fertilization)
fertilization
MC DA placentation occur with division b/n
days 4 and 8 post fertilization
MC MA placentation occurs with division b/n
days 8 and 12 post fertilization
Division at or after day 13 results in
conjoined twins
Monozygotic Twins
Different Scenarios of Cleavage
Scenario 1
Monozygotic twin pregnancy
Bi-chorial and bi-amniotic
If the separation takes place just after the first
cellular division [1st 3 days ] both of the twins
will have their own placenta and an amniotic sac
each.