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1-3%
10% of perinatal mortality, morbidity and neurodevelopmental problems
Twins- 60%
Triplets- 90%
Quadruplets- 100%
<2500grams- very low birth weight related to fetal gestation
Increased risk is for each fetus and is not simply because there are more fetuses per
pregnancy
Adverse Outcomes Associated with Multifetal Pregnancies
Congenital malformations
Pre-eclampsia
Post-partum hemorrhage
Maternal Deaths
Peripartum Hysterectomy
Depression for the Mother
Twin Fetus
Superfetation
Superfecundation
o Fertilization of two ova within the same menstrual cycle but not at the same coitus nor
necessarily by sperm from the same male.
Pituitary Gonadotropin
FSH level
o Common factor linking race, age, weight and fertility to multifetal gestation
Increased fecundility and higher rate of dizygotic twinning have been reported in
women who conceive within 1 month after stopping OCPs, but not during subsequent
months
o May be due to sudden release of pituitary gonadotropin in amounts greater than
usual during the 1st spontaneous cycle after stopping hormonal contraception
Declining fertility but increasing twinning with advancing maternal age
o Exaggerated pituitary release of FSH in response to decreased negative feedback
from impending ovarian failure
Relation in zygosity
Increased rates of perinatal mortality and neurological injury in monochorionic
diamnionic twins compared with dichorionic pairs
Fetal demise in one or both monochorionic twins was twice that in dichorionic multifetal
gestations
Biochemical Tests
Prolonged Pregnancy
Twin gestations have empirically been considered to be prolonged at 40 weeks
AOG
The cerebral palsy, risk is higher among twins and higher-order multiples
Related to an icreased risk of fetal growth restriction, congenital anomalies,
twin-twin transfusion syndrome and fetal demise of a cotwin
Monoamnionic Twins
o High fetal death rate from cord enlargement, congenital anomalies, preterm
birth or TTTS
Monozygotic twinning results in two amnionic sacs and a common surrounding chorion
o This leads to anatomical sharing of the two fetal circulations through
anastomoses of placental arteries and veins
Artery-to-artery anastomoses
Most common
Those with significant pressure or flow gradients, a shont will
develp between fetuses
Clinical Syndromes associated with Chronic Fetofetal Transfusion
1. Twin-twin Transfusion Syndrome (TTTS)
1-3 per 10, 000 births
Blood is transfused from a donor twin to its recipient sibling such that
Donor may eventually become anemic and its growth may be
restricted
o pale
Recipient become polycythemic and may develop circulatory
overload manifested as hydrops
o Plethoric
o May die due to heart failure and severe hypervolemia and
hyperviscosity
o Polycythemia may also lead to severe hyperbilirubinemia
and kernicterus
One portion of the placenta often appears pale compared with the
remainder
Occlusive thrombosis is another concern
Pathophysiology
o Unidirectional flow through arteriovenous anastomoses
o Deoxygenated blood from a donor placental artery is promted
into a cotyledon shared by the typically through arterioarterial
anastomoses leads to an imbalance to blood volume
o Syndrome typically presents in midpregnancy
When the donor becomes oliguric from decreased
renal perfusion and develops oligohydramnios
Recipient develops severe hydramnios, presumably
due to increased urine production
o Virtual absence of amnionic fluid in the donor sace prevents
fetal motion, giving rise to Stuck twin or Polyhydramnios-
Oligohydramnios-Syndrome Poly-Oh
o Amnionic Fluid Imbalance Associated with the following:
o Growth restriction, contractures and pulmonary
hypoplasia in the donor twin and premature rupture of
the membranes and heart failure in the recipient
TTTS Two Criteria
o Presence of a monchorionic diamnionic pregnancy
o Hydramnios- if the largest-vertical pocket s >8cm in one twin;
Oligohydramnios- if the largest vertical pocket is <2cm in the other
twin
Only 15% of pregnancies complicated by lesser degrees of
fluid imbalance progress to TTTS
Staging System
o Stage 1
Discordant amnionic fluid volumes as described above, but
urine is still visible
Sonographically within the bladder of the donor twin
o Stage 2
Criteria of stage 1, but urine is not visible within the donor of
the bladder
o Stage 3
Criteria of stage 2, and abnormal Doppler studies of the
umbilical artery, ductus venosus, or umbilical vein
o Stage 4
Ascites or frank hydrops in either twin
o Stage 5
Demise of either fetus
Cardiac Function of the Recipient Twin
o Myocardial Performance Index (MPI) or Tei Index
o Parland Memorial Hospital
ECG, MPI calculation, Doppler velocimetry and MRI, genetic
counseling and amniocentesis and placental mapping
Management and Prognosis
o Prognosis of Multifetal Gestations is complicated by:
TTTS related to Quintero Stage and Gestational age at
presentation
o More than ¾ of stage 1 remains stable or regress without
intervention
o Stage 3 or higher are much worse and the perinatal loss rate is 70-
100%
o Amnioreduction
o Laser Ablation of vascular anastomosis- for severe TTTS (stage 3 and
4)
o Selective feticide
o Selective reduction has generally been considered if severe
amnionic fluid and growth disturbance develop before 20
weeks
o Septostomy
o Intentional creation of a communication in the dividing
amnionic membrane
2. Twin anemia Polycythemia Sequence (TAPS)
Etiopathogenesis
Diagnosis
Fetal Biometry
o % disconcordancy = weight of larger twin – weight of smaller twin
o Abdominal circumference reflects fetal nutrition, some differe more than 20mm
or if the estimated fetal weight difference is 20% or more
o Weight disconcordancy > 25-30% most accurately predicts an adverse perinatal
outcome
Management
o Sonographic monitoring of growth within a twin pair and calculating disconcordancy has
become a mainstay in management
o Every 2 weeks in monochorionic twins
o Dichorionic twins are evaluated every 6 weeks
o Nonstress testing, biophysical profile scores and umbilical artery Doppler assessment
When to Deliver?
Fetal Demise
Preterm Birth
o Fetus in turned to a breech presentation using the hand placed into the uterus
o Obstetrician grasps the fetal feet to then effect delivery by breech extraction
Strict protocol for second twin management
o Abdominal manipulation
o Intrapartum external version of a noncephalic second twin
1. Twin A- non-vertex
Caesarean Section
2. Twin A- vertex; twin B- vertex
Vaginally
o If the first twin presents cephalic, delivery can usually be accomplished
spontaneously or with forcep
If not engaged 2nd twin
o Options are conversion to breech and deliver by breech extraction or CS
if felt the safest
3. Twin A- vertex; twin B- non-vertex
Caesarean section
Vaginal for both twin or breech extraction of twin B
Locked Twin
Intrapartum Management
Labor
o Establish the presentation and EFW by UTZ
o Oxytocin induction or augmentation
Anesthesia
o Regional