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Archives of Perinatal Medicine 13(3), 7-16, 2007 REVIEW PAPER

Twin pregnancy – physiology, complications and the mode of delivery


The aim of the article is to present actual knowledge concerning twin pregnancy. After the physiological changes observed during such
pregnancy, main complications such as intrauterine growth restriction (IUGR), prematurity, premature rupture of membranes (PROM) and
hypertension are discussed. The paper ends with discussion about the possible routes of delivery in twin pregnancy.
Key words: twin pregnancy, IUGR, hypertension, prematurity, mode of delivery

The incidence of multiple births has been rising steadily Monozygotic Twins
for over past 30 years. The reasons for this trend include The second type of twins develops from a single ovum and
advances in reproductive medicine as well as a greater pro- is known as monozygotic or identical twins. This phenomenon
portion of older pregnant mothers who naturally have a higher is a random genetic event, which occurs 1 in 250 pregnancies.
incidence of multiple gestations. Twin pregnancies in an un- Depending on the splitting of the primary zygote at various
medical population comprise 1% of all pregnancies, but ac- stages of development into two genetically identical embryonic
count for at least 10% of prenatal mortality [1, 2]. The indi- structures, three types of monozygotic twin pregnancies are
vidual twin’s risk of prenatal death is at least three times that distinguished: dichorionic diamniotic – if the splitting occurs
of a singleton, and the incidence of stillbirth is twice that of before 4 days after insemination; monochorionic diamniotic –
singletons [3, 4]. Low birth weight and prematurity are the when the split occurs between day 4 and 7 day; and, finally,
main causes of high prenatal morbidity and mortality in twins, monochorionic monoamniotic – when it occurs more than 7
whereas malpresentation and the hazards of delivery are next days after insemination. Monozygotic twinning occurs inde-
in order of concern. For these reasons, twin pregnancy is con- pendently of ethnicity, maternal age, parity, nutritional status
sidered a high-risk pregnancy; different aspects of the risk and environmental factors, but the rate of occurrence may be
include the mode of delivery, which remains a subject of a con- doubled after induction of ovulation and is increased with in-
troversy and discussion among obstetricians. vitro fertilization. Monochorionic placentation increases the
risk of early pregnancy loss (before 24 week) and may result
Multiple pregnancies in serious pregnancy complications such a twin-to-twin trans-
Multiple gestation is a pregnancy where more than one fusion syndrome [7]. Monochronicity and monozygosity are
fetus develops simultaneously in the womb. Depending on the associated with increased risk of preterm birth as well as an
number of developing fetuses, one can distinguish twin, trip- increased risk of congenital anomalies, growth restriction and
let, quadruplet, or quintuplet pregnancy, and so forth. The me- prenatal death [8-10].
chanism of development of multiple pregnancies is one of the
most interesting in the etiology of the human development. The incidence of twin births
Twins pregnancies occur naturally about one in every 90 The rate of multiple pregnancies has been rising signi-
births and result from 1 of 2 mechanisms that determine zygo- ficantly world wide, especially in countries such as Canada and
sity [5]. United States. For example, the rate of multiple births in
Dizygotic twins Canada increased from 1.9% in 1981 to 2.5% in 1997 [11]. The
Approximately two-thirds of twins in a Caucasian popu- phenomenon in these countries is mainly associated with
lation are dizygotic or fraternal, their incidence of 7-11/1000 increased numbers of births to older mothers and increased
births increasing with increasing maternal age [6]. They result use of fertility treatments as well as assisted conception. The
from simultaneous ovulation of two oocytes and fertilization by increase in the incidence of multiple pregnancies in Poland
two different spermatozoa. Both zygotes have very different has been rather steady and not so visible, considering the
genetic constitutions, and each implants individually in the overall increase in births; it reached its peak between 1980
uterus and develops its own placenta, its own amnion and its and 1991 and then stabilized after 1998 [12]. This steady
own chorionic sac. Conditions, which can influence the deve- increase is considered mainly associated with the limited avail-
lopment of dizygotic twin pregnancy, include maternal race, ability of assisted reproductive techniques, as well as a young
age and weight, past obstetric history, genetic predisposition age of the mother and cultural and religious differences, which
and the time of the year during which the conception took do not favor so-called “unnatural” forms of therapy.
place. Most if not all are associated with an increase in the It is generally recognized that 97% of multiple pregnan-
level of gonadotropic hormones in the maternal blood serum. cies are twin pregnancies [5]. Approximately 40% of these

Department of Perinatology and Gynecology, Medical University in Poznań, Poland
The Chicago Medical School, Chicago, Il, USA
8 A. Dera, G. H. Bręborowicz, L. Keith

present as cephalic-cephalic, 35% as cephalic/non-cephalic and nancy should be approximately 16 to 20.5 kg, which is appro-
the remaining 25% of twins present with twin A in the non- ximately 0.68 kg/week. At least one study has indicated that
cephalic presentation at birth [13, 14] . The mode of delivery weight gain below 0.39 kg/week may be associated with an
in cases of twin pregnancies with vertex-nonvertex presen- increase in premature birth and its consequences [15]. Luke
tation is associated with the greatest controversy, as it is et al. reported that maternal weight gain early during preg-
speculated that the greatest danger exists for the second twin. nancy might improve outcome of twins as well as triplets
[16-19]. This conclusion was based on the assumption that
Physiologic changes in multiple pregnancy multiple pregnancies involve greater nutritional requirements
Pregnancy is a time during which multiple adaptive chan- than in the case with singletons. When this need is appro-
ges take place in the maternal organism to allow optimal con- priately met by adequate maternal weight gain during preg-
ditions for developing fetus. The physiologic adaptations occur nancy, improved outcomes were observed in terms of pro-
in the mother in response to the demands of pregnancy. The- longing length of gestation and in larger birth weights [16, 17].
se demands include support of the fetus, protection of the fe- Physiological changes
tus, preparation of the uterus for labor and protection of the Circulatory system. The changes in the circulatory sys-
mother from potential cardiovascular injury at delivery. All ma- tem are mainly associated with the increased demand for oxy-
ternal systems are required to adopt; however, the quality, de- gen. This appears early (5 weeks after the last menstrual
gree, and timing of the adaptation varies from one individual period) and is much more intensified compared to singleton
to another and from one organ system to another. Multiple pregnancy. Due to increased demand for oxygen, the cardiac
pregnancy significantly affects the ability of the mother to output increases 35-40% by the end of first trimester until it is
adapt to the demands of pregnancy. The knowledge and under- approximately 50% greater than that of a nonpregnant woman.
standing of these physiologic adaptive changes allows health This phenomenon is mainly associated with the increased
care providers to foresee pathology, anticipate the effects of volume of the circulating blood – about 35% during multiple
multiple pregnancy on underlying medical conditions and to pregnancies comparing to singleton pregnancy. The etiology
manage pregnancy-associated complications. These pathologic of this process is controversial, but is thought to be associated
changes are mainly associated with disturbances of the adapti- with an activation of rennin-angiotensin-aldosterone system
ve mechanisms. Multiple pregnancy, as a high-risk pregnancy, and increased levels of placental hormones [20]. Maternal
is associated with changes, which are a little bit different from cardiac output increases as early as 10 weeks of gestation and
those, which take place in a singleton pregnancy. This fact is peaks at 30-50% over nonpregnant values by the latter part of
mainly associated with the presence of more than one fetus in the second trimester. This rise (from 4.5 l/min nonpregnancy
the uterine cavity. Of great importance, these physiological to 6.0 l/min in the second trimester of pregnancy) is sustained
changes may become so intense that they border on patholo- for the remainder of the pregnancy. The increase in cardiac
gical. The changes may be divided into anatomical and physio- output is associated with an increase in heart rate by 15-20%
logical. over the nonpregnant level by the end of the first and second
Anatomical changes trimester [21]. It is likely that the increase in heart rate is a
The anatomical changes of multiple pregnancy are mainly secondary (compensatory) effect resulting from the decline in
associated with the number of fetuses in the uterine cavity systemic vascular resistance during pregnancy. Stroke volume
and, at the same time, the size of uterus within the abdominal increases by approximately 25% to 30% by the end of second
cavity. The size of the uterus is almost the same as singletons trimester and remains at this level until term. The increase in
until the second trimester of pregnancy; after the 18 week, it stroke volume is due primarily to an increase in cardiac
is twice as big as in a singleton pregnancy and, in the 25th preload which is due, in turn, to a disproportionate increase
week, the uterine size is the same as a term singleton preg- in circulating blood volume [22]. Left ventricular end-diastolic
nancy. Another important anatomical change is associated volume increases during gestation, whereas end-systolic
with cervical length, which is crucial in terms of the duration volume remains unchanged resulting in an increase in ejection
of the gestation. During twin pregnancy, the cervical length fraction. Blood pressure is the product of cardiac output and
shortens about 0.8 mm a week, a circumstance that not only systemic vascular resistance and reflects the ability of the
acts as a risk factor but also definitely predisposes this type of cardiovascular system to maintain perfusion to the various
pregnancy to a premature birth. Further, the amniotic fluid organ systems, including fetoplacental unit. The blood flow
volume is greater than in the singleton pregnancy. This volu- through the pregnant uterus increases 20 to 40 times compare
me greatly increases until the second trimester and then to singleton pregnancy. The high concentration of pro-
stabilizes during the beginning of third trimester, decreasing gestagens in multiple pregnancy causes a decrease in systemic
between the 33rd and 36th weekly. The normative values for vascular resistance, which is associated with a decrease of the
MAF are the same as in singleton pregnancy (5-25 cm). Fi- diastolic blood pressure. The greater mass of fetuses, amniotic
nally, weight gain in multiple pregnancies is different than in fluid and placentas may readily compress the neighboring
singleton pregnancy. According to American College of Obste- vessels such as the aorta and inferior vena cava causing the
tricians and Gynecologists, weight gain during multiple preg- supine hypotensive syndrome. This syndrome is a result of
Twin pregnancy – physiology, complications and the mode of delivery 9

profound drop in venous return for which the cardiovascular increased size of the uterus secondarily displaces the intraab-
system cannot compensate. Physiologic compensatory dominal segment of the esophagus into the thorax. This then
mechanisms in the maternal circulation include increase in causes a reduction in tone of the lower esophageal high-pre-
the heart rate and increase resistance in the vasculature of the ssure zone (LEHPZ), which normally prevents the reflux of
lower limbs. acidic gastric content at the same time causing pyrosis (heart-
Respiratory system. There are numerous changes in burn) in the pregnant women.
the maternal respiratory system during pregnancy. These Renal Physiology. During pregnancy the glomerular
changes result initially from the endocrine changes of preg- filtration rate (GFR), as measured by creatinine clearance,
nancy and later, from the physical and mechanical changes increases by approximately 50% by the end of the first tri-
brought about by the enlarging uterus. As the enlarging uterus mester to a peak of around 180 ml/min [24]. This results in a
enters the abdominal cavity, it compresses veins and causes decrease in serum blood urea nitrogen and creatinine levels
increase venous pressure in the lower parts of the maternal during pregnancy, such that a serum creatinine value of
body; this, along with the decrease in the oncotic pressure, greater than 0.8 mg/dl may be an indicator of underlying renal
causes the patient to experience edema around the ankles. dysfunction. An additional effect of the increased GFR is an
The elevation of the relaxed diaphragm, which occurs as the increase in urinary protein extraction. Indeed, urinary protein
enlarging uterus, enters the true abdominal cavity causes a de- loss of up to 260 mg per day can be considered normal during
cline in the functional residual capacity (FRC) and an increase pregnancy [25]. These functional changes are not significantly
in inspiratory reserve volume. The total lung capacity, residual different between singleton and twin pregnancies.
volume and expiratory reserve volume are all decreased, but Hematologic System. Circulating blood volume increases in
these changes are minimalized by an increase in the flaring of pregnancy to maintain preload and thereby cardiac output.
the ribs as well as an increase in both the anteroposterior and There is a similar but less pronounced increase in red cell
transverse diameters of the thoracic cage [21]. The increase mass of approximately 30% in both singleton and twin preg-
of ventilation during pregnancy results from hormonal chan- nancies. This increase in red cell mass lags significantly be-
ges and increased carbon dioxide production. The arterial par- hind the change in plasma volume, which occurs later in preg-
tial pressure of carbon dioxide (PaCO2) is closely related to nancy. The difference in timing between the increase in red
the blood level of progesterone. This hormone increases the blood cell mass and plasma volume expansion results in
sensitivity of the central respiratory center to carbon dioxide physiologic fall in hematocrit in the first trimester despite
and acts as a direct respiratory stimulant. Estrogens also may adequate iron stores (physiologic or dilutional anemia of preg-
contribute to increased ventilation. Because increased ventila- nancy), which persists until the end of the second trimester.
tion and maternal hypocapnia precede the increase in carbon The number of erythrocytes increases approximately 25% in
dioxide production, early changes in ventilation result from comparison to singleton pregnancy. Erythropoesis is stimu-
elevated hormone levels, whereas later changes are the result lated by erythropoetin, which increases in pregnancy under
of both factors. Respiratory rate and mean inspiratory flow are the influence of placental hormones (chorionic somato-
unchanged in pregnancy [23]. On the other hand, ventilatory mammotropin, progesterone, and possibly prolactin) and dilu-
drive is increased during pregnancy (due to direct stimulatory tional anemia [26]. This dilutional effect also leads to decrease
effect of progesterone), leading to a state of hyperventilation in circulating platelet count (gestational thrombocytopenia)
as evidenced by an increase in minute ventilation, alveolar [27]. In contrast, circulating white blood cell counts increase
ventilation (70%) and tidal volume (45%). Although the lite- in pregnancy due to a selective bone marrow granulopoiesis.
rature lacks specific information about adaptive changes This increase peaks at around 30 weeks of gestation and
associated with multiple pregnancy, it is reasonable to assume although a white blood cell count of 5000 to 12,000/mm3 is
that beside the greater elevation of the diaphragm, no other considered normal in pregnancy only around 20% of women
changes in the respiratory mechanism can differentiate mul- will have a white blood count of greater than 10,000/mm3 in
tiple from singleton pregnancy. the third trimester [28].
Gastrointestinal system. The frequency of gastric emp- Pregnancy is associated with changes in the coagulation
tying is increased in multiple pregnancy. Its appearance is so and fibrinolytic cascades that favor thrombus formation.
characteristic that by itself can suggest the presence of multi- These changes include an increase in circulating levels of fac-
ple pregnancy. Gastric emptying is mainly associated with the tors XII, X, IX, VII, VIII, von Willebrand factor and fibrinogen.
increase in level of the chorionic gonadotropin. However, the Factor XI decreases, and levels of prothrombin (factor II) and
great increase of progesterone in the blood of the patient in factor V are unchanged. In contrast antithrombin III and pro-
multiple pregnancy compared to a singleton pregnancy, causes tein C levels are either unchanged or increased, and protein
intensification of the changes associated with the functioning S levels decrease in pregnancy [29]. The effect of these chan-
of the gastrointestinal system. Progesterone directly impairs ges is an increased predisposition to thrombosis during preg-
peristalsis of the stomach and intestines, and also decreases nancy and puerperium. The hypercoagulable state of preg-
food absorption as well as the tone of the lower esophageal nancy helps to minimize blood loss at delivery. However, the-
sphincter. The upward displacement of the stomach due to the se same physiologic changes also put the mother at increased
10 A. Dera, G. H. Bręborowicz, L. Keith

risk of thromboembolic events in pregnancy and the puerpe- • Bedrest and hydration are thought to be a factor, which
rium. supports the reduction of uterine activity. However, numerous
Care of the mother in twin pregnancy studies have failed to show that bed rest decreases the risk of
The main aim of prenatal care during pregnancy is to preterm birth, lengthens gestation and improves neonatal
achieve fetal maturity, to plan an optimal method of delivery, outcome in multiple gestations.
and to achieve the best possible neonatal outcome, which will • Tocolytic therapy – the aim is to increase the gestational
guarantee normal physical and psychological development of length of multiple gestation by decreasing of the uterine mus-
the children. These aims are the same for singleton and mul- cle reactivity or uterine contractions. This type of pharmaco-
tiple pregnancies. The physician should make sure that the therapy is associated with a controversy among different
pregnancy as well as the circumstances of delivery are as safe authors. According to Rodts-Paletnik and Morrison, it is very
as possible for the mother and the fetus. Both are possible important to correctly qualify the patient for this therapy in
with the knowledge of the numerous complications, which may order to accomplish the expected result. This therapy should
occur during multiple pregnancy (Table 1). Using early pro- be aimed for women with diagnosed preterm labor with the
phylactic-diagnostics methods, one can detect different patho- use of objective methods such as cervical length or fetal fibro-
logies, which occur more often in multiple than in singleton nectin [35]. Different view is represented by Oyelese and asso-
pregnancies. Multiple gestation is associated with higher rates ciates, who distinguish prophylactic, therapeutic and tocolysis
of almost every potential complication of pregnancy, with the in multiple gestations [36]. However, judicious use of this the-
exception of postterm pregnancy and macrosomia. Antepar- rapy is required in every patient but especially for women
tum complications develop in over 80% of multiple pregnan- carrying multiples, as they are at risk for developing compli-
cies as compared with approximately 25% of singleton gesta- cations such as pulmonary edema and cardiac arrythmias.
tions [30]. Some of specific complications are discussed in de- • Cervical cerclage – There is too little data to comment on
tail below. The knowledge of these complications allows early the use of cervical cerclage in high-order multiple pregnan-
detection, prophylaxis and treatment of these pathologies. cies. The only one randomized study carried by Dor and asso-
ciates did not find benefit in a prophylactic cerclage in twin
Preterm Labor and Birth pregnancy [37]. It is also worth to mention that this surgical
Preterm (premature) labor and birth occurs in 7%to 12% procedure carries potential risks for both the mother and her
of all deliveries, but accounts for over 85% of all perinatal fetus, so cerclage placement for multiple gestation is generally
morbidity and mortality [31-33]. Spontaneous preterm birth is reserved for women with either a strong history or objectively
a clinical diagnosis characterized by increasing intensity and documented cervical incompetence.
frequency of uterine contractions, leading to effacement and • Antibiotics – Although effective in the setting of PROM,
dilation of the cervix, and culminating in expulsion of the there is no role for broad-spectrum antibiotics therapy to
products of conception before 37 week of gestation. App- prolong latency in preterm labor with intact membranes [38].
roximately 57% of twin pregnancies deliver before 37 week of
gestation although not all preterm deliveries are spontaneous. Intrauterine Growth Restriction (IUGR)
Several tests have been introduced to identify women at Intrauterine growth restriction occurs more frequently in
high risk of preterm labor and birth. Cardiotopography as twins and higher order multiple gestations than in singleton
well as home uterine activity monitoring allows early uterine pregnancy and is a significant cause of increased neonatal
activity monitoring at the same time early detection of pre- morbidity and mortality. IUGR in multiple pregnancies is a
term labor as well as medical intervention to stop the uterine radiologic diagnosis that requires either an estimated fetal
contractions (tocolysis). Serial sonographic measurement weight (EFW) <3rd percentile (2 standard deviations from the
of cervical length, which can identify some twin pregnancies mean) for gestational age or an EFW <10th percentile for
at risk for preterm birth. Cervical length measurement has low gestational age along with evidence of fetal compromise (usu-
positive predictive value but is reassuring in symptomatic wo- ally oligohydramnions or abnormal umbilical artery Doppler
men. One study demonstrated that women in twin pregnancy velocimetry) [39, 40]. Of course, accurate gestational age
and preterm contractions with cervical length # 2.5 mm have dating is clearly critical for the diagnosis. Alexander et al.
a increased risk of delivering within 7 days [34]. Fetal fibro- clearly show that until the 27th week no difference is present
nectin (fFN) in cervicovaginal secretions measured at 22 between birth weights of singletons, twins or triplets. At 28
to 34 weeks of gestation is useful as a marker for preterm weeks, however, birth weight of twins and triplets starts to lag
birth in singleton pregnancies and may be of some predictive behind that of singletons, with little difference between twins
value in twin gestations. It is indicated that 99% of patients and triplets until 32 weeks [39]. This apparently normal dec-
with a negative fFN test will not deliver within 7 days. rease in growth rate in twin pregnancies after 28 week has
It is well indicated that obstetric health providers are been attributed to placental crowding and anomalous umbilical
getting better at identifying women at risk of preterm birth cord insertion. It is indicated that neonatal morbidity (meco-
but their ability to prevent this adverse outcome is limited. nium aspiration syndrome, hypoglycemia, polycythemia, pul-
A number of interventions have been recommended in at- monary hemorrhage) may be present in up to 50% of IUGR
tempt to prevent preterm birth: neonates [40-42]. Long-term studies show a twofold increase
Twin pregnancy – physiology, complications and the mode of delivery 11

in the incidence of cerebral dysfunction (ranging from minor mation was significantly lower in the nonpresenting as com-
learning disability and cerebral palsy) in IUGR infants deli- pared with the presenting twin, but only in dichorionic placen-
vered at term, and an even higher incidence if infant was born ta [50]. Discordant infection in twins may be important since
preterm [43]. Principles of management include identification the fetal inflammatory response syndrome is associated with
of women at risk, early antepartum diagnosis, attempts to an increased risk of impaired neurologic outcome, however,
identify etiology, regular fetal surveillance, and appropriate this has not been systematically studied in twin pregnancies
timing of delivery. [51, 52].
Fetal Growth Discordance (defined as a $20% difference The management of PROM should not differ significantly
in EFW between fetuses of the same pregnancy) is a marker in twin as compared with singleton pregnancies. It should inc-
of growth abnormality and is associated with an increased risk lude documentation of fetal wellbeing, exclusion of intraute-
of fetal death and neonatal mortality of morbidity. It is evident rine infection, broad-spectrum antibiotic therapy to prolong
in 5% to 15% of twins and 30% of triplets and is associated with latency, avoidance of tocolytics and antenatal corticosteroids
six-fold increase in perinatal morbidity and mortality. Signi- [53-55].
ficant risk factors for discordant growth include monochorio- Hypertensive disorder of pregnancy
nic placentation, preeclampsia and antepartum bleeding [44]. Hypertensive disorders of pregnancy are one of the main
Principles of management are the same as for IUGR. complications of multiple gestation; these include hyperten-
Premature Rupture of Membranes (PROM) sion induced by pregnancy and preeclampsia. According to
PROM refers to rupture of the fetal membranes before Newman and Luke, hypertension induced by pregnancy in
the onset of labor or before 37 week of gestation. Preterm twin gestation account for 14 %, in triplets 21% and quadrup-
PROM complicates 2-4% of singleton and 7% to 10% of twin lets even 41% [56]. Hypertensive disorders of pregnancy are
pregnancies. It is associated with 30 to 40% of preterm births the second most common cause of maternal death in the
and 10% of all perinatal mortality [45]. One of the major risk United States (behind thromboembolism), accounting for
factors include prior PROM (recurrence risk is 20-30%), 15-20% of all maternal deaths [57, 58]. It actually increases the
unexplained vaginal bleeding, placental abruption (seen in risk for the mother of pulmonary embolism and stroke, which
10-15% of women with PROM, but may be a result rather than can be even 3 to 12 times greater during third trimester as
cause), cervical insufficiency, vaginal and/or intrauterine infec- well as during labor and pueripartum [59]. Hypertension is
tion, amniocentesis, smoking, polyhydramnios and chronic also associated with high perinatal mortality and morbidity
steroid treatment. In multiple pregnancies, PROM typically rates, primarily due to iatrogenic prematurity.
occurs in the presenting sac, but it can occur in the non- Most adverse event occurring in the setting of preeclam-
presenting twin, especially after invasive procedures such as psia. Preeclampsia (gestational proteinuric hypertension) is an
amniocentesis. idiopathic multisystem disorder complicates 6-8% of all preg-
The period from PROM to delivery is dependent on seve- nancies [57, 58]. Both pregnancy-induced hypertension and
ral factors: preeclampsia are more common in women carrying twins. A
a. gestational age (at term 50% of women with PROM go secondary analysis of a large prospective multicenter trial of
into spontaneous labor within 12 hours and 95% within 72h; women with twins (n = 684) and singleton (n = 2946) pregnan-
latency is generally longer if PROM occurs preterm with 50% cies designed to investigate the efficacy of low dose aspirin for
of women going into labor within 24-48h and 70-90% within the prevention of preeclampsia was done by Sibai et al. Rates
seven days [46], of gestational hypertension and preeclampsia were twice as
b. severity of oligohydramnions (severe oligohydramnions high as compared with singleton pregnancies (13% vs 5-6%).
is associated with shorter latency period) and number of fetu- In addition, early severe preeclampsia and HELLP syndrome
ses (twins have shorter latency period than singletons) [3, were seen more frequently with multiple gestations [60].
47, 48]. The diagnosis, management and course of gestational
Neonatal complications are related primarily to prema- hypertension are not usually affected by the fetal number.
turity, including respiratory distress syndrome (RDS), intra- However, multiple gestation with PIH requires close care
ventricular hemorrhage (IVH), necrotizing enterocolits (NEC) often associated with hospitalization. Overall, the recom-
and sepsis. Overall PROM is associated with a four-fold incre- mendations associated with management of multiple gestation
ase in perinatal mortality and a threefold increase in neonatal are known. Still, since the risk of IUGR as well as preterm
morbidity [31, 48]. Maternal complications include increased delivery increases, it is required to have much closer and
cesarean delivery, intraamniotic infection and postpartum more frequent surveillance of the fetus and the mother.
endometritis. The largest study which looked at the outcome Recommendation for care include collection of a precise
after PROM in twins versus singleton pregnancies concluded gynecologic and obstetric medical history which includes
that perinatal and neonatal outcome were similar in the two knowledge of the conception (spontaneous or assisted), chro-
groups; however the median latency period was significantly nicity, previous deliveries, previous operations, weight gain,
shorter in twins (11.4 versus 19.5 hours) [49]. Another study history of uterine contractions, monitoring of blood pressure
reported that chorioamnionitis as well as advanced inflam- as well as history of any chronic diseases of the circulatory,
12 A. Dera, G. H. Bręborowicz, L. Keith

Table 1. Significant risks associated with twin pregnancies and exist especially in the vertex-nonvertex presentations.
Obstetric complications Risks* Opinions regarding the mode of delivery have been changing
Anemia ×2 over the decades. Prior to 1970, the route of delivery of twin
Pre-eclampsia ×3 gestations was dictated by the presentation of the first twin;
Eclampsia ×4 with delivery of the first twin complete, maneuvers then con-
Antepartum hemorrhage ×2 sidered appropriate to deliver the second twin included inter-
Postpartum hemorrhage ×2 nal podalic version and complete breech extraction [61].
Fetal growth restriction ×3
Taylor in 1976 suggested a cesarean delivery for all twins with
Preterm delivery ×6
malpresentation of the second twin regardless of fetal weight
Cesarean section ×2
[62]. Others recommended that vaginal delivery, irrespective
of the position of the second twin, is valid as long as the fetal
*Compared with singleton pregnancies weight is >1500 g and the gestational age is $ 32 weeks [63,
64]. Because of the existing controversy, multiple retrospe-
ctive studies and one randomized study have been conducted
Table 2. Complications associated with twin pregnancy to determine the best mode of delivery, which would decrease
Uteroplacental Fetal the mortality and morbidity among twins [64, 65]. Unfortu-
complications complications nately, not even one of these studies has reached a final an-
Placental abruption Intrauterine growth restriction swer. It is presently agreed that delivery should be based on
Cord entanglement Congenital anomalies individual needs and may depend on the clinician’s practice
Placenta previa Twin-to-twin and experience. In case of vertex-vertex presentation in twin
transfusionsyndrome pregnancies, it is anticipated that vaginal delivery is appro-
Preterm premature rupture Fetal growth discordance priate in such cases.
of membranes Twin A-Vertex with Twin B-Vertex. According to re-
Postpartum hemorrhage Intrauterine fetal demise cent literature, vertex/vertex twins should be delivered vagi-
of one or both twins nally. Several large studies show no increase in neonatal mor-
Malpresentation bidity and mortality when twins were allowed to deliver vagi-
Twin reversed arterial nally [21, 66-69]. Most authors agree that vaginal birth is
perfusion (TRAP) syndrome
appropriate for vertex/vertex twins born after 33 week or
weighing at least 1500 to 2000 g. The American College of
respiratory or metabolic system. The patient should undergo Obstetricians and Gynecologists in their educational bulletin
gynecologic examination to evaluate the cervical length and states that vaginal birth is appropriate for vertex/vertex twin
dilatation, the height or size of the uterus and the presence or gestations unless there are specific contraindications to
absence of any vaginal infections. Following, an ultrasono- vaginal birth [70]. Cesarean delivery should be performed for
graphic examination should be performed to check the ges- the same indications applied for singleton gestations.
tational age on the base of fetal measurements, number of fe- Twin A-Vertex with Twin B-Nonvertex. This presen-
tuses, zygosity of the twins, localization of the umbilical cords tation accounts for approximately 35% of twins and represents
and the presence of congenital malformations as well as one of the major areas of controversy among obstetricians.
cervical length. During the second trimester, beside the eva- Present recommendations regarding delivery of twins in such
luation of fetal size and cervical length, it is necessary to presentation are not clear. The literature contains mostly re-
perform fetal electrocardiography. During the third trimester, trospective and one randomized study, but all failed to reach
it is important to check the continuation of fetal growth (after final answer and do not permit formulation of a policy for de-
the 28 week of pregnancy twins are smaller than singletons) livery. Rabinovici, based on his randomized study, stated that
and intrauterine well-being. It is essential to make sure that the neonatal outcome of twins with vertex-breech or vertex-
the patient is aware of the risk of complications, which may transverse presentation after the thirty-fifth week of gestatio-
appear during pregnancy. Properly set visits should allow early nal age was not significantly influenced by the route of delive-
detection of cervical dilatation, premature labor, hypertension ry [64]. Other authors suggested that it is reasonable to allow
induced by pregnancy and twin-to-twin transfusion syndrome. labor and vaginal delivery, irrespective of the presentation of
Early treatment and the patient cooperation may decrease the the second twin as long as the fetal weight is $ 1500 g and the
risk of delivering premature neonates. gestational age $32 weeks [63, 71, 72]. Apart from all these
findings, the rate of cesarean sections is significantly incre-
Mode of delivery in twin pregnancy asing with the main indication being malpresentation in twin
Multiple pregnancies are at a higher risk than singletons pregnancy. Due to the fact that the second twin is at a signi-
for both prenatal morbidity and mortality. One of the most ficant disadvantage, most of the obstetricians make their de-
controversial subjects is mode of delivery in twin pregnancies. cisions trying to avoid complications [73]. In the view of many
The greatest problems are associated with the second twin practitioners experienced in the management of labor and
Twin pregnancy – physiology, complications and the mode of delivery 13

delivery, substantial numbers of twins in this presentation will of more than 1 hours is rather rare. At a time when conti-
present with serious acute intrapartum problems following the nuous fetal and uterine monitoring is possible, the time inter-
delivery of twin A, including cord prolapse, prolonged interval val between delivery of twin A until the time of delivery of twin
to delivery of twin B, birth trauma, risk of emergency cesarean B has no practical significance. However, the clinician should
section, prenatal death and neonatal morbidity [74, 75]. Addi- always think about the remaining fetus and the time interval
tionally, a policy of planned vaginal birth is associated with 30- should be limited by the risk of possible complications.
40% rate of emergency cesarean section. Even among those Optimal delivery timing
twins in which twin A is delivered vaginally, there is still a 7%
risk of the mother needing to deliver twin B by emergency The optimal timing of delivery for twin pregnancy is when
cesarean section. Considering the risk of maternal death, the health care provider and his/her team can deliver two heal-
which is the highest if delivery is by emergency cesarean sec- thy infants. It has been long thought that multifetal pregnan-
tion, the obstetrician has to think about planned vaginal birth cies achieve maturity earlier than fetuses of singleton ge-
or planned cesarean section in order to be prepared for com- station. Underlying this statement with evidence that preterm
plications, which may occur during delivery. infants of multifetal pregnancies achieve better outcomes than
infants of singleton pregnancies, there is also evidence that
Twin A –Nonvertex. In general, cesarean section is the optimal prenatal outcome occurs earlier and at lower birth
method of choice when the first twin is nonvertex, such as weight in multifetal pregnancies than in singleton pregnan-
breech or transverse presentation. In pregnancies of greater cies. Luke reported that in the United States the lowest fetal
then 24 weeks, most authors agree with cesarean section as death rates in twin pregnancies occurred at 36 to 37 weeks of
a preferred route of delivery, basing their decision on the gestation and at 40 to 41 weeks of gestation in singleton preg-
increased rate of complications associated with vaginal deli- nancies [89]. The most recent study by Hartley suggested that
very such as interlocking twins which occurs 10 times more the optimal gestational age for twin delivery is 37 to 38 weeks
frequently in breech/vertex than in vertex/breech [76]. In this of gestation, indicating that during this time the rates of pre-
type of collision, the percentage of prenatal neonatal and fetal natal mortality, RDS and long hospital stay are the lowest [90].
death is between 43 and 72%, depending on the type of colli- Considering these facts, induction of labor at 37 to 38 weeks
sion, and it mainly concerns the first twin [77]. of gestation should be routinely considered in twin pregnancy.
Fetal morbidity and mortality in the aspect of mode of delivery Anesthesia in twin gestation
The literature indicates that the increased number of
cesarean sections performed for twins with low birth weight The decision about anesthetic techniques when it comes
didn’t cause significant changes in the frequency of cerebral to cesarean section should be considered individually for every
palsy nor did it decrease the risk of stillbirth [78-80]. In ad- patient according the anesthesiologic and obstetric risk.
dition, it failed to have any significant impact on the long-term Looking at the literature it is evident that whether the cesa-
development of twins with different birth weights and increase rean section is performed under emergency or elective con-
in the morbidity and mortality of second twins. Most authors ditions, the use of regional anesthesia should be considered.
agree that the follow up of neurodevelopment and psychomo- Regional anesthetic techniques include epidural and subarach-
tor development at the end of first year of life does not indicate noid blockade. Some authors avoid the latter based on an
differences between children born as first and second [81, 82]. increased incidence of hypotension [91, 92]. The use of regio-
nal type of anesthetic technique has benefits for the mother as
Interval between birth of twins well as the fetus. The mother is able to stay conscious,
In the past an interval between twins of more than 30 mi- breathe by herself, which protect her from the risk of aspira-
nutes was considered as an factor which increases morbidity tion and hypoxia. In addition, it supports her hemodynamic
and mortality in the second twin by reducing the uterine-pla- stability much better than in case of general anesthesia. Addi-
cental circulation [83]. The optimal time for this interval was tionally it stabilizes and even improves the blood flow through
10 to 20 minutes. Earlier delivery <10 min was associated with placenta, which in case of hypertension induced by pregnancy
increased frequency of intrapartm injury and what followed or preeclampsia protects the fetuses from hypoxia [93]. More
increased mortality of the second twin [83, 84]. In addition, a so, especially during premature deliveries, it eliminates the
longer interval than 20 minutes was not indicated because it fetal exposition to harmful drugs, which are injected during
was supposed to lead to intrauterine fetal hypoxia. Some au- the general anesthesia.
thors had a different point of view; in four studies which were It is now recognized that there is increased maternal mor-
performed in 1980 with continuous electronic fetal monitoring tality rate associated with general anesthesia in singleton
there was no increase in morbidity and mortality related to an pregnancies and theoretically further increases in multiple
increased interdelivery time period [85-88]. In one of these pregnancies [94, 95]. The larger uterus encroaches to a grea-
studies, Rayburn et al. indicated that there was no difference ter degree upon the functional residual capacity, increasing
in fetal acidemia or base excess in those delivered at fewer hypoxemia in the supine position. An unfavorable shift in the
than 30 min or greater than 30 min after the first twin [83]. angle of the lower esophageal sphincter increases the like-
Nowdays, in most of the developed countries the time interval lihood of regurgitation of gastric contents, which can result in
14 A. Dera, G. H. Bręborowicz, L. Keith

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