Multiple pregnancy…

RACHANA CHIBBER
MBBS; DGO ; MD ; MRCOG (UK) ; FRCOG (UK)
OBJECTIVES:
•Definition.
•Incidence and epidemiology.
•Clinical characteristics.
•Classification.
•Diagnosis.
•Complications.
•Abnormalities of the twinning process.
•Management.
DEFINITION

• Any pregnancy which two or more embryos or

fetuses present in the uterus at same time.

• It is consider as a complication of pregnancy

due to ;

• The mean gestational age of delivery of twins

is approximately 36w.

• The perinatal mortality &morbidity increase.

Terminology vs. number Singletons one
fetus
Twins →two fetuses.
Triplets → three fetuses.
Quadruplets → four fetuses.
Quintuplets → five fetuses.
sextuplets → six fetuses.
Septuplets → seven fetuses.
Mean gestational age of delivery

Number of babies Weeks of Gestation

1 40 weeks

2 36 weeks

3 33 weeks

4 29 ½ weeks
Incidence & epidemiology

• The incidence of multiple pregnancy in US is

approximately 3% (increase annually due to ART ).
• Monozygotic twins ( approx. 4 in 1000 births ).
• Triplet pregnancies ( approx. 1 in 8000 births ).
• Multiple gestation increase morbidity & mortality for
both the mother & the fetuses.
• The perinatal mortality in the developed countries
• Twins = 5 – 10 % births.
• Triplets = 10 – 20 % births.
HELLIN’S RULE

Twins 1 in 80
Triplets 1 in 80^2
Quadruplets 1 in 80^3

-
 Types of twins………

DIZYGOTIC MONOZYGOTIC
 DIZYGOTIC 2
chorions
amnion amnion

Always dichorionic & diamnionic

Factors affecting dizygotic
twinning

Ethnic group

Increasing maternal age

Increasing parity

Family h/o twinning, esp

maternal

Ovulation induction
MONOZYGOTIC
MONOZYGOTIC

>8days
MONOZYGOTIC

4-7 days
 Chorionicity
Type of placentation
Prenatal detection by USS

Clinical implications in antepartum &

intrapartum management…
 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
LAMBDA SIGN (dizygotic)

In dichorionic diamniotic twin pregnancy, there is a triangular projection of

placental tissue which extends from the placenta between the layers of
amniotic and chorionic membranes of each fetus. This ultrasound finding
is called "lambda" or "twin peak" sign. By 20 weeks only 85% of
dichorionic pregnancies demonstrate this sign.
DIZYGOTIC
MONOCHORIONIC & DIAMNIONIC TWIN PREGNANCY

T SIGN

In monochorionic diamniotic twin pregnancy, the inter-twin membrane

consists only of the two layers of amnion. The chorionic tissue within the
septum is missing. The ultrasound examination shows so called "T" sign at
the placental side.
MONOCHORIONIC MONOAMNIOTIC
 MATERNAL COMPLICATIONS

Antepartum

hyperemesis

hydramnios
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

monochorionic

Shift of blood
Normal
Death of one twin 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…
•Severe IUGR
•Stuck Twin
Donor(arterial side) •poor renal perfusion
•Anuria
•severe oligohydramnios
•Hypervolemia
•Polyuria with polyhydramnios
recipient •CCF…..hydrops…death
Management Options
 Serial amnio reduction,
fetoscopic laser ablation of
anastomosis
Uss of TTS….STUCK TWIN
6. Vanishing twin
Identification of a multifetal gestation with
subsequent disappearance of one or more fetuses.
Cessation of cardiac activity in a previously viable Fetus papyraceous…
foetus. In vanishing twin syndrome, there may be
complete reabsorption of a fetus, formation of a fetus one of twin fetuses that has died and
papyraceus (ie, a "mummified" or compressed fetus), been pressed flat against the uterine
or development of a subtle abnormality on the wall by the growth of the living fetus
placenta such as a cyst, subchorionic fibrin, or
amorphous material.[
 7. Congenital anomalies

Structural Chromosomal
malformations anomalies

Conjoint twins Down’s syndrome

Acardiac fetus
Anencephaly
Talipes
Dislocation of hip
etc..
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 Twins: Twin Reversed Arterial Perfusion (TRAP)
•This phenomenon occurs only in a twin pregnancy where the babies share the same placenta. The
incidence is about 1 in every 35,000 identical twin births.

•One twin is normally developed and referred to as the 'pump' twin. He pumps blood for himself as well as
for the other twin. The other twin is not fully developed and often lacks any personable features. This twin
does not have a heart and is referred to as the 'acardiac' or abnormal twin.

•The term 'reversed perfusion' is used because the blood enters the undeveloped twin through the vessels
in the opposite direction.

•This sequence of events places the normal twin at risk for heart failure. Left untreated, there is a 50%-75%
chance of mortality for the normal twin. The cause of TRAP is unknown.
•What testing is recommended during the pregnancy?

•Ultrasound examination can confirm the diagnosis and will be used to monitor the pregnancy. The size of
both babies is an important determinant for the outcome of the normal twin. If the estimated weight of the
abnormal twin is greater than 75% of the normal twin, the survival for the normal twin is about 10%.

TRAP Maternal Treatment

abdominal wall Radio
Acardiac Monster
Uterine wall frequency
ablation needle

Pump twin

Acardiac acephalic twin

 Acardiac foetus
A-A anastamoses
Umb. A
in placenta

Umb
De oxygenated
blood
.A

Minimal oxy. extracted by lower

Normal fetus/pump part of Acardiac fetus
twin
Fully de oxygenated

Umb.V V-V anastomoses Umb.V Upper part of fetus ,no growth

in placenta
Acardiac twins
Anencephaly
Intrapartum complications

PROM & cord prolapse

Abruption in the 2nd twin

Interlocking of twins
 ANTEPARTUM MANAGEMENT

Diet

• Energy sources increased by another 300

kcal/day

• Iron supplementation of 60 to 100 mg/day

• Folic acid, 1mg/ day if inadequate protein

intake
Antepartum Surveillance

• Serial sonography is usually employed

throughout the third trimester

• Non stress test

• Biophysical profile

• Doppler study to assess feto-placental

perfusion
Prevention of Preterm Delivery-
nothing really works!

• Rest? Routine hospitatlization is not

recommended

• Tocolysis?: No significant benefit

•Cerclage?: No proven benefit

Labour Complications

• Preterm labour

• Uterine dysfunction

• Abnormal presentations

• Prolapse of the umblical cord

•Premature separation of the placenta

• Postpartum hemorrhage
Intrapartum Management
• Appropriately trained obstetrical attendant

• Continuous external/internal electronic fetal

monitoring

• Blood transfusion products should be readily

available

• Intravenous fluid infusion

• Ampicillin, 2g IV, every 6 hours when preterm

labour is diagnosed
Continued

•USS for identification of fetal parts should be

available at all times .

•Analgesia and anesthesia. Anesthesiologist

should be immediately available

• Two neonatal team, skilled in resuscitation

• Adequate space for maternal and infants

management
Presentation
• Cephalic-cephalic 42%

• cephalic-breech 27%

• cephalic-transverse 18%

• Breech-breech 5%
Mode of delivery
• vaginal for cephalic-cephalic
• Controversial for cephalic-non cephalic
(breech) especially

if prematurity is a concern
• Controversial for breech-cephalic because of
rare risk of

Locked Twins
Locked Twins
Delivery of the Second Twin
• Interval between first and second twins can be prolonged
more than 30 minutes if continuous fetal monitoring is
employed
• Cesarean delivery rate is increased if interval is > 15
minutes
• Intrapartum external version of the noncephalic second
twin may be used for non fixed presenting part
• Internal Podalic Version: The fetus is turned so as to
deliver the feet first to effect delivery by breech
extraction
Multiple gestation with more than two fetuses

● Most frequent cause is iatrogenic from the use of

ovulation induction agent.
● Prematurity increase as the number of fetuses increase

Management options:
1) Multifetal reduction may be offered:
Reduce the risk to the mother & the remaining fetuses.
Performed only in the setting of dichorionic /diamniotic
gestation.

2) Selective termination:
Termination of one or more fetuses with structural or
chromosomal anomalies.

Delivery: Ideally by cesarean section with optimal

paedtric NICU facilities
THANK YOU FOR YOUR ATTENTION