REVIEW
Twin pregnancy
Emma Ferriman
Stephen Stratton
Vicky Stern
Abstract
Twins account for 2e3% of all births. They carry significant risks to
both mothers and babies. These risks include preterm delivery, intra-
uterine growth restriction, and pre-eclampsia. In addition, monochor-
ionic gestations confer an even higher rate of perinatal morbidity
and mortality arising from a shared placenta due to placental anasto-
moses, which may lead to twin-to-twin transfusion syndrome (TTTS) or
twin anaemia-polycythaemia sequence (TAPS). It is essential that cho-
rionicity is established in the first trimester in order to initiate the
appropriate antenatal management and surveillance. In view of the
high risk of both maternal and fetal complications, twin pregnancies
are ideally managed in a dedicated clinic according to agreed proto-
cols with both obstetric and midwifery input.
Keywords chorionicity; dichorionic; monochorionic; twins
Introduction
Twin pregnancies account for approximately 3% of all live
births, but account for 6.3% of stillbirths and 12.7% of neonatal
deaths. Twins are more at risk of pregnancy complications (Table
1). Monozygotic twin frequency rates remain relatively stable
worldwide at 3.5/1000 maternities, but dizygotic twins have a
variable rate depending on a number of factors including
geographical location, assisted reproductive techniques and
increasing maternal age. Rates vary from 1.3 to 49/1000 mater-
nities. Monochorionic twin gestations are associated with even
higher perinatal risk. Multiple pregnancies have been described
as a modern epidemic and carry considerable resource implica-
tions for health providers. In order to reduce the numbers of twin
pregnancies conceived as a result of assisted conception tech-
niques, a number of strategies have been proposed such as
elective single embryo transfer, selective fetal reduction and
single blastocyst transfer.
Zygosity and chorionicity
Twin pregnancy usually results from the fertilization of more
than one oocyte, producing dizygotic or non-identical fetuses.
Emma Ferriman MBChB FRCOG is a Consultant in Feto-Maternal
Medicine at The Jessop Wing, Sheffield, UK. Conflicts of interest:
none declared.
Stephen Stratton BSc MBChB MRCOG is a Senior Registrar with a
special interest in Fetal Medicine at The Jessop Wing, Sheffield, UK.
Conflicts of interest: none declared.
Vicky Stern MBChB MRCOG is a Fetal and Maternal Medicine Sub-
specialty Trainee at The Jessop Wing, Sheffield, UK. Conflicts of
interest: none declared.
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Frequency of fetal complications in twins
Singleton Dichorionic Monochorionic
Miscarriage 11e23 weeks 1% 2% 10%
Perinatal death 0.5% 1.5% 3%
IUGR 5% 20% 30%
Preterm delivery <32 weeks 1% 5% 10%
Major defects 1% 1% 4%
Table 1
Splitting of a single fertilized oocyte produces a monozygotic
twin pregnancy with two genetically-identical co-twins. Non-
identical twins develop their own placentae: monozygotic twins
may share a placenta according to the time of separation
(Figure 1). Dichorionicity occurs in 80% of twins, and genotyp-
ing is required to confirm zygosity in these cases ie dichorionic
twins can be monozygous.
Monochorionicity confers major increases in perinatal
morbidity and mortality when compared to dichorionic gesta-
tions. Chorionicity may be accurately determined by ultrasound
from between 10 and 14 weeks’ gestation. A number of methods
are widely used, including the presence of the lambda or ’twin
peak sign’ for dichorionicity and the ’T sign’ for mono-
chorionicity. In addition, the thickness of the intertwin mem-
brane may be determined e a membrane thickness of less than 2
mm is suggestive of monochorionicity. Other indicators in the
second trimester may be the presence of two separate placental
masses or discordant fetal sex. All twin pregnancies should be
offered an ultrasound scan between 11 and 13 þ 6 weeks to
assess viability, determine chorionicity and to screen for Down’s
syndrome. In monochorionic twins it is important to exclude
acardiac twinning.
If a woman with a twin pregnancy presents after 14 weeks, it
is important to determine chorionicity at the earliest opportunity
by ultrasound using the number of placental masses, the lambda
or T sign, the membrane thickness and discordant fetal sex. If
chorionicity remains uncertain, even after senior review, the
pregnancy should be managed as monochorionic.
Screening for abnormality in twins
Aneuploidy screening
The risk of Down’s syndrome (Trisomy 21) is 1 in 700 preg-
nancies. The risk for monozygotic twins is the same as for sin-
gletons, but for dizygotic twins this risk is doubled as each twin
has its own individual risk. The screening test of choice for twins
is combined first trimester screening at between 11 and 13 þ 6
weeks’ gestation with a calculated risk for the pregnancy in
monochorionic twins and an individual risk per baby in dichor-
ionic twins. Combined screening uses the measurement of the
nuchal translucency combined with first trimester measurements
of pregnancy associated plasma protein A (PAPP-A) and human
chorionic gonadotrophin (HCG). The detection rate varies ac-
cording to the chorionicity of the pregnancy: in monochorionic
twins the detection rate should be the same as for singletons
(80% with a 3% false positive rate), however, in dichorionic
twins where one baby is affected with aneuploidy, the detection
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 REVIEW
The relationship between zygosity and chorionicity
DIZYGOTIC
(non-identical)
DICHORIONIC
Figure 1
rate may fall to between 40 and 50% with a 3% false positive
rate. Detection rates can be improved further using additional
ultrasound markers such as the presence of the nasal bone and
ductus venosus and tricuspid Doppler waveform analyses.
Additional biochemical markers, alpha-fetoprotein (AFP) and
oestriol, can increase the detection rate further (up to 87%). For
women who present beyond 14 weeks the quadruple test may be
offered up to 20 weeks gestation.
Finally, the advent of Non-Invasive Prenatal Testing (NIPT)
offers a further choice in screening for women with twin preg-
nancies. Detection rates are between 98 and 99% in singletons
with false positive rates of <0.2%, however data for NIPT in
twins is still being collected. There seems little doubt it will
perform in twins much more highly that the combined or
quadruple tests.
Following a high-risk screening result, or the detection of a
fetal abnormality including an increased nuchal translucency, the
option of invasive testing should be discussed. Both amniocen-
tesis and CVS are possible in twin pregnancy, but these proced-
ures should be performed in a specialist fetal medicine unit to
ensure that the pregnancy is mapped correctly and the samples
taken are correctly attributed to each of the fetuses. The risks of
miscarriage and other procedure-related complications are
quoted as around 1 in 50 in twin pregnancies. Both amniocen-
tesis and chorionic villus sampling are valid options, but there is
some evidence to suggest that a double amniocentesis has a
lower risk of mistakenly sampling the same fetus twice.
Anomaly screening
The frequency of fetal abnormality in dizygotic twins is compa-
rable to that of singleton pregnancies (2e3%). This contrasts
with the increased frequency of anomalies seen in monozygotic
pregnancies where rates of up to 10% have been reported, or 2 to
3 times those which occur in dizygotic twinning. Several different
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MONOZYGOTIC
(identical)
MONOCHORIONIC
types of anomaly are thought to be more commonly seen in twin
pregnancies, including neural tube defects and congenital heart
disease. In monozygotic twinning, abnormal vascular connec-
tions predispose to limb reduction defects and bowel atresias.
Disorders of laterality occur when embryonic migration has
begun prior to zygotic splitting and may explain the increased
incidence of cardiac anomalies in monozygotic twin pregnancies.
A fetal echocardiogram is ideally offered at 20e22 weeks
gestation.
While the majority of monozygotic twins appear to be almost
identical, there are monozygotic offspring who are genetically
and phenotypically dissimilar. Mechanisms may include unequal
allocation of blastomeres between the two embryos, disrupted
embryonic migration, somatic mosaicism or chimerism, and
variations in penetrance of single gene disorders producing
phenotypic discrepancy.
The type of discordance varies from genetic and chromosomal
abnormalities through to isolated structural anomalies. Discor-
dant single gene disorders, imprinting defects and aneuploidy
have all been reported in monozygotic twins. Case reports detail
a range of discordant structural anomalies found in monozygotic
twin pairs, from neural tube defects and holoprosencephaly to
lateral and ventral body wall defects, and anomalies related to
the VATER association.
Management of twins discordant for fetal anomaly
The diagnosis of discordant anomaly in twins creates significant
dilemmas for parents, and careful counselling is required in
centres with expertise in this area. Accurate diagnosis and
determination of chorionicity is critical for subsequent manage-
ment. Depending on the anomaly detected, parents may be faced
with a choice of continuing the pregnancy and delivering both a
normal and an affected baby, or of terminating the affected fetus
and risking the viability of the healthy co-twin. Invasive testing
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 REVIEW
for chromosomal abnormality in dichorionic twins requires dual
puncture in most cases. In general, monochorionic twins require
a single puncture but in cases of discordant anomaly, both fe-
tuses should be sampled.
Selective feticide using intracardiac lignocaine or potassium
chloride injections of the affected fetus is only possible in
dichorionic twin pairs due to their separate inter-twin circula-
tions. It is associated with an increased risk of pregnancy loss,
and if not performed in the first trimester, is usually delayed
until the third trimester when viability of the normal twin is
more certain. This must be balanced against the risk of spon-
taneous premature labour, especially in cases complicated by
polyhydramnios such as anencephaly. Selective feticide in
monochorionic twins requires a cord occlusive technique such
as intrafetal laser or radiofrequency ablation of the umbilical
cord insertion, or bipolar diathermy to the cord. These tech-
niques also carry a significant risk of loss of the entire
pregnancy.
Pregnancy complications specific to twins
Complications specific to both mono- and dichorionic twin
pregnancies include vanishing twin and fetus papyraceous. Se-
lective fetal growth restriction (sFGR) is also possible in both
however it is more frequent in monochorionic pregnancies and
given the nature of a shared placenta poses a greater challenge to
manage. Abnormalities unique to monochorionic pregnancies
are twin-to-twin transfusion syndrome (TTTS); twin anaemia-
polycythaemia sequence (TAPS) and the twin reversed arterial
perfusion syndrome (TRAP). Monoamniotic pregnancies will
also be discussed.
Vanishing twin and fetus papyraceous
Up to 21% of twin pregnancies are complicated by either
miscarriage or loss of one twin in the early stages. This ‘van-
ishing twin’ phenomenon is increasingly detected by high-
resolution ultrasound and it is suggested that the miscarriage
rate in these pregnancies is about five times higher than that of
normal twins. No increased monitoring should be necessary if
the baby appears structurally normal, as the pregnancy is most
likely to progress as expected for a singleton. Care should be
taken where pregnancies have begun as multiple gestations in
women undergoing screening for chromosomal abnormality as
the non-viable fetus may cause false positive results.
The loss of a co-twin in the second or third trimester carries a
risk of preterm delivery, neurological sequelae or death to the
remaining fetus. It may result in the phenomenon known as fetus
papyraceous, where the anatomically-preserved demised fetus
can be identified at the later delivery of the surviving twin.
Selective fetal growth restriction
Selective Growth Restriction (sFGR) complicates 10e15% of
monochorionic twin pregnancies. The natural history and path-
ophysiology of this condition is different between monochorionic
and dichorionic twins. Growth in dichorionic pregnancies reflects
both genetic potential and placental function, but monochorionic
twin growth is also subject to the effects of unequal blastomere
separation, velamentous cord insertion and placental vascular
communications.
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Selective fetal growth restriction is defined as an estimated
fetal weight (EFW) discordance of >20%. The diagnosis may be
confused with TTTS as the smaller twin may have reduced li-
quor, but the larger twin will tend to have normal liquor volume
(not increased) and both bladders are visible. sFGR is an inde-
pendent risk factor for an increase in perinatal mortality and
morbidity. Once identified, sFGR in monochorionic twins should
be referred to a fetal medicine centre for further management.
Three types of sFGR have been identified; type I where there is
discordant growth but normal Dopplers, type II where there is
absent or reversed EDF in the UA Doppler and type III where
there is alternating positive, absent and reversed EDF in the UA
Doppler. Type I should be delivered between 34 and 36 weeks
gestation whereas type II and III should have planned delivery by
32 weeks.
Management of this condition prior to twenty-four weeks may
include selective termination of pregnancy using vaso-occlusive
techniques in order to protect the appropriately grown twin.
After 24 weeks frequent monitoring of the growth, umbilical
artery Doppler, middle cerebral artery peak systolic velocity and
ductus venous waveform is essential, and consideration must be
given to elective delivery. Paradoxically, the vascular anasto-
mosis between monochorionic twins which predispose to TTTS
can actually benefit the smaller twin in sFGR because artery
eartery connections can compensate for the placental insuffi-
ciency. This means that fetal demise may occur later in a mon-
ochorionic twin pregnancy complicated by fetal growth
restriction (average 10 weeks from onset) than in dichorionic
twins (3e4 weeks from onset of the growth restriction).
Twin-to-twin transfusion syndrome (TTTS)
Twin-to-twin transfusion syndrome (TTTS) complicates 10e15%
of monochorionic twin pregnancies. Feto-fetal transfusion occurs
via multiple vascular anastomoses between the circulations of
each co-twin, such that there is a net flow of blood from one twin
(the ‘donor’) to the other (the ‘recipient’). This results in hypo-
volaemia and oligohydramnios in the donor twin and hyper-
volaemia and polyhydramnios in the recipient.
Progression of the syndrome in the donor leads to growth
restriction and in severe cases, absent or reversed end-diastolic
frequencies in the umbilical artery. The recipient may develop
organomegaly, with abnormal ductus venosus Doppler fre-
quencies related to polycythaemia and hydrops. Tricuspid
regurgitation is an ominous sign of cardiac dysfunction in the
recipient and is associated with significant postnatal cardiac
dysfunction (Figure 2). Twin-to-twin transfusion syndrome ac-
counts for about 20% of stillbirths in multiple pregnancies.
Pathophysiology: both superficial and deep placental vascular
connections are present in the monochorionic placenta. Deep
anastomoses occur between arteries and veins. These arteriove-
nous (AV) connections are unidirectional and require the pres-
ence of ‘balancing’ superficial anastomoses to prevent TTTS.
Superficial anastomoses are bi-directional and are commonly
found between arteries (arterio-arterial anastomoses) and veins
(veno-venous anastomoses). Bidirectional flow allows compen-
satory activity in the event of vascular flow differences across the
deep anastomoses of the placenta, and if it is reduced or absent
then TTTS may develop.
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 REVIEW
Figure 2 Shows the enlarged bladder of the recipient twin with poly-
hydramnios in twin-to-twin transfusion syndrome.
Diagnosis of TTTS: most commonly, the diagnosis of TTTS is
made in the second trimester following the detection of discor-
dant growth or discrepant liquor volumes. A ‘stuck twin’ may be
visible, compressed against the uterine wall, where the donor is
constricted by anhydramnios and the tense sac of the poly-
hydramniotic co-twin. Acute TTTS may present as the sudden
onset of maternal discomfort and increasing girth, following
rapid development of polyhydramnios. Mortality is extremely
high usually as a consequence of premature delivery, either
spontaneous or iatrogenic.
A diagnostic staging system proposed by Quintero describes a
progression from early (stage I) to late (stage IV) disease (Table
2). A high stage at diagnosis is associated with increased
neurological morbidity and mortality, but progression of the
disease from early to a more advanced stage is also important for
prognosis. Uncertainty exists regarding the optimum manage-
ment of early (stage I) disease, where there is some evidence that
aggressive treatment may confer little benefit.
Management options for TTTS: several management options
exist for the treatment of TTTS, however there is now
The Quintero classification system
Stage Classification
1 There is a discrepancy in amniotic fluid volume
with oligohydramnios of a maximum vertical
pocket (MVP 2 cm) in one sac and
polyhydramnios in the other sac (MVP 8 cm).
The bladder of the donor twin is visible and
Doppler studies are normal
II The bladder of the donor is not visible, but
Doppler studies are normal
III Abnormal Doppler studies in either twin
characterised by reversed EDF in the umbilical
artery, reversed flow in the ductus venosus or
pulsatile umbilical venous flow
IV The presence of hydrops in the recipient
V Death of one or both twins
Table 2
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overwhelming evidence that laser ablation of the communicating
placental vessels has better outcomes. Other options are serial
amnioreduction with or without septostomy, and occlusive
feticide.
Endoscopic placental laser ablation aims to coagulate the
vascular anastomoses contributing to TTTS and may be selective
or non-selective. Non-selective coagulation destroys all vessels
crossing the intertwin membrane, including the healthy circula-
tion, and may increase mortality in the donor twin. This alter-
native is to selectively ablate only specific vascular connections
(the Solomon Technique). This carries the risk of incomplete
treatment and a recurrence of the condition. Amnioreduction is
performed prior to laser ablation in most cases.
The Eurofetus randomised trial demonstrated increased sur-
vival of one or both twins following laser (76%) compared with
serial amnioreduction (56%). The median gestational age at
delivery was increased in the laser group (33 weeks vs 29 weeks)
and laser was associated with a reduced incidence of periven-
tricular leukomalacia. As live birth rates were similar in both
groups, this survival advantage may reflect the differences in
gestation rather than a consequence of the therapy. In addition,
early stage disease was not well-represented in this study, leav-
ing persistent doubt about the benefit of laser in early disease.
A systematic Cochrane review in 2008 included only two
randomised controlled trials (including Eurofetus) with similar
results. Long term neurological sequelae have a reported inci-
dence of 13%e17% and do not appear to be reduced following
laser compared with amniodrainage.
Following successful laser ablation, the incidence of intra-
uterine death is reported to be 13e33%, and that of ruptured
membranes approaches 10%. High stage disease is more likely to
result in mortality. Late complications of laser are increasingly
reported, and mainly relate to the presence of persistent
communicating vessels causing recurrent TTTS or reversal of
flow (reverse TTTS). Despite this, since the Eurofetus study, laser
has been considered the first-line treatment for TTTS.
Amnioreduction aims to reduce liquor volume in the recipient
twin and to prevent premature delivery. It is likely to require
repeated procedures and does not treat the underlying cause of
feto-fetal transfusion. Associated risks include premature labour,
ruptured membranes, chorioamnionitis and placental abruption.
Septostomy aims to disrupt the inter-twin membrane allowing
normalisation of liquor volume between the two sacs and may be
followed by amniodrainage as an adjunctive treatment.
A randomised controlled trial comparing amnioreduction with
septostomy in TTTS before 24 weeks of gestation found that the
rate of survival of at least one twin was similar in both groups
(78% vs 80%), with no significant advantage of septostomy with
amnioreduction over amnioreduction alone.
Possible disadvantages of septostomy include the fact that the
resulting chorioamniotic separation may hinder subsequent laser
ablation. Amnioreduction is now most commonly utilised at later
gestations or where laser ablation is not feasible and is useful in
stage I disease where the evidence for laser ablation is less
robust.
Selective feticide
The termination of one fetus by disruption of the cord is an op-
tion, particularly in the presence of discordant anomaly. Laser
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 REVIEW
ablation, radiofrequency ablation and cord occlusion are the
techniques possible. Laser is usually reserved for the first
trimester, radio frequency 22e24 weeks gestation and cord
occlusive techniques at gestations greater than 24 weeks. Parents
may choose to terminate a severely affected twin to increase the
survival chances of the other, less affected twin and reduce the
risk of losing both babies. From the limited available evidence,
singleton survival rates after the procedure would appear to be
about 67%, ruptured membranes in 5e10% and severe neuro-
logical sequelae in the region of 6%.
Twin anaemia-polycythaemia sequence (TAPS)
This syndrome has a similar pathology to TTTS however it is
thought to occur by much smaller (<1 mm), hair like arterio-
venous connections, which allow insidious flow of blood from
one twin to the other. The result is one twin becomes anaemic
(donor) whilst the other twin becomes polycythaemic (recip-
ient). It is thought to complicate 5% of monochorionic twin
pregnancies, increasing to 13% following laser ablation therapy.
Diagnosis prenatally is by the measurement of the peak systolic
velocities (PSV) in the middle cerebral artery (MCA). The difference
is considered significant where the donor twin has an MCA-PSV
greater than 1.5 multiple of the median (MoMs) and the recipient
twin has an MCA-PSV less than 1.0 MoMs. Similar to TTTS, there is
a staging system. At present there is no clear consensus on the
frequency of measurement of the MCA-PSV in monochorionic twin
pregnancy with some authorities recommending screening every
two weeks whilst others not recommending any routine screening
at all. Given the significant increase in its occurrence after laser
therapy, MCA-PSV is considered an essential part of surveillance
after the procedure has been performed.
The outcome in TAPS can vary from delivery of healthy twins
which need treatment for anaemia/polycythaemia in the
neonatal period, through to a twin suffering severe hydrops or
fetal demise. There is also evidence that this condition has im-
plications on neurodevelopment, with up to 20% of twins having
some degree of impairment.
There is no consensus on how to manage TAPS, but the op-
tions should be discussed on an individual basis and are heavily
dependent on gestational age. These include conservative man-
agement, early delivery, fetoscopic later ablation (as discussed
above), intrauterine blood transfusion for the anaemic twin and
partial exchange transfusion of the polycythaemic twin.
Twin reversed arterial perfusion sequence (TRAP)
Acardiac anomaly is a rare complication of monochorionic twin
pregnancies, occurring in approximately 1 in 35,000 cases. In this
condition, arterial blood flows in a retrograde fashion from the
pump twin towards the affected twin via a single arterio-arterial
anastomosis; hence the synonym twin reversed arterial perfusion
syndrome (TRAP). The poorly oxygenated blood entering the
circulation of the affected twin preferentially perfuses the caudal
structures rather than the cephalad, resulting in abnormal
development of all organ systems. The head and the heart are
commonly absent, with a preserved central trunk and rudimen-
tary spine. The lower limbs may be more preserved due to the
improved blood supply. Acardiac twins are frequently hydropic
due to their abnormal lymphatic and vascular drainage.
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The diagnosis of TRAP usually follows the detection of a
grossly abnormal co-twin within a monochorionic pair. The
absence of cardiac pulsation in the acardiac twin is usually
evident, although rudimentary cardiac tissue or transmitted
pulsations may produce the appearances of normal cardiac
function. Paradoxical blood flow may be visualised by colour
Doppler ultrasound to confirm the diagnosis.
Once diagnosed, the primary aim of management is to
improve survival chances for the structurally normal pump twin.
Poor prognostic features include increasing size of the acardiac
twin with signs of cardiac insufficiency in the donor secondary to
increased demand. Management options for intervention include
cord occlusion techniques, or an intrafetal approach to ablate the
vasculature in the acardiac twin.
Selective feticide
The termination of one fetus by disruption of the cord is an op-
tion, particularly in the presence of discordant anomaly. Laser
ablation, radiofrequency ablation and cord occlusion are the
techniques possible. Laser is usually reserved for the first
trimester, radio frequency 22e24 weeks gestation and cord
occlusive techniques at gestations greater than 24 weeks. Parents
may choose to terminate a severely affected twin to increase the
survival chances of the other, less affected twin and reduce the
risk of losing both babies. From the limited available evidence,
singleton survival rates after the procedure would appear to be
about 67%, ruptured membranes in 5e10% and severe neuro-
logical sequelae in the region of 6%.
Monochorionic, monoamniotic twins
Monoamniotic twinning occurs in 1e2 % of monochorionic
gestations (1 in 3000e6000 pregnancies) as a result of zygotic
separation beyond eight days of conception. The diagnosis is
usually made following the first trimester ultrasound, showing a
single placenta and two freely moving fetuses with no inter-twin
membrane evident.
These pregnancies are associated with the highest perinatal
loss rate of all twins, at around 30e60% in most series. Umbilical
cord accidents and prematurity account for much of this loss
rate, along with higher rates of congenital anomaly (20e25%)
and fetal growth restriction. More recent series suggest a fall in
perinatal mortality, possibly associated with earlier diagnosis
and intensive surveillance in these cases. Despite the shared
placenta, chronic TTTS appears to be less common in these
gestations (5%).
Up to 60% of the antenatal fetal deaths occur prior to 32
weeks’ gestation. This is thought to be related to cord entangle-
ment and occlusion, although cord entanglement will be present
at almost all gestations. Consequently, this complication is not
preventable and cannot be predicted by cardiotocographic
monitoring. Strategies have been reported to reduce amniotic
fluid levels, limiting fetal movement to prevent tightening of the
tangled cords. Medical amnioreduction with oral prostaglandin
synthase inhibitors has been described with 100% survival of
forty fetuses (twenty pairs). However, the majority of mono-
amniotic pregnancies undergo intensive surveillance with serial
ultrasound monitoring in an attempt to detect impending cord
occlusion.
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 REVIEW

will opt for termination. Survival depends on the organs joined.

Maternal risks associated with twins
Maternal risks associated with multiple pregnancy
Hyperemesis
Increased mechanical symptoms of pregnancy
Gastro-esophageal reflux
Hypertensive disorders
Gestational diabetes mellitus
Anaemia
Operative delivery
Post-partum haemorrhage
Perinatal mental health disorders
Table 3
Elective delivery at 32 weeks’ gestation following adminis-
tration of steroids is usually advocated, since at this point
neonatal survival is comparable to term survival in most cen-
tres. Meta-analyses of perinatal loss report a rate of around 10%
in monoamniotic pregnancies continuing beyond this point.
Vaginal delivery of monoamniotic pairs has been achieved
successfully but is associated with the risks of cord prolapse
and fetal impaction in the maternal pelvis. Vaginal delivery is
usually reserved for the extremely premature or non-viable
fetuses.
Conjoined twins
Incomplete division of the embryo may result in conjoined twins.
The classification of this anomaly is largely descriptive and
dependent on the anatomical areas joined. Conjoined thorax
(thoracopagus) and conjoined thorax and abdomen (thoraco-
omphalopagus) are the commonest subtypes with conjoining at
the pelvis and head (ischiopagus and craniopagus) being less
common.
With the advent of improved ultrasound techniques, most
cases are identified in the first trimester, and in view of the sig-
nificant mortality and morbidity, a significant number of parents
50% are stillborn and of the survivors up to 75% may have
inoperable defects. Elective caesarean delivery is usually advo-
cated, but there are reports of vaginal deliveries occurring.
Antenatal management of twin pregnancies
Women with twin pregnancies should be given the same advice
about diet, lifestyle and nutritional supplements as in routine
standard care. There is a higher incidence of anaemia in women
with twin pregnancies therefore a full blood count should be
performed at 20e24 weeks to identify women who need sup-
plementation with iron or folic acid. This should then be repeated
at 28 weeks as in routine antenatal care.
It is vital to offer antenatal care in an appropriate setting
aiming to provide standardised care to all women with multiple
pregnancies. Clinical care for women with twin pregnancies
should be provided by a nominated multidisciplinary team con-
sisting of named specialist obstetricians, specialist midwives and
ultrasonographers, all of whom have experience and knowledge
of managing twin pregnancies. In addition, women should have
access to a perinatal mental health specialist, women’s health
physiotherapist, an infant feeding specialist and a dietician. A
dedicated clinic allows the close surveillance required by this
population along with the specialised care they may need in
terms of preparation for birth and psychological support.
Mothers with twin pregnancies are at higher risk of all obstetric
complications and should be counselled appropriately (Table 3).
In general, maternal mortality associated with multiple births is
2.5 times higher than singleton births.
NICE and the RCOG consensus document has recommended
two distinct care pathways for monochorionic and dichorionic
twins (Table 4).
Hypertension
Women with twin pregnancies may be at higher risk of hyper-
tension. NICE suggest that women with multiple pregnancies
should take 75 mg of aspirin daily from 12 weeks until the birth

Schedule of antenatal scans and timing of delivery

Type of pregnancy (uncomplicated) Scans Delivery

Monochorionic diamniotic twins
Dichorionic, diamniotic twins
Monoamniotic monochorionic twins
Approximately 11 weeks 0 dayse13 weeks 6 From 36 þ 0 weeks following antenatal
days (viability, chorionicity, 1st trimester steroids.
screening) and 16, 18, 20, 22, 24, 28, 32 and
34 weeks e fetal growth and TTTS  Fetal
echo at 20 weeks
Approximately 11 weeks 0 dayse13 weeks 6 From 37 þ 0 weeks.
days (viability, chorionicity, 1st trimester Consider steroids for elective caesarean
screening) and 20, 24, 28, 32 and 36 weeks e sections
fetal growth
11 weeks to 13 þ 6weeks (viability, From 32 þ 0 weeks following antenatal
chorionicity, 1st trimester screening) and steroids.
16,18,20,22,24,26,28,30 weeks e fetal Delivery by elective caesarean section
growth, polyhydramnios, TTTS  Fetal echo at
20 weeks

Table 4

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of their babies if they have one or more of the following risk
factors for hypertension:
 First pregnancy
 Age 40 years or older
 Pregnancy interval of greater than 10 years
 BMI of 35 kg/m2 or more at first visit
 Family history of pre-eclampsia
Preterm birth
Twin pregnancies are at high risk of spontaneous or iatrogenic
preterm delivery. The incidence of preterm delivery prior to 37
weeks can be up to 50 %. Delivery at less than 32 weeks appears
to vary with the type of twinning, ranging from 5% for dichor-
ionic twins and 10 % for monochorionic twins, compared with
1% for singleton pregnancies. Current evidence suggests that
cervical length assessment, progesterone supplementation and
cervical cerclage do not prevent early preterm labour in twin
pregnancies and therefore the routine measurement of cervical
length is not recommended. Studies into mechanical devices to
prevent preterm labour in twins such as the Arabin pessary are
ongoing. The use of untargeted single or multiple courses of
corticosteroids is also not recommended.
Intrauterine growth restriction
Twin pregnancies are known to be at a significantly increased risk
of intrauterine growth restriction (IUGR) and this is partly due to
the increase in risk of placental dysfunction, with rates varying
from 20% in dichorionic twins to 30% in monochorionic pairs.
Two thirds of unexplained stillbirths in multiple pregnancies are
associated with a birthweight below the tenth centile. It is
important to estimate fetal weight discordance using two or more
biometric parameters at each ultrasound scan from 20 weeks.
The optimum surveillance for IUGR in twins less than 32
weeks with abnormal Doppler studies has not been defined. The
timing of delivery at very early gestations is a balance between
the risks of prematurity and the risk of exposing the fetus to
prolonged hypoxaemia. Surveillance of growth-restricted twins
will include monitoring of fetal Doppler waveform analyses
(umbilical artery, MCA and ductus venosus), liquor volume and
computerised cardiotocography.
Single intrauterine fetal death
The death of one twin carries an increased risk to the remaining
fetus, which is greater in monochorionic pregnancies. The sur-
viving twin of a monochorionic pair has a 15% risk of death,
with neurological sequelae in 26% and preterm delivery of 68%.
In dichorionic pairs, the risk of death is just 1%, with 4%
developing neurological disability and less than 50% subse-
quently delivering prematurely. This significant difference in risk
has been attributed to substantial haemodynamic shifts within
the shared placenta following the death of one fetus of a mono-
chorionic twin pair. These patients should be carefully coun-
selled regarding the prognosis for the surviving twin, and an MRI
of the fetal brain is advocated in monochorionic gestations.
Delivery
NICE guidance recommends delivery from 37 to 38 weeks
gestation for uncomplicated dichorionic twins and from 36 to 37
weeks gestation for uncomplicated monochorionic diamniotic
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twins. There is marked variability in practice. It should be
remembered, however, that 58% of twins will deliver sponta-
neously before 37 weeks. There is significant evidence that
perinatal mortality rates increase after 38 weeks even in un-
complicated twin pregnancies. Additionally, intervention at 37
weeks does not appear to be associated with a significant dif-
ference in mode of delivery or maternal complications when
compared to expectant management. For women declining de-
livery, weekly monitoring should occur.
Retrospective cohort data suggested that, when compared to the
presenting twin, the second twin is at higher risk of intrapartum
mortality due to the complications of vaginal delivery. However,
the publication of the Twin Birth Study in 2013 has refuted this. The
study was a large, prospective, randomized, controlled trial
comparing planned Caesarean section to planned vaginal birth for
twins delivered between 32 and 38 weeks gestation where the
presenting twin was cephalic. It found that planned caesarean
section did not reduce the risk of fetal or neonatal death or serious
neonatal morbidity when compared with planned vaginal delivery.
There was a higher risk of adverse perinatal outcomes for the sec-
ond twin, but this was not reduced by a planned caesarean birth.
Current practice supports the policy of planned vaginal birth in
uncomplicated pregnancies with a cephalic first twin.
On a more practical level, delivery should be conducted in a
unit where continuous electronic fetal monitoring is available
and there is access to early recourse to caesarean section. An
experienced operator should be present at delivery to enable
expert management of the second twin, in particular with regard
to vaginal breech delivery. Overall, there is a higher risk of
emergency caesarean section in labour for twin pregnancies,
with rates approaching 50% overall and between 3 and 5% for
the second twin following vaginal delivery of the first twin.
Conclusions
Multiple pregnancy is a common cause of morbidity for both
mothers and babies. Antenatal care focuses on screening for
anomalies and for early signs of complications such as fetal
growth restriction, TAPS and TTTS. Accurate diagnosis of cho-
rionicity in the first trimester is essential and allows appropriate
surveillance to be planned. Following the results of the Twin
Birth Study there is no evidence to support a policy of elective
caesarean section for all twins. Current practice in the UK would
be to support vaginal delivery in uncomplicated dichorionic
twins in which the first baby has a cephalic presentation. For
monochorionic twins, this practice is less clear-cut due to the
incidence of acute twin-to-twin transfusion occurring in labour
(up to 10%), but no national guidance currently recommends
routine birth by caesarean section in this group as yet. A
FURTHER READING
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nicity and zygosity in multiple pregnancy. Prenat Diagn 1997 Dec;
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D’Antonio F, Khalil A, Thilaganathan B. Southwest Thames Obstetric
Research Collaborative (STORK). Second-trimester discordance
and adverse perinatal outcome in twins: the STORK multiple
pregnancy cohort. BJOG 2014; 121: 422e9.
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Fisk NM, Duncombe GJ, Sullivan MH. The basic and clinical science of
twin-twin transfusion syndrome. Placenta 2009 May; 30: 379e90.
Barrett Jon FR, Hannah ME, Hutton EK, et al. A randomized trial of
planned cesarean or vaginal delivery for twin pregnancy. N Engl J
Med 2013; 369: 1295e305.
Khalil A, Rodgers M, Baschat A, et al. ISUOG Practice Guidelines: role
of ultrasound in twin pregnancy. Ultrasound Obstet Gynecol 2016;
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Kilby MD, Bricker L, on behalf of The Royal College of Obstetricians
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MBRRACE-UK. Perinatal Confidential Enquiry. Term, singleton, intra-
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MBRRACE-UK. Saving lives, improving Mother’s care, December
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Multiple Pregnancy. The management of twin and triplet pregnancies
in the antenatal period. National Institute for Health and Clinical
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Pharoah POD, Adi Y. Consequences of in-utero death in a twin
pregnancy. Lancet 2000; 355: 1597e602.
Quintero RA, Morales WJ, Allen MH, Bornick PW, Kruger M. Staging of
twin-twin transfusion syndrome. Obstet Gynecol 2002; 100: 1257e65.
Senat MV, Deprest J, Boulvain M, Pauper A, Winer N, Ville Y. Endo-
scopic laser surgery versus serial amnioreduction for severe twin-
to-twin transfusion syndrome. N Engl J Med 2004; 351: 136e44.
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BMJ 2002; 325: 1004e6.
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Practice points
C Early assessment of chorionicity is essential for the planning of
subsequent management.
C First trimester combined screening by nuchal translucency and
first trimester biochemistry should be offered between 11 weeks
and 13 weeks and 6 days.
C A fetal anomaly scan should be offered between 18 and 22 weeks
gestation.
C For twins discordant for fetal anomaly referral to a specialist fetal
medicine centre is recommended.
C Clinicians should appreciate the increased risk of congenital
anomaly, in particular congenital heart defects in monochorionic
twins.
C Discordant fetal growth with abnormal Doppler assessment
should be referred to a specialist centre when diagnosed.
C The appropriate antenatal pathways should be followed with
increased surveillance of monochorionic twins.
C Uncomplicated dichorionic twins should be offered delivery be-
tween 37 and 38 weeks gestation and uncomplicated mono-
chorionic twins should be offered delivery between 36 and 37
weeks gestation.
C Monoamniotic twins should be delivered by elective caesarean
section at 32 weeks gestation
C In twins planning a vaginal delivery, an experienced practitioner
must be present or easily accessible during the intrapartum
period.
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