TWIN PREGNANCY

Objectives

Incidence
Types of presentation
Where to deliver
Mode of delivery
Management of labour
Incidence
Spontaneus twins occur in approximately 1
in 90 pregnancies
Increased use of reproductive technology
has significantly increased this rate
High risk pregnancy
Two third dizygotic, one third monozygotic
 Perinatal mortality

Five times in twins than singleton

Premarture related complications :
monochorionic 5%, dichorionic 2%

Sebire et al 1996
Miscariage before 24 weeks

Singleton = 1 %
Dichorionic = 2%
Monochorionic = 10%

Sebire et al 1997
 Preeclampsia

The prevalence four times greater in

twin than singleton pregnancy. No
difference between monochorionic or
dichorionic

Sawidov et al 2001
 Preterm delivery (24-32 weeks)

Singleton 1 %
Dichorionic 5 %
Monochorionic 10 %

Sebire et al 1997
 Growth restriction

Singleton pregnancy 5%
Dichorionic twins 20%
Monochorionic twins 30%
 Conjoined twins

Division of the embrionic disk at more

than 13 days after fertilization
Is not affected by genetic factors, race,
parity, or maternal age
Incidence 1 : 50.000 – 100.000 births
70% are female
Twin to Twin Transfusion Syndrome

15% of monozygotic twin gestation

Is associated with high perinatal
morbidity and mortality rates if
untreated
 Lies and Presentation of Twins (%)
First twin

Cephalic Breech Other

Second Cephalic 39 13 0,6

twin Breech 26 9 0,6
Other 8 4 0,5

Thompson et.al 1987

Location for delivery of twins

Discussed and planned in advance

Consultation with patient, family
attending physician and obstetrician
Recommended delivery in hospital
Location for delivery of twins (2)

Obstetrician in attendance for labour, if

possible
Same resources as required for
singleton with extra staffing (nursing,
physicians, midwives)
Consider transfer of labouring patient if
resources unavailable locally
Method of delivery

Consider the lie and presentation of

each fetus
Vaginal delivery is the goal unless there
are specific contraindications
Placenta should not be drained and
cord bloods not taken untill after
delivery of second twin
First twin cephalic
First twin cephalic : vaginal
Second Twin :
 Cephalic : vaginal
 Breech : vaginal
• Breech extraction acceptable
• Caution if EFW of B >> A
 Other :
• Prompt internal or external version
• If fails perform caesarean
 First twin breech

Selection for labour and vaginal delivery

similar to singleton breech
Consider risk of “locked” twins if twin B is
cephalic
Second twin (if first twin delivered vaginally)
 Cephalic : vaginal
 Breech : vaginal
• Breech extraction acceptable
• Caution if EFW of B >> A
 Other
• Prompt internal or external version
• If fails perform caesarean
First Twin Non-Longitudinal

Caesaren Section
Management of Labour

Preterm labour common

 Educate re: warning sign
 Steroid indicated as in singleton
 Use tocolytics judiciously (pulmonary edema)
Induction as per singleton indications plus
twin specific indications (e.g. EFW disparity)
Augmentation as per singleton, may be
helpful following delivery of first twin
Management of Labour – Fetal Well Being
Intermittent auscultation of both fetal
heart rates
No absolute time limit on duration
between delivery of twins if second twin
is well
Postpartum Management of Twins

Active management of third stage

Pathology examination of placenta
Increased risk of postpartum depression
 Discussion of issues from early pregnancy
 Extra support with babies