Is it good NEWS to be told that you

are going to have twins?

Definition

Two or more fetus simultaneously develops in the uterus is
called multiple pregnancy.
Prevalence
Twinpregnancy represents 2 to 3% of all pregnancies.

Risk factors
1- assisted reproductive techniques (IVF& induction of ovulation )
2-high parity
3- black race
4- maternal family history
5- increasing maternal age.

VARIETIES
Dizygotic twins fom two ova Non identical
twins
*Always have two separate placentas (DC)
*separate amniotic cavities (DA)
*the fetuses either the same or different sex
pairing
Monozygotic twins from single ova
Identical twins
Arise from fertilization of single egg
Always of same sex
Either MC or DC

Types of monozygotic twins
Results from division of fertilized
egg:
0-72 H. Diamniotic dichorionic.
4-8 days Diamniotic monochor.
9-12 days Monoamnio.monochor.
>12 days Conjoined twins.



70% are diamniotic monochorionic.

30% are diamniotic dichorionic
Conjoined twins or Siamese twins
*Anterior (thoracopagus)
*Posterior (pygopagus)
*Cephalic (craniopagus)
*Caudal (ischiopagus)
Results from division of fertilized
egg:
0-72 H. Diamniotic dichorionic.
4-8 days Diamniotic monochor.
9-12 days Monoamnio.monochor.
>12 days Conjoined twins.

Maternal Physiological Adaptation
Increase blood volume and cardiac output.
Increase demand for iron and folic acid.
Maternal respiratory difficulty.
Excess fluid retention and edema.
Increase attacks of supine hypotension.
Complications of pregnancy
1- preterm labour
2-pregnancy-induced hypertension
3-anaemia
4-polyhydramnia
5-congenital malformation
6- growth restriction
7-miscarriage
8- high perinatal mortality & morbidity
Complication of labour
1-malpresentation
2-postpartum haemorrhage
3-cord prolapse
4- locked twins
In monochorionic twins death of one fetus
may result in immediate complications in
the survivor (brain damage ,death,
neurodevelopment handicap)
Acute hypotensive episodes secondary to
placental vascular anastamosis between
the two fetuses result in haemodynamic
volume shifts from the life to the dead
fetus.
Fetal abnormalities
The risk of fetal abnormalities carry at least twice the risk in
twins pregnancy
*In each DC twins the risk of structural abnormalities
,such as spina bifida is similar to that for singleton
pregnancy
*Each MC twins carries the risk 4 X that of singleton
pregnancy
Multiple gestations with an abnormality in one fetus can be
managed expectantly or by selective fetocide of the
affected fetus
1-When the abnormality is not lethal the parents should
outweighs the risk of loss of a normal fetus from fetocide
related complications

When the abnormality is lethal it may better to avoid
such risk to the fetus
In MC twins selective fetocide is dangerous for the
second twins so they do cord occlusion techniques,
these require significant instrumentation of the
uterus & are therefore associated with higher
complications.
Chromosomal defects & twining
1-monozygotic twins are affected either both or non of
the twins will be affected ( the risk is based upon
maternal age)
2- in DZ twins the risk will be twice that of singleton
pregnancy ( e.g. the risk of Down syndrome 1/50)
Differential diagnosis of twin pregnancy
1-polyhydramnious
2-big baby
3-ovarian cyst or mass
4-uterine fibroid
5-retention of urine.
TWIN-TWIN transfusion
Chronic shunt occurs ,the donor bleeds into
the recipient so one is pale with
oligohydraminos while the other is
polycythemic with hydraminos.

If not treated death occurs in 80-100% of
cases.
Complications unique to
monochorionic twins
Twin twin transfusion syndrome
Either mild , moderate or sever depends on the degree of imbalance
the donor fetus suffers from
1- hypovolaemia & hypoxia
2-growth restricted
3- oliguric
4-oligohydramnious
The recipient fetus suffers
1-hyprrvolaemic
2-polyhydraminous
3- myocardial damage
4- high output failure
Sever disease appear at18-24w
Mother complain of
1- sudden increase in abdominal girth.
2- extreme discomfort
3- polyhydramnious (detcted by US)
90% of TTTS end in miscarriage or preterm labour
due to polyhydramnious or death of one fetus.
Treatment
*Amniocentesis every 1-2w
*fetoscopically guided laser coagulation to disrupt
the placental blood vessels that connect the
circulation of the two fetuses
Other Complications in Monochorionic
Twins:
Congenital malformation. Twice that of singleton.

Umbilical cord anomalies. In 3 4 %.

Conjoined twins. Rare 1:70000 deliveries. The
majority are thoracopagus.

PNMR of monochorionic is 5 times that of
dichorionic twins(120 VS 24/ 1000 births)
Diagnosis of Multiple Fetuses
1. History.

2. Clinical Examination.

3. Investigations.
History ovulation inducing drug
Family history of twin
Exaggerated symptoms
Cardiopulmonary embarrassment
Excessive fetal movement

Per abdominal examination
Height of the uterus more than the period of
gestation
Too many fetal parts
Two fetal head
Two distinct fetal heart sound, at separated
spot, provided the difference at least 10
beats per minute
Lab Investigation
Ultrasonography
Two gestational sacs can be detected as
early as 10 weeks of pregnancy
Radiography
Should be done after 30 weeks
General examination
Anaemia more than single pregnancy
Unusual weight gain
Management
1. Antenatal.
2. In Labor.
Antenatal Management
Early diagnosis (mainly by ultra sound)

Adequate nutrition:-
1- Caloric consumption increased by 300 Kcal per day.
2- Iron 60-100 mg per day.
3- Folic acid 1mg per day.

Frequent prenatal visit:-
observe maternal and fetal complications
1- Frequent ultra sound fetal growth, congenital
anomalies, amniotic fluid.
2- Doppler.
3- BPP(Biophysical profile).
Management of twin pregnancy
The patient is seen more often than usual from mid-
pregnancy onwards .
She should be seen every two weeks until 20 weeks
& every weeks till 36 weeks
Investigations
1-confirming a diagnosis
2-determining chorionicity
3-detecting fetal anomalies
4-evaluating fetal growth
5-confirming fetal wellbeing
6-assisting in delivery
Antepartum management
1-Preterm labour (40%) in twin pregnancies &(75%) in
triplet pregnancies

*bed rest at home or in the hospital has not proved
effective in preventing preterm labour or delivery
2- pre-eclampsia
the risk of gestational hypertension or pre-eclampsia has
been reported to range from 10-20% in a twin
pregnancy, 25-60% in triplet pregnancy.
3- other maternal complications
Daily supplementation of at least 60 mg of elemental iron
&1mg of folic acid is recommended because of the
increased risk of iron &folate deficiency anaemia
multiple pregnancy is a particular risk for the occurrence
of acute fatty liver of pregnancy
Intrapartum management
1- all twin and multiple fetuses should be
delivered by 40 weeks
2-the use of prostaglandins for induction &
oxytocin for induction or augmentation of
labour is an acceptable alternative to the
elective delivery by CS
2- requires adequate obstetric & nursing staff
3-US to confirm fetal presentation & size before a
decision is made on mode of delivery
Four principal combinations of presentations
Cephalic/cephalic 60%
Cephalic/breech 20%
Breech/cephalic 10%
Breech/breech 10%

The presentation of the fetuses may be
1- vertex- vertex twins
2- vertex nonvertex twins
3-higher order multiple gestation
Vertex- vertex twins
In the absence of obstetrical indications for CS
delivery ,vaginal delivery should be planned
regardless of gestational age.
Delay of over half an hour in the delivery of the
second twin increases the ocurrence of fetal
morbidity, thus the CS rate for the second twin
increases with the increase in the delivery time

Vertex nonvertex presentaton
Vertex breech or vertex-transerse presentation occurs in
35-40% of all twin pregnancies selection of delivery
depends on the following
*the size of the second twin
*presence of growth discordance
The availability of an obstetrician skilled in assisted
breech delivery , internal podalic version & total breech
extraction
If the second twin in a transverse lie or a footling
presentation, the membrane should be left intact until
the feet can be secured in the pelvis, following which
immediate rupture of the membranes & total breech
extraction should be performed
Nonvertex first twins
Breech-vertex or breech-breech occurs in
15-20% of all twin pregnancies. These cases
are almost always managed by CS
Higher order multiple gestation
Cesarean delivery is recomended
C.S. for Multiple Pregnancy:
Indications of C.S. :
More than 2 viable fetuses, if:
weight < 2 kg,
discordant growth ( i.e.; IUGR or twin-twin transfusion, or
disproportionate twins, twin B larger than A (BPD > 2 mm),
twin A: is non-vertex.
Conjoined Twins
Single amniotic cavity (as diagnosed by U/S or amniogram).
Previous Uterine scar.
During Labor: if delayed progress, fetal distress, or if twin B
transverse and cervix is thickened (retained second twin).
Associated pregnancy complication i.e.; severe PIH, placenta previa.
Contracted Pelvis
Lack of expertise
Requirements for twin
delivery
Large delivery room
Operating theatre and staff ready
Anaesthetist present
Senior obstetrician present
At least two midwives present
Twin resuscitaires
Ventous/forceps to hand
Blood grouped and saved
Intravenous access
Neonatologists present
Pre-mixed oxytocin infusion ready



Conjoined twins Chang and Eng Bunker (1811-1874), Chinese
brothers born in Siam, now Thailand .They traveled with
Barnum's circus and were billed as the Siamese Twins .They
had fused livers