TWIN PREGNANCY

ASSOCIATE PROFESSOR
Blidaru Iolanda-Elena, MD, PhD.
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♣ a high-risk pregnancy
early and excessive distension of the uterus
inappropriate uterine contractility

sharing the intracavitary space and placental

nutrition IUGR
abnormal fetal presentation
placenta praevia
velamentous insertion of the cord

prematurity, HTA, caesarian section

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Incidence
 multiple gestations → 12% of total
conceptions
 14% of these survive to term
THE “VANISHING TWIN”
- before the 2-nd trimester (20-60%)
 no evidence
 no risk
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Clasification
Monozygotic = identical twins
- a single fertilized ovum

Dizygotic = fraternal twins

- two separate ova
- variable rate - 1.3 (Japan) - 49.0
(Nigeria)/ 1000 births
- Recessive autosomal trait (female
line)
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 Frequency of twins
a- Monozygotic: 1:250 (independent)
b- Dizygotic: 1:90 caucasians USA
1:20 Africans

Depend on race, heredity, age of

mother, parity, fertility drugs, post-
OC use moment.
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Etiology – FSH LEVELS
1. Race - high in blacks, less in Asians
2. Heredity - mother more important
than father
3. Age - peak incidence → 30-40 years
4. Parity
5. Drugs - inductors of ovulation
6. Assisted Reproductive Techniques
(ART)
7. Season - frequent in summer
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 DIVISION
 First 72 hours  two embryos, diamniotic,
dichorionic.
 4-8 days  two embryos, diamniotic,
monochorionic.
 About 8 - 14 days  two embryos,
monoamniotic, monochorionic.
 After 14 days  cleavage is incomplete,
conjoined twins.
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Determination of ZYGOSITY
and CHORIONICITY
 US evaluation of chorionicity
 “twin peak” sign, ”T” sign

 fetal gender

 placental examination
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 Dichorionic diamniotic
dizygotic or monozygotic

 Monochorionic diamniotic
monozygotic

 Monochorionic monoamniotic
monozygotic
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MORPHOLOGY OF THE OVULAR ELEMENTS
Monozygotic 30%
 single egg;
 an unique placenta, with
vascular anastomoses;
 unique or double amniotic
sacs;
 phenotypic and genotypic
identity;
 twin-twin transfusion
syndrome (TTTS);
 hydramnios;
 malformations.
Dizygotic 70%
 eggs distinctly separated
(dichorionic-diamniotic);
 absence of vascular
anastomoses;
 normal volume of
amniotic fluid;
 fetuses without
phenotypic or genotypic
identity;
 same or different sex.
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 Conjoined twins or Siamese twins

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Vascular anastomoses between fetuses
♣ only in monochorionic twins (≈100%).
♣ 3 variants of vascular relationships:
 hemodynamic balance;
 marked asymmetry (15 to 30%); the perfused fetus presents
hypervolemia, heart failure, acute polyhydramnios,
hyperbilirubinemia, hepatosplenomegaly; the hypo-perfused
fetus has hypoxemia and oligohydramnios (twin-twin
transfusion syndrome);
 slight asymmetry - slow transfusion (the tranfused fetus has
higher weight and mild polycytemia.
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 TWIN TO TWIN TRANSFUSION
SYNDROME (TTTS)
Due to the common placental circulation and the anastomosis
of the 2 fetal circulations

 FETUS PAPYRACEOUS
One will regress in size, with oligohydramnios in its sac (if 2
sacs), may perish; then becomes dehydrated and mummified.
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VASCULAR ANASTOMOSES BETWEEN FETUSES
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VASCULAR ANASTOMOSES BETWEEN FETUS
PLACENTAL ANASTOMOSES
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VASCULAR ANASTOM OSES BETWEEN
FETUSES
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FETUS PAPYRACEOUS IN
TRANSFUSION SYNDROME
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 TWIN TO TWIN TRANSFUSION

SYNDROME
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 CL INICAL DIAGNOSIS

1. History.

2. Clinical
Examination.

3. Investigations.
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HISTORY
 Family history (maternal side)
 History of ovulation induction
 High parity
 Advanced maternal age
 Greater weight gain than expected
 Abdominal size >duration of amenorrhea
 Pressure symptoms (dyspnea, dyspepsia)
 Marked edema of lower limb.
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CLINICAL EXAMINATION
●Uterine size - larger than expected for GA
+5cm (II trim.)
●Palor, early edema, varicose veins
●Glossy skin, striae, evident colateral circulation.
●Uterine palpation → two fetal heads or multiple
similar fetal parts.
●Auscultation of FHS: 2 different sites and
different frequency
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CL INICAL EXAMINATION
Bimanual examination
 a fetal pole, smaller than expected
(related to uterine size)
 sometimes, in hypogastrum the fetal
poles can't be detected
 uterine cervix may be effaced

 the membranes are under tension.

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INVESTIGATIONS

Ultrasound examination
→ the number of fetuses
→ type of placentation
→ fetal size and possible anomalies
→ presentation, position and relation to each
other
→ fetal well-being and growth pattern for
each
→ guidance to perform some maneuvers:
amniocentesis, villous sampling
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INVESTIGATIONS

Biochemical tests
1. hCG in plasma and in urine
2. AFP level (alone is not diagnostic)
3. estriol
4. HPL
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Differential diagnosis
1. Hydramnios.
2. Hydatidiform mole.
3. Uterine myomas / ovarian cyst.
4. Fetal macrosomia (single pregnancy)
5. Elevation of the uterus by
distended bladder.
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Maternal responses
 Cardiac output
 Plasma volume by 1/3 > singletons
 Red cell mass 300 ml > singletons
 Pre-eclampsia 5-10 times more
 Postpartum depression

↓Hematocrit and hemoglobin

↓Renal blood flow
↓Iron stores
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Fetal complications
 Spontaneous early pregnancy loss rate
 Discordant twins
 Twin to twin transfusion syndrome (TTTS)
 Intertwining of umbilical cords (monoamniotic twins)
 Conjoined twins
 Twin-reversed arterial perfusion sequence (TRAP) =
acardiac twin
 Intrauterine growth restriction (IUGR)
 Preterm labour
 Cerebral palsy > 3 times > in twins
10 times > in triplets
Acardiac twin weighing 475 grams. The underdeveloped head is
indicated by the black arrow. Its viable donor co-twin was delivered
vaginally at 36 weeks and weighed 2325 grams.
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The perinatal mortality
The principal causes of fetal death
- prematurity,
- IUGR
- prolapsed cord,
- infection,
- hypoxia during delivery,
- malformations,
- transfusion syndrome.
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Preterm birth:
a- The most common complication of
multiple pregnancies affecting long
term outcome.
Tocolytics
b- prophylactic use Bed rest

Cerclage
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MANAGEMENT
1. ANTENATAL

2. IN LABOR
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ANTENATAL MANAGEMENT

Early diagnosis (US)

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 visits - observe maternal and fetal

complications
1- Frequent ultra sound  fetal growth, congenital
anomalies, amniotic fluid.
2- Doppler.
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IN LABOR MANAGEMENT
 Trained obstetrical attendant.

 Available blood.

 Good access I.V line.

 Cardiotocography monitoring.

 Anesthetist.

 Pediatrician for each fetus.

 Mode of delivery - presentation of the first baby.

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IN LABOR MANAGEMENT
 40% of 0P and 60% of parous women
present in labor with a cervix dilated more
than 3 cm.
 The latent phase is shorter.
 The active phase is longer.
 Uterine overdistension ▬ hypotonic uterine
dysfunction.
 Increased risk of postpartum hemorrhage
(uterine atony).
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Indications for cesarian section

first twin presentation other than vertex
 hypotonic uterine dysfunction
 fetal distress
 prolapsed umbilical cord
 prematurity
 placenta praevia
 hypertension induced or aggravated by
pregnancy.
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 The interval between delivery of the first and
second twin is commonly cited to be safest if
less than 30 minutes.
 Internal podalic version – for 2-nd twin
 If separation of the placenta is delayed or
bleeding is brisk, extract the placenta
manually after the final delivery.
 Postpartum hemorrhage is common.
 Hypotony should be treated promptly with
oxytocin by rapid intravenous infusion and
massage of the fundus.