2. Definition: Any Pregnancy in which 2 or more
embryos or fetuses occupy the uterus
simultaneously
Increased incidence (assisted reproductive
technology)
Twins account for about 1% of pregnancies
Hellins law (80 n-1)
- Twins → 1 in 80
- Triplets → 1 in 802
- Quadruplets → 1 in 803
3. ↑maternal age and parity
Assisted reproduction techniques
- Ovulation induction agents
(gonadotropins)
- In-vitro fertilization (IVF)
Family history
5. Monozygotic twins (identical)
Originate by fertilization of
single ovum by single sperm.
The twinning may occur at
different periods after
fertilization and this influences
the process of implantation and
the formation of the fetal
membranes.
9. A. History Taking
Family history of multiple
pregnancy
Recent infertility treatment
Excessive nausea and vomiting
Excessive lower limb swelling
and varicosities
Excessive fetal movement and
abdomen overdistension
Extremely fatigue
10. B. Physical Examination
Anaemia & oedema
Raised BP
Uterus larger than dates
Polyhydramnios (> in monozygotic
twins)
Multiple fetal parts & poles
> 1 heart sound with different rates
Abnormal weight gain
11. Zygosity
Ultrasound-
=> Gender discordance = dizygotic
DNA fingerprinting, from amniotic fluid sample
(amniocentesis), placental tissue (chorionic
villi sampling) and fetal blood (cordocentesis)
Chorionicity
Characteristic of membrane(US)-
13. Why so important to
differentiate???
Prenatal diagnosis of chorionicity is important as
monochorionic pregnancies have increased rates and
severity of all types of obstetric complications when
compared with dichorionic pregnancies.
14. Maternal
• ↑ Sx of early pregnancy (↑HCG)
• Miscarriage
• Anaemia (↑ Fe,folate & B12 )
• Polyhydramnios (uniovular twins)
• PIH (↑3-5x)
• APH (placenta praevia)
• PPH (uterine atony d2 over
stretching)
• GDM (↑diabetogenic placental
hormones)
• Ineffective labour (malpresentation)
• Thromboembolic ds (↑pelvic vein
compression)
Fetal
• Single fetal death
• Preterm labour (d2
overdistended uterus, polyH,
intrauterine infection)
• IUGR (discordant growth)
• Stillbirth
• Congenital abnormality
• Twin to twin transfusion
syndrome
• Asphyxia (cord entanglement)
• Intrauterine death
15.
16. TTTS is found in MCMA as well as MCDA
pregnancies.
TTTS is more common in MCDA pregnancies than
MCMA pregnancies, possibly reflecting that there
are more protective artery–artery anastomoses in
the latter.
Rarely (in approximately 5% of cases), the
transfusion may reverse during pregnancy, with the
donor fetus demonstrating features of a recipient
fetus and vice versa
Unequal placental sharing and peripheral,
‘velamentous’ cord insertions are common in TTTS
17. Affects 10-15% of monochorionic twin
pregnancies.
Pathophysiology:
Result of transfusion of blood from donor to
recipient twin through abnormal artery-to-
vein anastomoses in the placenta
The donor suffers hypovolaemia and hypoxia →
IUGR, smaller in size, oligohydramnios & high
output cardiac failure
The recipient fetus exhibit hypervolemia →
large size, polyhydramnios, cardiomegaly, CCF
18.
19.
20. More than 90% ends in miscarriage/severe preterm
delivery
To monitor:
US doppler 2 weekly
Management:
I. Laser coagulation – occlude the vascular
anastomosis between twins (presenting prior to
26weeks of gestation)
II. Amnioreduction every 1 - 2/52, drain amniotic
fluid from recipient sac
III. Septotomy (cord entanglement risk)
IV. Anticipate preterm delivery – corticosteroid
(promote fetal lung maturity
21. Occur in monochorionic twin
Fetal demise <14weeks-not increase risk on
the survivor twin
Confers risk to survivor twin if fetal
demise after 14 weeks.
Dt transfer of thromboplastin from dead
twin > produce thrombotic arterial occlusion
> occlusions of ant & mid cerebral arteries >
multicystic encephalomalacia & neurologic
damage.
Induce consumptive coagulopathy in mother.
23. • All women with a multiple pregnancy should be
offered an ultrasound examination at 10–13weeks
of gestation to assess:
I. viability
II. chorionicity
III. major congenital malformation
IV. nuchal translucency for designation of risk of
aneuploidy and twin-to-twin transfusion
syndrome.
24. 1. Ultrasound at 10–13 weeks: (a) viability; (b)
chorionicity; (c) NT: aneuploidy
2. Structural anomaly scan at 20–22 weeks.
3. Serial fetal growth scans e.g 24, 28, 32 and then
two- to four-weekly.
4. BP monitoring and urinalysis at 20, 24, 28 and
then two-weekly.
5. 34–36 weeks: discussion of mode of delivery and
intrapartum care.
6. Elective delivery at 37–38 completed weeks.
7. Postnatal advice and support (hospital- and
community-based) to include breastfeeding and
contraceptive advice
25. 1. Ultrasound at 10–13 weeks: (a) viability; (b)
chorionicity; (c) NT: aneuploidy/TTTS
2. Ultrasound surveillance for TTTS and discordant
growth: at 16 weeks and then two-weekly.
3. Structural anomaly scan at 20–22 weeks (including
fetal ECHO).
4. Fetal growth scans at two-weekly intervals until
delivery.
5. BP monitoring and urinalysis at 20, 24, 28 and then
two-weekly.
6. 32–34 weeks: discussion of mode of delivery and
intrapartum care.
7. Elective delivery at 36–37 completed weeks (if
uncomplicated).
8. Postnatal advice and support (hospital- and
community-based) to include breastfeeding and
contraceptive advice.
26. Dietary advice: adequate caloric intake to meet
increased demands, supplement of iron (60-80
mg /day), folic acid, calcium, vitamins
Monitor for infection, anaemia, PIH, preterm
labour & malpresentation
Corticosteroid if strong possibility of preterm
labour (for lung maturity)
28. INTRAPARTUM MANAGEMENT OF TWINS
Criteria for vaginal delivery fulfilled
Deliver the 1st twin
Clamp and cut the cord
Note lie of 2nd twin
Transverse lie Longitudinal lie
Attempt External Cephalic
Version and vaginal delivery
under GA
If unsuccessful C-section
Amniotomy with controlled oxytocin
infusion if there is uterine inertia
Note presentation
Vertex Breech
Vaginal delivery or optionally
outlet forceps or ventouse
Breech extraction
or assisted breech
delivery
29. In PIH and cardiac disease: give oxytocin 10
unit i.m
Syntometrine 1 ml (5 unit oxytocin and 500
mcg ergometrine i.m) with delivery of anterior
shoulder of 2nd baby
Placenta delivered with controlled cord traction
In high risk of uterine atony and PPH, i.v
infusion 40 units oxytocin over 6 hours after
delivery)
Episiotomy/perineal repair if needed
30. i) ELECTIVE
1st baby non-cephalic
especially shoulder
Conjoined twins
Congenital abnormality
precluding safe vaginal
delivery
IUGR in dichorionic twin
Chronic TTTS
Monoamniotic twin
Placenta praevia
Triplets or more
Contracted pelvis
Previous C-section
Pre-eclampsia
ii) EMERGENCY
Fetal distress
Cord prolapse in 1st
baby
Non-progress of
labour
Collision of both
twins
2nd twin transverse,
version failed after
1st delivery of twin