1. MULTIPLE PREGNANCY
Dr Avinash kumar
Moderator : Dr Manish
Dr Shobhna

2. Introduction
• More than one fetus develops simultaneously in the
womb
• Spontaneous twinning highest among blacks and East
Indians
• Account for 2.5% of births
• Rate of monozygotic twin 3.5 /1000 live birth(constant)
• Rate of dizygotic twin is variable
• Influenced by several factors like ethinicity , maternal
age, genetic tendency
• Actual rate of twining is much higher because early
fetal loss with vanishing twin is more common than
recognised.
• Hellin-Zelleny law: if twins frequency is 1/n ,then triplet
at 1/n2 ,quadruplets at 1/n3 and so on.

3. Embryology
• Zygote: sperm + oocyte
• Embryo: prenatal period between 14 days to 9 week
• Implantation occurs in form of blastocyst on 6 to 8 day
• Fetus: prenatal period between 9 week to birth
Primitive uteroplacental circulation: begins at the end of
2nd week
• Placenta: chorion frondosum(fetal)+decidua
basalis(maternal)
• Placental borders :chorionic plate (fetal side) and
desidual plate(maternal side)
• Amnion: innermost avascular layer facing fetus

4. Cont……
• Chorion begins to form at 3rd day after
fertilization
• Amnion begins to form between day 6 to 8

6. Cont.
• Zygosity: determined by number ova fertilized
• Multiple pregnancy can be multizygotic ,
monozygotic or combination of both
• superfecundation: fertilization of an ovum
after one ovum is already fertilized
• Superfetation: fertilization and development
of ovum when one fetus is in utero

7. classification
1. Monozygotic or identical twin: develop from
single fertilized egg after division of inner cell
mass of blastocyst
2. Dizygotic or fraternal twin: from two
separately fertilized eggs.
• Dizygotic represents 2/3rd cases and
monozygotic are 1/3rd

9. Genesis of Monozygotic Twinning

11. Etiology
• Increasing maternal age
• Maternal parity
• Nutritional factor
• Family history
• Infertility therapy
• Assisted reproductive therapy
• High pituitary gonadotropins

12. Clinical diagnosis
• Uterine size more than expected age
• Weight gain more than expected
• Two fetal heart sound
• Hyperemesis gravidarum

13. Diagnosis…
• By USG as early as 5weeks by
multiple gestational sac
• At 6th week by cardiac activity
• From 10th to 14th weeks by
placentation
• Lambda sign: internal dividing
membrane or ridge at placental
surface in dichorionic
• Increased maternal AFP,hcg

14. Maternal complication
• Preterm labour(57% in twin,76-90% in higher
order multiple)
• PROM
• Operative delivery(66% in twins and 91%)
• Postpartum endometritis
• Anemia
• Hypertensive diseases
• HELLP syndrome
• Acute fatty liver

15. Cont….
• PIH (2.5 times)
• Complication associated with tocolytic treatment
• Gestation diabetes mellitus
• Spontaneous abortion(vanishing twin)8%to36%
• Incompetent cervix(up to 14%)

16. Fetal complication
• Prematurity
• Low birth weight
• IUGR
• Fetal growth discordance
• Intra uterine fetal demise
• Congenital malformations

17. Cont…..
• Chromosomal anomalies
• TTTS
• Velamentous cord insertion and vasa previa
• Perinatal mortality
• Thromboembolic arterial occlusion
• Necrotic limb
• Small bowel atresia
• Horse shoe kidney

18. Fetal growth discordance
• Intrapair difference in birth weight >20% of
larger twin`s weight
Classification:
Mild <15%
Moderate15-30%
Severe>30%
Risk factors :TTTS,placental dysfunction,fetal
infection,fetal structural and chromosomal
abnomalities,antepartum bleeding,velamentous
cord insertion

19. Velamentous cord insertion

21. Case reports……
Intrauterine Fetal Death of a Monochorionic Twin with Peripheral Pulmonary
Infarcts: Potential Thromboembolic Events Following Death of Co-Twin
Amy A. Lo, Ona M. Faye-Petersen, and Linda M. Ernst
Pediatric and Developmental Pathology
March/April 2012, Vol. 15, No. 2, pp. 142-145
• Twin reversed arterial perfusion (TRAP) sequence in association with VACTERL
association: a case report
• Sharan Athwal*, Katherine Millard and Kokila Lakhoo
Journal of Medical Case Reports 2010, 4:411

22. Management (antenatal)
• Early diagnosis
• Nutritional intervention
• Prophylactic tocolytic
• Steroid stimulation of fetal lung maturity
• Therapeutic amniocentesis
• Multifetal reduction
• Bed rest beginning before 28 week

23. Management in labor and delivery
• Best method of delivery depend on
1. No of fetus
2. Presentation of first fetus
3. Gestational age
Twin presentation
Vertex-vertex:42.5%
Vertex-nonvertex:38.4%
Nonvertex:19.1%

24. Mode of delivery
• Vertex-vertex=vaginal and interval should not
be >20 min
• Vertex –breech=vaginal by senior obstetrician
• Breech-vertex=prefer CS to avoid
interlocking(a rare complication 1/1000)
• Breech-breech=CS

25. Twin to twin transfusion

26. TTTS…
• Only in monochorionic gestation
• Complicates 10-20% of such pregnancy
• Pathophysiology :
1. placental vascular anastomoses
2. Unequal placental sharing
3. Abnormal umbilical cord insertion
• AV anastomoses with unidirectional flow leads
to shunting of blood from one twin to other
• AA connections are thought to be protective

27. DIAGNOSIS
• Usually made between 17 and 26 weeks gestation
• May occur as early as 13 weeks
• Criteria:
1. Monochorionicity
2. Cord size discrepancy
3. Significant growth discordance(>20%wt difference and Hb
difference>5g/dl)
4. Polyhydroamnios in recipient sac and oligohydramnios in
donor sac
5. Cardiac dysfunction in polyhydroamniotic twin ,abnormal
umbilical artery and/or ductus venosus doppler
velocimetry
• Staging system for severity :quintero,CVPS,CHOP
,cincinnati staging system

33. Fetus papyraceous

34. Lithopedion(stone child)

35. Treatment modes of twin-to-twin
transfusion syndrome
Conservative management and monitoring:
• USG
• Biophysical profile
• Doppler blood flow velocimetry
• Fetal echocardiography
• Cardiotocography
• Digoxin
• Serial aminoreduction
• Fetoscopic laser occlusion of placental vessels

36. Treatment cont….
• Selective feticide:
-Cord embolization
-Nd:YAG laser technique
-Fetoscopic cord ligation
-Bipolar coagulation
ref: fanaroff and Martin’s neonatal-perinatal
medicine 8th edition

37. TRAP sequence( ACARDIA)
• Rare
• 1% monoamniotic twin pregnancy
• Twin reverse arterial perfusion is a type of vascular disruption
syndrome occurs early in gestation
• Large anastomoses between embryo may cause unequal arterial
perfusion
• Embryo which receives only low pressure blood flow through
umbilical artery and preferentially perfuses lower extremity
• Co-twin is well formed

39. Conjoined twin

40. Conjoined (siamese twin)
• Result of late incomplete embryonic division
• Only in monochorionic –monoamniotic twins
• Incidence -1 in 50,000 to 100,000 births
• Mostly female sex
• Most common –thoracopagus
• Serial USG required for fetal anatomy and
management
• Ex utero intrapartum treatment(EXIT):procedure
for delivery of co-twin when one twin is not likely
to survive