Multiple Fetal

Pregnancy

Riza Sufriadi
Content:

1- Incidence and epidemiology.

2- Etiology of multiple fetus.
3- Types of twins:-
a- Determination of zygosity.
b- Risk of zygosity:
* Risk of fetuses.
* Maternal complications.
* Problem specific to monochorionic twins
4- Management of twins:-
a- Antenatal.
b- In labor.
 Incidence and epidemiology
• Rate of twins increase by Assisted production
technique(ART)and ovulation induction.
• The natural rate of twinning dizygot is 1:90,
monozygot 1:250
• In USA the incidence is 3%, African> white
• Depend on race, hereditary, age, parity and fertility
drugs
 Types
• Monozygotic • Dizygotic
• 70-80%
• 20-30% • Fertilization of 2 seperate ova
• Fertilization of a single ovum, • Its actual prevalence is
increasing due to:
• Similar sex. • Induction of ovulation
• Identical in every way including the • Change of the ages of women
experiencing their first
HLA genes pregnancy and delivery ( > 35
years age).
• Not genetically determined
• Constant in all races; its prevalence:
1/250.
Dizygotic Twins

(8 – Simpson & Creehan)

Monozygotic Twins

(8 – Simpson & Creehan)

Monozygotic
Dichorionic/diamniotic monozygotic twins:
Cleavage in the first 3 days after fertilization
Each fetus will be surrounded by amnion & chorion(
each fetus has its own placenta)like dizygotic twins
Has the lowest mortality rate of monozygotic twins
<10% of all monozygotic twins
Monochorionic/diamniotic:
Cleavage between day 4 and 8 after fertilization
Share single placenta but separate amniotic sac
The mortality is 25%
Monochorionic/monoamniotic:
< 1% of cases
Cleavage after the 8th day (day 9-12)
Share single placenta & single sac
Mortality is 50-60%, usually before 32 weeks
Zygosity
Conjoined twins:
Cleavage after day 12
Incidence is 1: 70,000deliveries
The fetuses may fuse in a number of ways, most
commonly chestand/or abdomen
Assessment of chorionicity
T sign
Twin Peak Sign (Lambda)
Monochorionic twin
Dichorionic twins

Conjoined twins
Clinical Examination

• Late in first trimester by Doppler  two fetal

hearts.

• Uterine palpation can feel two fetal heads or

multiple fetal parts.

• Uterine size is larger than expected for the

gestational age determined from menstrual data.
Complications of multiple pregnancy
-High perinatal mortality & morbidity (3-4 times higher than singleton pregnancy)
-Abortion
-Preterm labour (50%) Decrease duration of gestation:
a- 57% of twins  at 35 weeks.
b- 92% of triplets  at 32 weeks.
c- all quadruplets  at 29–30 weeks
-IUGR
-Congenital anomalies
-Placental abruption, placenta previa
-Discordant twin growth ( more than 20%discrepacy in fetal weights)
-Malpresentation
-Postpartum hemorrhage
- Preeclampsia
-C-Section
 Twin to Twin transfusion
Occur in 20-25% of monochorionic twins
Almost exclusively occurs in monochorionic (1
placenta) diamniotic (2 amniotic sacs) pregnancies
-One fetus donate blood to the other due to vascular
anastomosis
• Twins are often of different sizes:
• Donor twin = small, pallied, dehydrated
(IUGR), oligohydramnios (due to
oliguria), die from anemic heart failure.
• Recipient twin = plethoric, edematous,
hypertensive, ascites, kernicterus (need
amniocentesis for bilirubin), enlarged
liver, polyhydramnios (due to polyuria),
die from congestive heart failure, and
jaundice.
TTTS
 Reduction Amniocentesis Septostomy

Selective Vessel Laser Ablation Umbilical Cord Occlusion/Ablation

Quintero Staging
Presentation
☻Cephalic - Cephalic 42%
☻Cephalic - Breech 27%
☻Cephalic - Transverse 18%
☻Breech - Breech 5%
☻Other 8%
Management in First stage
Second stage
Third stage (PPH)
 C.S. for Multiple Pregnancy:
Indications of C.S. (Chervenak, 1985):
• 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
 Post-natal care
• Hemorrhage – Guard against postpartum hemorrhage
• Fundal checks!
• Uterine Contraction
• Breastfeeding
• Psychological support.
• Advise for contraception.