TWIN PREGNANCYTWIN PREGNANCYBy Sophia Bano By Sophia Bano

0808 -- 186186Batch-LBatch-L

Final Year MBBSFinal Year MBBS

Definition and Types Definition and Types

Twin pregnancy means that woman is carrying Twin pregnancy means that woman is carrying two fetuses at a time two fetuses at a time ..

TYPES. TYPES.

1.1. Dizygotic twins/binovular/fraternal Dizygotic twins/binovular/fraternal

2.2. Monozygotic twins/uniovular /identicalMonozygotic twins/uniovular /identical

Dizygotic Twins Dizygotic Twins They result when two oocytes are They result when two oocytes are

simultaneously released from the same or simultaneously released from the same or both ovaries and fertilized by two separate both ovaries and fertilized by two separate spermatozoa derived at the same coitus.spermatozoa derived at the same coitus.

Account for 75% of all twins.Account for 75% of all twins. WWithin the uterus the two zygotes implant ithin the uterus the two zygotes implant

separately each having its own set of separately each having its own set of placenta and membranes( dichorionic placenta and membranes( dichorionic diamniotic(diamniotic(

Monozygotic TwinsMonozygotic Twins Ovum is fertilized by a sperm & a zygote is Ovum is fertilized by a sperm & a zygote is

formedformed If cell mass of zygote gets divided in first 3 If cell mass of zygote gets divided in first 3

days after fertilization - dichorionic days after fertilization - dichorionic diamniotic twidiamniotic twins23% ns23%

Division between 3 & Division between 3 & 88 days after fertilization - days after fertilization - monochorioinic diamnioticmonochorioinic diamniotic twins75% twins75%

Division between Division between 88 & & 1313 days after fertilization - days after fertilization - monochorioinic monoamniotic twinsmonochorioinic monoamniotic twins

Division after Division after 1313 days - days - conjoint twinsconjoint twins

TwinsMonozygotic

Dichorionic/Monochorion

ic depending on time of

cleavage

Same gender ,blood

Group and karyotype.

Dizygotic

Dichorionic/Diamniotic.

same or different blood .

groups and gender.

Different Karyotype.

TwinTwin Pregnancy Pregnancy Aetiology Aetiology Incidence Incidence Monozygotic twins - 3.5-5% Monozygotic twins - 3.5-5% Dizygotic twins; depends on -Dizygotic twins; depends on - Race Race ParityParity AgeAge Family historyFamily history BuiltBuilt RecurrenceRecurrence

In Vitro fertilizationIn Vitro fertilization– Intrauterine inseminationIntrauterine insemination– Assisted HatchingAssisted Hatching– Frozen Embryo Transfer, Blastocyte Embryo Frozen Embryo Transfer, Blastocyte Embryo

TransferTransfer

Fertility DrugsFertility Drugs– Clomiphene citrate (clomid, serrophene)Clomiphene citrate (clomid, serrophene)– Gonadotropins (Gonadotropins (GonalF, follistim,GonalF, follistim,

Role of LH and FSHRole of LH and FSH

What contributes to the perils of twin pregnancyWhat contributes to the perils of twin pregnancyMaternalMaternal Risks Risks Exaggerated early symptomExaggerated early symptom) hyperemesis ) hyperemesis

gravidarumgravidarum) ) Pregnancy induced hypertensionPregnancy induced hypertension AnemiaAnemia Urinary tract infectionsUrinary tract infections Placental abruptionPlacental abruption Increased minor disorders of pregnancy (back-ache, Increased minor disorders of pregnancy (back-ache,

leg pain, inability to walk properlyleg pain, inability to walk properly,supine ,supine hypotension syndrome dyspnoea and dyspepsiahypotension syndrome dyspnoea and dyspepsia) )

Ante partum hemorrhage (APH) Ante partum hemorrhage (APH)

preterm labour preterm labour

Need for antenatal hospitalization Need for antenatal hospitalization

Risk of operative delivery Risk of operative delivery

Increased risk for C/S Increased risk for C/S

Postpartum hemorrhage (PPH) Postpartum hemorrhage (PPH)

Postnatal problemsPostnatal problems

Concerns – Higher Fetal RisksConcerns – Higher Fetal Risks

Congenital MalformationsCongenital Malformations::

Unique to Unique to twintwin pregnancy are pregnancy are

conjoined twins,fetal acardia,exstrophyconjoined twins,fetal acardia,exstrophy

OOf cloaca.f cloaca.

Malformations more frequent to twin Malformations more frequent to twin

pregnancy but not unique to it include pregnancy but not unique to it include

AAnencephaly,encephalocele,hydrocephalusnencephaly,encephalocele,hydrocephalus

BBowel atresia, cardiac anomalies congenital owel atresia, cardiac anomalies congenital dislocation of hip jt.dislocation of hip jt.

Acardiac twin

MiscarriagesMiscarriages

Vanishing twin syndromeVanishing twin syndrome

Loss of both twinsLoss of both twins

Intrauterine death of one twin in Intrauterine death of one twin in early pregnancy early pregnancy

Fetus PapyraceousFetus Papyraceous

Single fetal death during 2nd half of Single fetal death during 2nd half of GGestationestation

PPrognosis of surviving twin varies with chorionicity.rognosis of surviving twin varies with chorionicity.

DDichorionic surviving twin has good prognosis .ichorionic surviving twin has good prognosis .

MMonochorionic may develop renal cortical cysts onochorionic may develop renal cortical cysts

and lesions in brain called multicystic encephalo-and lesions in brain called multicystic encephalo-

malacia. malacia.

Intrauterine growth restriction Intrauterine growth restriction

Twin reversed arterial perfusion sequenceTwin reversed arterial perfusion sequence

MMonozygotic twins ,umbilical cords are linked by large arterio arterial onozygotic twins ,umbilical cords are linked by large arterio arterial

anastomosis and twin with high arterial pressure anastomosis and twin with high arterial pressure pumps blood in other twin with low pressure pumps blood in other twin with low pressure former is called pump twin and latter perfused former is called pump twin and latter perfused twin.lower part of perfused fetus shows varying twin.lower part of perfused fetus shows varying development while cephalic pole fails to develop development while cephalic pole fails to develop .Heart is absent and presented by large pulsating .Heart is absent and presented by large pulsating vessel thus called ACARDIAC MONSTER.Perfused vessel thus called ACARDIAC MONSTER.Perfused twin has CONFIRMED MORTALITY while pump twin has CONFIRMED MORTALITY while pump twin has high risk of polyhydraminos.twin has high risk of polyhydraminos.

Malpresentations:Malpresentations:

Of all types are seen.At time of labour first Of all types are seen.At time of labour first

twin presents with vertex in 70 % of casestwin presents with vertex in 70 % of cases

and 30% of fetuses have and 30% of fetuses have malpresentation.Malpresentation malpresentation.Malpresentation

IIncrease incidence of cord prolapse, intrapartum ncrease incidence of cord prolapse, intrapartum asphyxia and hence perinatal mortality.asphyxia and hence perinatal mortality.

Risks specific to Monoamniotic Risks specific to Monoamniotic 2/3 monozygotic are 2/3 monozygotic are

monochorioinic monochorioinic 2% monozygotic are monoamniotic 2% monozygotic are monoamniotic Risk of cord accidents is increased Risk of cord accidents is increased Twin to twin transfusion syndrome Twin to twin transfusion syndrome Interlocking at birth Interlocking at birth

INTERLOCKING TWINSINTERLOCKING TWINS

Twin to twin transfusion syndrome (TTTS)Twin to twin transfusion syndrome (TTTS) Placental vascular anastomosis between both fetal placentae Placental vascular anastomosis between both fetal placentae

76-98% of monochorioinic twins 76-98% of monochorioinic twins

Discordant fetal size & amniotic fluidDiscordant fetal size & amniotic fluid

volume between both fetusesvolume between both fetuses

Recipient twin - Polycythemia ,Recipient twin - Polycythemia ,

hypervolemia ,polyhydramnios hypervolemia ,polyhydramnios

Donor twin - anemia/ hypovolemia/ oligohydramnios &IUGR Donor twin - anemia/ hypovolemia/ oligohydramnios &IUGR

Ascites, pleural effusion, pericardial effusion may develop in Ascites, pleural effusion, pericardial effusion may develop in both twins both twins

Mortality if syndrome occurs early at 18-26 weeks - 79-100%Mortality if syndrome occurs early at 18-26 weeks - 79-100%

TTTS ManagementTTTS Management

Serial therapeutic amniocentesis Serial therapeutic amniocentesis

Pregnancy termination Pregnancy termination

Indomethacin to reduce amniotic fluid Indomethacin to reduce amniotic fluid

Selective feticideSelective feticide of donor twin of donor twin

Laser ablation of placental vascular anastomosis Laser ablation of placental vascular anastomosis

Fetal phlebotomy & transfusionFetal phlebotomy & transfusion

ManagementManagement of Twin pregnancy of Twin pregnancy PrepregnancyPrepregnancy - discuss twin pregnancy risk with - discuss twin pregnancy risk with

ART etcART etc PrenatalPrenatal Frequent visits (every 2 weeks or more often) Frequent visits (every 2 weeks or more often) Folate supplementation Folate supplementation Iron supplements in early second trimester Iron supplements in early second trimester Anomaly scan at 18-20 weeks Anomaly scan at 18-20 weeks Check Chorionicity / amniocity Check Chorionicity / amniocity Educate the patient Educate the patient

Frequent USG evaluations every 3-4 weeks Frequent USG evaluations every 3-4 weeks

Umbilical artery Doppler etc as requiredUmbilical artery Doppler etc as required

Rest in lateral decubitus for min 2 hrs each morning & Rest in lateral decubitus for min 2 hrs each morning & afternoon ; sleep for 10 hrs atleast each nightafternoon ; sleep for 10 hrs atleast each night

Frequent vaginal examinationFrequent vaginal examination

Careful monitoring throughout antenatal periodCareful monitoring throughout antenatal period

DETERMINATION OF CHORIONICITYDETERMINATION OF CHORIONICITY::

USG in first trimester with thick intertwin septumUSG in first trimester with thick intertwin septum

comprising of two amnion and two chorion measuringcomprising of two amnion and two chorion measuring

MMore than 2mm indicates dichorionic twinsore than 2mm indicates dichorionic twins

A Single extraembryonic coelom with two yolk sacs A Single extraembryonic coelom with two yolk sacs

separated by a thin septum comprising only of two separated by a thin septum comprising only of two

amnions and measuring less than 2mm is amnions and measuring less than 2mm is

monochorionic diamniotic placentation.monochorionic diamniotic placentation.

A Single coelom with single yolk sac and no dividing A Single coelom with single yolk sac and no dividing

septum indicates monochorionic monoamniotic septum indicates monochorionic monoamniotic

placentation. placentation.

Optimal time of delivery ?Optimal time of delivery ? Singleton pregnancy mostly deliver between 39 – 40 Singleton pregnancy mostly deliver between 39 – 40

weeksweeks

Twins deliver between 37 - 38 weeks Twins deliver between 37 - 38 weeks

Fetal lung maturity occurs at an earlier gestation in Fetal lung maturity occurs at an earlier gestation in twintwin pregnancy pregnancy at 32 weeks at 32 weeks

Fetal monitoring should be performed betweenFetal monitoring should be performed between

35 – 38 weeks in case of twins35 – 38 weeks in case of twins

Postmaturity is uncommonPostmaturity is uncommon

Concerns about labour/ delivery managementConcerns about labour/ delivery management Induction of labor in cases of : PIH, IUGR Induction of labor in cases of : PIH, IUGR

Preterm labour/PPROM -Steroids for lung maturity Preterm labour/PPROM -Steroids for lung maturity

Risk of APH (Ante partum hemorrhage) Risk of APH (Ante partum hemorrhage)

Risk of PPH (Postpartum hemorrhage) Risk of PPH (Postpartum hemorrhage)

Continuous fetal heart monitoring for both twins Continuous fetal heart monitoring for both twins

Epidural analgesia Epidural analgesia

Mode of delivery depending on presentations & other Mode of delivery depending on presentations & other associated risk factors. associated risk factors.

How to avoid perils of deliveryHow to avoid perils of delivery Careful consideration of Careful consideration of Gestational age Gestational age Weight of twins Weight of twins ChorionicityChorionicity Presentation of twins : Presentation of twins : Nine possible combinationsNine possible combinations 1. Vertex-vertex 1. Vertex-vertex 2. Vertex-2. Vertex-breechbreech 3. 3. BreechBreech – vertex – vertex 4. Breech – 4. Breech – breechbreech 5. Vertex - transverse5. Vertex - transverse Others….Others….

MODE OF DELIVERYMODE OF DELIVERYELECTIVE CAESAREAN SECTION IFELECTIVE CAESAREAN SECTION IF PPregnancy induced hypertesion regnancy induced hypertesion Diabetes mellitusDiabetes mellitus Antepartum haemorrhageAntepartum haemorrhage RRh-isoimmunisation h-isoimmunisation IIntrauterine growth restrictionntrauterine growth restriction MMalpresentation of 1st twinalpresentation of 1st twin CConjoined twinsonjoined twins MMonoamniotic twins onoamniotic twins

PPolyhydramniosolyhydramnios SScarred uteruscarred uterus

Vaginal DeliveryVaginal Delivery RRoute of choice for uncomplicated twin oute of choice for uncomplicated twin

pregnancy with 1st twin in cephalic pregnancy with 1st twin in cephalic presentationpresentation

Prerequisites for SafePrerequisites for Safe Vaginal Vaginal Delivery Delivery Knowledge of lie, presentation & weight of each fetusKnowledge of lie, presentation & weight of each fetus

Portable ultrasound scanner & a CTG with dual monitors Portable ultrasound scanner & a CTG with dual monitors

Preferable to monitor one fetus externally & other internally Preferable to monitor one fetus externally & other internally by scalp electrode by scalp electrode

Intravenous accessIntravenous access

Availability of cross matched blood Availability of cross matched blood

Two skilled obstetricians & neonatologistsTwo skilled obstetricians & neonatologists

Continuous epidural analgesia is a good option due to Continuous epidural analgesia is a good option due to frequent manipulative proceduresfrequent manipulative procedures

Lithotomy position Lithotomy position

Management of first stage of LabourManagement of first stage of Labour If facilities avaliable labour in twin is monitoerd by If facilities avaliable labour in twin is monitoerd by

continuous electronic fetal heart rate monitoring .continuous electronic fetal heart rate monitoring . LLatent phase of labour is often short due to atent phase of labour is often short due to

increased pre labour cervical dilatation.Active phase increased pre labour cervical dilatation.Active phase maybe prolonged and dysfunctional labour pattern maybe prolonged and dysfunctional labour pattern of all types are more common.of all types are more common.

Epidural is the ideal mode of analgesiEpidural is the ideal mode of analgesiaa in labour in in labour in twins as it allows safe manipulation of second twin .twins as it allows safe manipulation of second twin .

Management of 2nd stageManagement of 2nd stage Delivery of 1st twinDelivery of 1st twin;;VVertex presentation delivery same as singelton ertex presentation delivery same as singelton

PPregnancy need for episiotomy and forceps are same.regnancy need for episiotomy and forceps are same.

AAt delivery of 1st twin placental side of cord must be t delivery of 1st twin placental side of cord must be

SSecured to avoid hemorrhage from 2nd twin if ecured to avoid hemorrhage from 2nd twin if

MMonochorionic.onochorionic.

Delivery of 2nd twin ;Delivery of 2nd twin ;2nd twin is at high risk due to placental separation.2nd twin is at high risk due to placental separation.

Recommended is that 2nd twin better be delivered withRecommended is that 2nd twin better be delivered with

IIn 15 min.of delivery of first.If uterine contractions n 15 min.of delivery of first.If uterine contractions

donot resume by this time oxytocin infusion may bedonot resume by this time oxytocin infusion may be

started an ARM is then performed and delivery of 2ndstarted an ARM is then performed and delivery of 2nd

twin is contemplated.twin is contemplated.

SSpecial circumstances for 2nd twinpecial circumstances for 2nd twin

deliverydelivery IIf 2nd twin in vertex presentation fails to descend –f 2nd twin in vertex presentation fails to descend –

high vaccum extraction applicationhigh vaccum extraction application

AAbnormal lie uncorrectable at ext.version,internal bnormal lie uncorrectable at ext.version,internal podalic version may be usedpodalic version may be used

CCaserean indicated ifaserean indicated if: Abnormal lie not corrected at : Abnormal lie not corrected at ECV and internal podalic version not feasibleECV and internal podalic version not feasible

ROM+Abnormal lie with or without cord prolapseROM+Abnormal lie with or without cord prolapse FFetal distress due to bolus of oxytocin administered etal distress due to bolus of oxytocin administered

by mistke between delivery of two twins.by mistke between delivery of two twins.

Internal podalic versionInternal podalic version• Experienced operatorExperienced operator EFW > 1500 gm EFW > 1500 gm Adequate liquorAdequate liquor Available anesthesia for Available anesthesia for

effective uterine relaxationeffective uterine relaxation Simultaneous preparation Simultaneous preparation

for emergency C/S for emergency C/S

Management of 3rd stageManagement of 3rd stage Most dangerousMost dangerous

Risk of PPHRisk of PPH

Large placenta – longer time to separateLarge placenta – longer time to separate

More profuse bleedingMore profuse bleeding

May occupy lower segment ( insufficient retraction )May occupy lower segment ( insufficient retraction )

Uterine inertia following over distention of uterusUterine inertia following over distention of uterus

Active management of 3Active management of 3rdrd stage, use of oxytoci stage, use of oxytocin and n and even ergometrine if patient is normotensive. even ergometrine if patient is normotensive.

Special CasesSpecial Cases

Twins with previous scarTwins with previous scar Trial of scar if twins has a first vertex Trial of scar if twins has a first vertex should not be an should not be an

absolute contraindication absolute contraindication Judicious external or internal manipulations are not Judicious external or internal manipulations are not

contraindicated contraindicated Prefer caesarean if tranverse / breech ? Prefer caesarean if tranverse / breech ? Success rate 30-75%Success rate 30-75% Risk of uterine rupture is the same as VBAC in a Risk of uterine rupture is the same as VBAC in a

singleton pregnancysingleton pregnancy

Management of Mono Amniotic TwinsManagement of Mono Amniotic Twins Timing / mode of delivery !!!!!! Timing / mode of delivery !!!!!! Antenatal hospitalization Antenatal hospitalization Fetal heart monitoring & cord entanglement diagnosis Fetal heart monitoring & cord entanglement diagnosis

Greatest risk for intrauterine fetal death is at < 30 wks Greatest risk for intrauterine fetal death is at < 30 wks Labor / vaginal delivery do not increase perinatal deathLabor / vaginal delivery do not increase perinatal death

Risk of cord of twin B being inadvertently clamped during Risk of cord of twin B being inadvertently clamped during

delivery of twin A in case of vaginal deliverydelivery of twin A in case of vaginal delivery Patient should be informed about complicationsPatient should be informed about complications

Best delivered by elective caesarean sectionBest delivered by elective caesarean section

Demise of One Fetus in TwinsDemise of One Fetus in Twins Management depends on – Management depends on –

Gestational age at the time of death Gestational age at the time of death

Cause of death Cause of death

Chorionicity Chorionicity

If dichorionic & cause of death is intrinsic to affected If dichorionic & cause of death is intrinsic to affected twin - well being of survivor twin is not jeopardized twin - well being of survivor twin is not jeopardized

Monitoring of maternal platelets & fibrinogen ??Monitoring of maternal platelets & fibrinogen ??

If cause of death is unknown; very close observation of If cause of death is unknown; very close observation of survivor twin ! survivor twin !

Death of One of the Death of One of the Twins when MonochorioinicTwins when Monochorioinic

Leads to - Leads to - Microcephaly / hydrocephaly Microcephaly / hydrocephaly Cerebral palsy / atrophy Cerebral palsy / atrophy Limb reduction deformities Limb reduction deformities Intestinal atresia Intestinal atresia Renal necrosis Renal necrosis Pulmonary / Hepatic / splenic infarctsPulmonary / Hepatic / splenic infarcts

Conjoined twinsConjoined twins

Result when zygote divided after 13 days fom time ofResult when zygote divided after 13 days fom time of

fertilization.TWO groupsfertilization.TWO groups EEqual conjoined twins qual conjoined twins ThoracophagusThoracophagus PyophagusPyophagus CraniophagusCraniophagus IIschiophagus.schiophagus. UUnequal conjoined twinsnequal conjoined twins

Post Natal ManagementPost Natal Management

Prolonged hospital Prolonged hospital stay stay

Breast feeding Breast feeding encouraged encouraged

Discuss and stress Discuss and stress on use of on use of contraceptioncontraception

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