Multiple Gestation

Supervised by:

Prof. Salah Roshdy

Done by:
Yasser Abdulmohsen Alresiny
426035045

OBJECTIVES:

Definition.
Incidence and epidemiology.
Clinical characteristics.
Classification.
Diagnosis.
Complications.
Abnormalities of the twinning process.
Management.

DEFINITION:
Any pregnancy which two or more embryos or
fetuses present in the uterus at same time.
It is consider as a complication of pregnancy due
to ;
The mean gestational age of delivery of twins is
approximately 36w.
The perinatal mortality &morbidity increase.

Terminology vs. number

Singletons one fetus
Twins tow fetuses.
Triplets three fetuses.
Quadruplets four fetuses.
Quintuplets five fetuses.
sextuplets six fetuses.
Septuplets seven fetuses.

Mean gestational age of delivery

Number of babies
1

Weeks of Gestation
40 weeks

36 weeks

33 weeks

29 weeks

Incidence & epidemiology

The incidence of multiple pregnancy in US is
approximately 3% (increase annually due to ART ).
Monozygotic twins ( approx. 4 in 1000 births ).
Triplet pregnancies ( approx. 1 in 8000 births ).
Multiple gestation increase morbidity & mortality
for both the mother & the fetuses.
The perinatal mortality in the developed countries
Twins = 5 10 % births.
Triplets = 10 20 % births.

Clinical characteristics:
Multiple gestation should be suspected when ;
Uterine size is greater than expected for
gestational age.
Multiple FHRs are heard
Multiple fetal parts are felt.
hCG & serum alpha-fetoprotein levels are
elevated for gestational age.
If the pregnancy is a result of ART.
Diagnosis is confirmed by US .

DDx of uterus that is greater than

expected for gestational age:
1- Polyhydramnios.
2- Macrosomia.
3- Placental abruption.
4- Gestational trophoplastic disease.
5- Uterine fibroid.
6- Ovarian mass.

Classification
Monozygotic (<30%)

Dizygotic (>70%)

Dichorionic/Diamniotic
Dichorionic/Diamniotic
(8%(

Monochorionic/Monoamniotic
(1%)

Monochorionic/Diamniotic
(20%)
N.B. : Placentation in higher-order multiples ( triplets, quadruplets( follows the same
principles, except monochorionic & dichorionic may coexist.

Important notes:
1- Monozygotic twins having same sex & blood
group.
2- Process of formation of chorion is earlier than
formation of amnion.
3-Dizygotic twins must be dichorionic/diamniotic.

4- There is no dichorionic/ monoamniotic.

A- Dizygotic twins (fraternal):

Most common represents 2/3 of cases.
Fertilization of more than one egg by more than
one sperm.
Non identical ,may be of different sex.
Two chorion and two amnion.
Placenta may be separate or fused.
each fetus is contained within a complete
amniotic-chorionic membrane

Cont
The incidence of dizygotic twins is higher in ;
1. Certain families .
2. Race ;African Americans .
3. Increases with maternal age, parity, weight and
height .
4. Ovulation induction.

B- Monzygotic twins:
Constitutes 1/3 of twins
These twins are multiple gestations resulting from
cleavage of a single, fertilized ovum.
The timing of cleavage determines the
placentation of the pregnancy.
Constant incidence .
Not affected by heredity.
Not related to induction of ovulation.

Time of
cleavage

Nature of membranes

Perinatal
mortality

0 - 72 hr

diamniotic,dichorionic

8.9%

4 8 days

diamniotic,monochorionic

20

25%

9-12days

monoamniotic,monochorionic

50-60%

>13 days

Conjoined twin

----

-----

Placentation in Higher-Order Multiples ;

The relationship of placentas among triplets,
quadruplets, and higher-order multiple fetuses
generally follows the same principles, except that
monochorionic and dichorionic placentation may
coexist, and placental anomalies are more frequently
found in higher-order multiples.

Diagnosis:
History:

Family hx of dizygotic twins.

Use of fertility drugs.
sensation of excessive fetal movements.
Exaggerated symptoms of pregnancy (hyperemesis
gravidarum ).

Examination:
GPE ( weight gain, Pre-eclampsia signs )
Abdominal examination (excessive uterine fundal
growth, and auscultation of fetal heart rates in separate
quadrants of the uterus are suggestive but not
diagnostic).

Sonographic examination ( diagnostic )

Ultrasound evaluation:
The diagnosis of multiple gestation requires a
sonographic examination demonstrating two
separate fetuses and heart activities.
The diagnosis can be made as early as 6 weeks of
gestation.

DETERMINATION OF ZYGOSITY:
Very important as most of the complications occur in
monochorionic monozygotic twins.

By ;
Ultrasound : genders,numbar of placentas,
Blood groups.
HLA.
DNA analysis.

 During pregnancy by US :
Very accurate in the first trimester, two sacs,
presence of thick chorion between amniotic
membrane .
Less accurate in the second trimester the
chorion become thin and fuse with the amniotic
membrane .
Different sex indicates dizygotic twins.
Separate placentas indicates dizygotic twins

After birth ;
By examination of the MEMBRANE,
PLACENTA,SEX , BLOOD group .
Examination of the newborn DNA and HLA may
be needed in few cases.

DETERMINATION OF ZYGOSITY:
Findings

Zygosity

Freq.

Different genders

dizygotic

30%

Two placentas,same gender

different blood groups

dizygotic

27%

One placentas

monozygotic

23%

Two placentas,same gender

Same blood group

HLA & DNA analysis

20%

US

dizygotic
twins

different

same

gender

different

Monozygotic
twins

Number of
placenta

same

same
HLA & DNA
analysis

different

Blood
group

Septum

Placental type

Twin type

1- None

Monochorionic/Monoamniotic

monozygotic

2- Amnion only

Monochorionic/Diamniotic

monozygotic

3- Amnion & chorion

Dichorionic/ diamniotic

Dizygotic or monozygotic

4- No common septum

Dichorionic/ diamniotic

dizigotic

Complications:
A - Maternal:

Antepartum

Anemia.
Miscarriage.
Preeclampsia ( 40% in twins & 60% in triplets ).
Polyhydramnios ( 5 8%).
PTL ( Twin account for 10% of all PTL & 25% of all preterm
perinatal deaths ).
Cervical incompetence.
Hyperemesis gravidarum.

Intrapartum
CS.

Postpartum

postpartum uterine atony.

post partum Hemorrhage.
postpartum endometritis

b/c of
Over distended uterus

Cont..
B - Fetal:

Malpresentation.
Umblical cord prolapse.
Placenta previa & abruptio placenta.
PROM & Prematurity.
IUGR .
Congenitial anomalies.
Increase perinatal morbidity & mortality

Causes of perinatal morbidity and

mortality in twins:

Respiratory distress syndrome

Birth trauma
Cerebral hemorrhage
Birth asphyxia
Birth anoxia
Congenital anomalies
Stillbirths
Prematurity

Abnormalities of the twinning process:

Conjoined Twins.
Interplacental Vascular Anastomosis.
Twin-Twin Transfusion Syndrome.
Fetal Malformations.
Umbilical Cord Abnormalities.
Discordant Twin Growth.
Locked twins ( delivered by CS ).
Single fetal death
Rupture of membrane in single sac

Locked twins

Conjoined Twins ;
Etiology : It result from cleavage of the embryo is
incomplete because it happen very late (after 13 days,
when the embryonic disc has completely formed).

Incidence : once in 70,000 deliveries.

Classification:

Thoracopagus (antreior) most common.

Pygopagus (posterior)
Craniopagus (cephalic)
Ischiopagus (caudal)

Delivery by C.S.

Thoracopagus

Craniopagus

Interplacental Vascular Anastomoses:

It occurs almost exclusively in monochorionic
twins at a rate of 90% or more.
Type:
Arterial_artarial(most common).
Arterial_venous.
Venous_venous.

Complications:

Abortion.
Hydramnios.
Twin-twin transfusion syndrome (TTTS).
Fetal malformations.

Twin-Twin Transfusion Syndrome ;

Definition:
15% of monochorionic twins have domensturable
anastomosis.
The presence of unbalanced anastomosis in the placenta
(typically arterial-venous connections) leads to a syndrome in
which one twins circulation perfuses the other Twin.

Complication:
Donor : anemic HF, hypovolemia, hypotension, anemia,
oligohydramnios, growth restriction. ( do intrauterine blood
trans fusion).
Recipient : hypervolemic HF , hypervolemia, hypertension,
polyhydramnios, thrombosis, hyperviscosity,cardiomegaly,
polycythemia, hydrops fetalis. ( do repeated amnioreduction).
Both: risk of demise & PTL.

Management of TTTs ;
If not treated death occurs in 80-100% of cases.
If extreme prematurity prevents immediate delivery,
Several interventions can be considered in view of the
high mortality associated with expectant management.

Repeated amniocentesis from ( recipient) .

Intrauterine transfusion of the anemic (donor) twin
is of no benefit in this condition.
Indomethacin.
Fetoscopy and laser ablation of communicating
vessels.

Fetal Malformations:
Incidence:
Twice as common in twins & 4 times more common
in triplets than in singleton infants.
Monozygotic > Dizygotic.

Etiology:
Usually result from arterial-arterial anastomosis.
Common deformations in twins include limb
defects, plagiocephaly, facial asymmetry, and
torticollis.
Acardia and twin-reversed arterial perfusion
(TRAP) rare but unique to multiple pregnancy.

Amniocentesis:
If U/S shows abnormality.

Normal
(pump) twin

Acardiac
twin

Umbilical Cord Abnormalities:

Absence of one umbilical artery occurs in about
3% to 4% of twins (30% of case absence of one
artery associated with other congenital
anomaliesrenal agenesis ).
Cord entanglement ( esp. in monochorionic
monoamniotic twins ).

Discordant Twin Growth:

Definition:
Discrepancy of more than 20% in the estimated fetal
weights.

Causes:

TTTS.
Chromosomal or structural anomalies.
Discordant viral infection.
Interplacental Vascular Anastomoses.

Specific indication C/S in Twins ;

1.
2.
3.
4.
5.
6.
7.

monochorionic monoamniotic twins

Conjoined twins
Non vertex presentation of first twin
Locked twins
Twin-reversed arterial perfusion (TRAP)
Placentation in Higher-Order Multiples
Other obstrictic indication of C/S

Management:

Antepartum
Adequate nutrition.
Adequacy of maternal diet is assessed due to the increased
need for overall calories, iron, vitamins, and folate .
The Institute of Medicine (IOM) recommends women with
twins gain a total of 16.0 to 20.5 kg during the pregnancy.

More frequent prenatal visits.

Periodic U/S assessment every 3-4 weeks from23weeks
gestation to monitor the growth and detection of
discordant growth or TTTS.
Fetal surveillance:
Performance of NST is not indicated before 34 wks unless to
confirm IUGR or discordant growth.
( avoid CST )

Amniocentesis. ( If indicated )

In case of death of one fetus is managed based on the gestational

age and condition of the surviving fetus.
1- fetal surveillance
2- maternal clotting profiles
surviving fetus is exhibited

weekly measured Until evidence

of fetal lung maturity in the

Delivery should be considered if :

1) Fetal lung maturity is demonstrated
2) If compromise of the remaining fetus develops
3) If evidence of disseminated intravascular coagulation in the
mother is present.
In the setting of TTTS, the death of one twin should prompt
consideration of delivery, particularly after 28 weeks, given the
high rates of embolic complications in the surviving twin.

Cont..
Intrapartum
The route of delivery depends on:

Presentation of the twins.

Gestational age.
Presence of maternal or fetal complications.
Experience of obstetrician.
Availability of anesthesia & neonatal intensive
care.

Delivery:
Vertex/Vertex(43%):
Vaginal delivery. (Successful in 70-80%of cases).
Surveillance of twin B with real-time U/S.

Vertex/Nonvertex(38%):
Vaginal delivery ( better ) (in absence of discordant
growth).
Either external cephalic version or podalic version
with breech extraction may be attempted.
CS.

Nonvertex Twin A(19%):

CS .

Cont.
postpartum
Active management of PPH:
By giving oxytocin in the 3nd stage of labor just
after delivery of both fetuses and placentas.

Multiple gestation with more than

two fetuses
Most frequent cause is iatrogenic from the use of
ovulation induction agent.
Prematurity increase as the number of fetuses
increase .
1) Multifetal reduction may be offered:
Reduce the risk to the mother & the remaining
fetuses.
Performed only in the setting of dichorionic
/diamniotic gestation.
2) Selective termination:
Termination of one or more fetuses with structural or
chromosomal anomalies.

Summary:
1- Definition.
2- Incidence why Increased?
3- Types (2).
4- Diagnosis (History, examination & US).
5- Complication( Maternal, fetal & placentation
process).
6- Management (antepartum, intrapartum &
postpartum).

References
The Johns Hopkins manual of gyencology &
obestetrics.
Essentials of gyencology & obestetrics by
Hacker, Moore & Gambone.
Pictures: From internet.

Thank You