OB3B Multifetal Gestation CAUSES:

Dr. Olivar MONOZYGOTIC DIZYGOTIC

Relatively constant Heredity
Largely independent of race, Increasing maternal age
SUPERFETATION heredity, age and parity Increasing parity
 An interval as long as or longer than a menstrual cycle Assisted reproductive therapy Nutritional factors
intervenes between fertilizations. Pituitary gonadotropin
 Requires ovulation and fertilization during the course of Infertility therapy
an established pregnancy Assisted reproductive therapy
 Not yet proven in humans

SUPERFECUNDATION
 Fertilization of two ova within the same menstrual cycle GENESIS OF DIZYGOTIC TWINNING
but not as the same coitus, nor necessarily by sperm
from the same male.

“once a structure has already differentiated, it will no longer

divide”

POST FERTILIZATION
CHORION Day 4
AMNION Day 8
EMBRONIC DISK Day 12

GENESIS OF MONOZYGOTIC TWINNING

ETIOLOGY OF MULTIPLE FETUSES

FRATERNAL TWIN IDENTICAL TWINS

Fertilization of two separate
ova
“double – ovum”, or dizygotic
Twins arise from single fertilized
ovum
“single-ovum”, monozygotic
Have increased incidence of
discordant malformations

BERNABE, Maria Katrina R. 1

Medicine 3i - 2015
 DIAGNOSIS OF MULTIPLE FETUSES
DIZYGOTIC MONOZYGOTIC
(Dichorionic, Diamniotic) (Dichorionic, Diamniotic)

MONOZYGOTIC
(Monochorionic,Diamniotic)
Ultrasonography
 Separate gestational sacs can be identified early in
MONOZYGOTIC twin pregnancy
(Monochorionic, Monoamniotic)  Two fetal heads or two abdomens should be seen in
the same plane, to avoid scanning the same fetus
twice and interpreting it as twins.

MATERNAL ADAPTATION
 Nausea and vomiting in excess of that characterizing
singleton pregnancies.
 Maternal blood volume expansion is greater
 Increased in cardiac output is 20% greater than
singleton
 Blood loss for twin delivery via NSD 1000 ml
MONOZYGOTIC (CONJOINED TWIN)
PREGNANCY OUTCOME

 Abortion
o 3x > than singleton pregnancies
o Monochorionic : Dichorionic
o Risk: 18:1
 Malformation
o Defects resulting from twinning itself
o Defects resulting from vascular interchange
between monochorionic twins
o Defects that occur as the result of crowding.
DETERMINATION OF ZYGOSITY  Low birthweight ( more on monozygotic than dizygotic)
 Preterm birth

UNIQUE COMPLICATIONS

MONOAMNIONIC TWINS

Infant Sex and blood type

 Twins of the opposite sex are almost always dizygotic
 Infants of different blood types are dizygotic  Associated with high risk fetal death rate
o cord entanglement
Ultrasound o congenital anomaly
 the number of placenta (chorionicity) can give a clue o preterm birth
on zygosity o twin to twin transfusion sydrome
 Can determine chorionicity as early as the first trimester
Management
 1 hour daily FHR monitoring beginning at 26-28 weeks
DICHORIONIC presence of two separate placentas and  corticosteroid therapy at this time to promote fetal lung
a thick – generally 2mm or greater – maturity
dividing membrane  CS at 34 weeks
(“twin – peak” sign)
MONOCHORIONIC membrane generally less than 2mm in
thickness and reveals only 2 layers.
( “T” sign)

Placental Examination
 Visual examination of the placenta and membranes
 Placenta should be carefully delivered to preserve the
attachment of the amnion and chorion to the
placenta
BERNABE, Maria Katrina R. 2
Medicine 3i - 2015
TWIN TO TWIN TRANSFUSION  Develops oligohydramnios, and the recipient fetus
develops severe hydramnios, presumably due to
increased urine production.
 Virtual absence of amnionic fluid in the donor sac
prevents fetal motion, giving rise to the descriptive term
stuck twin.
 Hydramnios–oligohydramnios combination can lead to
growth restriction, contractures, and pulmonary
hypoplasia in one twin, and premature rupture of the
membranes and heart failure in the other.

Management:
 Amnioreduction
 Septostomy
 Laser ablation of vascular anastomoses
 Selective feticide

ACARDIAC TWIN
(TWIN REVERSED ARTERIAL PERFUSION) TRAP SEQUENCE)

Ultrasonographic criteria for TTTS

Monochorionicity
Gender concordance
Polyhydramnios/
Oligohydramnios
Growth discordancy >20%
Umbilical cord size
discrepancy
Cardiac dysfunction in the
recipient twin
Abnormal Doppler studies ACARDIUS ACEPHALUS Failure or disrupted growth of the
head
THE QUINTERO CLASSIFICATION SYSTEM ACARDIUS partially developed head with
MYELACEPHALUS identifiable limbs
STAGE DESCRIPTION ACARDIUS AMORPHOUS failure of any recognizable
1 Polyhydrmanios / Oligohydramnios structure to form
Doppler studies are normal
2 The bladder of the donor twin is not visible Management
Doppler studies are not critically abnormal  Without treatment, the
3 Doppler studies are critically abnormal in either twin donor or "pump" twin has
Donor: absent or reversed EDF; been reported to die in
Recipient: reversed a wave or pulsatile umbilical vein 50 to 75 percent
 Methods of in utero
4 (+) hydrops fetalis
treatment of acardiac
5 One or both babies are dead
twinning: goal is
interruption of the
vascular communication
Diagnosis: between the donor and
 postnatal diagnosis: recipient twins.
o weight
discordancy
between twins
of 15 – 20%
o hemoglobin
level
difference of 5
g/dL or greater
 Typically presents in the midtrimester when the donor
fetus becomes oliguric due to decreased renal
perfusion.

BERNABE, Maria Katrina R. 3

Medicine 3i - 2015
DISCORDANT TWINS PREVENTION OF PRETERM DELIVERY
 Size inequality of twin  Bed rest
fetuses  Tocolytic therapy
 20 mm difference in  Corticosteroids for lung maturation
abdominal circumference  Cerclage – not been shown to improve perinatal
outcome
 Twin gestation with preterm ruptured membranes are
managed expectantly much like singleton
pregnancies.
% discordancy weight of bigger – weight of smaller
20% weight of the bigger twin ANTEPARTUM SURVEILLANCE
 Ultrasound at 10 – 13 weeks
Pathology  CAS at 18 – 22 weeks
 Biometry every 4 weeks
 BPS / NST
MONOCHORIONIC placental vascular anastomoses that  Doppler studies in cases of IUGR
TWINS cause hemodynamic imbalance between
the twins INTRAPARTUM MANAGEMENT
DIZYGOTIC may have different genetic growth  Timely attendance by a physician competent to
FETUSES potential manage a twin birth
 Assessment of lie and presentation
 Blood readily available for use
Principles In The Management of Growth Discordancy
 Epidural anesthesia is advantageous
 Continuous EFM for both twins
 IUGR is more predictive of poor perinatal outcome than
 Active management of the third stage
growth discordancy alone
 Growth discordancy alone is NOT an indication for
immediate delivery Presentation and Position
 Increased surveillance is warranted in cases of
significant growth discordancy
 Fetal Well Being Studies
Biometry every 2 weeks
NST / BPS twice weekly
Doppler studies Weekly
Steroid at 24-34 weeks

DEATH OF ONE FETUS

 The prognosis for the surviving twin depends on the
gestational age and chorionicity  Most common presentations at admission for delivery
 VANISHING TWIN o cephalic–cephalic
o cephalic–breech
Dichorionic Pregnancies o cephalic–transverse
 Risk of complication is small  These presentations, especially those other than
 Delivery at 37 weeks cephalic–cephalic, are unstable before and during
labor and delivery
Monochorionic Pregnancies  Compound, face, brow, and footling breech
 Risk of complication is increased presentations are relatively common, especially when
 Neurological abnormality the fetuses are small, amnionic fluid is excessive, or
 Remote from term: expectant maternal parity is high.
 Neonatal survival is likely: immediate delivery
DELIVERY
ANTEPARTUM MANAGEMENT OF TWIN PREGNANCY
 Delivery of markedly preterm infants be prevented. A. CEPHALIC – CEPHALIC Vaginal
 Failure of one or both fetuses to thrive be identified and Diamnionic
fetuses so afflicted be delivered before they become
moribund. B. CEPHALIC - NON-CEPHALIC Vaginal
 Fetal trauma during labor and delivery be avoided. EFW 1500 – 4000 kg
 Expert neonatal care be available.
CS
DIET
 Caloric requirment is increased C. TWIN A, NON-VERTIEX Planned CS
 Iron supplement is doubled
 Folic acid is increased to 1 mg/day
INTERVAL BETWEEN FIRST AND SECOND TWINS
PRENATAL CARE
 Every month until 24 weeks  The American College of Obstetricians and
 Every 2 weeks until 32 weeks Gynecologists (1998) has determined that the interval
 Weekly thereafter between delivery of twins is not critical in determining
the outcome of the twin delivered second.

BERNABE, Maria Katrina R. 4

Medicine 3i - 2015