CHAPTER

39

Multifetal Gestation

Dr. Reyes, Abeleda MD

INTRODUCTION o Twin fetuses usually result from fertilization

of two separate ova–dizygotic or fraternal
Outline: twins.
• monozygotic or identical twins:
1. Etiology of Multifetal gestations
o Less often, twins arise from a single
2. Diagnosis of multiple fetuses fertilized ovum that subsequently divides–
3. Maternal adaptation to Multifetal pregnancy monozygotic or identical twins.
4. Pregnancy outcome
5. Unique complications Genesis of monozygotic twins:
6. Discordant twins
7. Twin demise • Diamnionic, dichorionic twin pregnancy
8. Complete hydatidiform mole and coexisting fetus • Diamnionic, monochorionic twin
9. Antepartum management of twin pregnancy • Monoamnionic monochorionic twin
10. Preterm labor prediction • Conjoined twins
11. Labor and delivery
12. Triplet or higher-order gestation
13. Selective reduction or termination

Definition of Multifetal Gestation:

• Monozygotic or identical twins: arise from a single

fertilized ovum that subsequently divides
• Dizogotic or fraternal twins: result from fertilization
of two separate ova

Etiology of Multifetal gestation:

• Fraternal vs identical twins

o Monozygotic or identical twins
§ Usually not identical
§ May actually be discordant for
genetic mutations as the insult of a
postzygotic mutation, or may have
the same genetic disease
§ Have an increased incidence of
often discordant malformations
o Dizygotic twins:
§ Not in a strict sense true twins:
because they result from the
maturation and fertilization of two
ova during a single ovulatory cycle
§ Same sex may appear more nearly
identical at birth than monozygotic Mechanism of monozygotic twinning. Black boxing and blue
twins arrows in columns A, B, and C indicates timing of division. A.
At 0 to 4 days postfertilization, an early conceptus may divide
into two. Division at this early stage creates two chorions and
Etiology of Multifetal Gestations
two amnions (dichorionic, diamnionic). Placentas may be
separate or fused. B. Division between 4 to 8 days leads to
• dizygotic or fraternal twins: formation of a blastocyst with two separate embryoblasts
(inner cell masses). Each embryoblast will form its own
amnion within a shared chorion (monochorionic, diamnionic).
C. Between 8 and 12 days, the amnion and amnionic cavity • One twin is lost or “vanishes” before the second
form above the germinal disc. Embryonic division leads to trimester in up to 20 to 60 percent of spontaneous
two embryos with a shared amnion and shared chorion twin conceptions
(monochorionic, monoamnionic). D. Differing theories explain • Only one fetus dies, and the remaining fetus delivers
conjoined twin development. One describes an incomplete as a singleton
splitting of one embryo into two. The other describes fusion • Cause an elevated maternal serum alpha-FP level, an
of a portion of one embryo from a monozygotic pair onto the elevated amnionic fluid alpha-FP level, and a positive
other. amnionic fluid acetylcholinesterase assay result
• Cause a discrepancy between the Karyotype
Superfetation: established by chorionic villus sampling and the
Karyotype of a surviving twin when tissue form a
• An interval as long as or longer than a menstrual vanished twin is inadvertently sampled.
cycle intervenes between fertilizations
• Requires ovulation and fertilization during the Factors that influence twinning:
course of an established pregnancy
• Result from markedly unequal growth and • Race
development of twin fetuses with the same o Varies significantly among different races
gestational age and ethnic groups
o Pt is already pregnant, but please remember o Racial variations in levels of (FSH)
in the lecture on placental hormones: when • Heredity:
you get pregnant last month April and there o Family history of the mother is much more
are certain hormones like activin and inhibin important than that of the father
that should be produced and this should o Dizygotic twin women: 1 set/58 births
prevent another ovulation. But what o Dizygotic twin husband: 1 set/116
happens is you got pregnant last month but pregnancies
you had another ovulation this month such • Maternal age and parity:
that, I didn’t realize I was pregnant before. o Rate of natural twinning peaks at age 37
Then had sex with husband and got years
pregnant with another child. If you o Increasing parity: increase the incidence of
compute AOG, it’s first day of LMC, but since twinning independently
placental hormones didn’t work properly, o Nulli: 2%
she had another pregnancy that would have o G6 or more: 6.6%
the same gestational age, but different • Nutritional factors
gestational age, b/c that pregnancy didn’t o Taller, heavier women: 25 to 30% twinning
prevent or having another ovulation. o Large and tall women: Dizygotic twinning is
more common
Superfecundation: o Higher folate intake and plasma folate
concentrations: increase rate of twinning
• Fertilization of two ova within the same menstrual • Pituitary Gonadotropin
cycle but not at the same coitus, nor necessarily by o sudden release of pituitary gonadotropin in
sperm from the same male. amounts greater than usual
o White women was raped by black man and o The common factor linking race, age,
then after several days she had sexual weight, and fertility to multifetal gestation
intercourse with her husband. She got may be FSH levels
pregnant on that cycle and gave birth to • Infertility Therapy
two babies, one white and one black. o Ovulation induction with FSH plus chorionic
gonadotropin or clomiphene citrate
Frequency of twins:
remarkably enhances the likelihood of
multiple ovulations.
• Monozygotic twinning: one set per 250 births
o Independent of race, heredity, age and o gonadotropin therapy is 16 to 40 percent,
parity of which 75 percent are twins
o Increased following ART o Superovulation therapy with hMG: 25 to
30%:
• Dizygotic twinning: is influenced remarkably by race,
hereditary maternal age, parity and especially • Assisted Reproductive Technology (ART)
fertility treatment. o The greater the number of embryos that are
transferred, the greater the risk of twins
The “vanishing twin” and multiple fetuses
• Reducing Multifetal Gestation
 o American Society for Reproductive o As the second neonate is delivered, two
Medicine (1999) initiated a concerted effort clamps are placed on that cord
to reduce the incidence of higher-order o neonates are of the same sex: blood typing
multifetal gestation. of cord blood samples.
o number of embryos transferred per cycle
decreased. Infant Sex and Zygosity
• Sex Ratios with Multiple Fetuses
o In humans, as the number of fetuses per • Twins of opposite sex are almost always dizygotic.
pregnancy increases, the percentage of • monozygotic twins may be discordant for phenotypic
male conceptuses decreases. sex.
o Females predominate even more in twins o This occurs if one twin is phenotypically
from late twinning events. female due to Turner syndrome (45,X) and
o mortality rates are lower in females. her sibling is 46,XY.
o female zygotes have a greater tendency to
divide.
Diagnosis of Multiple Fetuses

Determination of Chorionicity
History and Clinical Examination

• The rate of twin-specific complications varies in

• A maternal personal or family history of twins,
relation to zygosity and chorionicity.
advanced maternal age, high parity, and large
• There are increased rates of perinatal mortality and
maternal size are weakly associated with multifetal
neurological injury in monochorionic diamnionic
gestation.
twins compared with dichorionic pairs
• Administration of either clomiphene citrate or
• Monozygotic dichorionic twins had perinatal
gonadotropins or pregnancy accomplished by ART
outcomes equivalent to those of dizygotic twins
are much stronger associates.
o There were two mature eggs, fertilized by
two different sperms,
Clinical examination:
• Sonographic Evaluation
o Chorionicity can sometimes be determined
in the first trimester. • accurate measurement of fundal height,
o Dichorionic: The presence of two separate • Between 20 and 30 weeks, fundal heights were on
placentas and a thick–generally 2 mm or average approximately 5 cm greater.
greater–dividing membrane supports a • difficult to diagnose twins by palpation of fetal parts
presumed diagnosis of dichorionicity before the third trimester
o Fetuses of opposite gender are almost • fetal heart action may be detected with Doppler
always dizygotic, thus dichorionic. ultrasonic equipment
o Twin-peak sign: a triangular projection of
placental tissue is seen to extend beyond In women with a uterus that appears large for gestational
the chorionic surface between the layers of age, the following possibilities are considered:
the dividing membrane, then there are two
fused placentas–the twin-peak sign. 1. Multiple fetuses
o monochorionic pregnancies have a dividing 2. Elevation of the uterus by a distended bladder
membrane that is so thin it may not be seen 3. Inaccurate menstrual history
until the second trimester. 4. Hydramnios
§ The membrane is generally less 5. Hydatidiform mole
than 2 mm thick, and magnification 6. Uterine leiomyomas
reveals only two layers 7. A closely attached adnexal mass
o T sign: This right-angle relationship between 8. Fetal macrosomia (late in pregnancy)
the membranes and placenta with no
apparent extension of placenta between Sonography
the dividing membrane is called the T sign.
• Placental Examination
• By careful sonographic examination, separate
o A carefully performed visual examination of
gestational sacs can be identified early in twin
the placenta and membranes following
pregnancy.
delivery serves to establish zygosity and
• each fetal head should be seen in two perpendicular
chorionicity
planes so as not to mistake a cross section of the
o As the first neonate is delivered, one clamp
fetal trunk for a second fetal head.
is placed on a portion of its cord.
 • Ideally, two fetal heads or two abdomens should be • diastolic blood pressure of mothers carrying
seen in the same image plane, to avoid scanning the singletons, theirs is lower at 20 weeks but increases
same fetus twice and interpreting it as twins. more by delivery. The increase is at least 15 mm Hg
in 95 percent of women carrying twins
Other Diagnostic Aids • Uterine growth greater than singleton pregnancy.
• rapid accumulation of excessive amounts of
• Radiological Examination amnionic fluid may develop. In these circumstances,
o can be helpful maternal abdominal viscera and lungs may be
o Radiographs, however, are generally not compressed and displaced by the expanding uterus.
useful and may lead to an incorrect
diagnosis if there is hydramnios, obesity, Pregnancy Outcome
fetal movement during the exposure, or
inappropriate exposure time. Additionally, • Abortion
o fetal skeletons before 18 weeks' gestation o Spontaneous abortion is more likely with
are insufficiently radiopaque and may be multiple fetuses.
poorly seen. Although not typically used to o Monochorionic greatly outnumber
diagnose multifetal pregnancy, dichorionic abortuses with an 18:1 ratio
o MRI may help delineate complications in • Malformations
monochorionic twins. o Major malformations develop in 2 percent
• Biochemical Tests and
o no biochemical test that reliably identifies o minor malformations in 4 percent of twins
multiple fetuses. o high incidence of structural defects in
o Levels of human chorionic gonadotropin in monozygotic twins.
plasma and in urine, on average, are higher o anomalies in monozygotic twins generally
than those found with a singleton fall into one of three categories:
pregnancy.
o Twins are frequently diagnosed during 1. Defects resulting from twinning itself: a
evaluation for an elevated maternal serum process that some consider to be a
alpha-fetoprotein level teratogenic event. This category
includes conjoined twinning, acardiac
Maternal Adaptation to Multifetal Pregnancy anomaly, neural-tube defects,
holoprosencephaly, and sirenomelia,
• the degree of maternal physiological change is which involves fusion of the lower
greater with multiple fetuses than with a single extremities.
fetus. 2. Defects resulting from vascular
• Beginning in the first trimester, and temporarily interchange between monochorionic
associated with higher serum beta-hCG levels, twins.
• women with multifetal gestation often have nausea 3. Defects may develop from fetal
and vomiting in excess of women with a singleton crowding–examples include talipes
pregnancy. equinovarus (clubfoot) or congenital
• Normal maternal blood volume expansion is greater: hip dislocation. Dizygotic twins are also
an additional 500 mL. subject to these.
• increased iron and folate requirements predispose
to a greater prevalence of maternal anemia. • Birthweight
• Average blood loss with vaginal delivery of twins is o more likely to be low birthweight than
1000 mL, or twice that with a single fetus. singleton pregnancies, due to restricted
• Cardiac output was increased 20 percent compared fetal growth and preterm delivery.
with that of women with a singleton pregnancy. This o the more fetuses, the greater the degree of
was predominantly due to growth restriction.
• greater stroke volume, and to a much lesser degree, o In dizygotic pregnancies, marked size
increased heart rate. At the same time, discordancy usually results from unequal
• pulmonary function tests do not differ between placentation, with one placental site
women with twins and those with singletons. receiving more perfusion than the other.
o Women carrying twins also have a ... o The degree of growth restriction in
• typical pattern of arterial blood pressure change. monozygotic twins is likely to be greater
Compared with the ... than that in dizygotic pairs.
• Duration of Gestation
 o As the number of fetuses increases, the traditionally ascribed to incomplete splitting
duration of gestation decreases of an embryo into two separate twins.
• Preterm Birth o An alternative hypothesis describes early
o major reason for increased neonatal secondary fusion of two originally separated
morbidity and mortality rates in twins. embryos
o Spontaneous preterm labor accounted for a § aberrant twinning encompasses a
larger and preterm ruptured membranes spectrum of abnormalities that
for a smaller proportion of twin preterm includes not only conjoined twins
birth. but also external parasitic twins
o Indicated preterm delivery accounted for and fetus in fetu.
equal proportions of prematurely delivered o united or conjoined twins are commonly
twins and singletons. referred to as Siamese twins–after Chang
• Prolonged Pregnancy and Eng Bunker of Siam (Thailand), who
o twin pregnancy of 40 weeks or more should were displayed worldwide by P.T. Barnum.
be considered postterm. § Joining of the twins may begin at
• Long-Term Infant Development either pole and may produce
o attributed to sequelae of preterm delivery characteristic forms.
o Height, weight, head circumference, and o EXAM Of these, parapagus is the most
intelligence often remained greater in the common.
twin who weighed more at birth. o Identified using sonography at
midpregnancy
Unique Complications o Surgical separation of nearly completely
joined twins may be successful if essential
organs are not shared
• A number of unique complications develop in
• External Parasitic Twins
multifetal pregnancies. Although these have been
o a grossly defective fetus or merely fetal
best described in twins, they also occur in higher-
parts, attached externally to a relatively
order multifetal gestation.
normal twin.
• Monoamnionic Twins
o Parasites are believed to result from demise
o Approximately 1 percent of monozygotic
of the defective twin
twins are monoamnionic
• Fetus-in-Fetu
o Their associated high fetal death rate may
o Early in development, one embryo may be
result from cord entanglement, congenital
enfolded inside its twin.
anomaly, preterm birth, or twin-twin
o These masses are typically supported by
transfusion syndrome
their host by a few large parasitic vessels.
o Management
§ problematic due to the • Vascular Anastomoses between Fetuses
unpredictability of fetal death o present only in monochorionic twin
resulting from cord entanglement placentas
and to the o Most common: Artery-to-artery
§ lack of an effective means of anastomoses are most common
monitoring for it. o Vein-to-vein and artery-to-vein
§ color-flow Doppler sonography communications are each found in
§ 26 to 28 weeks: approximately half.
o Significant patterns include acardiac
• daily fetal heart rate
twinning and twin-twin transfusion
monitoring and
syndrome
betahmethasone
§ 34 weeks: • Acardiac twin:
o Twin reversed-arterial-perfusion (TRAP):
• If fetal testing remains
rare: 1 n 35000 births
reassuring, cesarean
o A normally formed donor twin who has
delivery is performed at
features of heart failure
34 weeks after a second
o A recipient twin who lacks a heart
course of betamethasone.
(acardiacs) and other structures
Unique complications:
Twin-Twin Transfusion Syndrome (TTTS)
• Abnormal Twinning:
o Conjoined twins: may result from
aberrations in the twinning process,
• blood is transfused from a donor twin to its recipient o prognosis is extremely guarded.
sibling such that the donor becomes anemic and its o the most serious form of TTTS, with
growth may be restricted (pale). acute hydramnios in one sac and a
• recipient becomes polycythemic and may develop stuck twin with anhydramnios in the
circulatory overload manifest as hydrops. other sac, usually presents between 18
o The donor twin is pale, and its recipient and 26 weeks.
sibling is plethoric o amnioreduction, laser ablation of
o In the recipient twin, the neonatal period vascular anastomoses, selective
may be complicated by circulatory overload feticide, and septostomy (intentional
with heart failure, if severe hypervolemia creation of a communication in the
and hyperviscosity are not identified dividing amnionic membrane).
promptly and treated.
o Occlusive thrombosis Discordant twins:
o polycythemia in the recipient twin may lead
to severe hyperbilirubinemia and • Discordant twin:
kernicterus. o size inequality of twin fetuses: be a
• Fetal Brain Damage sign of pathological growth restriction
o Cerebral palsy, microcephaly, porencephaly, in one fetus
and multicystic encephalomalacia o As the weight difference within a twin
o caused by ischemic necrosis leading to pair increases, perinatal mortality
cavitary brain lesions rates increase proportionately
o In the donor twin, ischemia results from o The earlier discordancy in pregnancy
hypotension, anemia, or both. develops, the more serious the
o In the recipient, ischemia develops from sequelae
blood pressure instability and episodes of • Pathology:
severe hypotension. o Often unclear but etiology differs in
• Diagnosis monochorionic compared with
o sonographic findings as being suggestive of dichorionic twins
this diagnosis: o Monochorionic twins: attributed to
§ (1) monochorionicity, placental vascular anastomoses that
§ (2) same-sex gender, cause hemodynamic imbalance
§ (3) hydramnios defined if the between the twins
largest vertical pocket is > 8 cm in o Dichorionic twins: variety of factors
one twin and oligohydramnios o Dizygotic fetuses
defined if the largest vertical § Have different genetic growth
pocket is < 2 cm in the other twin, potential, especially if they
§ (4) umbilical cord size discrepancy, are of opposite genders
§ (5) cardiac dysfunction in the § Placentas are separate and
recipient twin with hydramnios, requires more implantation
§ (6) abnormal umbilical vessel or space (one of the placentas
ductus venosus Doppler would have a suboptimal
velocimetry, and implantation site)
§ (7) significant growth discordance. § In utero crowing plays a role
• staged by the Quintero staging system in fetal growth restriction
o Stage I: discordant amnionic fluid • Diagnosis:
volumes as described above, but urine o Uses all fetal measurements to
still visible sonographically within the compute the estimated weight of each
donor twin's bladder twin and then to compare the weight
o Stage II: criteria of stage I, but urine is of the smaller twin with that of the
not visible within the donor's bladder larger twin
o Stage III: criteria of stage II and § Percent discordancy = weight
abnormal Doppler studies of the of larger twin minus weight of
umbilical artery, ductus venosus, or smaller twin, divided by
umbilical vein weight of larger twin
o Stage IV: ascites or frank hydrops in § Weight discordancy greater
either twin; and than 25 to 30 percent most
o Stage V: demise of either fetus. accurately predicts an adverse
• Therapy and Outcome perinatal outcome
 o When abdominal circumferences differ o They recommended conservative
by more than 20 mm management of the living fetus
• Management:
o Mainstay in management à Impending death of one fetus:
sonographic monitoring of growth
within a twin pair and calculating • Delivery maybe be the best option for the
discordancy compromised fetus yet may result in death
o Depending on the degree of from immaturity of the second
discordancy and the gestational age, • Fetal lung maturity is confirmed, salvage of
fetal surveillance may be indicated, both the healthy fetus and its jeopardized
especially if one or both fetuses sibling is possible
exhibit growth restriction • Ideal management if twins are immature:
o Delivery is usually not performed for problematic, should be based on the chances of
size discordancy alone, except intact survival for both fetuses
occasionally at advanced gestational
• Amniocentesis for fetal karyotyping in women
ages.
of advanced maternal age

Death of both twin fetuses:

Twin demise:
• Causes implicated in these deaths were
monochorionic placentation and discordant
• Death of one fetus fetal growth
o One fetus dies remote from term, but
pregnancy continues with one living
Complete hydatidiform mole and coexisting fetus:
fetus
o The risk of subsequent death in the
surviving twin: six fold greater in • Different form a partial molar pregnancy
same: sex twins because there are two separate conceptuses
o Death rate • A normal placenta supplies nutrition to one
§ Same-sex Dizygotic twins: twin, and the co-pregnancy is a complete molar
0.8% gestation
§ Monochorionic twins: 3% • Optimal management: uncertain
o At delivery • Preterm delivery: required because of bleeding
§ Fetus compressus or severe preeclampsia
§ Fetus papyraceous
o Prognosis for the surviving twin Antepartum management of twin pregnancy:
depends on the:
§ Gestational age at the time of • To reduce perinatal mortality and morbidity
the demise rates
§ Chorionicity o Delivery of markedly preterm
§ Length of time between the neonates be prevented
demise and delivery of the o Fetal-growth restriction be identified
surviving twin and afflicted fetuses be delivered
o Management decisions should e based before they become moribund
on the cause of death and the risk to o Fetal trauma during labor and delivery
the surviving fetus be avoided
o Morbidity in the monochorionic twin o Expert neonatal care be available
survivor is almost always due to • Diet:
vascular anastomoses. o Increase requirements for calories,
o Occasionally, death of one but not all protein, minerals, vitamins and
fetuses results forma maternal essential fatty acids
complication such as diabetic o Caloric consumption should be
Ketoacidosis or severe preeclampsia increase by another 300 kcal/day
with abruption o Weight gain with triplet pregnancies:
o The most common associations were at least 50 pounds
monochorionic placentation and o Supplementation:
severe preeclampsia § iron: 60 to 100 mg/day
 § folic acid: 1 mg/day of folic different from those for
acid singleton gestation
• Hypertension: o Cervical Cerclage
o More likely to develop with multiple § Has not been shown to
fetuses à tends to develop earlier improve perinatal outcome in
and to be more severe women with multifetal
o Fetal number and placental mass are pregnancies
involved in the pathogenesis of
preeclampsia Preterm Labor Prediction
• Antepartum surveillance
o Serial sonographic examinations: fetal • only cervical length and fetal fibronectin levels
growth, amniotic fluid volume predicted preterm birth
o Oligohydramnios may indicate • At 24 weeks, a cervical length of 25 mm or less
uteroplacental pathology and should was the best predictor of birth before 32 weeks.
prompt further evaluation of fetal • At 28 weeks, an elevated fetal fibronectin level
well-being was the best predictor.
• Tests of fetal well-being • Pulmonary Maturation
o Nonstress test or biophysical profile o Pulmonary maturation is usually
o Care must be taken to evaluate each synchronous in twins as determined by
fetus separately the L/S ratio (not exceed 2.0 by
• Doppler velocimetry approximately 32 weeks)
o Evaluation of vascular resistance o Some cases: markedly different, with
o Increased resistance with diminished the smallest, most stressed fetus being
diastolic flow velocity often more mature
accompanies restricted fetal growth • Preterm Premature Membrane Rupture
o Clinical utility of this technology is o managed expectantly much like
controversial singleton pregnancies
o labor ensued earlier in twins.
Prevention of preterm delivery: o 90 percent: delivered within 7 days of
membrane rupture.
• 50% of twin, 75% of triplet, and 90% of • Delayed Delivery of Second Twin
quadruplet pregnancies o Infrequently, after preterm birth of the
o Bed rest presenting fetus, it may be
§ Routine hospitalization is not advantageous for undelivered fetus(es)
beneficial in prolonging to remain in utero.
multifetal pregnancy (26 o If asynchronous birth is attempted,
weeks) there must be careful evaluation for
§ Limited physical activity, early infection, abruption, and congenital
work leave, more frequent anomalies.
health care visits and o The mother must be thoroughly
sonographic examinations, counseled
and structured maternal
education
o Tocolytics
§ No valid evidence that Labor and Delivery
tocolytic therapy improves
neonatal outcomes in
• Labor
multifetal gestation
o Recommendations for intrapartum
o Progesterone therapy
management include:
§ Weekly injections of 17-
hydroxyrogesterone caproate
fail to reduce birth rates in 1. An appropriately trained
women carrying twins or obstetrical attendant should
triplets remain with the mother
o Corticosteroids for lung maturation throughout labor. Continuous
§ Guidelines for the use of external electronic monitoring is
corticosteroids are not employed.
 2. Blood transfusion products are § placed in full lateral position
readily available during and after induction of
3. An IV infusion system capable of epidural analgesia.
delivering fluid rapidly is o general anesthesia
established. o Pudendal blockade
4. An obstetrician skilled in • Vaginal Delivery
intrauterine identification of fetal o Cephalic-Cephalic Presentation
parts and in intrauterine § During labor, the presenting
manipulation of a fetus should be twin typically dilates the
present cervix.
5. A sonography machine § If a first twin is cephalic,
6. Experienced anesthesia personnel delivery can usually be
7. For each fetus, two attendants accomplished spontaneously
8. adequate space delivery area or with forceps.
§ planned cesarean delivery
• Presentation and Position does not improve neonatal
o All possible combinations of fetal outcome when both twins are
positions may be encountered cephalic.
o Cephalic-Noncephalic Presentation
§ The optimal delivery route for
cephalic–noncephalic twins is
controversial.
§ Several reports attest to the
safety of vaginal delivery of
second noncephalic twins who
weigh more than 1500 g
§ Thus, when the estimated
fetal weight is greater than
1500 g, vaginal delivery of a
nonvertex second twin is
reasonable.
§ If the estimated fetal weight is
less than 1500 g, the issue is
less clear, although
comparable or even improved
fetal outcomes have been
reported with vaginal delivery
o Breech Presentation

§ As in singletons, if a first fetus
Only cephalic-cephalic or cephalic/breech can be delivered presents as a breech, major
vaginally. problems may develop if:

1. The fetus is unusually

Locked twins: these are rare and impossible to delivery alive
large, and the after
except by CS
coming head is larger than
the birth canal
• Induction or Stimulation of Labor 2. The fetus is sufficiently
o Although labor is generally shorter with small.
twins, it can be desultory 3. The umbilical cord
• Analgesia and Anesthesia prolapses.
o Epidural analgesia is recommended by
many because it
§ cesarean delivery is often
§ provides excellent pain relief
preferred except in those
and
instances in which the fetuses
§ can be rapidly extended
are so immature that they will
cephalad if internal podalic
not survive.
version or cesarean delivery is
§ Locked twins: rare (breech-
required
cephalic)
o Vaginal Delivery of the Second Twin § The obstetrician grasps the
§ the presenting part of the fetal feet to then effect
second twin, its size, and its delivery by breech extraction.
relationship to the birth canal § Breech extraction was
should be quickly and carefully considered superior to
ascertained by combined external version, because less
abdominal, vaginal, and at fetal distress developed.
times, intrauterine o Vaginal Birth after Cesarean (VBAC)
examination. § the same risk for uterine
§ fetal head or the rupture as an attempt at
breech is fixed in the vaginal birth with a singleton
birth canal, moderate gestation
fundal pressure is o Cesarean Delivery
applied and § Twin fetuses create unusual
membranes are intraoperative problems.
ruptured. § Hypotension
§ exclude § The uterine incision should be
prolapse of large enough to allow a
the cord. traumatic delivery of both
§ dilute fetuses.
oxytocin may § Piper forceps can be used just
be used to as for a vaginal delivery: head
stimulate is obstructed.
contractions. § second fetus is much larger
§ 30 minutes: the safest than the first and is breech or
interval between transverse.
delivery of the first
and second twins was Triplet or Higher-Order Gestation
commonly cited as
less than. • Best delivered by cesarean
§ EFM • Vaginal delivery
§ Hemorrhage may o Survival is not expected because
indicate placental fetuses are markedly immature
abruption. o Maternal complications make cesarean
§ If the occiput or breech delivery hazardous to the mother
presents immediately over the o The safety of vaginal triplet delivery
pelvic inlet, but is not fixed in depends on the skill and experience of
the birth canal, the presenting the operator
part can often be guided into
the pelvis by one hand in the
Selective Reduction or Termination
vagina, while a second hand
on the uterine fundus exerts
moderate pressure caudally. • reduction in the number of fetuses to two or
§ Intrapartum external three improves survival of the remaining
version of a fetuses.
noncephalic second • Selective reduction implies early pregnancy
twin has also been intervention,
described (Chervanak • selective termination is performed later.
and co-workers, • Selective Reduction
1983) o can be performed transcervically,
§ CS transvaginally, or transabdominally, but
o Internal Podalic Version the transabdominal route is usually
§ With this maneuver, a fetus is easiest.
turned to a breech o Transabdominal fetal reductions are
presentation using the hand typically performed between 10 and 13
placed into the uterus weeks.
§ This gestational age is chosen
because most spontaneous
 abortions have already 1. Abortion of the remaining
occurred, fetuses
§ the remaining fetuses are 2. Abortion of the wrong
large enough to be evaluated (normal) fetus(es)
sonographically, 3. Retention of genetic or
§ the amount of devitalized fetal structurally abnormal
tissue remaining after the fetuses after a reduction
procedure is small, in number
§ and the risk of aborting the 4. Damage without death to
entire pregnancy as a result of a fetus
the procedure is low. 5. Preterm labor
o The smallest fetuses and any 6. Discordant or growth-
anomalous fetuses are chosen for restricted fetuses
reduction. 7. Maternal infection,
o Potassium chloride hemorrhage, or possible
• Selective Termination disseminated
o With the identification of multiple intravascular
fetuses discordant for structural or coagulopathy because of
genetic abnormalities, three options retained products of
are available: conception.
§ abortion of all fetuses,
§ selective termination of the Psychological Reaction
abnormal fetus,
§ or continuation of the • decision highly stressful.
pregnancy. • Persistent depressive symptoms were mild,
o entails greater risk. although moderately severe sadness and guilt
o usually not performed unless the continued for many for them.
anomaly is severe but not lethal, • most were reconciled to the termination of
o considered because the abnormal fetus some fetuses to preserve the lives of a
may jeopardize the normal one.
remaining few.
o Prerequisites to selective termination
include a
§ precise diagnosis for the
anomalous fetus
§ absolute certainty of fetal
location.
o should be performed only in
multichorionic multifetal gestations to
avoid damaging the surviving fetus(es)
o potassium chloride
o gestational age at the time of the
procedure did not appear to affect
pregnancy loss

Selective reduction or termination:

• Ethics
o The ethical issues associated with these
techniques are almost limitless.
• Informed Consent
o discussion of the morbidity and
mortality rates expected if the
pregnancy is continued;
o risks of the procedure itself:
§ Specific risks that are common
to selective termination or
reduction include: