Module: Women’s Health

Multifetal Pregnancy
Objectives
• To discuss the different types of multifetal pregnancy and
pathophysiology
• To discuss the antepartum and intrapartum assessment of multifetal
pregnancy
• To discuss the complications of multifetal pregnancy on the fetuses
and the mothers
• To discuss management principles of the possible complications of
multifetal pregnancy.
Sources
• William’s Textbook of Obstetrics 25th edition. Chapter 45
• https://www.nice.org.uk/guidance/ng137
Incidence and Epidemiology
• 1-3% of all pregnancies
• Incidence in Philippines: 0.72% of all pregnancies
• As much as 10% of perinatal mortality, morbidity,
neurodevelopmental problems
• Increased incidence in developed countries
• Increased incidence with the advent of assisted reproductive
techniques

Clinical Practice Guidelines on Multiple Pregnancy (2nd ed.). (2011).

Definition
• Simultaneous development of more than one fetus in
the uterus
• 2 fetuses –twins (most common)
• Triplets, quadruplets – HIGHER ORDER MULTIFETAL
GESTATION
Incidence
• Monozygotic = 3-5/1000 births
• Dizygotic = varies depending on
maternal age, race and geographical
distribution
Etiology
• Assisted reproduction techniques
• Increase parity
• Increase maternal age
• Family history
• Previous multiple pregnancy
• African race
Definitions

• ZYGOSITY - Refers to the Type of Conception.

- only determined by DNA testing

• CHORIONICITY - Type of Placentation

- determined prenatally by ultrasound
- postnatally by examining membranes.
I.DIZYGOTIC TWINS
75%

Fertilization of 2 ova by different spermatozoa.

Each twin has its own placenta, chorion , amnion.

Hence always dichorionic, diamniotic.

Factors affecting - ethnic group

- increasing maternal age
- increasing parity
- Family history of twinning
- ovulation induction with clomiphene citrate/ gonadotrophins resulting in
multiple ovulation.
DIZYGOTIC TWINS
II.MONOZYGOTIC

25%

Result from splitting of a single fertilized ovum

Always same sex.

Rate of monozygotic twinning is relatively constant , not affected

by any factors.

True etiology unknown.

Type of placentation is determined by the time of splitting

MONOZYGOTIC TWINS
MONOZYGOTIC
CHORIONICITY
• Type of Placentation

• Postnatally- Examination of Membranes

• Prenatally- By Ultrasound

• Ideal time for assesment is before 14 weeks

Which is more important, zygosity or
chorionicity?
CHORIONICITY………
• Dichorionic twins can be either mono/dizygotic.
• Dichorionic twins develop as two distinct organs. – so no risk.
CHORIONICITY………
• Monochorionic twins have increased vascular anastomoses between
the two circulation
– so high risk!!
 Monozygotic Dizygotic

1.1/3 twins 1.2/3 twins

2.1 sperm and 1 ovum 2.2 sperms and 2 ova

3.Identical 3.Dichorionic Diamniotic twins

4.Type of placenta depends on 4.Presence of chorionic tissue

the time of splitting of embryo between 2 amniotic sac

5.Incidence is independent of 5.Incidence is dependent of

race, age, parity race, age, parity, and ovulation
inducing drugs
Clinical presentation
Symptoms :
• ↑ nausea, vomiting
• ↑ pressure symptoms:
• constipation, pedal edema, varicosity of veins,
• palpitations, precordial pain
• Fatigue, indigestion, backache, sleeplessness
• Overdistension
• Preterm labor
• Excessive fetal movements
• History of use of ovulation inducing drugs
SIGNS :
• Anemia
• Edema
• Abnormal Weight Gain
• Uterine Height > Age of gestation by Last Menstrual Period
But it may be normal size in case of twins when 1 of the babies die in
utero
Palpation:
Feel 2 separate heads/ > 2 poles
Auscultation :
2 fetal heart tones with difference of at least 10 beats heard on 2
sides of uterus by 2 people, at least 6 inches away
Role of ultrasound
• Confirmation of chorionicity
• Twin peak sign / Lambda sign = dichorionic placenta
• Identify the number and site of placenta, fuse or
separate
• Lie and presentation of twin
• Amniotic fluid assessment
 Maternal Complication

Antenatal :
1.Hyperemesis gravidarum
2.↑chances of abortion
3.hydramnios
4.Increased incidence of Hypertensive disorders of
pregnancy, Diabetes during pregnancy
5.Placenta previa, abruptio
6.Anemia
• Intrapartum :
1.Prolonged labor (uterine inertia)
2.Malpresentation
3.Cord prolapse
4.Abruptio placenta for 2nd twin
5.Postpartum Hemorrhage
Fetal complications
1.Preterm delivery
2.IUGR
3.Congenital Abnormalities
4.Cord abnormalities :
1. Single umbilical artery
2. Velamentous insertion
3. Cord entanglement
4. Cord prolapse
5.Monochorionic twins :
1. Discordant growth
2. Twin to twin syndrome
3. Single fetal Demise
Fetal Complications Unique
to Monochorionic Twins
Twin to Twin Trasfusion Syndrome
 Twin to Twin Transfusion Syndrome
Occur in 10-15% of monochorionic twins
Mostly during 2nd trimester
Due to imbalance of blood flow across placental AV
anastomosis
Associated with a tense uterus with excessive
amniotic fluid volume
Ultrasound : Polyhydramnios in recipient twin and
oligohydramnios in donor twin
Introduction
• Vascular communications exist between the two
placentas in ALL monochorionic twins, which are
usually artery to artery vein to vein.
• As the pressure is equal on both sides with no
gradient, the blood supply to the fetuses is not
compromised.
• But in TTTS the artery of one fetus communicates
with the vein of the other fetus,giving rise to
pressure gradient.
• Thus blood flows unidirectionally from one fetus to
the other resulting in hyperperfusion of the recipient
twin and hypoperfusion of the donor twin.
• The donor becomes
anemic and its growth
maybe restricted, while
the recipient becomes
polycythemic and may
develop circulatory
overload manifest as
hydrops.

• One portion of the

placenta appears pale
compared to the other.
Prevalence
• The prevalence of this condition is approximately 1 to
3 per 10,000 births.
 Pathophysiology

• Chronic TTTS results from unidirectional flow through

arteriovenous anastomoses.
• Deoxygenated blood (donor) from placental artery is
pumped into a cotyledon shared by the recipient.
• Once oxygen exchange is completed in chorionic villus, the
oxygenated blood leaves the cotyledon via a placental vein
of the recipient twin.
• Unless compensated, typically through arterioarterial
anastomoses—this unidirectional flow leads to an
imbalance in blood volumes.
• TTTS is chronic and there is significant vascular
volume differences between the twins.
• However, in MC twin pregnancy complicated
by this syndrome, there is no difference in the
haemoglobin concentrations between the
donor and recipient twins.
• The syndrome presents in mid pregnancy
wherein the donor foetus becomes oliguric
from decreased renal perfusion presenting
with oligohydramnios and recipient foetus
showing polyhydramnios due increased urine
production
Donor twin
Hypovolemic & oliguric/anuric
Result in stuck twin phenomenon where
the twin appears in a fixed position
against uterine wall
Ultrasound may fail to visualize fetal
bladder because of absent urine
Both twin can develop hydrops foetalis
Donor can become hydropic because of
anemia and high output heart failure
Recipient twin
Hypervolemic & polyuric
Can also develop HTN,hypertrophic
cardiomegaly,disseminated intravascular
coagulation,and hyperbilirubinemia after
birth
Recipient becomes hydopic because of
hypervolemia
Diagnosis
• TTTS is diagnosed based on two criteria:
✤presence of a monochorionic diamnionic pregnancy
✤hydramnios defined if the largest vertical pocket is
>8cms in one twin and oligohydramnios defined if
the largest vertical pocket is <2cms in the other twin.
• Once identified, TTTS is typically staged by the Quintero
staging system:
✴Stage I—discordant amnionic fluid volumes, but
urine is still visible sonographically within the
bladder of the donor twin.
✴Stage II—criteria of stage I, but urine is not visible in
the donors bladder.
✴Stage III—criteria of stage II and abnormal Doppler
studies of the umbilical artery, ductus venosus, or
umbilical vein.
✴Stage IV—ascites or frank hydrops in either vein.
✴Stage V—demise of either fetes.
 Stuck Twin
• Also known as
polyhydramnios-
oligohydramnios
syndrome— “POLY-OLI”
• This is a condition wherein
the visual absence of
amniotic fluid in the donor
sac causes the dividing
membrane to attach to the
fetal body thereby
preventing fetal
movements— “stuck twin”.
Management
• It greatly depends on gestation age and the stage of
the disease.
• Serial amnioreduction- removal of amniotic fluid from
the recipient twin by amniocentesis under ultrasonic
guidance.
• Laser ablation of communicating vessels using
fetoscope.
• Septostomy- puncturing of the septum between the
two sacs to create an iatrogenic mono amniotic sac.
• Selective fetocide- used in TTTS that occurs before
20weeks of gestation.
AMNIOREDUCTION

L A S E R A B L AT I O N
Video of fetoscopic laser ablation for TTTS
• https://www.youtube.com/watch?v=bhzlJzujISM

https://www.youtube.com/watch?v=bhzlJzujISM
Twin Reversed Arterial Perfusion (TRAP)

Steenhaut, P. et al. Perinatal Mortality in Multiple Pregnancy. St. Luc University Hospital. Belgium.2012
 Fetal growth discordance
• Intrapair difference in birth weight >20% of larger twin`s
weight
• Growth Discordance
= (wt of bigger twin – wt of smaller twin) X 100
wt of bigger twin
Discordancy

Mild <15%
Moderate 15-30%
Severe >30%

• Discordancy greater than 20% is associated with

increased perinatal mortality
POGS CPG on multiple pregnancy. November 2011
 Intrapair Differences in the Various Ultrasound
Parameters in Predicting Discordancy

Sensitivity Specificity PPV (%) NPV (%)

(%) (%)
BPD > 6 mm 71 77 63 83
AC > 20mm 80 85 62 93
FL > 5 mm 60 93 75 87
EFW > 20 % 80 93 80 93

Sumpaico et al. Obstetrics and Gynecology Ultrasound for Practicing Clinician. Second Edition. 2006
Selective Intrauterine Growth Restriction

TYPE DOPPLER PATTERN

Type 1 sIUGR Positive Diastolic Flow in Umbilical
Artery of the small twin
Type 2 sIUGR Persistently Absent or Reversed End-
Diastolic Flow in the umbilical artery
Type 3 sIUGR Presence of intermittent absent or
reversed end-diastolic flow in the
umbilical artery Doppler of the IUGR
twin

Steenhaut, P. et al. Perinatal Mortality in Multiple Pregnancy. St. Luc University Hospital. Belgium.2012
 IUGR and Discordancy

• Not indications for immediate delivery but for

closer antenatal surveillance
• BPS and biometry with Doppler indices every
two weeks

POGS CPG on multiple pregnancy. November 2011

Twin Reversed Arterial Perfusion (TRAP)

Steenhaut, P. et al. Perinatal Mortality in Multiple Pregnancy. St. Luc University Hospital. Belgium.2012
Velamentous cord insertion
Congenital Anomalies
• 2% in the population of 15,000 babies
• Monozygotic 1 or 2 in a million pregnancies
• Dizygotic 14/15 in a million
• Philippines 4th most common birth defect 114 per 10,000
First Trimester Screening in Twins
• Serum biochemical marker concentrations in twin pregnancies reflect
the presence of two fetuses rather than one.
• 11–13 weeks maternal serum concentrations are approximately
double those found in singleton pregnancies.
• monochorionic twins the average of the two NT measurements can
be used to calculate the pregnancy risk
• dichorionic twins the individual NT measurements can be used to
calculate the fetus-specific risk
• first-trimester NT and maternal serum biochemistry markers can
improve the overall DR to around 80% at a 5% FPR
• PAPP-A, the median MoM values are higher in dichorionic twins than in
monochorionic twins, approaching 2.1 MoM and 1.6 MoM, respectively, at week
13.
• Free β-hCG-MoM values in dichorionic and monochorionic twins increase to a
similar level with gestation, approaching 2.0 MoM at 13 weeks’ gestation
• In twins the levels of serum PAPP-A and free β- hCG change with gestation and
these levels are lower in monochorionic twins than in dichorionic twins.
• dichorionic twins both markers increase from approximately 1.5 MoM of the
singleton median in gestational weeks 8–9 to approximately 2.0 MoM at 13–14
weeks.
• In monochorionic twins the levels of both biochemical markers are approximately
equal to the singleton median at 8–9 weeks and increase at 13–14 weeks to 2.0
MoM for free β-hCG and 1.5 MoM for PAPP-A.
• Trisomy 21-affected singletons, with decreased PAPP-A-MoM and
increased free β- hCG-MoM.
• dichorionic twins affected by trisomy 21, the mean logMoM fitted
well with the model assuming half the level of that in singleton
pregnancies with trisomy 21.
Cervical Assessment in Multiple Gestation
• Despite the lack of precision, clinical cervical assessment
appears to be safe and may be effective in monitoring twin
gestations, if transvaginal ultrasound is not available or
determined to be too expensive. However, compared to
transvaginal sonography, digital examination is more subjective
and less reproducible.

• Transvaginal sonographic cervical assessment provides insight

into the cervical status, as well as the likelihood of preterm
birth in twin pregnancies. There appears to be good correlation
between cervical length and the risk of preterm birth.

Management of Twin Pregnancies. SOGC Consensus Statement. 2000

Cervical Length in Multiple Pregnancy
• There is a steady physiologic decrease in cervical
length starting at 22 weeks
• No standard intervention for shortened cervix
• A cervical length of <25mm at 24 weeks was
associated with an increased risk of preterm birth
before 32, 35 and 37 weeks gestation. However, until
such time as an intervention is identified that
reduces the risk of preterm birth in twins, cervical
length measurements are rendered unhelpful and
not recommended

Clinical Practice Guideline in Management of Multiple Pregnancy. Institute of Obstetricians

and Gynecologits. Royal College of Physicians of Ireland.2014
 Progesterone in Twin Pregnancy

• Studies regarding benefit of vaginal progesterone in pregnancy have

been inconclusive.

• More studies need to be conducted to determine if it reduces risk of

preterm labor.

Brizot, et.al. Prophylactic Administration of Natural Progesterone in the Prevention of

Preterm Delivery in Twin Pregnancies: A Randomized, Double-Blind, Placebo-Controlled
Trial. Brazil. 2014
Steroids in Multiple Pregnancy
• Antenatal corticosteroid therapy reduces the
incidence of RDS, neonatal death and intraventricular
hemorrhage.

• The efficacy of neonatal surfactant therapy is

enhanced by antenatal exposure to corticosteroids.

• The use of antenatal corticosteroids in multiple

pregnancies is recommended, but a significant
reduction in rates of RDS has not been demonstrated.

Antenal Corticosteroids to Prevent Respiratory Distress Syndrome. Royal College of Obstetrics and
Gynecology. 2004
 Single Fetal Demise
• > in Monochorionic twin
• If one twin dies after 14wk,there is high risk of neurological
damage to survivor twin :
• This is due to thromboplastin release resulting to possible
thrombotic arterial occlusion of anterior & middle cerebral
arteries causing multicystic encephalomalacia
 Important Points in the manangement of
single fetal demise
• Determine the chorionicity
• Evaluate fro fetal anomalies/ do fetal surveillance
• Steroid prophylaxis for lung maturity if preterm delivery
• Conservative management unti 37 weeks
• Post-mortem examination of the stillborn. Send placenta for histological
examination
• Counselling and support
• Pediatric assessment and long-term follow-up
Conjoined twin
Conjoined (siamese twin)
• Result of late incomplete embryonic division
• Only in monochorionic –monoamniotic twins
• Incidence -1 in 50,000 to 100,000 births
• Mostly female sex
• Most common –thoracopagus
• Serial Ultrasound required for fetal anatomy and
management
• Ex utero intrapartum treatment(EXIT):procedure for
delivery of co-twin when one twin is not likely to
survive
Prenatal Care
• OPD visits:
• Monthly until 24th week
• Starting 24th week: periodic cervical assessment for dilatation
• Every 2-3 weeks until 30-32 weeks
• Ultrasound every 4 weeks from 24 weeks

Clinical Practice Guidelines on Multiple Pregnancy (2nd ed.). (2011).

Prenatal Care
• Nutrition and weight gain
• Weight gain for Normal BMI: 37-54 lbs
• Additional 450 kcal/day
• TER for Normal weight:
• 30 kcal/kg/day for sedentary
• 35 kcal/kg/day for light activity
• 40 kcal/kg/day for moderate activity

Clinical Practice Guidelines on Multiple Pregnancy (2nd ed.). (2011).

Antepartum Fetal Surveillance
Objective Evaluation
Determine Ultrasound at 10-14 weeks AOG
chorionicity
Detect fetal Ultrasound at 18-22 weeks:
anomalies detailed scan, 4-chamber cardiac
view
Evaluate fetal Serial ultrasound every 3-4 weeks
growth

Clinical Practice Guidelines on Multiple Pregnancy (2nd ed.). (2011).

Antepartum Fetal Surveillance

Objective Examination
Diagnose twin AC difference of 20mm
discordance EFW difference (based on BPD&AC or
AC&FL) >20%
Assess fetal well-being BPP
NST
AFV
Single overall AFI
Individual AFI per sac
Largest 2-diameter pocket per sac
Subjective assessment
Doppler velocimetry

Clinical Practice Guidelines on Multiple Pregnancy (2nd ed.). (2011).

 RCOG recommended antenatal care
Dichorionic Monochorionic
-Lead clinician with multidisciplinary -Lead clinician with multidisciplinary
team team
-US at 10-13wk : US at 10-13wk :
viability,chorionicity,NT:aneuploidy viability,chorionicity,NT:aneuploidy/TTTS

-Structural anomaly scan at 20-22wk -US surveillance for TTTS and discordant
growth at 16wk and then 2weekly
-Serial fetal growth scan eg:24,28,32 then -Structural anomaly scan 20-22wk
2-4weekly (including fetal ECHO)
-BP monitoring and urinalysis at 20,24,28 -fetal growth scan 2wkly interval until
and then 2weekly delivery
-Discussion of mother’s/family needs -BP monitoring and urinalysis at 20,24,28
relating to twins then 2weekly
-34-36wk : discussion of mode of delivery Discussion
and intrapartum care - 32-34wk :discussion of mode of delivery
and intrapartum care
Timing of delivery
• Uncomplicated dichorionic – by
38 week
• Uncomplicated monochorionic –
by 34 to 37 6/7 week
• TTTS – depend on current
situation
• MCMA – 32-34 week, by
Cesarean Section
Mode of delivery
Depend on presentation of 1st twin
Both vertex / 1st twin vertex –
vaginal delivery
Indication for Cesarean Sectio
-More than 2 fetuses
-1st twin malpresentation, CPD
-Scarred uterus
-MCMA
-Conjoined twin
-IUGR in dichorionic twin
-TTTS
 Mode of Delivery
Delivery of the First Twin

Breech
Cephalic

Vaginal delivery,
Cesarean followed by
delivery immediate
clamping of cord
Clinical Practice Guidelines on Multiple Pregnancy (2nd ed.). (2011).
 Delivery of the Second Twin
Transverse/
Vertex or Breech Oblique Lie

Amniotomy; start External cephalic Amniotomy

oxytocin infusion for version or internal
hypotonic uterine podalic version
contractions
Internal podalic
Amniotomy version

Delivery by vacuum
or forceps extraction,
Delivery by cephalic
breech extraction Breech extraction
or breech extraction
Clinical Practice Guidelines on Multiple Pregnancy (2nd ed.). (2011).
Thank You