PATHO OB

MULTIFETAL PREGNANCY
Dr. Joseph Olivar | September 2020 | 3E Batch 2020

Note: Colored font is lifted from Williams th Edition. You may opt

to skip the information if you would like

Read the sample cases provided by Doc Olivar at pp. 4-5 and 9 for the
synchronous discussion CAUSES
MONOZYGOTIC DIZYGOTIC
Course objective: Relatively constant More common
1. How multifetal pregnancy occurs Largely independent of Heredity
2. How diagnosis is made race, heredity, age, and Increasing maternal age
3. Antepartum and intrapartum management parity (37 y/o: at risk of having
4. Unique complications Assisted Reproductive twins already)
therapy (ART) increases Increasing parity
Generally speaking: its incidence Nutritional factors
Twin gestation accounts for 1-3% of all pregnancies Pituitary gonadotropin
Infertility therapy
Local statistics: 0.72% incidence
Assisted Reproductive
Although uncommon, 10% of perinatal mortality and
Therapy (ART)
morbidity is due to multifetal pregnancy
Maternal age is an important risk factor
o Thus, when a pregnancy is multifetal, it is always
o Paradox: declining fertility yet higher chances of
considered a high-risk type of pregnancy or
twinning rates in advanced maternity
under pathologic obstetrics
In heredity, the family history of the mother supersedes that of
the father

Dizygotic twinning is more common and more affected by

temporal and environmental factors versus monozygotic

In one menstrual cycle, only one oocyte is ovulated single

fertilized zygote singleton pregnancy

ETIOLOGY OF MULTIPLE FETUSES

FRATERNAL TWINS
Fertilization of two separate ova
o Fertilized by two sperms
Do ble-o m or dizygotic
Basically two singleton pregnancies inside one uterus
o Therefore there are twins that do not look alike
Not in a strict sense true twins since they result from the
maturation and fertilization of 2 ova during a single
ovulatory cycle
There are some medications women take which in her
genetic library, may enable her to ovulate two ova rather
than a single ovum
IDENTICAL TWINS
Twins arise from a single fertilized ovum
o Formed zygote divides into two twins
Single o m or monozygotic
Increased incidences of discordant malformations
This set of twin comes from a single zygote which divided
during the time that the zygote is travelling (travelling
takes one week) in the fallopian tube kaya they look
similar
Although the number of fetuses is important when we
discuss about multiple pregnancies, equally important is
the number of placenta and amnionic sac Chorionicity
In a singleton pregnancy, the fetus is supplied by its own placenta and
is enclosed by its own amnionic sac. So in twins it really matters how
many placentas and amnionic sacs we have.
Common sense will tell you if there are two placentas and each fetus
is surrounded by its own amnionic sac, then that would be less
complicated versus a twins with a single placenta supplying both, or a
twin with one amnionic sac enclosing both.
Kapag ka o ng kapatid mo pinagsama sa isang kama malamang ma
isang malalaglag one way to imagine how complications mat arise
if there is just one amnionic sac
COMPLICATIONS
More complications Less complications
Only one placenta Two placentas with each twin +
Only one amnionic sac separated by two amnionic sacs

1/9
 GENESIS OF DIZYGOTIC TWINS Ex: If a monozygote will divide by day 2 and the placenta has not yet
differentiated then it is possible that in this type of monozygotic twin
to form two placentas, two amnions, and two separate embryonic
disks

Therefore, in monozygotic twinning, the number of chorion and

amnion is variable and depends on when the zygote divides relative
to the differentiation of the chorion and amnion

Dizygotic twins which are basically two ova or two singleton Ex: If the division happened within the first 4 days after fertilization,
pregnancies placed inside a single uterus, the since the chorion has not differentiated yet, we can produce two
chorionicity/placentation is: DICHORIONIC, DIAMNONIC chorions, two amnions, and two fetuses
ALWAYS! [Chorionicity: DICHORIONIC, DIAMNIONIC]

Ex: If the division occurs between 4-8 days, the chorion has already
differentiated (can no longer divide) however, the amnion and
embryo is still capable so we produce a single chorion, two amnions,
and two fetuses
[Chorionicity: MONOCHORIONIC, DIAMNIONIC]
2 placentas and each fetus is surrounded by its own amnionic
sac Ex: If the division occurs between 8-12 days, only the embryo has not
been differentiated yet. We produce one chorion, one amnion, and
GENESIS OF MONOZYGOTIC TWINNING two separate fetuses
[Chorionicity: MONOCHORIONIC, MONOAMNIONIC]
Again, this is a single zygote
travelling in a fallopian tube Divisions beyond the 12th day will be incomplete Conjoined twins
dividing into 2 before it [Chorionicity: MONOCHORIONIC, MONOAMNIONIC]
implants so the number of
placentas and amnionic sacs RULE OF THUMB:
produced will vary on when The chorion differentiates first before the amnion, a dichorionic
the zygote division occurred placentation will always be DIAMNIONIC
Generally poorly understood A monoamnionic placentation will always be monochorionic
Chorionicity is more complex Monochorionic placentation may either be monoamnionic or
Once a structure has diamnonic
already
differentiated/formed, it will Dizygotic
no longer divide Dichorionic, Diamnionic
0-4 days
o We are talking about a single zygote dividing into two
o Outcome of this process depends on when the
division occurs
Monozygotic
Dichorionic, Diamnionic
3 STRUCTURES TO REMEMBER ON POST-FERTILIZATION
0-4 days
Chorion (placenta) Day 4 differentiated
Amnion Day 8 differentiated
Embryonic disk Day 12 differentiated Monozygotic
Monochorionic,
If a single zygote will divide on day 3 post-fertilization, you can still Diamnionic
4-8 days
divide the chorion into two because the chorion will only differentiate
by day 4. (Matic nang dalawang placenta pa rin mapoproduce mo and
magkahiwalay na fetuses; If there are 2 placentas kahit hindi mo na Monozygotic
iisipin, definitely, there are two amnions and two embryonic disks Monochorionic,
separate from each other) Monoamnionic
8-12 days

Day 6 division: placenta will no longer divide but amnion and

embryonic disk may still divide. (1 placenta, 2 amnion, 2 embryonic Monozygotic
Monochorionic,
disks) Monoamnionic
Conjoined twins
Day 9 division: Chorion and amnion will no longer divide. You produce Beyond day 12
twins separate from each other but they are just supplied by 1 Nagdifferentiate na
placenta, enclosed in 1 amnionic sac, and 2 embryonic disks. embryonic disk dito so
hindi na sila mag

2/9
 hihiwalay (this is the
reason for conjoined
twinning)
DETERMINATION OF ZYGOSITY
2 gestational sacs in a first trimester UTZ means that there are
two placentas (chorionicity: DICHORIONIC, DIAMNIONIC)
Whenever you see a gestational sac, it means there is a
placenta there
o 2 gestational sacs = 2 placentas
Left image, there are two gestational sacs, with
DICHORIONIC, DIAMNIONIC chorionicity
o However, the zygosity is still indeterminable
o Dizygotic is di/di and monozygotic (between 0-4
days) is also di/di
o If you see this kind of UTZ, it is safe to say that this
is di/di but you cannot tell if it is monozygotic or
dizygotic
Right image, a single gestational sac has only one placenta
therefore, MONOCHORIONIC
o Monozygotic na automatic since dizygotic is always
dichorionic and in the picture, it has only one GS
When can you say that the twin pregnancy is really dizygotic?
You can only safely say that it is dizygotic (2 ova) if the genders
and/or blood types are different.
Recap: In female physio, genetic sex is established during fertilization.
Therefore, if there are 2 different genders, it cannot come from a
single zygote. If the blood types are different despite having the same
gender, this is automatically dizygotic. Because if it monozygotic, it
should always be the same. (Doc said it is not important to know the
zygosity. The more important part is the number of chorion since
problems will arise in a monochorionic and monoamnionic types )
2 parameters that determine dizygosity:
Infant sex and blood type
o Twins of the opposite sex are almost always dizygotic
o Infants of different blood types are dizygotic
o Gender and blood type concordance however, will
not determine the zygosity
Shift the focus to determine the chorionicity since determining
the zygosity is difficult
Ultrasound
Early and accurate determination of amnionicity and
chorionicity is critical in the antenatal management of twins
hence, ultrasound is done
The number of placenta (chorionicity) can give a clue on
zygosity
Can determine chronicity as early as 1st trimester
o best time between 10-13 weeks so in this time, it is
safe to see that there are two gestational sacs
DICHORIONIC MONOCHORIONIC
Presence of two separate Membrane generally <2 mm in
placentas and a thick generally thickness and reveals only 2 layers
mm dividing membrane t in- (T-sign)
peak sign or lambda sign)
Placental Examination
Visual examination of the placenta and membranes
This establishes zygosity and chorionicity promptly
Placenta should be carefully delivered to preserve the
attachment of the amnion and chorion to the placenta
Determination of the etiology of growth restriction, early diagnosis of
twin-twin transfusion syndrome, management of surviving twin in
cases of single fetal demise, and manner of delivery are examples of
the clinical management that depends on the chorionicity. Thus,
every attempt must be made to determine and report chorionicity
and amnionicity when a twin pregnancy is identified. Ideal time to
determine chorionicity is between 10-13 weeks AOG.
1. Upper left: Dichorionic, diamnionic
a. We cannot tell the zygosity
2. Upper right: Monochorionic, monoamnionic
a. Single GS and there are no amnions surrounding the
fetuses so probably monozygotic
b. Division probably occurred bet. 8-12 days (cannot
be more than 12 cos the fetuses are separated)
3. Lower left: Seeing two yolk sacs indicates that there are 2
amnions so since there is only a single gestational sac it is
monochorionic, diamnionic
a. Monozygotic
4. Lower right: Monochorionic, diamnonic
Presence of a yolk sac indicates amnionicity (2 YS = 2 Amnions)
Beyond the 1st trimester, the two separate gestational sacs may
no longer be distinctly separated
In the second trimester, you do not expect the gestational sacs to still
be separated from each other since they merge usually. Thereby,
there are clues to know if it is dichorionic or monochorionic based on
the 2nd and 3rd UTZ especially if the two placentas look fused with one
another.
3/9
 CLUES OF DICHORIONICITY: Separate gestational sacs can be identified early in twin
Presence of 2 separate pregnancy
placentas Subsequently, each fetal head should be seen in two
Twin-peak sign: perpendicular planes so as not to mistake a cross section of
presence of a thick the fetal trunk for a second fetal head
dividing membrane Two fetal heads or two abdomens should be seen in the
o Triangular same plane, to avoid scanning the same fetus twice and
thickening interpreting it as twins
o Indication of fused placentas DICHORIONIC Early in the first trimester, the number of chorions equates
to the number of gestational sacs
MONOCHORIONIC A thick band of chorion separating 2 gestational sacs signals
PLACENTATION a dichorionic pregnancy, whereas monochorionic twins
Absent thick have a single gestational sac
dividing membrane
Only a thin dividing
amnion separating
the two
o Arises from the single placenta and is called the
T-sign (indicative of monochorionicity)
o Monochorionic, diamnionic

Examination of placenta: OTHER DIAGNOSTIC AIDS

1st: 2 umbilical cords arising from one placenta
(monochorionic)
2nd: two fused placentas
DIAGNOSIS OF MULTIFETAL GESTATION
Accurate fundic height measurement is essential
Between 20 and 30 weeks AOG, fundic heights are
approximately 5 cm greater than expected for singletons
of the same fetal age
Diagnosing twins via palpation of fetal parts before 3rd
trimester is difficult even so in late pregnancy
o Obesity
o Hydramnios
Late in the 1st trimester, 2 fetal heartbeats may be
differentiated with Doppler
Clinical criteria alone to diagnose multifetal gestation is
unreliable
Ultrasonography
The only safest and reliable method for accurate diagnosis
of multiple gestation
During the 1st trimester, the number of gestational sacs can
be accurately seen (early detection)
o Chorionicity is easily seen
During the latter part of pregnancy (2nd-3rd trimester), same
fetal parts must be seen in the same plane to accurately
diagnose this as twins
o Must be two SAME fetal parts in a SINGLE plane
(ex: 2 heads/hearts/abdomen in one plane) to
safely say that it is a twin gestation
o If one head is in RUQ and another in LLQ, you
might just be scanning a single fetus na akala mo
magkaiba lang ng location
Abdominal Radiography
o If fetal number in a higher-order multiple
gestation is uncertain
o Inaccurate
Magnetic Resonance
o Not typically used to diagnose
o Used to delineate complications in
monochorionic twins
o Helpful for conjoined twins
Serum urine levels of B-hCG + maternal serum alpha-
fetoprotein
o Generally higher in twins vs. singletons however,
these levels may vary considerably and may
overlap singleton pregnancies
A 28 y/o G2P1 had a TVS at 7 weeks which showed this
result. What best describes this image?
A. Monozygotic
B. Dizygotic
C. Dichorionic, diamnionic
D. Monochorionic, monoamnionic
You cannot answer A or B because 2 GS, it can be monozygotic or dizygotic. It
cannot be D because there are 2 GS.
When trying to establish chorionicity of
the pregnancy shown in the image on
the right, which of the following
statements is TRUE?
A. There are two placentas
B. The twins must be monozygotic
C. The twins share the same
amnion
D. The twins must have arisen from two ova
You cannot answer A because there is only 1 GS. C is not the answer because
there are two amnions and there are 2 yolk sacs so it must be diamnionic. D is
not an answer kasi if dizygotic sya, dapat yan, di/di.

4/9
Regarding the sonographic image on the
right, how many days after fertilization
must the division of this zygote have
occurred to lead to the abnormality shown?
A. 0-4
B. 4-8
C. 8-12
D. >12
This is an example of conjoined twinning. There is the presence of shared
organs.
A 37 y/o primi, term, came in labor. She had no prenatal check-up but she has
one UTZ done a few days ago indicating twin gestation, both in cephalic
presentation. Twin A is a boy and Twin B is a girl. Placental location was not
mentioned in the result. What is the chorionicity in this case?
A. Dichorionic, Diamnionic
B. Dichorionic, Monoamnionic
C. Monochorionic, Diamnionic
D. Monochorionic, Monoamnionic
A 37 y/o at 28 weeks of pregnancy presented at the out-patient for her 1st
prenatal care. She claims that she feels multiple parts moving. Her fundic
height is 35 cm. UTZ was requested which revealed one head at the RUQ and
another head at the LLQ. One plane showed 2 heartbeats. Which among the
findings commit to the diagnosis of multifetal pregnancy?
A. Multiple parts moving
B. Larger fundic height
C. Fetal heads on different locations
D. 2 fetal hearts in one plane
Maternal adaptation
Different compared to singleton
Complications and physiologic burdens are typically higher
vs. singletons
Nausea and vomiting in excess of that characterizing
singleton pregnancies (due to high serum B-hCG and
estrogen)
o Kasi either two placentas or isang malaking placenta
will be more than a regular singleton placenta
higher serum B-hCG & estrogen
o The more placental hormones, the greater
probability that symptoms will be worse
Maternal blood volume expansion is greater
o This augmented hypervolemia teleologically offsets
blood loss with vaginal delivery of twins, which is
twice that with a single fetus
o Iron supplementation is required during pregnancy
(OD) and in twin gestation, it must be given BID since
prone to anemia due to higher expansion of blood
o Since the uterus is highly distended, atony will
become a problem
o Anything that will distend the uterus like CAP genes,
GRPs, etc., you expect higher preterm gestation vs.
singleton
Increase in cardiac output is 20% greater than singleton
o Due to hypervolemia and decreased PVR
o Predominantly due to greater SV than HR
o PVR is significantly lower in in twin gestations
throughout the pregnancy
Blood loss for twin delivery via NSD is 1000 mL
PREGNANCY OUTCOMES
Spontaneous Abortion
o 3x greater than singleton pregnancies
o Monochorionic : Dichorionic risk is 18:1
Congenital Malformation
o Significantly higher vs. singleton
o Monochorionic twin malformation rate is twice
that of dichorionic gestation due to imbalance of
supply
o Congenital heart disease is 73% greater vs.
singleton
o Defects resulting from twinning itself
o Defects resulting from vascular interchange
between monochorionic twins
o Defects that occur as the result of crowding
o Usually associated with the accessibility of ART
Low birthweight
o Monozygotic > Dizygotic
o Due to restricted growth and preterm delivery
o Degree of growth restriction increases with fetal
number
Preterm birth
o Twins > Singleton incidence
UNIQUE COMPLICATIONS
MONOAMNIONIC TWINS
Monozygotic twin that divided
bet. 8-12 (right pic)
Problem here: one amnionic
sac cord entanglement
(common cause of death bet.
1 or 2 fetuses and preterm delivery)
Associated with high risk fetal death rate
o Cord entanglement
o Congenital anomaly
o Preterm birth
o Twin to Twin Transfusion Syndrome (TTTS)
To emphasize this point, both fetuses are in the same amnionic sac so
pwede silang magbakbakan dyan sa loob nang hindi mo man lang
alam kala mo magalaw lang tapos yun pala nagpapatayan na pala
silang dalawa -Doc Olivar
Management
1 hour daily FHR monitoring beginning at 26-28 weeks
Corticosteroid therapy (28 weeks routinely for
monochorionic type) fetal lung maturity
CS at 34 weeks regardless of the presentation
o 34 weeks deliver already since these twins are at
higher risk for death and lung maturity is secured
na (benefit vs. risk)
o Do not deliver vaginally because if you do, the next
that will be delivered after the 1st twin may be the
umbilical cord of the 2nd twin; or prolapse
Generally speaking, we do not give steroids routinely in twins just
because we know that they are at risk for preterm labor. Twin
management is the same with singleton. We only give tocolytics and
steroids if the px is at risk for preterm labor (nagco-contract)
o However, this is different in monoamnionic twin
o Since the risk for preterm delivery is higher in
monoamnionic, ROUTINELY even if not in preterm
labor, we give it at 28 weeks
5/9
 TWIN TO TWIN TRANSFUSION SYNDROME (TTTS)
Typically presents in mid-pregnancy
Complication of a monochorionic placenta
2 umbilical cords are connected through a single placenta
where fetal vessels are anastomosed, the donor twin transfers
its blood to the recipient leading to donor anemia and growth
restriction while the recipient being plethoric (full of blood)
and hydropic (may suffer congestion)
o Donor oligohydramnios d/t low blood supply
o Recipient polyhydramnios
The recipient becomes polycythemic hyperbilirubinemia,
develops circulatory overload (hydrops) from heart failure,
severe hypervolemia, hyperviscosity
Donor twin is classically pale and recipient is plethoric
Risk of perinatal mortality is high
This type of monozygotic twins occur wherein a monochorionic
placenta, there is a solitary deep arteriovenous anastomosis
between the two fetuses
Usually the larger baby is more sick vs. the smaller one since
the smaller one is more adapted to a harsher environment
o Sanay sa hirap yung maliit tapos pag icompare natin
yung bigger bb nakatira sa village tapos yung smaller
bb nakatira sa kalye edi mas hindi sya magkakasakit
compared kay bigger bb -Doc Olivar
ULTRASONOGRAPHIC CRITERIA FOR TTTS
Monochorionicity (most important)
Gender concordance**
Polyhydramnios/Oligohydramnios****
(most important)
Growth discordancy >20%
Umbilical cord size discrepancy
Cardiac dysfunction in the recipient twin
Abnormal doppler studies
**They should be the same gender! If different genders, TTTS is not
entertained since the zygosity is di/di
****TTTS only if there is amnionic fluid volume concentration
difference (one is poly, other is oligo) in both compartments
Kahit magkaiba ang weight basta hindi nag-iiba ang AF
concentration in both compartments, you cannot entertain TTTS
(one of the most important criteria) -Doc Olivar
THE QUINTERO CLASSIFICATION SYSTEM FOR TTTS (1999)
Stage Description
I Polyhydramnios/Oligohydramnios
Doppler studies are normal
**Stage 1 begins with abnormal fluid vol. in each fetus
Discordant AFV but urine is still visible in UTZ within donor
twin bladder
II The bladder of the donor twin is not visible
Doppler studies are not critically abnormal
III Doppler studies of umbilical artery, ductus venosus, or
umbilical vein are critically abnormal in either twin
Donor: absent or reversed EDF
Recipient: reversed a wave or pulsatile umbilical vein
IV (+) Hydrops Fetalis; Ascites
V One or both babies are dead
Management
Fetoscopic ablation of vascular placental anastomoses (1st pic)
Amnioreduction (2nd pic) of the polyhdramniotic twin to prevent
preterm labor and to reduce donor twin compression
Septostomy (3rd pic)
o Intentionally creating a hole in the dividing amnionic
membrane (pero abandoned na yung procedure)
o Binutas ung septum para mag-equalize yung fluid
but dangerous since you are creating an iatrogenic
type of monoamnionic twin
TWIN REVERSED-ARTERIAL-PERFUSION (TRAP) SEQUENCE
ACARDIAC TWIN
Rare but serious complication of monochorionic gestation
A normal fetus (donor) pumps its blood to a malformed
recipient without any heart
o But the donor since it is donating blood to the
recipient, the recipient keeps on growing and the
donor twin is at risk for heart failure since it
pumps blood to both
A normally formed donor twin showing features of heart
failure and a recipient twin that lacks a heart (acardius) and
other structures
Pathophysiology:
Large artery-artery placental shunt accompanied by
venous-venous shunt
Arterial-arterial and venous-venous anastomoses between
the two fetuses
Within the single shared placenta, arterial perfusion
pressure of the donor twin exceeds the recipient twin who
receives reverse blood flow containing deoxygenated
arterial blood from its co-twin
The used arterial blood from the co-twin reaches the
recipient twin through the umbilical arteries and
preferentially go to the iliac vessels (only the lower body
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 gets perfused) disrupted gro th and dev t of the upper more favorable outcomes versus fetuses with weight
body leading to complications below: concordance but below the 10th percentile of
gestational age
ACARDIUS ACEPHALUS Failure or disrupted head growth o Twins of the same weight but IUGR is more
ACARDIUS MYELACEPHALUS Partially developed head with problematic versus discordant twins with normal
identifiable limbs weights
ACARDIUS AMORPHOUS Failure of any recognizable structure to Growth discordancy alone is not an indication for immediate
form delivery
o Exception: Cases of advanced gestational age
o Baka may baby na hindi maka-cope kasi maliit lang
talaga sya
o Growth discordancy is part of TTTS
Increased surveillance is warranted in cases of significant
growth discordancy
o Done especially in pregnancies remote from term
Management
Same with TTTS Surveillance is done by:
Ablation Fetal Well-Being Studies
Biometry every 2 weeks (measure fetal growth
DISCORDANT TWINS per twin)
Size inequality of twin fetuses Non-Stress Test/BPS twice weekly
Pathological growth restriction of one fetus Doppler velocimetry studies weekly
2 cm difference in abdominal circumference discordant Steroids at 24-34 weeks
na
o This is a method of diagnosis Sonographic monitoring
𝒘𝒆𝒊𝒈𝒉𝒕 𝒐𝒇 𝒃𝒊𝒈𝒈𝒆𝒓 𝒘𝒆𝒊𝒈𝒉𝒕 𝒐𝒇 𝒔𝒎𝒂𝒍𝒍𝒆𝒓 Mainstay in management
% discordancy = 𝒘𝒆𝒊𝒈𝒉𝒕 𝒐𝒇 𝒃𝒊𝒈𝒈𝒆𝒓 𝒕𝒘𝒊𝒏 Monochorionic twins are monitored more frequently due
o Significant weight discordancy: >20% to higher death risk
Generally as weight differences within a twin pair increases, o UTZ every 2-4 weeks
perinatal mortality increased proportionately Dichorionic pregnancies every 2 weeks

DIAGNOSIS
Fetal Biometry
o Computes for estimated weight per twin
o Weight of smaller twin is compared with larger
then % discordancy follows
PATHOLOGY 𝒘𝒆𝒊𝒈𝒉𝒕 𝒐𝒇 𝒃𝒊𝒈𝒈𝒆𝒓 𝒘𝒆𝒊𝒈𝒉𝒕 𝒐𝒇 𝒔𝒎𝒂𝒍𝒍𝒆𝒓
Monozygotic twins % discordancy = 𝒘𝒆𝒊𝒈𝒉𝒕 𝒐𝒇 𝒃𝒊𝒈𝒈𝒆𝒓 𝒕𝒘𝒊𝒏
o Placental vascular anastomoses that cause o Greater than 25-30% predicts an adverse
hemodynamic imbalance between the twins perinatal outcome
o Reduced pressure and perfusion of the donor twin
can cause diminished placental and fetal growth Abdominal Circumference
o UNEQUAL PLACENTAL SHARING most important o Reflects fetal nutrition
determinant of discordant growth in monochorionic o Done via UTZ to get AC for each twin
twins o >20 mm means fetal-growth restriction
Blood supply is greater in one vs. other
Dizygotic twins SINGLE TWIN DEMISE
o May have different genetic growth potential The prognosis for the surviving twin depends on two factors:
Especially of opposite genders o Gestational age
Discordanc is due to each fetus genetic o Chorionicity
potential Early demise/1st trimester
o Discordancy here is not as grave vs. monozygotic demise does not increase
o Since placenta in this type of twinning is separated death risk of the surviving
and requires more implantation space, one placenta twin
has suboptimal implantation site o Dead fetus will just
vanish vanishing
Principles in The Management of Growth Discordancy twin syndrome (dead
IUGR is more predictive of poor perinatal outcome than fetus is not toxic to remaining twin)
growth discordancy alone o The remaining twin continues as singleton
o Twins with significant discordance but whose weight After 20 weeks or towards the latter part of pregnancy, when
is above the 10th percentile of gestational age have one twin dies, prognosis will depend on chorionicity

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 o Dichorionic pregnancy: one dies but since the other
twin has its own supply, then ok lang to wait for term
pregnancy since singleton na lang sya
o Single placenta and one twin dies: most problematic
since dying twin gets all the blood supply as it dies. The
living twin suffers from brief hypotension affecting fetal
brain of living twin. This happens discreetly and once
discovered, the damage has already been done hence
no need to deliver asap.
o Pregnancy remote from term: living twin will not thrive
if ide-deliver na sya malamang so expectant
management
o Neonatal survival is likely deliver
Survival ill depend on NICU s capabilit
DICHORIONIC PREGNANCIES
Risk of death and neurologic abnormality for surviving twin is
small
Deliver at 37 weeks
However if the condition of the pregnancy (hypertension),
close surveillance and timely intervention for the surviving
twin are indicated to prevent 2nd fetal loss
o Otherwise, the surviving twin delivered at term
MONOCHORIONIC PREGNANCIES
Death in one twin in a monochorionic pregnancy: more
problematic
Increased probability of death and neurologic abnormality
in the surviving twin
Neurologic abnormality in the living twin occurs because
when one twin dies, the surviving twin is depleted of its
blood supply (these damages occur during single fetal twin
demise)
o Persistent hypotension
o Ischemia to organs notably (but not exclusively to
the brain)
Management
AOG is still remote from term expectant
Neonatal survival is likely immediate delivery
ANTEPARTUM MANAGEMENT OF TWIN PREGNANCY
Management principles
Delivery of markedly preterm infants be prevented
Failure of one or both fetuses to thrive be identified and
fetuses so afflicted be delivered before they become
moribund
Fetal trauma during labor and delivery be avoided
Expert neonatal care be available
PRENATAL CARE
Every month until 24 weeks
Every 2 weeks until 32 weeks (starting at 22 weeks)
Weekly thereafter
PC more frequently done in multifetal pregnancy
Prevent preterm delivery of markedly immature neonates
DIET
Caloric requirement is increased
Iron supplement is doubled
Folic acid is increased to 1 mg/day
Multifetal gestation is an indication to start on aspirin
between 12-28 weeks preferably before 16 weeks to
prevent the pregnant woman carrying a twin gestation
from having a hypertensive disorder sometime in the
pregnancy
Diet is increased since 2 fetuses
PRINCIPLES IN THE PREVENTION OF PRETERM DELIVERY
Bed rest
Tocolytic therapy
o Only if threatened (same as singleton)
Corticosteroids (lung maturation)
o Only if threatened (same as singleton)
o ROUTINELY 28 weeks is for monoamnionic type
ONLY
Cerclage
o Not been shown to improve perinatal outcome
o Done only if indicated
Twin gestation with preterm ruptured membranes are
managed expectantly much like singleton pregnancies
ANTEPARTUM SURVEILLANCE
Ultrasound at 10-13 weeks**
CAS at 18-22 weeks***
Biometry (fetal growth measurement) every 4 weeks
normally;
But if mono-di every 2 weeks starting 16 weeks to detect
TTTS
BPS/Non-Stress Testing
Doppler studies in cases of IUGR
**to document the accuracy of chorionicity
***due to risk of congenital anomaly
INTRAPARTUM MANAGEMENT OF TWIN PREGNANCY
Timely attendance by a physician competent to manage a
twin birth (lying-ins are not trained to deliver twins)
Assessment of fetal lie and presentation (UTZ)
Blood readily available for use (at risk for atony)
Epidural anesthesia is advantageous
Continuous EFM for both twins
Active management of the 3rd stage of labor
o Do not wait for placental signs of separation
o Do the maneuvers (oxytocin, controlled cord
traction) to minimize bleeding
PRESENTATION AND POSITION
Most common presentations at admission for delivery
o Cephalic-cephalic
o Cephalic-breech
o Cephalic-transverse A
B
One closest to the cervix is twin
A (pic: cephalic-breech)
These presentations, especially
those other than cephalic-cephalic, are unstable before and
during labor and delivery
Compound, face, brow, and footling breech presentations
are relatively common, especially when the fetuses are
small, amnionic fluid is excessive, or maternal parity is high
Cord prolapse is also frequent in these circumstances
Best confirmed sonographically
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MANNER OF DELIVERY (WILL DEPEND ON THE PRESENTATION)
1. Cephalic-Cephalic vaginal
a. As long as it is diamnionic
b. If it is monoamnionic regardless of C-C CS (34
WEEKS)
2. Cephalic-Non-cephalic individualized
a. As long as EFW: 1500-4000 grams (cephalic)
vaginal 1st twin (as long as OB is skilled in
delivering a vaginal-breech delivery)
How should the 2nd of twin (non-cephalic in
presentation) be delivered?
External Cephalic Version (ECV)
o May be attempted but operator skill-
dependent since uterus is contracting
already, hard to perform sya
o More associated with fetal distress
Total Breech Extraction (TBE)
o Possible
o Lower rates of CS and is preferred
CS when the second of twin is non-cephalic
(book recognizes this option along with ECV and
TBE once non-cephalic)
In C-NC, PREFERRED delivery of 2nd twin is still vaginal
however if hindi sanay sa breech, CS mo sya
If you can deliver twins vaginally, it is preferred
Which of the following is the MOST IMPORTANT predictor of neurological
outcome of the survivor after death of a co-twin?
A. Chorionicity
B. Gestational age at the time of demise
C. Malformations present in the deceased twin
D. Length of time between demise and delivery of survivor
Again, if single twin demise, remember the two factors: (1) AOG and (2)
chorionicity (if it is in the middle of the pregnancy, chorionicity yung titignan
mo). If dichorionic, okay lang yon. If monochorionic, it is risky.
Which is NOT part of the active management of the 3rd stage of labor?
A. Oxytocin 1 minute after childbirth
B. Controlled cord traction
C. Bimanual uterine massage
D. Fundal massage
Bimanual uterine massage is a maneuver done if the active management of
the 3rd stage and uterotonics are failing.
PPT + Asynchronous + Synchronous Lectures
Williams th Edition
Mdluna 2018 trans
Use at your own risqué

3. Twin A, Non-Vertex Planned CS

a. If presenting twin (A) is non-cephalic (non-vertex)

INTERVAL BETWEEN FIRST AND SECOND TWINS

ACOG (1998) has determined that the interval between
delivery of twins is not critical in determining the outcome
of the twin delivered second
o Conventional: delivery interval must be 30
minutes
o C-C: As long as 2nd twin FHT is good expectant
even if more than 30 mins
o Non-vertex 2nd twin TBE
o C-NC: do not wait for 2nd twin TBE

A 31 y/o G2P1 (1001) had her 1st consult at 10 weeks for prenatal care. 1st
trimester UTZ showed twin gestation and each fetus compatible with 10
weeks, monochorionic monoamnionic. Which statement is CORRECT?
A. Complication is significantly reduced with meticulous care
B. Division of zygote occurred 13 days post-fertilization
C. Vaginal delivery is possible
D. Steroids is routinely given at 28 weeks
Should be CS, fetus is separated and should be 8-12 days, and complication is
NOT reduced.

A 31 y/o G2P1 (1001) had an UTZ at 31 weeks. Results showed TWIN A

cephalic, FHT 140 bpm, EFW 1650 g, SVP 2.0 cm; Twin B fetal demise
measuring 26 weeks (760 g); mono-mono. What is the BEST management?
A. Immediately deliver TWIN A
B. Give steroids, fetal surveillance then deliver after steroids therapy
C. Deliver TWIN A at 37 weeks if stable
D. Await spontaneous onset of labor
Yo on deli er in A beca e malii pa Probabl in A ill arran
steroid therapy before delivery. Do not wait 37 weeks since it is too far. Kaya
na by 28 weeks in FEU. Do not also await for spontaneous delivery. B is the
answer since 31 weeks na sya and we can deliver na by 28.

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