Management of twin pregnancy

Do Don’t
Advise limited physical Bed rest
activity to patient
Repeated antenatal USG Cervical circlage
to check cervical length
More frequent antenatal Progesterone
visits
tocolytics

 Obstetrical management of twins:

 Most common presentation: both twins are vertex
 Rarest presentation: both twins transverse lie

 If 1st twin is breech, and 2nd twin is cephalic.

 If breech delivers first, so head will come last.
 So head of breech baby, will lock to head of cephalic
baby.
 Called interlocking of twins.
 Mode of delivery in twin: it is decided by
presentation of 1st twin.
 How to know 1st twin? Fetus nearer to the internal
os.
 If 1st twin is vertex, then vaginal delivery is possible.
 If 1st twin is breech or transverse lie = cesarean
section

 If 1st twin is vertex, there are 3 possibilities.

 INTERNAL PODALIC VERSION:
 Done in OT
 Done under GA
 Only indication: if 2nd twin is transverse lie
 Disadvantage: leads to uterine rupture
 Contraindicated: previous cesarean section

 What is hellins rule?

 Incidence of twins = 1 in 80 pregnancy
 Incidence of triplets = 1 in (80) pregnancy
2

 Incidence of quadruplets = 1 in (80) pregnancy

3

 Multifetal reduction;
 If there is more than 2 fetuses inside uterus, then
reduce extra fetus by putting KCL in heart of fetus.
 But keep 2 fetuses.
 DOC: KCL
 Trans vaginal route: 9-10 weeks
 Trans abdominal route: 10-14 weeks
 Superfecundation: 2 ova are fertilized in same cycle
by 2 different act of coitus
 It is possible in human, till uterine cavity is not
obliterated.
 Uterine cavity obliterated by 14-16 weeks.

 Superfetation: 2 ova are fertilized in 2 different cycle

by 2 different act of coitus.
 Not seen in humans.
 Seen in cattle, horses.

 Maximum time for delivery of 2nd twin after the

delivery of 1st twin: 30 min
 Indication of urgent delivery of the second baby:
 Severe vaginal bleeding
 Cord prolapse of the second baby
 Inadvertent use of intravenous ergometrine with the
delivery of the anterior should of the first baby
 First baby delivered under GA
 Appearance of fetal distress

 Indication for cesarean in twin pregnancy:

 MCMA twin
 Conjoined twin
 TTTS
 Discordant growth in twins such that smaller twin is
< 1.5 kg
 1st twin is non vertex or breech or transverse lie
 Question:
 26 year old primi gravid with a twin gestation at 30
weeks presents for a USG. The sonogram indicates
that she fetuses are both male and placenta appears
to be diamniotic and Monochorionic. Twin B is
noted to have oligohydraminos and to be much and
to be much smaller that twin A. in this clinical
scenario, all of the following are concerns for twin
A except,,,,,
 CHF
 Anemia
 Hydramnios
 Widespread thrombosis

 Twin peak sign seen in?

 Correct statement about establishing the chorionicity

in twin pregnancy is…….
 Same sex rule out dichorionicity
 Twin peak in dichorionicity
 Thick membrane is present in Monochorionic
 Best detected after 16 weeks
 Vaginal delivery is allowed in all except
 MCMA twins
 First twin cephalic and 2nd breech
 Extended breech
 Mento anterior face presentation