MULTIFETAL PREGNANCY

COME PGI – LEGAL, ROLDAN JR. FERNANDO

COME PGI – MUHARRANI, MOHAMMAD ALEXANDER YU
FACILITATOR – DR. FATIYA B. ABUBAKAR
REFERENCES
OBJECTIVES
TO DISCUSS THE FOLLOWING
1. MECHANISM AND DIAGNOSIS OF MULTIFETAL GESTATIONS
2. MATERNAL PHYSIOLOGICAL ADAPTATIONS
3. PREGNANCY AND UNIQUE FETAL COMPLICATIONS
4. SPECIAL CASES IN MULTIPLE GESTATIONS
5. PRENATAL CARE, LABOR, AND DELIVERY
MECHANISMS OF MULTIFETAL GESTATIONS
• Multifetal gestations are often described by
• zygosity, amnionicity, chorionicity
• DIZYGOTIC / FRATERNAL TWINS - result from fertilization of two
separate ova
• Twins of opposite sex are almost always dizygotic.
• MONOZYGOTIC / IDENTICAL TWINS - arise from a single fertilized
ovum that divides
MECHANISM OF
MONOZYGOTIC
TWINNING
THE OUTCOME OF THE
MONOZYGOTIC
TWINNING PROCESS
DEPENDS ON WHEN
DIVISION OCCURS
MECHANISM OF MONOZYGOTIC TWINNING
Time Zygotic Chorionic Amniotic Placenta
0 – 4 days Mono Di Di 2 distinct / 1 fused
4 – 8 days Mono Mono Di 1 fused
8 – 12 days Mono Mono Mono 1 fused
>13 Mono Mono Mono 1 fused (conjoined)

MECHANISMS UNDERLYING MONOZYGOTIC TWINNING ARE

POORLY UNDERSTOOD
MECHANISM OF MONOZYGOTIC TWINNING
• SUPERFECUNDATION - fertilization of two
ova within the same menstrual cycle but
not at the same coitus nor necessarily by
sperm from the same male
• SUPERFETATION - an interval as long as
or longer than a menstrual cycle
intervenes between fertilizations.
• It is likely due to ART
FACTORS AFFECTING TWINNING
• Dizygotic twinning is much more common than monozygotic splitting
of a single oocyte, and its incidence is positively infuenced by
infertility treatment and by maternal age, race, heredity, and size.
• Frequency of monozygotic twin births is relatively constant
worldwide – approximately one set per 250 births. This incidence is
generally independent of most demographic factors, except ART.
DIAGNOSIS OF MULTIFETAL GESTATION
• Clinical Evaluation
• Sonography
• Other Diagnostic Aids
• Placental Examination
CLINICAL EVALUATION
EARLY DIAGNOSIS CAN HELP WITH MANAGEMENT OF THE
ASSOCIATED RISKS POSED BY TWINS

1. Fundal height
2. Palpation
3. Hand-held Doppler ultrasonic unit

CLINICAL CRITERIA ALONE TO DIAGNOSE MULTIFETAL GESTATIONS IS

UNRELIABLE
SONOGRAPHY
SONOGRAPHIC EXAMINATION SHOULD DETECT PRACTICALLY ALL
SETS OF TWINS
• Fetal number
• Estimated gestational age
• Chorionicity
• Amnionicity
SONOGRAPHY
• Gestational
sac
• Fetal head
• Chorionicity
SONOGRAPHY
ACCURACY DIMINISHES AS GESTATIONAL AGE ADVANCES.

IT HAS A 98% ACCURACY IN THE FIRST TRIMESTER BUT MAY BE

INCORRECT IN UP TO 10% OF SECOND-TRIMESTER EXAMINATIONS.
OVERALL, CHORIONICITY CAN BE CORRECTLY DETERMINED WITH
SONOGRAPHY BEFORE 24 WEEKS IN APPROXIMATELY 95% OF CASES
10-14 WEEKS
1. Number of
placental masses
2. Presence of an
intervening
membrane dividing
the sacs
3. Thickness of that
membrane
1. Twin peak sign /
lambda or delta
sign (>=2 mm)
2. T sign (<2 mm)
4. Fetal gender
OTHER DIAGNOSTIC AIDS
• Magnetic Resonance Imaging
• Abdominal radiography

NO BIOCHEMICAL TEST RELIABLY IDENTIFES MULTIFETAL GESTATIONS.

SERUM LEVELS OF Β-HCG AND OF MATERNAL SERUM ALPHA-

FETOPROTEIN (MSAFP) ARE USUALLY HIGHER, BUT RANGES MAY
OVERLAP WITH THOSE OF SINGLETONS.
PLACENTAL EXAMINATION
• Visual examination of the placenta
and membranes
• With one common amnionic sac or
with juxtaposed amnions not
separated by chorion, the fetuses
are monozygotic
• If adjacent amnions are separated by
chorion, the fetuses could be either
dizygotic or monozygotic, but
dizygosity is more common
MATERNAL PHYSIOLOGICAL ADAPTATIONS
THE PHYSIOLOGICAL BURDENS OF PREGNANCY AND LIKELIHOOD OF
SERIOUS MATERNAL COMPLICATIONS ARE TYPICALLY GREATER WITH
MULTIFETAL GESTATIONS THAN WITH SINGLETON ONES.
• Nausea and vomiting
• Anemia
• Hypervolemia + decreased vascular resistance = increased cardiac output
• Augmented cardiac output was predominantly due to greater stroke volume rather
than higher heart rate
• Uterine growth: = abdominal viscera and lungs can be compressed and
displaced = sedentary existence
• Renal function
PREGNANCY COMPLICATIONS
• Spontaneous Abortion and Vanishing Fetus
• Congenital Malformations
• Low birthweight
• Hypertension
• Long-term Infant Development
Spontaneous Abortion and Vanishing Fetus
• Among twins, monochorionic twins have significantly higher early
fetal loss rates
• Twins achieved through ART may be at greater risk for abortion
compared with those conceived spontaneously
• Sonography studies in the first trimester have shown that one twin
dies and “vanishes” before the second trimester. The incidence is
higher following ART conception
• A vanishing fetus is more common in higher-order multiples
Congenital Malformations
• The incidence is appreciably higher
• This rate in monochorionic twins was almost twice that of
dichorionic twin gestations
• One large study found that twins had a 73 % greater risk of congenital
heart disease
Low Birthweight
• Multifetal gestations are more likely to be low birthweight due to
restricted fetal growth and preterm delivery
• Birthweights in twins closely paralleled until 28 to 30 weeks
• Thereafter, twin birthweights progressively lagged. Beginning at 35 to
36 weeks, birthweights clearly diverge
• Thus, abnormal growth should be diagnosed only when fetal size is
less than expected for multifetal gestation
Hypertension
• Multifetal gestations are more likely to develop a pregnancy-
associated hypertensive disorder
• Similar to singleton pregnancies with hypertensive disorders, fetal-
growth restriction is a potential outcome
• Aspirin therapy is recommended to help prevent preeclampsia
Long-term Infant Development
• Cerebral palsy (CP) risk is twofold higher among multifetal
pregnancies compared with singletons
• The higher CP rate in multifetal gestations was attributed mainly to
prematurity
• Fetal-growth restriction, congenital anomalies, twin-twin trans-
fusion syndrome, and fetal demise of a co-twin are other potential
contributors
UNIQUE FETAL COMPLICATIONS
• Monoamniotic Twins
• Unique and Aberrant Twinning
• Conjoined Twins
• External Parasitic and Fetus-in-fetu
• Monochorionic Twins and Vascular Anastomoses
• Twin-Twin Transfusion Syndrome
• Twin Anemia-Polycythemia Sequence
• Twin Reversed-arterial-perfusion Sequence
• Hydatidiform Mole with Coexisting Normal Fetus
Monoamniotic Twins
• <1 % of all twin pregnancies; 4% of monochorionic pairs
• HIGH RATES OF MANY SIGNIFICANT COMPLICATIONS
• Fetal loss rates are substantial
• Among fetuses alive before 16 weeks’ gestation - <1/2 survive to the neonatal
period
• Fetal abnormalities and spontaneous miscarriage
• High perinatal death rate
• preterm birth, twin-twin transfusion syndrome, cord entanglement,
birthweight discordance, and congenital anomalies
Monoamniotic Twins
• Congenital anomaly rates: 18 – 28%
• Concordance of anomalies: 25%
• Greater risk of cardiac anomalies:
fetal echocardiography
• Twin-twin transfusion syndrome
rates: lower than diamniotic twins
• Arteioarterial anastomoses
• Twin-twin transfusion syndrome
surveillance
Monoamniotic Twins
• Umbilical cord entanglement is a
frequent event
• Color-flow Doppler sonography
• Factors that lead to pathological
umbilical vessel constriction are
unknown
Monoamniotic Twins
• Optimal surveillance is unclear
and may include nonstress
testing or biophysical profile
assessment
• Betamethasone is considered to
promote pulmonary maturation
IF FETAL TESTING REMAINS
REASSURING AND NO OTHER
INTERVENING INDICATIONS
ARISE, CESAREAN DELIVERY IS
PERFORMED AT 320/7 TO 340/7
WEEKS’ GESTATION
Society for Maternal-Fetal Medicine (2020)
Unique and Aberrant Twinning
• Incomplete splitting of an embryo
• Early secondary fusion of two separate embryos
• Symmetrical or asymmetrical
• Spectrum of asymmetrical twinning includes
• External parasitic twins
• Fetus-in-fetu
• Twin reversed-arterial-perfusion (TRAP) sequence
Conjoined Twins
• Frequency: 1.5 in 100,000 births; thoracopagus: most common type
Conjoined Twins
• Sonography in the 1st trimester. This provides an opportunity to
decide whether to continue the pregnancy
• Other clues
• >3 vessels in the umbilical cord
• Fewer limbs than expected
• Spine hyper-flexion
• Bifid fetal pole
• Increased nuchal thickness
• 3D ultrasound, color Doppler, MRI
POSTNATAL SURGICAL SEPARATION MAY BE SUCCESSFUL IF
ESSENTIAL ORGANS ARE NOT SHARED
Conjoined Twins
VIABLE-AGED CONJOINED TWINS
SHOULD BE DELIVERED BY CESAREAN

FOR PREGNANCY TERMINATION, VAGINAL DELIVERY IS POSSIBLE

BECAUSE THE UNION IS OFTEN PLIABLE
DYSTOCIA IS COMMON AND VAGINAL DELIVERY MAY BE
TRAUMATIC TO THE UTERUS OR CERVIX
External Parasitic Twins & Fetus-in-fetu
ATTACHED TO A RELATIVELY NORMAL TWIN
A FUNCTIONAL HEART / BRAIN IS ABSENT
• EXTERNAL PARASITIC TWIN – is a grossly
defective fetus or merely fetal parts
• FETUS-IN-FETU – one embryo may enfold
early within its co-twin and mainly
intraabdominally
Monochorionic Twins &
Vascular Anastomoses
• Anastomoses between these
twins are unique
• Artery-to-artery
• Vein-to-vein
• Artery-to-vein
• The number, size, and direction
of these seemingly haphazard
connections vary markedly
Monochorionic Twins and Vascular
Anastomoses
WHETHER THESE ANASTOMOSES ARE DANGEROUS TO EITHER TWIN
DEPENDS ON THE DEGREE TO WHICH THEY ARE HEMODYNAMICALLY
BALANCED

TWIN-TWIN TRANSFUSION SYNDROME (TTTS)

TWIN ANEMIA–POLYCYTHEMIA SEQUENCE (TAPS)
TWIN REVERSED-ARTERIAL-PERFUSION (TRAP) SEQUENCE
Twin-Twin Transfusion Syndrome
• Blood is transfused from a donor twin to its recipient sibling
• Donor twin
• Anemic, restricted growth, pale, smaller
• Recipient twin
• Polycythemic may lead to severe hyperbilirubinemia and kernicterus, larger,
volume excess, hyperviscosity and occlusive complications, circulatory
overload with heart failure manifest as hydrops
• TTTS complicates 10 - 15 % of monochorionic twins
Twin-Twin Transfusion Syndrome
• TTTS typically presents in midpregnancy when the donor becomes
oliguric from hypovolemia and decreased renal perfusion.
• The donor develops oligohydramnios, and the recipient develops
severe hydramnios, due to increased urine production from
hypervolemia
• Absence of amnionic fluid prevents fetal motion
• stuck twin or polyhydramnios–oligohydramnios syndrome—“poly–oli”
• This amnionic fluid imbalance is associated with growth restriction,
contractures, and pulmonary hypoplasia in the donor twin, and
premature rupture of the membranes and heart failure in the
recipient.
Twin-Twin Transfusion Syndrome
• What will happen if one twin of an affected pregnancy dies?
• Blood is acutely transfused from high-pressure vessels of the living
twin through anastomoses to low-resistance vessels of the dead
twin. This leads rapidly to hypovolemia and possible ischemic
antenatal brain damage in the survivor.
• A less likely cause is emboli of thromboplastic material originating
from the dead fetus.
Twin-Twin Transfusion Syndrome
• The acuity of hypotension following the death of one twin with TTTS
makes successful intervention for the survivor nearly impossible.
• Even with delivery immediately after a co-twin demise is recognized,
the hypotension that occurs at the moment of death has likely
already caused irreversible brain damage.
• As such, immediate delivery is not considered beneficial in the
absence of another indication.
Diagnosis
• TTTS is diagnosed based on two sonographic criteria
1. A monochorionic pregnancy is identified.
2. Hydramnios defined by a largest vertical pocket >8 cm in one sac and
oligohydramnios defined by a largest vertical pocket <2 cm in the other
twin is found.
• Growth discordance or growth restriction may be found, but these
per se are not considered diagnostic criteria
• Recommend sonographic surveillance of pregnancies at risk for TTTS
• Examinations begin at 16 weeks’ gestation and studies are performed every 2
weeks
Classification
QUINTERO (1999) STAGING SYSTEM
• Stage I—discordant amnionic fluid volumes, but urine is still visible
sonographically within the bladder of the donor twin
• Stage II— stage I, but urine is not visible within the donor bladder
• Stage III—stage II and abnormal Doppler studies of the umbilical
artery, ductus venosus, or umbilical vein
• Stage IV—ascites or frank hydrops in either twin
• Stage V—demise of either fetus
Cardiac function of the recipient twin also declines with TTTS
Management and Prognosis
• The prognosis is related to Quintero stage and gestational age at
presentation
• Some stage I cases remain stable or regress without intervention
• At stage III or higher, the perinatal loss rate is 70 to 100 % without
intervention
• Several therapies include laser ablation of vascular placental
anastomoses, amnioreduction, and selective feticide
• Laser ablation is preferred for stages II–IV. Optimal therapy for stage I
is controversial, and laser ablation or expectant surveillance is an
option
Management and Prognosis
• Delivery timing is usually infuenced by TTTS recurrence, fetal-growth
restriction, or by abnormal Doppler velocimetry values
• Selective fetal reduction
• Feticidal methods aim to occlude the umbilical vein or umbilical cord.
• Radiofrequency ablation, Fetoscopic ligation, or coagulation with
laser, monopolar, or bipolar energy are options.
• Early termination of the entire pregnancy is yet another option
 Twin Anemia–Polycythemia Sequence
• Chronic fetofetal transfusion underlies this form, characterized by
signifcant hemoglobin differences between donor and recipient twins
• Donor is anemic and smaller than recipient, which is polycythemic
• TAPS lacks the discrepancies in amnionic fluid volumes typical of TTTS
• Sonographically, measuring blood flow velocity in the fetal MCA can
accurately identify fetal anemia
• Antenatally, TAPS is diagnosed by discordant MCA peak systolic velocity
values between twins
• Screening for spontaneous TAPS is controversial
Management
• Options include expectant care, delivery, laser surgery, intrauterine
transfusion, selective feticide, and pregnancy termination
• Antenatal surveillance mirrors that just described for TTTS
• Delivery timing is usually infuenced by worsening fetal growth or by
abnormal Doppler velocimetry values
• Postnatal treatment often requires blood transfusion for the donor
twin and partial exchange transfusion of the recipient twin
 Twin Reversed-arterial-perfusion Sequence
• Acardiac twinning: normally formed donor twin that shows features of
heart failure and a grossly malformed recipient twin that lacks a heart
• Arterial perfusion pressure of the donor exceeds that in the recipient.
The recipient thus receives reversed blood flow containing deoxygenated
arterial blood. This “used” arterial blood reaches the recipient through
its umbilical arteries and preferentially goes to its iliac vessels
Twin Reversed-arterial-perfusion Sequence
• Acardius acephalus; acardius
myelacephalus; acardius amorphous
• The normal donor twin must not only
support its own circulation but also must
pump blood to and through the
underdeveloped acardiac recipient. This
may lead to cardiomegaly and high-output
heart failure in the donor twin
• RISK IS DIRECTLY RELATED TO SIZE OF THE
ACARDIAC TWIN
• Radiofrequency ablation is the preferred
modality of therapy
Hydatidiform Mole with
Coexisting Normal Fetus
• Normal fetus & complete molar pregnancy
• Diagnosis in the 1st half of pregnancy
• Often, these pregnancies are terminated
Hydatidiform Mole with Coexisting Normal
Fetus
• Risk of gestational trophoblastic neoplasia is similar whether the
pregnancy is terminated or not
• Complications of expectant management include vaginal bleeding,
hyperemesis gravidarum, thyrotoxicosis, and early-onset
preeclampsia
• Many of these complications result in preterm birth with its
attendant adverse perinatal outcomes
• Logically, close antepartum and postpartum surveillance is needed
for those continuing the pregnancy
DISCORDANT GROWTH
GROWTH OF TWIN FETUSES
• FETAL SIZE INEQUALITY, THE WEIGHT DIFFERENCE
OF WITHIN A TWIN PAIR
• Uneven placental sharing is most likely the most
important cause of discordant growth in
monochorionic twins.
• In dichoriotic twins, discordancy may have result
from different genetic growth potential. One
placenta may have a poor implantation site.
GORWTH OF TWIN FETUSES
• Diagnosis:
• Sonographic fetal biometry (surveillance after after 1st
trimester) to compute an estimated weight for each
twin.
• Percent discordancy is then calculated as the weight of the
larger twin minus the weight of the smaller twin, divided by the
weight of the larger twin.
GORWTH OF TWIN FETUSES
• Diagnosis:
Selective growth of one twin fetus is termed
Selective Fetal Growth Restriction (sFGR), if the
abdominal circumference (AC) measurement exceeds
20 mm or If the fetal-growth discordance is >20
percent

• Management: Sonographic monitoring

FETAL DEMISE
DEATH OF ONE FETUS
• One or more Fetuses may die at any time during a
multifetal pregnancy, either simultaneously or
sequentially.
• “Vanishing twin” - When this occurs early in
pregnancy
• “Fetus compressus” - dead fetus that is barely
identifiable, and compressed appreciably
• “Fetus papyraceous” – dead fetus may be
flattened remarkably through desiccation
DEATH OF ONE FETUS:
• Management:
• If one of the fetuses in a monochorionic twin pregnancy dies after the
first trimester but before viability, pregnancy termination is
considered.
• If after viability: maternal and cotwin safety, gestation prolongation,
antenatal corticosteroid is considered for the survivor lung maturity
• If demise was after 34 weeks, delivery is reasonable
PRENATAL CARE
PRENATAL CARE
Prenatal checkup
• women with multifetal gestations are seen every 2 weeks beginning
at 22 weeks of gestation

Diet
• The Institute of Medicine recommends a weight gain of 37 to 54
pounds for women with twins and a normal BMI.
• For women with twins, the daily recommended increased caloric
intake is 40 to 45 kcal/kg/day. (20% protein, 40% carbohydrate, and
40% fat divided into three meals and three snacks per day.)
PRENATAL CARE
Fetal Surveillance
• Identification of abnormal fetal growth or discordancy
• serial sonographic examinations are usually performed throughout
the third trimester.
• Assessment of amnionic fluid volume is also important.
• Associated oligohydramnios may indicate uteroplacental pathology and
should prompt further evaluation of fetal well-being
• Deep vertical pocket < 2 cm = oligohydramnios
• Deep vertical pocket ≥ 8 cm = polyhydramnios
PRETERM BIRTH
• With increasing fetal number, gestational length and preterm risk
increase.
• Preterm birth rates vary by chorionicity and are higher in
monochorionic twins than in dichorionic twins.
LABOR AND DELIVERY
DELIVERY TIMING
• ACOG recommends:
• Delivery at 38 0/7 to 38 6/7 weeks for Uncomplicated Dichorionic Diamniotic
pregnancies
• Delivery at 34 0/7 to 37 6/7 weeks for Uncomplicated Monochorionic
Diamniotic pregnancies
• Delivery at 32 0/7 to 34 0/7 weeks for Uncomplicated Monochorionic
Monoamniotic pregnancies

• Cephalic-cephalic, cephalic-breech, and cephalic transverse are the

most common presentation combinations at admission or delivery.
Delivery route
• Cephalic-Cephalic: delivery can usually be
accomplished spontaneously
• Cephalic-non cephalic: optimal delivery route
remains controversial.
• Options: Cesarean delivery of both twins; vaginal delivery of
cephalic first twin, then eternal cephalic version of the 2nd
twin extraction (hand placed into the uterus grasps fetal feet
to deliver the fetus by breech )
• Preferred interval between delivery of the first and
second fetus is < 30 minutes (longer may
associated with poorer outcome of the second
twin)
Delivery route
• Breech Presentation of First Twin: Problems with the first twin
presenting as breech are similar to those encountered with a
singleton breech fetus.
• If for vaginal delivery, major problems may develop if
1. The fetal body can be small, and delivery of the extremities and
trunk through an inadequately effaced and dilated cervix can leave
the relatively larger head trapped above the cervix.
2. The umbilical cord prolapses.
3. Twin fetuses may become entangled during delivery if the first is
breech and the second is cephalic.
Delivery route
• Triple or Higher-order gestation
• The first neonate is usually born with little to no manipulation, subsequent
fetuses are delivered according to the presenting part (total breech
extraction with or without internal podalic version, or cesarean delivery)
REDUCING FETAL NUMBER
REDUCING FETAL NUMBER
• Multiple Pregnancy Reduction (MPR): aims to lower fetal number to
improve survival rates of the remaining fetuses.
• Selective termination: early pregnancy intervention focuses on the
fetus with an anomaly or serious health risk.

• Both are done in the late first trimester, because most spontaneous
abortion have already occurred and the remaining fetuses are large
enough to be sonography ally evaluated
REDUCING FETAL NUMBER
• specific risks include
1. loss of all remaining fetuses,
2. abortion or retention of the wrong fetus,
3. Damage without death to a fetus
4. preterm labor
5. fetuses with discordant or growth restriction,
6. maternal complications.

Complications: infections, hemorrhage, or disseminated intravascular

coagulopathy because of the products of conception
 THANK YOU!

MULTIFETAL PREGNANCY
COME PGI – LEGAL, ROLDAN JR. FERNANDO
COME PGI – MUHARRANI, MOHAMMAD ALEXANDER YU
FACILITATOR – DR. FATIYA B. ABUBAKAR