MULTIFETAL PREGNANCY PATHO OB

Dr. Joseph U. Olivar || September 2021 AY 2021-2022 1st sem

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I. MULTIFETAL PREGNANCY ● assisted reproductive ● nutritional factors

Incidence is only 1-3%; locally 0.72%, but 10% of perinatal mortality therapy ● infertility therapy: FSH
and morbidity is secondary to the consequences of twinning. + hCG or clomiphene
citrate
SUPERFETATION ● Pituitary
● An interval as long as or longer than a menstrual cycle gonadotropin: FSH
intervenes between fertilizations. ● assisted reproductive
● Requires ovulation and fertilization during the course of an
established pregnancy 💬
💬
therapy
more common
more affected by temporal
● Not yet proven in humans
and environmental factors
SUPERFECUNDATION
● Fertilization of two ova within the same menstrual cycle but
not as the same coitus, nor necessarily by sperm from the
same male SAMPLE CASES
1. What type of twinning increases when the maternal age is
💬● 1 menstrual cycle = only 1 follicle becomes dominant
already 45?
2. What type of twinning increases when a sibling of the
pregnant patient is also carrying twins?
because the decreasing FSH level makes the 11 other
to degenerate. ANSWERS:
● And that 1 follicle has many receptors that make it 1. Dizygotic
dominant. 2. Dizygotic
● But how does twinning occur? There are 2
possibilities:
○ 2 ova can be ovulated GENESIS OF DIZYGOTIC TWINNING
○ a single ovum is ovulated fertilized by a ● 2 singleton pregnancy is placed inside a single uterus. 1 twin
single sperm however that zygote during the will have its own amniotic sac and own placenta.
7 days that it is travelling in the fallopian ● There will be 2 placenta and 2 amniotic sac (the placentation
tube before it implants, divides. or the chorionicity is ALWAYS: DICHORIONIC,
DIAMNIOTIC)
MECHANISM OF MULTIPLE GESTATIONS
GENESIS OF MONOZYGOTIC TWINNING
FRATERNAL TWINS IDENTICAL TWINS
● Fertilization of two ● Twins arise from
separate ova single fertilized ovum
● “double – ovum”, or ● “Single-ovum”,

💬 dizygotic
2 singleton pregnancies
in a single uterus
●
monozygotic
Have increased
incidence of
discordant
malformations: 12-fold
greater congenital

💬 heart defects
The formed zygote divides
into two resulting to twins

Figure 1.

Differentiation

FACTORS THAT INFLUENCE TWINNING 1st 4 days Since the chorion has not yet differentiated, we
will produce
MONOZYGOTIC/IDENTICAL DIZYGOTIC/FRATERNAL ● 2 chorion
● relatively constant ● Heredity: long arm of ● 2 amnion
● largely independent of chromosome 6 ● 2 fetuses
race, heredity, age ● increasing maternal Chorionicity: dichorionic/diamnionic
and parity age (>37) and parity

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 4-8 days The chorion has already differentiated SAMPLE CASES
● 1 chorion 1. If the zygote divides on Day 5 post fertilization, how many
● 2 amnion placenta can we have?
● 2 fetuses 2. If the zygote divides by Day 9, how many placentas do you
Chorionicity: monochorionic/diamnionic have? How many amniotic bag?
8-12 days Only the embryo has not yet differentiated
ANSWERS:
● 1 chorion 3. Only 1 because it already differentiated by day 4
● 1 amnion 4. Only 1. Only 1
● 2 fetuses
Chorionicity: monochorionic/monoamnionic II. DETERMINATION OF ZYGOSITY
Beyond 12 ● Incomplete division
days ● Monochorionic/monoamnionic
● Conjoined twins
● The chorion differentiates first before
the amnion

💬
● Dichorionic placentation will always be
diamnionic
● Monoamnionic placentation will always
be monochorionic
● Monochorionic placentation may either
be diamnionic or monoamnionic

POST FERTILIZATION
● General Rule: “ONCE A STRUCTURE HAS ALREADY
DIFFERENTIATED, IT WILL NO LONGER DIVIDE”
● CHORION - already differentiated during DAY 4
● AMNION - during DAY 8
● EMBRYONIC DISK - during DAY 12
Figure 2. Dichorionic diamnionic. Determine zygosity.

Dizygotic
- Dichorionic,
Diamniotic
- 0 to 4 days

Monozygotic
- Dichorionic,
Diamniotic
- 0 to 4 days

Monozygotic Figure 3. A single gestational sac means only 1 placenta, therefore,

- Monochorionic, monochorionic. Determine zygosity.
Diamniotic
- 4 to 8 days
A. INFANT SEX AND BLOOD TYPE
● Twins of the opposite sex are almost always DIZYGOTIC
● Infants of different blood types are DIZYGOTIC
● Genetic sex is established during fertilization.
Monozygotic ● If it is a female and the zygote divides (monozygotic), it will
- Monochorionic, only produce twins with the same gender.
Monoamniotic ● If it is different gender, it should be 2 zygotes.
- 8 to 12 days ● Gender and blood type concordance do not determine
zygosity.
● Since zygosity is not easy to determine, we shift our focus
into determining the chorionicity, which is the more important
Monozygotic determinant of twin-specific complications.
- Monochorionic,
Monoamniotic
- Conjoined Twins
- Beyond Day 12

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 SAMPLE CASES Figure 6. Seeing 2 yolk sacs indicates that there are two
1. A 37 yo primi, term, came in labor. She had no prenatal amnions, only 1 gestational sac, hence this is
checkup but she has 1 UTZ done few days ago indicating monochorionic, diamnionic
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?

ANSWERS:
Dichorionic, diamnionic (zygosity: dizygotic)

B. ULTRASOUND
● most accurate way
● The following depends on chorionicity which can be
assessed via ultrasound
○ Determination of etiology of growth restriction
○ Early diagnosis of twin-twin transfusion syndrome
○ Management of surviving twin in cases of single
fetal demise
○ Manner of delivery
● First trimester (10 to 13 weeks AOG) - the best time to
determine the chorionicity or the number of placenta by an Figure 7. Monochorionic, diamnionic
ultrasound which can give a clue on zygosity.
● After the 1st trimester, the benefit of seeing two gestational
sacs is no longer there because the gestational sacs will
usually merge. That’s why we do ultrasound as early as
10-13 weeks.
● After the 1st trimester the following will give us clues to tell if
there are 2 placentas:
○ DICHORIONIC:
■ presence of two separate placentas and
a thick – generally 2mm or greater –
dividing membrane
■ (“twin – peak” or Lambda sign)
○ MONOCHORIONIC:
■ Membrane generally less than 2mm in
thickness and reveals only 2 layers.
■ A thin dividing amnion arising from the
Figure 4. Dichorionic diamnionic
placenta
■ (“T” sign)

Figure 8. Twin peak sign of dichorionicity

Figure 5. Monochorionic monoamnionic

Figure 9. T sign of monochorionicity

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 III. DIAGNOSIS OF MULTIPLE FETUSES
In women with a uterus that appears large for gestational age, the
following possibilities are considered:
● Multiple fetuses
● Elevation of the uterus by a distended bladder
● Inaccurate menstrual history
● Hydramnios
● Hydatidiform mole
● Uterine myomas
● A closely attached adnexal mass
● Fetal macrosomia (late in pregnancy)

Figure 10. Twin peak and T sign A. ULTRASONOGRAPHY

● Separate gestational sacs can be identified early in twin
C. PLACENTAL EXAMINATION pregnancy
● Two fetal heads or two abdomens should be seen in the
● Visual examination of the placenta and membranes same plane, to avoid scanning the same fetus twice and
● Placenta should be carefully delivered to preserve the interpreting it as twins.
attachment of the amnion and chorion to the placenta.

SAMPLE CASE
1. A 37 yo at 28 weeks of pregnancy presented at the OPD for
her 1 st prenatal care. She claims that she feels multiple
parts moving. Her FH is 35 cm. UTZ was requested which
revealed one head at the RUQ and another head at the LLQ.
One plane showed 2 heart beats. Which among the findings
commit to the dx of multifetal pregnancy?

ANSWERS:
2 fetal hearts in one plane

B. RADIOLOGIC EXAMINATION
● Not useful and may lead to an incorrect diagnosis
Figure 11. 1 fused placenta
C. BIOCHEMICAL TESTS
● Amounts of chorionic gonadotropin in plasma and in urine,
on average, are higher than those found with a singleton
pregnancy, but not so high as to allow a definite diagnosis of
multiple fetuses

IV. MATERNAL ADAPTATION

● Nausea and vomiting in excess of that characterizing
singleton pregnancies.
● Maternal blood volume expansion is greater
● Increased in cardiac 20% greater than singleton
● Blood loss for twin delivery via NSD 1000 ml

Figure 12. 2 fused placentas
Figure 13. Dichorionic diamnionic twin placenta. The membrane
partition that separated twin fetuses is elevated and consists of chorion
(c) between two amnions (a)
V. PREGNANCY OUTCOME
ABORTION
● 3x > than singleton pregnancies
● Monochorionic: dichorionic (Risk: 18:1)
MALFORMATION
● Defects resulting from twinning itself.
○ This category includes conjoined twinning,
acardiac anomaly, sirenomelia, neural-tube
defects, and holoprosencephaly.
● Defects resulting from vascular interchange between
monochorionic twins.
○ Vascular connections may also conduct dramatic
blood pressure fluctuations, causing defects such
as microcephaly, hydranencephaly, intestinal
atresia, aplasia cutis, or limb amputation.
● Defects that occur as the result of crowding.
● Low birthweight (more on monozygotic than dizygotic)
● Preterm birth

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 VI. UNIQUE COMPLICATIONS Donor ● Blood is transfused from a donor
twin to its recipient sibling such
A. MONOAMNIOTIC TWINS
that the donor becomes anemic
● Associated with high risk fetal death rate and its growth may be restricted
○ cord entanglement ● Polyhydramnios
○ congenital anomaly ● Most of the time is better
○ preterm birth because the recipient is volume
○ twin to twin transfusion syndrome overloaded

MANAGEMENT
ULTRASONOGRAPHIC CRITERIA FOR TTS 📌
● Monochorionicity
● Polyhydramnios/ Oligohydramnios
● Somewhat problematic due to the unpredictability of fetal
○ The two most important criteria are
death resulting from cord entanglement
monochorionicity and oligo/poly sequence
● 1 hour daily FHR monitoring beginning at 26-28 weeks
● Gender concordance
● Corticosteroid therapy at this time to promote fetal lung
○ If the fetuses have different gender, it will be
maturity
dizygotic which means 2 placenta. It is not
● Cesarean section at 34 weeks regardless of presentation
possible to have TTTS if you have 2 placenta.
● Always cesarean, never vaginal because once you ruptured
● Growth discordance >20%
the bag of water and deliver the 1st twin, that could be
● Umbilical cord size discrepancy
followed by the cord of the other twin. At 34 weeks the
● Cardiac dysfunction in the recipient twin
fetuses are already okay. Lungs are good.
● Abnormal Doppler studies

B. TWIN TO TWIN TRANSFUSION QUINTERO CLASSIFICATION SYSTEM

● is used to classify the heterogeneity and gauge the severity
of TTTS, and assumes increased severity with advancing
stage

Stage Description

1 Polyhydramnios/Oligohydramnios
Doppler studies are normal

Figure 14. 2 The bladder of the donor twin is not visible

Doppler studies are not critically abnormal

3 Doppler studies are critically abnormal in either twin

Donor: absent or reversed EDF
Recipient: reversed a wave or pulsatile umbilical
vein

4 (+) hydrops fetalis

5 One or both babies are dead

FETAL CONSEQUENCES OF TTTS

● circulatory overload with heart failure
● Occlusive thrombosis is also much more likely to develop in
this setting.
● Polycythemia may lead to severe hyperbilirubinemia and
Figure 15. Twin to twin transfusion syndrome
kernicterus.
DIAGNOSIS OF TTTS
PATHOPHYSIOLOGY
● Presence of solitary, deep arteriovenous anastomoses ● Postnatal diagnosis:
between the two fetuses ○ weight discordancy between twins of 15 – 20%
● Through a single placenta where fetal vessels are ○ hemoglobin level difference of 5 g/dL or greater
anastomosed, the donor twin transfers its blood to the ● Typically presents in the midtrimester when the donor fetus
recipient twin. becomes oliguric due to decreased renal perfusion.
● Develops oligohydramnios, and the recipient fetus develops
severe hydramnios, presumably due to increased urine
production.
● Virtual absence of amnionic fluid in the donor sac prevents
Recipient ● Becomes polycythemic and may fetal motion, giving rise to the descriptive term stuck twin.
develop circulatory overload ● Hydramnios–oligohydramnios combination can lead to
manifest as hydrops growth restriction, contractures, and pulmonary hypoplasia in
● Oligohydramnios one twin, and premature rupture of the membranes and
● Plethoric heart failure in the other.

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 ● As the weight difference within a twin pair increases,
MANAGEMENT OF TTTS
perinatal mortality increases proportionately.
● Amnioreduction ● The earlier in pregnancy discordancy develops, the more
● Septostomy serious the sequelae.
● Laser ablation of vascular anastomoses ● Pathology:
● Selective feticide ○ In monozygotic twins, discordancy is usually
● Treatment: Ablate the connection, but it is not done locally. attributed to placental vascular anastomoses that
We can reduce the fluid in the recipient so that the cause hemodynamic imbalance between the
compression of the donor will be decreased. One option is to twins.
puncture the amnion so that the fluid will be distributed; ○ Dizygotic fetuses may have different genetic
however, you are creating monoamniotic twinning. growth potential, especially if they are of opposite
genders.
Sample Question:
What is the definitive management for TTTS for our local setting?
DELIVERY - to stop the transfusion but the problem is, if the AOG is PRINCIPLES IN THE MANAGEMENT OF GROWTH
remote from term you cannot deliver instead you do close monitoring. DISCORDANCY

C. ACARDIAC TWINS ● IUGR is more predictive of poor perinatal outcome than

● TWIN REVERSED-ARTERIAL-PERFUSION (TRAP) 💬

growth discordance alone
twins with significant growth discordance but whose
weights are above the 10th percentile have a more favorable
SEQUENCE is a rare (1 in 35,000 births) but serious
complication of monochorionic, monozygotic multiple outcome than those with weight concordance but below the
gestation. 10th percentile for AOG
● In the TRAP sequence, there is usually a normally formed ● Growth discordance alone is NOT an indication for
donor twin who has features of heart failure as well as a immediate delivery except for advanced AOG.
recipient twin who lacks a heart (acardius) and various other ● Increased surveillance is warranted in cases of significant
structures. growth discordance
● Caused in the embryo by a large artery-to-artery placental ● Fetal Well Being Studies
shunt, often also accompanied by a vein-to-vein shunt. ○ Biometry every 2 weeks
● The perfusion pressure of the donor twin overpowers that in ○ NST/BPS twice weekly
the recipient twin, who thus receives reverse blood flow from ○ Doppler study weekly
its twin sibling. ○ Steroid at 24-34 weeks
DIAGNOSIS
● Weight of larger twin minus weight of smaller twin, divided by
weight of larger twin.

● Most useful index of size discordancy - ultrasonographic

assessment of twin discordance: 20 mm (2cm) difference in
Figure 16. TRAP sequence abdominal circumference superior to head circumference,
femur length, or transverse cerebellar diameter

MANAGEMENT
ACARDIUS Failure or disrupted growth of the head
ACEPHALUS ● Ultrasonographic monitoring of growth
● Fetal surveillance
ACARDIUS Partially developed head with identifiable ● Delivery is usually not performed for size discordancy alone,
MYELACEPHALU limbs except occasionally at advanced gestational ages.
S
E. DEATH OF ONE FETUS
ACARDIUS Failure of any recognizable structure to
AMORPHOUS form ● Prognosis for the surviving twin depends on the gestational
age at the time of the demise, the chorionicity, and the length
of time between the demise and delivery of the surviving
MANAGEMENT twin.
● Early demise such as a "vanishing twin" does not appear to
● Without treatment, the donor or "pump" twin has been increase the risk of death in the surviving fetus after the first
reported to die in 50 to 75 percent trimester.
● Methods of in utero treatment of acardiac twinning: goal is ● Later in gestation, the death of one of multiple fetuses could
interruption of the vascular communication between the theoretically trigger coagulation defects in the mother.
● Management decisions should be based on the cause of
💬
donor and recipient twins.
same as TTTS
●
death and the risk to the surviving fetus.
Majority of cases of a single fetal death in twin pregnancy
involve monochorionic placentation.
D. DISCORDANT TWINS
DICHORIONIC PREGNANCIES
● Size inequality of twin fetuses ● Risk of complication is small

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 ●
💬
DELIVERY AT 37 WEEKS
if hypertension is present, close surveillance and timely
intervention are indicated to prevent a second fetal loss.
●
●
Bedrest
PREVENTION OF PRETERM DELIVERY

Tocolytic therapy
Otherwise, the surviving twin is delivered at term. ● Corticosteroids for lung maturation (only given if the patient
has s/sx of preterm labor, but then again corticosteroid is
routinely given in monoamniotic twinning at 28 weeks even
MONOCHORIONIC PREGNANCIES
without symptoms)
●
💬
Risk of complication is increased
such as death in the surviving twin
●
●
Cerclage – not been shown to improve perinatal outcome
Twin gestation with preterm ruptured membranes are
●
💬
Neurological abnormality
occurs because when one twin dies the surviving twin is
depleted of its blood supply resulting to persistent
managed expectantly much like singleton pregnancies.
DELIVERY OF TWIN FETUSES
● Complications of labor and delivery
hypotension and ischemia to organs notably but not
● preterm labor
exclusively to brain. This occurs during single fetal twin
● uterine contractile dysfunction
demise.
● abnormal presentation, prolapse of the umbilical cord
● Remote from term: EXPECTANT
● premature separation of the placenta
● Neonatal survival is likely: IMMEDIATE DELIVERY
● immediate postpartum hemorrhage

VII. MANAGEMENT
ANTEPARTUM MANAGEMENT OF TWIN PREGNANCY
● 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.
DIET
● Requirements for calories, protein, minerals, vitamins, and
essential fatty acids are further increased in women with
multiple fetuses.
● Caloric consumption should be increased by another 300
kcal/day.
● Supplementation with 60 to 100 mg/day of iron and with 1
mg of folic acid is recommended.
PRENATAL CARE
● Every month until 24 weeks
● Every 2 weeks until 32 weeks
● Weekly thereafter
RECOMMENDATIONS FOR INTRAPARTUM MANAGEMENT
● Trained obstetrical attendant should remain with the mother
throughout labor.
● Continuous external electronic monitoring is typically used.
● Fluids and blood transfusion products should be readily
available.
● An obstetrician skilled in intrauterine identification of fetal
parts and in intrauterine manipulation of a fetus should be
present.
● An ultrasonography machine should be readily available to
help evaluate the position and status of the remaining
fetus(es) after delivery of the first.
● An experienced anesthesiologist should be available
● For each fetus, two people should be immediately available
for neonatal resuscitation.
PRESENTATION AND POSITION
● Most common presentations at admission for delivery:
○ cephalic–cephalic
○ cephalic–breech (see picture)
○ cephalic–transverse

ANTEPARTUM SURVEILLANCE
● Ultrasound at 10 – 14 weeks (determine chorionicity)
● CAS at 18 – 22 weeks
● Biometry every 4 weeks (to measure the growth); if mono-di
every 2 weeks starting 16 weeks to detect TTTS
● BPS / NST Figure 17. Twin A - the one that is lowest or near the cervix
● Doppler studies in cases of IUGR Twin B - the one is higher
● These presentations, especially those other than cephalic–
INTRAPARTUM SURVEILLANCE cephalic, are unstable before and during labor and delivery
● Timely attendance by a physician competent to manage a ● Compound, face, brow, and footling breech presentations
twin birth are relatively common, especially when the fetuses are
● Assessment of lie and presentation small, amnionic fluid is excessive, or maternal parity is high.
● Blood readily available for use
● Epidural anesthesia is advantageous
● Continuous EFM for both twins
● Active management of the third stage Cephalic–cephalic ● Vaginal (diamniotic)
● CS at 34 weeks
● Assessment of amniotic fluid volume - associated (monoamniotic)
oligohydramnios may indicate uteroplacental pathology
and should prompt further evaluation of fetal well-being. Cephalic-noncephalic (breech ● Vaginal (if EFW of the
● The nonstress test or biophysical profile is commonly or transverse) 2nd twin is 1.5 - 4 kg)
used in management of twin or higher-order multiple ● CS (if cannot do
gestation. breech)
● Doppler evaluation of vascular resistance - Increased ECV may be attempted for the
resistance with diminished diastolic flow velocity often 2nd twin but this is
accompanies restricted fetal growth. operator-dependent and more
associated with fetal distress.
Total breech extraction is

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 associated with lower rates of
CS.
Noncephalic-noncephalic ● Planned CS (Elective
CS at 39 weeks)
SAMPLE CASES
1. Pregnant women with triplet gestation but delivered only a
singleton pregnancy. What is the final score?
2. Which of the ff is the most important predictor of neurological
outcome of the survivor after death of a co-twin?

ANALGESIA AND ANESTHESIA

● Epidural analgesia is recommended by many clinicians
ANSWERS:
because it provides excellent pain relief and can be rapidly
1. G1P1 (1021)
extended cephalad if internal podalic version or cesarean 2. Chorionicity
delivery is required.
VAGINAL DELIVERY REFERENCES
● As in singletons, when the first fetus presents as a breech, ● MDLuna Trans 2018
major problems are most likely to develop if: ● 2021 video lecture
○ Fetus is unusually large and the aftercoming head ● Cunningham, F. G., Leveno, K. J., Bloom, S. L., Spong, C. Y., Dashe,
J. S., Hoffman, B. L., Sheffield, J. S. (2018). Williams obstetrics (25th
is larger than the capacity of the birth canal.
edition.). New York: McGraw-Hill Education.
○ Fetus is sufficiently small so that the extremities
and trunk are delivered through a cervix
inadequately effaced and dilated to allow the head
to escape easily.
○ Umbilical cord prolapses.

VAGINAL DELIVERY OF THE SECOND TWIN

● As soon as the presenting twin has been delivered, the
presenting part of the second twin, its size, and its
relationship to the birth canal should be quickly and carefully
ascertained by combined abdominal, vaginal, and at times
intrauterine examination.

IF THE FETAL HEAD OR THE BREECH IS FIXED IN THE BIRTH

● Moderate fundal pressure is applied and membranes are
ruptured.
● Digital examination of the cervix is repeated to exclude
prolapse of the cord.
● Labor is allowed to resume, and the fetal heart rate is
monitored.
● With reestablishment of labor there is no need to hasten
delivery unless a nonreassuring fetal heart rate or bleeding
develops.
● If contractions do not resume within approximately 10
minutes, dilute oxytocin may be used to stimulate
contractions.
● If the occiput or the breech presents immediately over the
pelvic inlet but is not fixed in the birth canal, the presenting
part can often be guided into the pelvis by one hand in the
vagina while a second hand on the uterine fundus exerts
moderate pressure caudally.
● Alternatively, an assistant can maneuver the presenting part
into the pelvis using ultrasonography for guidance and to
monitor heart rate.
● It is essential to have an obstetrician skilled in intrauterine
fetal manipulation and an anesthesiologist skilled in
providing anesthesia to effectively relax the uterus for
vaginal delivery of a noncephalic second twin to obtain a
favorable outcome.

INTERVAL BETWEEN FIRST AND SECOND TWIN

● The American College of Obstetricians and Gynecologists
(1998) has determined that the interval between delivery of
twins is not critical in determining the outcome of the twin
delivered second.

CESAREAN DELIVERY
● The American College of Obstetricians and Gynecologists
(1998) has concluded that, in general, cesarean delivery is
the method of choice when the first twin is noncephalic.
● It is important that the uterus remain well contracted during
completion of the cesarean delivery and thereafter.

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