A PROJECT ON TWIN DEFORMITIES

Submitted to

AISSCE BIOLOGY PRACTICAL EXAMINATION

2023-2024

By

SUSRUDHAN S

GRADE-XII

DEPARTMENT OF BIOLOGY,

VELALAR VIDYALAYAA SENIOR SECONDARY SCHOOL,

MARUTHI NAGAR, THINDAL, ERODE-638012.

 VELALAR VIDYALAYAA SENIOR SECONDARY SCHOOL
ERODE-638012

CERTIFICATE

This is to certify that Master Susrudhan S , student of class XII, VelalarVidyalayaa Senior
Secondary School, Erode, has successfully completed the project titled “TWIN
DEFORMITIES” during the academic year 2023-2024 towards partial fulfillment of credit for
the Biology Practical evaluation of AISSCE-2023-2024 under my supervison.

Mr. A.VASUKUMAR,
Department of Biology,
VelalarVidyalayaa Sr. Sec. School,
School Seal Erode-638012.

Name of the Candidate : __________________________

Register Number : __________________________
Examination Centre : VelalarVidyalayaa Senior Secondary School, Erode.
Date of Practical Examination: __________________________
 Internal Examiner Principal External Examiner

ACKNOWLEDGEMENT

Gratitude is the deep perception which makes thread flow from one’s inner heart. I owe my

profound sense of gratitude to Mr. S.D. CHANDRASEKAR, Secretary, Vellalar Educational

Trust, Erode, Mr. R. NALLAPPAN, Senior Principal and Mrs. V. PRIYADHARSHINI,

Principal VelalarVidyalayaa Senior Secondary School, Erode, for their kind patronage and

facilities offered.

I expressed my whole hearted thanks to the faculty guide of Mr.A.VASUKUMAR who gave his

valuable suggestion which helped me in successful completion of the project.

My vocabulary falls short of right words to express my immense debts to my parents who were

the source of my will power and strength for my entire endeavor.

 Twin
deform
ities
TWIN DEFORMITY
Introduction

 In the last years, in relation to modernization of societies and consequent advanced

parental age, we assisted to a progressive falling in fertility rate. Actually, in more
developed nations, about one in six couples is infertile with a reported prevalence of
infertility 12.5% among women and 10.1% among men. Thus, more than half of these
subjects need medically assisted reproduction consisting of hormonal treatments and
assisted reproductive technology (ART), along with a reported certain reluctance to
talking about conceiving their children using medical or professional help.

 Twin pregnancies in India complicates 1% of pregnancies and are the cause of 10%
perinatal mortality.

 The rate of twinning continues to increase due to the combined effect of a rise in parental
age, urban residence and increased use of assisted reproductive technology. The risk of
congenital anomalies in twins is higher than in singletons, but it is less well reported in
relation to growth patterns. The auxological outcome of twin pregnancies when one or
both of twins are affected by one or more malformations.

 Fraternal and identical twins can be affected by pregnancy complications, and subsequent
birth defects.One of the most common issues is that twins are very often delivered
preterm, often due to premature rupture of the membranes. While most mother give birth
to healthy babies, there may be problems that lead to improper development of one or
both the fetuses. This increases the chance of twins being born with birth defects.

 TheART techniques including ovulation induction with or without IUI are associated
with a risk of multiple pregnancy of 8–10%. This increases up to 30% with IVF and two
blastocyst transfereffects by 50%.

Definition of Twins
Twins refer to the two offspring that are brought forth by the same pregnancy and birth. Twins
may be monozygotic (or identical) or dizygotic (fraternal).

Prevalence

 The prevalence of multiple gestation globally at present is 32 per 1000 deliveries. Recent
studies from India report an incidence of 30.5 per 1000 deliveries.
 Kodinhi- twin city in India,about 150km from Kochi, the village is home to 2,000 families.
And there are at least 400 pairs of twins or more among those families, as of 2017. But the
reason is still a mystery.

Classification of twins

Twins may be classified according to the degree of separation in utero: (1) dichorionic-
diamniotic twins, (2) monochrorionic-diamniotic twins, (3) monochorionic-monoamniotic twins,
and (4) conjoined twins.

1.Monozygotic twins

The National Library of Medicine says that monozygotic, or identical, twins are conceived from
one fertilized egg. This egg separates into two embryos after it has begun to divide. These two
embryos develop into two babies.

Genetic materials called chromosomes in both babies are completely identical. This is because
both babies come from the same egg and sperm. For this reason, both children are assigned the
same sex at birth and share the same genetic characteristics, such as eye and hair color.

Still, because of differences in the environment where they’re born (like the amount of space
each had in the uterus), identical twins may have slight differences in appearance.

In monochorionic-diamniotic twins, the twins share the same placenta and (mostly) are
diamniotic, i.e. having two amniotic sacs. This is common in monozygotic twins (i.e. 60-70%).

2.Dizygotic twins/ Non identical/ Fraternal

Not all twins are identical, of course. More often than not, twins are born with unique physical
characteristics. Nonidentical twins are generally known as fraternal twins.
The scientific term for fraternal twins — “dizygotic” — refers to two fertilized eggs. Dizygotic
twins happen when the birthing parent’s body releases two eggs at the same time. A different
sperm will fertilize each egg.

Since fraternal twins are the result of different eggs and different sperm, they share the same
percentage of chromosomes as any other siblings. The National Human Genome Research
InstituteTrusted Source says that this is about 50 percent. This is why they don’t look exactly
alike and can be assigned different sexes at birth.

In dichorionic-diamniotic twins, the twins have separate chorions and amniotic sacs (hence, the
name). This is very common among dizygotic twins. This type also has the lowest mortality risk.

3. In monochorionic-monoamniotic twins, the twins share the same chorion and amniotic sac in
utero.

4. In conjoined twins, the identical twins are joined in utero and share one common chorion,
placenta, and amniotic sac.

Figure 1. Classification of twins and Conjoined twins

Twin deformity

A birth defect or deformity or anomaly is a medical term meaning irregular or different from
normal. Anomalies occur more frequently in identical twins than in other pregnancies.
Risk factors for twin deformities

 Genetic cause.

 Environmental causes.

 Maternal age-25-35 yrs.

 ART -assisted reproductive technology

TheART techniques including ovulation induction with or without IUI are associated
with a risk of multiple pregnancy of 8–10%. This increases up to 30% with IVF and two
blastocyst transfer effects by 50%.

 The first order born twin has the higher risk of birth defects.

 Monozygotic (MZ) twins are at an increased risk of birth defects compared to both
singletons and dizygotic (DZ) twins.

 Approximately 25% of congenital anomalies are attributed to chromosomal abnormalities

Causes for twin deformities

Fetal Factors

 Infection, chromosomal anomaly, structural anomaly, cord anomaly (entanglement,

velamentous), and placental [twin-to-twin transfusion syndrome (TTTS), selective
intrauterine growth retardation].

Maternal Factors

 Hypertensive disorders (i.e., preeclampsia), thrombophilia, and abruption placenta.

  Chorionicityis an important factor in the rate and outcome of SIUFD(Single intrauterine
fetal death)with monochorionic pregnancies having a much higher rate compared with
dichorionic pregnancies.One of the main reasons for this is the presence of a
communicating placental circulation and the potential risk of TTTS in monochorionic
pregnancies.

 Twins without TTTS, the presence of superficial arterio-arterial (AA) anastomosis or

veno-venous (VV) anastomosis had a higher incidence of intrauterine death, fetal anemia,
and neurological handicap. It is hypothesized that these AA/VV anastomoses allow a
relatively rapid transfer of blood from the live fetus to the dead fetus, causing
neurological damage or fetal demise.

Twin deformity

1.Birth weight defects

It is common for twins to be a little underweight compared to babies from singleton pregnancies.
This is because they are born premature or before the entire pregnancy term is finished. Since a
fetus mainly gains weight in the last trimester of pregnancy, in the case of preterm twins the
babies do not get the opportunity to gain weight before birth.

Babies will increase in weight soon after birth, but those born before 32 weeks and weighing less
than 3.3 pounds are at increased risk for long term problems. Such problems include blindness,
hearing loss, mental retardation and cerebral palsy.
Figure 2. The one baby is normal and another baby is having microcephaly, Decreased
weight

2. Chromosomal anomalies

Figure 3. Trisomy 21-Down syndrome/ Trisomy 18

3. Genital and urinary defects

A study conducted by the University of Florida’s Maternal Child Health Education Research and
Data Center, found that boys were at a 29% higher risk of developing birth defects in pairs of
opposite sex twins.

The boys were two times more likely to be born with defects affecting their genitals and urinary
organs than the girls. Researchers believe this is because boys develop at a slower pace in the
womb as compared to girls. They believe that if the baby is further ahead in development it
would be protected against certain birth defects.

Examples of Genitourinary defects

 Cryptorchidism and hypospadias

 Renal cortical necrosis
 Unilateral damage of the kidney
 Figure 4. Cryptorchidism and hypospadias

4. Muscular skeletal system

a. Congenital hip dislocation

The same study by researchers at the University of Florida also found that boys were five times
more likely to be born with an obstruction between the stomach and the small intestine.
However, a common birth defect in twin is congenital hip dislocation. Researchers computed
that girl were ten times more likely to end up with congenital hip dislocation than boys.

This condition has an abnormal hip joint wherein the ball at the top of the thigh bone, is not
stable within the socket which is supposed to hold it. This often causes the ball and socket joint
to dislocate at the time of birth. The ligaments on the hip are stretched or loosened due to this
dysplasia.
 b. Club foot

One hypoplastic ventral pair of legs without any spontaneous movements and one normally
developed dorsal pair of legs with spontaneous movements) as well as a pes equinovarus of the
right foot and an imperforate anus.

Figure 6. Club foot

5. Twin to twin transfusion syndrome

Identical twins who share a single placenta but have two separate amniotic sacs are called
monochorionic twins. The shared placenta connects the blood supply of the twins, allowing the
flow of blood between them.
In case there is unequal blood supply, the twins will develop at different rates. This can lead to a
condition where the smaller twin pumps blood to the larger twin. It is called twin to twin
transfusion syndrome (TTTS).

Figure 7.Twin to twin transfusion syndrome

6. Twin reversed arterial perfusion (TRAP) sequence

This uncommon condition, also termed Acardiac Twinning, affects less than 1% of
monochorionic twin pregnancies. In this condition, one twin develops with an abnormally
functioning heart. It may also be missing other organs such as the head or limbs. The acardiac
twin receives all its blood supply from the healthy twin as they are sharing umbilical artieres via
the placenta.

This places pressure on the healthy twin’s heart, putting it at risk of heart failure and even death.
The survival rate for the healthy twin is 25-50% if the TRAP sequence is not treated in time. The
condition can be identified by a simple ultrasound and will require prenatal care of the healthy
twin to reduce the risk of heart failure. Unfortunately, the acardiac twin will not survive.
Figure 8. Twin reversed arterial perfusion (TRAP) sequence

7. Congenital heart defects

Twins are more likely to develop a congenital heart defect than babies from singleton
pregnancies. Congenital heart defects are the most common form of birth defect and there has
been a have reduced mortality due to them in recent years. The term actually refers to a number
of different defects that may affect the heart, which are classified as cyanotic and non-cyanotic.

1. Cyanotic defects are easily identifiable based on the blue skin colour of the baby caused
due to the lack of oxygen.
2. Non-cyanotic defects may be tougher to identify at birth as they may not have any
obvious physical symptoms.
Figure 9. Conjoined twin girls who shared part of their livers and heart

8. Conjoined twins

Heterophagus twins are asymmetrical conjoined monochorionic-monoamniotic twins often

named “parasitic twins”. They have an estimated incidence of less than one per one million
live births [1] and represent only 1 to 2% of all conjoined twins [2]. The term “heteropagus”
describes a situation in which one of the twins has a mostly intact body that is able to survive and
is referred to as “autosite”, whilst the counterpart twin, referred to as “parasite”, is only
rudimentarily developed, physically attached to and nourished by the autosite. The fusion point
of heteropagus twins appears to be always in one of the same sites as of the more common
symmetrical or “complete” conjoined twins

Figure 10. Heterophagus twin with omphalopagus and ompahlocele.

Figure 11. Types of Conjoined twins

9. Gastro intestinal system

 Gastrointestinal (duodenal atresia)

 Congenital obstruction of small intestine, gastroschisis, and omphalocele.

Figure 12. Abdominal wall defects.

10. Central nervous system

Anencephaly, microcephaly, hydrocephaly, neural tube defects, limb reduction anomalies,

craniopagus twins). Decreased head circumference (Microcephaly) have in many of the
malformed twins

Figure 13. Neural tube defects/ Anencephaly/hydrocephly

11. Ocular Defects

Congenital glaucoma, optic nerve hypoplasiaand diaphragmatic hernia.

Figure 14. Congenital diaphragmatic hernia

12. Death of one fetus (Fetus papyraceous)

Outcome of twin pregnancy

 Preterm labor/birth
 Low birth weight and infant mortality.
 Single intra uterine fetal death

Investigation

Mothers are monitored by doing

 All routine antenatal investigations, coagulation profile, fibrin degradation products

(FDP), and D-dimer.
  Determination of chorionicity, particularly in the first trimester, is crucial. Subsequent
ultrasound scans serve to detect fetal anomalies and assess fetal growth and liquor
volume.

 These measurements are complemented by regular nonstress testing, biophysical

profiling, and Doppler ultrasonographic studies. Cranial sonography, if necessary, by the
transvaginal route, may provide additional information.

 Fetal monitoring was done by daily fetal movement count, biweekly nonstress test (if
more than 32 weeks).

 Chromosomal abnormalities can be diagnosed by karyotyping using chorionic villus or

amniotic fluid, prenatally, or peripheral blood, postnatally. Most of these tests are offered
in case of abnormal clinical findings

Treatment

1. Although there is high prenatal and postnatal mortality, successful separation has
become more common due to advances and improvements in neuroimaging, neuro-
anesthesia, and neurosurgical techniques.

2. There is a higher risk of preterm birth in twin pregnancies with SIUFD (Single
intrauterine fetal demise), so steroids should be administered <34 weeks to induce lung
maturity. Most studies favor conservative management until 37 weeks’ gestation, if fetal
movements, cardiotocography, and USG show no abnormalities. If there are no other
obstetric causes, delivery of dichorionic twin pregnancies with single fetus demise is not
recommended before the 38th week.

3. All twin pregnancies with one dead fetus should be managed in tertiary referral centers
with sufficient neonatal support. Intensive fetal surveillance is required and the
determination of chorionicity should be done early in the pregnancy.

4. A detailed study of the anatomic features by clinical examination and with the use of
different imaging modalities is mandatory for the surgical planning and several surgical
reconstructive steps had to be performed by a multidisciplinary team over the first years
 of life. Ultimately, however, there is an improvement in quality of life considerably and it
is likely that these children will be able to live an independent life in the future.

Prevention

1. Regular antenatal checkup.

2. Follow the regular investigations.
3. Creating awareness among the women’s/ parents regarding the twin’s outcome and
treatment.
4. Taking folic acid, reducing zinc deficiency prevent the neural tube defects.
5. Genetic counselling

Conclusion

 Use of fertility treatments has been considered the primary reason for the observed
increase in twinning, few studies have examined the impact of use of fertility treatment
on twins’ risk of birth defects.
 Twin pregnancies with congenital malformations in foetuses is associated with higher
morbidity and mortality both for the mother as well as the child Its incidence is 4 times
more common than single births.
 The clinicians can assist in counselling women on the risk of birth defects associated with
a twin pregnancy.
 Increased risk for a number of specific defects were observed in multiple, including
anencephaly,hydrocephalus, tetralogy of Fallot, pulmonary valve stenosis, coarctation of
the aorta,cleft lip with or without cleft palate,oesophageal atresia with or without
tracheoesophageal fistula,anorectal atresia, and hypospadias.
 All twin pregnancies with one dead fetus should be managed in tertiary referral centers
with sufficient neonatal support. Intensive fetal surveillance is required and the
determination of chorionicity should be done early in the pregnancy.
 Using valproic acid to treat epilepsy during pregnancy, obesity, zinc defciency,
hyperthermia, and folate defciency are all predisposing factors for neural tube defects.

References
1. https://www.imedpub.com/articles/hypospadias-and-associate-malformations-in-twins-
a-clinical-case.php?aid=22017
2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5299593/
3. Twinning_rates_in_Chennai,_India___A.35 (1).pdf
4. https://www.cntraveller.in/story/village-kerala-kodinhi-400-pairs-twins-no-one-knows/
5. https://www.babymed.com/monozygotic-dizygotic-monochorionic-dichorionic-twins
6. GROWETH PAATERNS AND ASSOCIATED RISK FACCTORS IN TWINS ITALIAN JOURNAL OF
PEDIATRICS 2020.pdf
7. https://doi.org/10.1016/B978-0-12-803239-8.00009-0
8. https://www.jsafog.com/abstractArticleContentBrowse/JSAFOG/25050/JPJ/fullText
9. BIRTH ANPOMOALEIES IN TWIN PREGANNCIES 2020 KASTHURI KSHITIJA.pdf
10. common aneuploidy in twin pregnancies 2022.pdf
11. global prevvalence- Nader salari 2022.pdf