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Judi Januadi Endjun

Gatot Soebroto Army Central Hospital/


Medical Faculty, University of Indonesia

ISUOG, Bali, 2009


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AGENDA
Introduction
Etiology of twins
Diagnosis of twins
Vanishing twins
Perinatal loss in twins
Placentation
Complications and Abnormality in twins pregnancy
Conclusion
Take home messages
References

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INTRODUCTION
Definition: any pregnancy in which ≥ 2 embryos or
fetuses occupy the uterus simultaneously
Epidemic of twins: ART, delayed childbearing, and
ovulation induction

USA (2003): 67% twins; 500% triplets and high-


order
The most profound implication: preterm delivery 
infant death
Maryam Tarsa et al. Multifetal gestation and malpresentation. In: Essentials of obstetrics and gynecology, 5 Ed
th

Young Mi Lee et al. Multiple pregnancy. In: Management of High-Risk Pregnancy. An Evidence-based Approach,
2007,304-315
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INTRODUCTION
3.2% of all live births (US 2003) (Natality Data Set, CDC, 1997 – 2002)
± 14 – 25% are IUGR and± 25% require NICU (Mauldin J et
al, 1998; Ettner SL et al, 1997)

Cerebral palsy: 4x (gemelli), 17x (triplet) (Elliott JP et al,


1992; Grether JK et al, 1993)

IUFD: 4x (ACOG, 2004)


The likelihood of not surviving the 1st year of life:
7x (Luke B et al, 1994; Kiely JL et al, 1992)
Twin-specific problems: TTTS, MCMA, conjoined
Maternal complications: preeclampsia, DM: 2 - 3x (Roach
VJ et al, 1998; Sibai BM et al, 2000)

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ETIOLOGY OF TWINS
Depending on the number of eggs fertilized at
conception  monozygotic or dizygotic

Monozygotic: identical, same genetic make up, the


rate is constant throughout the world (1/250
pregnancies), type of placentation (DCDA, MCDA, and
MCMA) and the likelihood of complications.

ART:  monozygotic twins: alter the zona pellucida


around the time of fertilization or delayed blastocyst
implantation
Egan JFX et al. Ultrasound evaluation of multiple pregnancies. In Ultrasonography in obstet
and gynecology. Callen, 5th Ed,2008;266-

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//www.centrus.com.br/DiplomaFMF/SeriesFMF/11-14weeks/chapter-05/images/fig05-01%20copy.jpg
http://www.youtube.com/watch?v=50JO-YtGshw
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http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-14weeks/images-thefetus/gem-04

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Twinning rate (per 1000
pregnancies) in England and
Wales, 1960–1990 for all twins
(diamond markers), dizygotic
twins (square markers) and
monozygotic twins (triangle
markers; adapted from Derom et
al. 1995)

http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-14weeks/chapter-05/images/fig05-0

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DA-DC DA-DC DA-MC MA-MC


Separate Fused Single Single
placentae placentae placentae placentae

Frequency 35% 27% 36% 2%

Mortality 13% 11% 32% 44%


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DIAGNOSIS OF TWINS
Anamnesis: risk factors
Physical examination: difficult
ULTRASOUND: should begin with a complete
imaging sweep of the uterus

FIRST TRIMESTER ULTRASOUND: number of GS


and embryo, location of placenta, dividing membrane,
AF, YS, and FHR  determine chorionicity 
potential complications

Egan JFX et al. Ultrasound evaluation of multiple pregnancies. In Ultrasonography in obste


and gynecology. Callen, 5th Ed, 2008;266-2
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ULTRASOUND IN TWIN
There is good evidence that the diagnosis of twin
gestation is improved by the routine use of
ultrasound.

There is consensus that serial ultrasonographic


evaluation every three to four weeks is indicated in
twin gestations. (I B)
SOGC, Management of twin pregnancy (Part 1), July, 2000

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ULTRASOUND IN TWIN
Fetal growth differs slightly in twin gestations
and twin specific charts may be used to define
the normal growth rate.

Precision may also be obtained by using sex


and race specific charts.

In clinical practice, however, these differences


are small and singleton growth curves may be
used.
SOGC, Management of twin pregnancy (Part 1), July, 200
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ULTRASOUND IN TWIN
Patterns of fetal growth are more important
than absolute measurements.

Both must be interpreted in the light of the


clinical history, together with all the genetic
and environmental factors that may affect
fetal growth. (III B)
SOGC, Management of twin pregnancy (Part 1), July, 200

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ULTRASOUND IN TWIN
The diagnosis of discordance has been based
on the following:

AC difference of 20 mm (sensitivity of 80%,


specificity 85%, PPV 62%)

EFW based on BPD and AC or AC and FL > 20 %


(sensitivity 25-55%) (II-2 B)

SOGC, Management of twin pregnancy (Part 1), July, 200


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1 TRIMESTER
ST

ULTRASOUND
 Every effort should be made to determine chorionicity
at
the time of diagnosis. (II-3 C)

 The optimal time to determine chorionicity is 10-14


weeks. (II-3 C)

 While these recommendations apply to diagnosis of


twin
pregnancy with regard to prenatal diagnosis and
counseling, there have been no studies relating the
establishment of prenatal chorionicity to pregnancy
outcome. SOGC, Management of twin pregnancy (Part 1), July, 20

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VANISHING TWINS
EARLY INTERMEDIATE LATE
(< 8 weeks) (> 8 and < 22 (> 22 weeks)
weeks)

Delivery < 32 W 1.9% 5.3% 21.4%


NICU > 28 days 8.7% 15.7% 43.8%
Neurodevelopment 3.3% 8.0% 9.7%
disorders

Pregnancy Comparable with


outcome singletons

Egan JFX et al. Ultrasound evaluation of multiple pregnancies. In Ultrasonography in obstet


and gynecology. Callen, 5th Ed,2008;266-2
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PERINATAL LOSS IN
TWINS
IMR: > 5 x = 32.9/1000 live-born twins (USA, 1999)
Survival depends on chorionicity: anomalies, growth
problems & prematurity
Cumulative loss rate: 3% dichorionic & 15% monochorionic
(Sabire et al, 1997)
Losses are more likely to occur between 16 – 22 W 
ultrasound examination every 1 – 2 W to screen TTTS
Fetal demise of one twin, cerebral palsy
Maternal complications: preeclampsia, GDM

Egan JFX et al. Ultrasound evaluation of multiple pregnancies. In Ultrasonography in obstet


and gynecology. Callen, 5th Ed,2008;266-2
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TWINS DISCORDANT
In twins discordant for abnormality, the option of
selective reduction should be offered.

The procedure should be performed in a tertiary


level center.

Transportation and out-of-province costs should be


covered.
SOGC, Management of twin pregnancy (Part 1), July, 20

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PLACENTATION
The most important is the identification of
chorionicity

Ultrasound is very useful in determining


placentation (chorionicity and amnionicity) and are
very important in predicting twin pregnancy
complications

Egan JFX et al. Ultrasound evaluation of multiple pregnancies. In Ultrasonography in obstet


and gynecology. Callen, 5th Ed,2008;266-2

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PLACENTATION
Chorionicity and amnionicity
First, second and third trimester
Membrane insertion, “twin-peak” sign
Membrane thickness
Membrane layers
Multiple sonographic markers to determine
chorionicity and amnionicity
Monoamniotic twins
Egan JFX et al. Ultrasound evaluation of multiple pregnancies. In Ultrasonography in obstet
and gynecology. Callen, 5th Ed,2008;266-2

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Sonographic determination of chorionicity
and amnionicity in first trimester twins
gestations
PlacentationGestational Yolk Sacs Embryos / Amniotic
Sacs Sac Cavities

DC, DA 2 2 1 2

MC, DA 1* 2 2* 2

MC, MA 1* 1 or partially 2* 1
divided*

* Amnionicity cannot be determined by this finding

Egan JFX et al. Ultrasound evaluation of multiple pregnancies. In Ultrasonography in obstetr


and gynecology. Callen, 5th Ed,2008;266-2
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CONJOINED TWINS
MC, MA twins
Embryo divides at 13 to 15 days from conception
The two fetal poles may be attached at varying sites (Early
ultrasound finding: bifid appearing fetal pole)
Visualizing in the same relative position in all views
Direct opposition of the twins from each other
Extreme extension of the fetal spine
Inseparable skin contour must be persistent
Prognosis: very poor

Egan JFX et al. Ultrasound evaluation of multiple pregnancies. In Ultrasonography in obstet


and gynecology. Callen, 5th Ed,2008;266-2
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Sumber: Dr. dr. Adityawarman, SpOG(K

Adapted from: Romero, R., Pilu, G., Jeanty, P., Ghidini, A. and Hobbins, J.C.(1988).
Prenatal Diagnosis of Congenital Anomalies, p 405. ( courtesy from Philippe Jeant
www.thefetus.net )
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Ectoparasitic twins are parts of
twins
implanted in another fetus.

In this case what appears to be


an omphalocele on the left is a
fetal abdomen with lower legs
on the extreme left.
(Courtesy Glynis Sack, MD,
www.TheFetus.net)

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TWIN TO TWIN
TRANSFUSION SYNDROME
MC twin  placental vascular anastamoses
communication of the two fetoplacental
circulations; may be arterio–arterial, veno–
venous, or arterio–venous in nature (Benirschke K. Twin
placenta in perinatal mortality. N Y St J Med 1961;61:1499–508)

This phenomenon of a shared circulation between


monochorionic twins was first described by Schatz
in 1882 (Schatz F. Eine besondere Art von einseitiger Polyhydramnie
mit anderseitiger Oligohydramnie bei eineiigen Zwillingen. Arch Gynakol
1882;19:329)
http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-14weeks/chapter-05/chapter-05-final.

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TWIN TO TWIN
TRANSFUSION SYNDROME
Anatomical studies arterio–venous anastomoses
are deep in the placenta but almost always proceed
through the cotyledonary capillary bed (Benirschke K,
Kim CK. Multiple pregnancy. N Eng J Med 1973;288:1276–84)

± 25% of MC twins  imbalance in the net flow of


blood across the placental vascular arterio–venous
communications from one fetus, the donor, to the
other, the recipient, twin-to-twin transfusion
syndrome; ± 50% of these casessevere twin-to-
twin transfusion syndrome acute polyhydramnios
in the second trimester
http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-14weeks/chapter-05/chapter-05-final.
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NEJM, July, 2004

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Staging of twin to twin transfusion syndrome,
Quintero RA et al, 1999
Stage Amniotic Fetal MCA Hydrops Fetal
Fluid Bladder Doppler, Demise
UA or UV
I D: oligo Normal Normal No No
R: poly
II As above D: bladder Normal No No
not seen

III As above As above Abnormal No No


IV As above As above Abnormal Yes, either No
twin

V As above As above Abnormal Yes, either Yes, either


twin twin
Egan JFX et al. Ultrasound evaluation of multiple pregnancies. In Ultrasonography in obstetr
and gynecology. Callen, 5th Ed,2008;266-2

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Twin reversed arterial
perfusion sequence
(TRAP)
The most extreme manifestation of TTTS ± 1%
of MC twin  is acardiac twinning (acardius
chorioangiopagus parasiticus).

The underlying mechanism is thought to be


disruption of normal vascular perfusion and
development of one twin (the recipient) due to an
umbilical arterio–arterio anastomosis with the
other (donor or pump) twin (Van Allen MI, Smith DW, Shepard TH. Twin reversed
arterial perfusion (TRAP) sequence: study of 14 twin pregnancies with acardius. Semin Perinatol 1983;7:285–93)

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Twin reversed arterial
perfusion sequence
(TRAP)
At least 50% of donor twins die due to
congestive heart failure or severe preterm
delivery, the consequence of
polyhydramnios50,51.

All perfused twins die due to the


associated multiple malformations.
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GENETIC TESTING
All women carrying twin pregnancies should
be referred for counseling to a centre for the
consideration of invasive testing at age 32.

The counseling must be individualized and


the final decision must be taken by the
parents since the risk of amniocentesis is
uncertain in twin gestation. (II-3 C)

SOGC, Management of twin pregnancy (Part 1), July, 20

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GENETIC SCREENING
Biochemical screening for aneuploidy is not
recommended in twins.

MS-AFP is useful for detection of open neural tube and


other birth defects. (II-3 C)

Evidence is promising that NT screening is useful for


identifying twin pregnancies at high risk of aneuploidy.

 This requires further prospective investigation. (II-3 C)

SOGC, Management of twin pregnancy (Part 1), July, 20


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INVASIVE GENETIC
TESTING
The fetal loss rates with invasive testing (amniocentesis
and CVS in twins are unclear. (II-3 C)

Development of a protocol for standardization of technique (as


determined by expert opinion) is recommended.

Invasive testing should be offered to twins according to


the usual standard of care.

SOGC, Management of twin pregnancy (Part 1), July, 20


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PRETERM BIRTH
PREVENTION
Routine hospitalization for bed rest in multiple gestation is not
recommended. (I E)
There is insufficient evidence to support prophylactic activity
restriction or work leave in multiple gestation. (III C)
There is moderate evidence against routine prophylactic cervical
cerclage in multiple gestation.
However, cerclage maybe indicated for the treatment of
incompetent cervix or other specific circumstances. (I;II-2 D)

SOGC, Management of twin pregnancy (Part 1), July, 20

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PROPHYLACTIC
TOCOLYSIS
There is moderate evidence against

prophylactic tocolysis in the management of


multiple gestation, but it may be indicated on
other grounds. (I;II-2 D)
SOGC, Management of twin pregnancy (Part 1), July, 2000

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ROUTINE CLINICAL CERVICAL
EXAMINATION
There is good evidence that premature cervical change
by digital examination predicts preterm birth in twins. (II-
2 A)

Since there are no well designed intervention trials


available, the role of sonographic clinical cervical
assessment in the prenatal period has not been
determined. (C) SOGC, Management of twin pregnancy (Part 1), July, 2000

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SONOGRAPHIC CERVICAL
ASSESSMENT
There is good evidence that transvaginal
sonographic measurement of cervical length
predicts preterm birth in twins. (II-1 A)

While the predictive ability of cervical length


measurement is established, there are no
intervention studies that have evaluated cervical
length measurement in the prevention of preterm
birth, and therefore the role of sonographic clinical
cervical assessment in theSOGC, prenatal period has not
Management of twin pregnancy (Part 1), July, 2000

been determined. (C)PENDIDIKAN DAN


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Risk of preterm delivery
using cervical length at 23
weeks (Heath et al 1998)

Cx LR
5 mm 52

10 mm 9,1

15 mm 2,7

20 mm 1,2
25 mm 0,7

30 mm 0,5

40 mm 0,5

50 mm 0,4

60 mm 0,1
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FETAL FIBRONECTIN
There is good evidence that the presence of

cervicovaginal fetal fibronectin in twins predicts


preterm birth.

Without well designed intervention trials available,

there is no basis for incorporating fetal fibronectin


screening into routine prenatal management of
SOGC, Management of twin pregnancy (Part 1), July, 200
multiple gestation. (C)
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ULTRASOUND
MANAGEMENT
a. Performed in 1st trimester: number, amnionicity,
chorionicity, and NT (10 – 14 W)

b. Detailed US examination: 18 – 20 W, fetal gender,


number of placenta, the thickness and number of layers in membrane,
and lambda (twin peak) sign

c. Dichorionic pregnancy: fetal growth (FG) evaluation every 3


– 4 W (if FG and AFV normal)

d. Monochorionic diamniotic: evaluation every 2 – 3 W,


TTTS,
Young Mi fetal
Lee et al. echocardiography
Multiple pregnancy. In: Management of High-Risk Pregnancy. An Evidence-based Approach, 2007,30

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ULTRASOUND
MANAGEMENT
e. Dichorionic or monochorionic: if IUGR,
discordant fetal growth, discordant AFV NST,
Biophysical Profile, Doppler studies

f. Monoamniotic: daily NST starting from 24 – 26 W


(risk of sudden IUFD from cord entanglement) 
variable deceleration  delivery?

Young Mi Lee et al. Multiple pregnancy. In: Management of High-Risk Pregnancy. An Evidence-based Approach, 2007,30

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umulative fetal loss rates in monochorionic (solid line) and Gestational age distribution at delivery of monochorionic (solid bars) and
chorionic (dashed line) twin pregnancies, from 12 weeks of gestation20
dichorionic (open bars) twin pregnancies. The proportion of pregnancies
delivering very preterm (before 32 weeks) is considerably higher in
monochorionic compared to dichorionic twins20

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http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-14weeks/chapter-05/chapter-05-final.h
ELECTIVE CAESAREAN
SECTION
The indications for elective Caesarean section
in twin gestations are:
a) Monoamniotic twins because the risk of
entrapment is too great to permit elective vaginal
delivery;

b) Conjoined twins other than at gestations remote


from term;

c) Indications as for singleton pregnancies. (III C)


SOGC, Management of twin pregnancy (Part 1), July, 2000

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CASE REPORT
Mrs I, 34 year, G1P0A0 20 weeks, dizygotic
twin pregnancy (28-03-2008)
Fetus: gemelli, breech-breech presentation,
boy and girl, no major anomaly seen
Placenta: normal, two placenta at right and
left side of the uterus
Amniotic fluid: normal, amniotic membrane
(+)
Biometry: equal to 19 weeks, EFW 1: 332 gr
and EFW 2: 338 gr
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CONCLUSIONS
ART and delayed childbearing increase multiple
pregnancy
High perinatal morbidity and mortality rates
Early diagnosis and serial ultrasound studies are
important on maternal and neonatal outcomes

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TAKE HOME MESSAGES
a. Diagnose the twin pregnancy (ultrasound !)
b. Determination of zygosity: !! Conjoined twins
c. Screening for fetal anomaly and growth
disturbances
d. When the best time to delivery?
e. Confident diagnosis of zygosity may require
detailed examination of the placenta after
delivery

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REFERENCES
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b. Young Mi Lee et al. Multiple pregnancy. In:


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