Judi Januadi Endjun: Gatot Soebroto Army Central Hospital/ Medical Faculty, University of Indonesia ISUOG, Bali, 2009

Judi Januadi Endjun
Gatot Soebroto Army Central Hospital/

Medical Faculty, University of Indonesia
ISUOG, Bali, 2009
JJE-20091119
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KESEHATAN
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 highorder

The most profound implication: preterm delivery
Maryam
Tarsa et al. Multifetal gestation and malpresentation. In: Essentials of obstetrics and gynecolog
infant
death
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
VJ et al, 1998; Sibai BM et al, 2000)
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(Roach
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 obstetrics
and gynecology. Callen, 5th Ed,2008;266-296)
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http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-14weeks/chapter-05/images/fig05-01%
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http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-14weeks/chapter-05/images/fig05-01%20copy.jpg
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http://www.youtube.com/watch?v=50JO-YtGshw
http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-14weeks/images-thefetus/ge
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Twinning rate (per 1000

pregnancies) in England and
Wales, 19601990 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/fig
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http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-14weeks/chapter-05/images/fig0
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http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-14weeks/images-thefetus/ge
DA-DC
Separate
placentae
DA-DC
Fused
placentae
DA-MC
Single
placentae
MA-MC
Single
placentae
Frequenc
y
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
and gynecology. Callen, 5th Ed, 2008;266-296)
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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, 20
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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.
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SOGC, Management of twin pregnancy (Part 1), July,

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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)
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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)
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1ST TRIMESTER
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.
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http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-14weeks/images-centrus/gem-dicor-
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http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-14weeks/images-centrus/gem-mo
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VANISHING TWINS
EARLY
(< 8 weeks)
INTERMEDIAT
E
(> 8 and < 22
weeks)
Delivery < 32 W
1.9%
5.3%
21.4%
NICU > 28 days
8.7%
15.7%
43.8%
Neurodevelopmen
t disorders
3.3%
8.0%
9.7%
Pregnancy
outcome
LATE
(> 22 weeks)
Comparable
with singletons
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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
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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.
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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

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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
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Sonographic determination of chorionicity

and amnionicity in first trimester twins
gestations
Placentatio Gestationa
n
l Sacs
Yolk Sacs
Embryos /
Sac
Amniotic
Cavities
DC, DA
MC, DA
1*
2*
MC, MA
1*
1 or partially 2*
divided*
* Amnionicity cannot be determined by this finding

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http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-14weeks/chapter-05/images/fig05-04b
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http://www.youtube.com/watch?v=PN3e7nyE
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http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-14weeks/images-thefetus/co
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
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Sumber: Dr. dr. Adityawarman, SpOG(
Adapted from: Romero, R., Pilu, G., Jeanty, P., Ghidini, A. and Hobbins, J.C.(19
Prenatal Diagnosis of Congenital Anomalies, p 405. ( courtesy from Philippe
www.thefetus.net )
http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-14weeks/images-thefetus/co
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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)
http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-14weeks/images-thefetus/ecto-pa
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TWIN TO TWIN
TRANSFUSION SYNDROME
MC twin placental vascular anastamoses
communication of the two fetoplacental
circulations; may bearterioarterial, veno
venous, or arteriovenous in nature (Benirschke K. Twin
placenta in perinatal mortality. N Y St J Med 1961;61:1499508)
This phenomenon of ashared circulation between
monochorionic twins was first described by Schatz

in1882 (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-
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TWIN TO TWIN
TRANSFUSION SYNDROME
Anatomical studies arteriovenous 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;288:127684)
25% of MC twins imbalance in the net flow of
blood across the placental vascular arteriovenous

communications from one fetus, the donor, to the
other, the recipient, twin-to-twin transfusion
syndrome; 50% of these casessevere twin-to-twin
transfusion syndrome acute polyhydramnios in the
second trimester
http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-14weeks/chapter-05/chapter-05JJE-20091119

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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
Fluid
Fetal
Bladder
MCA
Hydrops
Doppler,
UA or UV
Fetal
Demise
D: oligo
R: poly
Normal
Normal
No
No
II
As above
D:
bladder
not seen
Normal
No
No
III
As above
As above
Abnormal
No
No
IV
As above
As above
Abnormal
Yes, either No
twin
As above
As above
Abnormal
Yes, either Yes, either

twin
twin

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Twin reversed arterial

perfusion
sequence
The most extreme manifestation of TTTS 1%
(TRAP)
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 arterioarterio 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;7:28593)
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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.
http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-14weeks/chapter-05/chapter-05-
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http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-14weeks/images-thefetus/tr
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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)
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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)

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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.

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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)

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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)
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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)
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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 the prenatal
period
has(Partnot
SOGC, Management
of twin pregnancy
1), July, 20
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been determined.
(C)PENDIDIKAN DAN
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http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-14weeks/images-thefetus/incom-cervical/cx-d
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http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-14weeks/images-thefetus/incom-cervical/cx-d
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Risk of preterm delivery

using cervical length at 23
weeks
Cx
5 mm
LR
52
(Heath et al 1998)
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 multiple gestation. (C)

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http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-14weeks/images-centrus/gemelar/g
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ULTRASOUND
MANAGEMENT
Performed in 1 trimester:
st
number, amnionicity,
chorionicity, and NT (10 14 W)
Detailed US examination:
18 20 W, fetal gender,
number of placenta, the thickness and number of layers in membrane,

and lambda (twin peak) sign
Dichorionic pregnancy:
fetal growth (FG) evaluation every 3
4 W (if FG and AFV normal)
Monochorionic diamniotic:
evaluation every 2 3 W,
TTTS, fetal echocardiography
Young Mi Lee et al. Multiple pregnancy. In: Management of High-Risk Pregnancy. An Evidence-based Approach, 2
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ULTRASOUND
MANAGEMENT
Dichorionic or monochorionic: if IUGR,
discordant fetal growth, discordant AFV NST,
Biophysical Profile, Doppler studies
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, 2
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Cumulative fetal loss rates in monochorionic (solid line) and

Gestational age distribution at delivery of monochorionic (solid bars) an
dichorionic (dashed line) twin pregnancies, from 12 weeks of gestation20
dichorionic (open bars) twin pregnancies. The proportion of pregnancie
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-fi
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)

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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

Diagnose the twin pregnancy (ultrasound !)
Determination of zygosity: !! Conjoined twins
Screening for fetal anomaly and growth
disturbances
When the best time to delivery?
Confident diagnosis of zygosity may require
detailed examination of the placenta after
delivery
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REFERENCES
Tarsa M, Moore TR. Multifetal gestation and
malpresentation. In: Essentials of obstetrics and

gynecology, 5th Ed, 2010;160-172
Young Mi Lee et al. Multiple pregnancy. In:
Management of High-Risk Pregnancy. An

Evidence-based Approach, 2007,304-315
Egan JFX, Borgida AF. Ultrasound evaluation of
multiple pregnancies. In: Ultrasonography in

obstetrics and gynecology, Callen, 5 th Ed, 2008;181224
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THANK
YOU
http://www.youtube.com/watch?v=50JO-YtGs
http://www.facebook.com/judi.j.endjun?ref=profile
judijanuadi@hotmail.com
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Gatot Soebroto Army Central Hospital/

HANYA UNTUK PENDIDIKAN DAN

HANYA UNTUK PENDIDIKAN DAN

USA (2003): 67% twins; 500% triplets and highorder

HANYA UNTUK PENDIDIKAN DAN

Cerebral palsy: 4x (gemelli), 17x (triplet)

1992; Grether JK et al, 1993)

IUFD: 4x (ACOG, 2004)

life: 7x (Luke B et al, 1994; Kiely JL et al, 1992)

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conception monozygotic or dizygotic

HANYA UNTUK PENDIDIKAN DAN

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HANYA UNTUK PENDIDIKAN DAN

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Twinning rate (per 1000

HANYA UNTUK PENDIDIKAN DAN

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twin gestation is improved by the routine use

evaluation every three to four weeks is

indicated in twin gestations.

HANYA UNTUK PENDIDIKAN DAN

and twin specific charts may be used to define

and race specific charts.

are small and singleton growth curves may be

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

than absolute measurements.

clinical history, together with all the genetic

HANYA UNTUK PENDIDIKAN DAN

specificity 85%, PPV 62%)

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

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

The optimal time to determine chorionicity is 10-14

While these recommendations apply to diagnosis of

HANYA UNTUK PENDIDIKAN DAN

NICU > 28 days

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ultrasound examination every 1 2 W to screen TTTS

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selective reduction should be offered.

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

HANYA UNTUK PENDIDIKAN DAN

placentation (chorionicity and amnionicity) and are

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

HANYA UNTUK PENDIDIKAN DAN

chorionicity and amnionicity

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Sonographic determination of chorionicity

* Amnionicity cannot be determined by this finding

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(Early ultrasound finding: bifid appearing fetal pole)

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Sumber: Dr. dr. Adityawarman, SpOG(

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Ectoparasitic twins are

HANYA UNTUK PENDIDIKAN DAN