MULTIFETAL PREGNANCY

Incidence
• Increased with Assisted Reproduction
• Clomiphene citrate / Letrozol/ HMG, hCG
• Advanced Age
• Race – Afro-carribeans
• 1/90
 Multiple Pregnancy

More than one fetus simultaneously develops in the uterus.

Two fetus : Twin

Three fetus : triplets

Four fetus : quadruplets

Five fetus : quintuplets

Six fetus : sextuplets

 Twins

Types :
Binovular (fraternal/ dizygotic):
Commonest 2/3 rd
Result from fertilization of
two ova
Uniovular ( identical / monozygotic):
1/3 rd
Result from fertilization of
single ova
Conjoint twins :
Thoracopagus Craniopagus

Pyopagus Ischiopagus
 Chorionicity v/s Zygosity

All dizygous twins are dichorionic

• All monochorionic twins are monozygotic

Some monozygous twins are

dichorionic, some monochorionic
 Placentation

Dyzigotic twins:

dichorionic diamniotic

Monozygotic twins:

dichorionic diamniotic
monochorionic diamniotic
monochorionic monoamniotic
Sonographic determination of amniocity and chorionicity

In first trimester

Intradecidual sign :

4.5 – 5.5 wks chorion seen as echogenic ring within the

thickened decidua.

Double decidual sign:

After 5.5 wks chorion laeve / decidua capsularis is seen as

thick-walled, echogenic ring situated eccentrically within the
thick ring of decidua vera.
Sonographic determination of amniocity and chorionicity

In first trimester

The amnion thin and filamentous.

The amnion can be seen as 2mm bleb adjacent to yolk sac at

about 5.5 wks.

The amnion then becomes difficult until the CRL 8-12mm & seen
as thin filamentous, rounded membrane surrounding the embryo.

At 10 wks the amnion grown enough contact each other, appear as

a single, thin membrane separating two fetus.

After the first trimester

Determination of chorionicity and amniocity is more difficult.

Intradecidual sign
Figure .. Double decidual sac sign. US image of an early IUP
demonstrates two hyperechoic rings (arrows). The inner ring
represents the combined chorion-decidua capsularis, and the
outer ring represents the decidua parietalis.
Maternal risks associated with multiple pregnancy

Miscarriage
Hemorrhage
Pregnancy induced high blood pressure
Malpresentation
Pre-eclampsia occurs three to five times more frequently
Diabetes
Anemia
Polyhydramnios
Caesarean section is often needed in twin pregnancy, and
almost always required for triplets or more
Prolonged hospitalization resulting in higher cost of medical
care
Fetal complications associated with multiple pregnancy

Preterm delivery. The average length of a pregnancy is 39 weeks

for a single pregnancy, 35 weeks for twins and 33 for triplets.
Preterm delivery occurs over 50% in twin pregnancy and in 90%
of triplets. The proportion of twins and triplets delivering before
30 weeks pregnancy is around 7% and 15% respectively.

Multiple pregnancies have a four-fold increase in the rate of low

birth weight compared to single pregnancy. The risk of lifelong
disability is over 25% for babies weighing less than 1 Kg.

Stillbirth rates and neonatal death rates are higher for multiple
pregnancies compared to singletons. For example, for a single
birth the incidence is less than 1%, for twins 4.7% and for triplets
8.3%.

Birth defects are twice as common as in single birth.

Fraternal twins
Two different sperm fertilize two different eggs .
Each twin has its own sac of amniotic fluid and its own placenta.
Have two sets of membranes surrounding their amniotic fluid sacs known
as diamniotic, dichorionic.
 Fraternal twins

yolk sacs and fetal poles (the early fetus) are seen in 2
completely separate sacs.
Dichorionic-diamniotic twin pregnancy in the 13th week of gestation
Dichorionic/Diamniotic Twins
Dichorionic/Diamniotic Twins
IDENTICAL TWIN
One sperm fertilizes one egg but this splits into two embryos .
They have the same genetic material.
There are two separate amniotic sacs and two separate placentas.
2/3’s, each twin has its own amniotic sac but share a common placenta called
monochorionic, diamniotic.
Monochorionic twins are at higher risk for complications since they share a
common placenta.
Monozygotic twins with
Monozygotic twins with
monochorionic, diamniotic
monochorionic,
placentation.
monoamniotic placentation
 Identical (monozygotic) twins

One gestational sac is seen with 2 yolk sacs visible

Monozygotic twins in a single amniotic sac
Monochorionic/Diamniotic
are
Identical
 Dichorionic-Diamniotic
can be
Fraternal or Identical

 The twin peak sign indicates the presence of a dichorionic-

diamniotic twin gestation.
 It forms where two separate placentas grow contiguously and
appear fused. The twin peak can be of variable size, and only its
presence is required to suggest that the pregnancy is dichorionic-
diamniotic.
 This sign is most useful in assessing the chorionicity of
pregnancies after 10 weeks.
 Twin-Twin Transfusion Syndrome (TTTS)

• Monochorionic twins
• Donor twin is small, growth Anastomoses in TTTS
restriction
• Recepient twin is big
• Oligo / polyhydramnios
• Big bladder, heart enlarged in
recepient
• Oliguria, donor
• Abnormal Dopplers
In TTTS, the smaller twin (donor twin) does not get enough blood while
the larger twin ( recipient twin) becomes overloaded with too much
blood.

In an attempt to reduce its blood volume, the recipient twin will

increase the urine it makes. This will eventually result in the twin
having a very large bladder on ultrasound as well as too much amniotic
fluid around this twin. This known as polyhydramnios.

At the same time, the donor twin will produce less than the usual
amount of urine. The amniotic fluid around the donor twin will become
very low or absent. This is known as oligohydramnios.

As the disease progresses, the donor will produce so little urine that
its bladder may not be seen on ultrasound. The twin will become
wrapped by its amniotic membrane (known as a “stuck” twin).
 Prognosis - TTTS
• Staging (Quintero)
– Stage I
• Recipient hydramnios
• Donor bladder visible/present
– Stage II
• Recipient hydramnios
• Donor bladder remains empty (“stuck twin”)
– Stage III
• Abnormal Doppler studies:
– absent or reversed end-diastolic flow in Donor UA OR
– abnormal venous Doppler pattern in Recipient UA (reverse
flow in the ductus venosus or pulsatile umbilical venous flow)
– Stage IV
• Fetal hydrops means stage IV and the end
– Stage V
• Fetal death of one or both twins.
Acardiac twin or twin reversed arterial perfusion (TRAP) syndrome

An usual form of TTTS occurs in about 1 in 15,000 pregnancies.

In these monochorionic twins, one twin develops normally while the
other twin fails to develop a heart as well as other body
structures. The abnormal twin is called an acardiac twin

In these pregnancies, the umbilical cord from the acardiac twin

branches directly from the umbilical cord of the normal twin. Blood
flow to the acardiac twin comes from the normal twin which is also
known as apump twin.
This blood flow is reversed from the normal direction leading to the
name for this condition - twin reversed arterial perfusion syndrome;
TRAP.
Figure : Acardiac twin with absence of formed cranium. Diffuse
anasarca is seen with a focal cystic hygroma
 Conjoined or Siamese twins

Conjoined twins or Siamese Twins are the result

of incomplete division of the embryonic disc.

The twins here are partially joint at either of the

following points:

Head- craniopagus

chest- thoracopagus

abdomen- omphalopagus

pelvis- ischiopagus
 Conjoined Twins

Division occurs after the development of embryonic disc.

Figure : Dicephalus-conjoined twins seen on an 11-week ultrasound.

Two fetal heads (arrows) and a single thorax and abdomen are seen.
Figure : Fetal demise of one twin with a surviving co-twin at 21 weeks'
gestation. A. The collapsed cranium of the twin with the fetal demise
compared with the surviving twin's cranium. B. The abdominal
circumference of the fetal demise is compared with that of the
surviving twin.
Timing and Mode of Delivery

• Dichorionic twins – 38 weeks

• Monochorionic twins – 36 wks
• Vaginal delivery in uncomplicated DC or MC twins if
cephalic, cephalic presentations
• Precious pregnancy, abnormal presentations,
complications like IUGR, preterm, maternal DM/HT
usually delivered by LSCS
• Increased risk of placenta praevia and APH, PPH