Twin Pregnancy

Judi Januadi Endjun
Gatot Soebroto Army Central Hospital/

Medical Faculty, University of Indonesia
ISUOG Meeting, Bali,

2009
MATERI AJAR INI HANYA
UNTUKDIPERGUNAKAN
DALAM KEGIATAN
PENDIDIKAN DAN
KESEHATAN
HANYA UNTUK PENDIDIKAN DAN
JJE-‐20091119 KESEHATAN
AGENDA
⚫ Definitions
⚫ 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
DEFINITIONS
⚫Monozygotic twins : a pregnancy of 2 fetuses derived
from the same zygote that divided between the day of
fertilization and the 14th day. They can have phenotypic
and genotypic differences and can have either a
dichorionic or a monochorionic placentation.
⚫Dizygotic twins : a pregnancy of 2 fetuses derived from

2 different zygotes, resulting from the fertilization of 2
oocytes from the same cycle. They always have a
dichorionic placentation.
Matias A, Jeanty P, Toy EC. Sonography in multiple gestation. In: Sonography in Obstetrics & Gynecology, 7th Ed, 2011:337-375

DEFINITIONS
⚫Chorionicity : type of placentation in cases of multiple
pregnancy defined by the number of chorions.
⚫Lambda sign : sonographic sign resulting from the

juxtaposition of 2 layers of amnion and 2 layers of
chorion in a dichorionic twin pregnancy.

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, 5th Ed, 2010
Young Mi Lee et al. Multiple pregnancy. In: Management of High-‐Risk Pregnancy. An Evidence-‐based Approach, 2007,304-‐315

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)

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)

http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-‐14weeks/chapter-‐05/images/fig05-‐01%20copy.jpg

http://www.studentconsult.com/common/showimage.cfm?mediaISBN=9781416059400&FigFile=S9781416059400-‐013-‐f001.jpg&size=fullsize
http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-‐14weeks/chapter-‐05/images/fig05-‐01%20copy.jpg
http://www.youtube.com/watch?v=50JO-‐YtGshw
MONOCHORIONIC TWIN
http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-‐14weeks/images-‐thefetus/gem-‐04.jpg

TWINNING RATE
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-‐02.gif

GROWTH RESTRICTION
http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-‐14weeks/chapter-‐05/images/fig05-‐07a.gif
http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-‐14weeks/images-‐thefetus/gem-‐03.jpg
Frequency and mortality according to

the types of placentation
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%
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)
SONOGRAPHY IN TWINS
⚫Determination of the number of fetuses, amnionicity,
chorionicity, placental location, fetal presentation
⚫ Detection of complication such as :

⚫ Growth discrepancy
⚫ Abnormal vascular anastomosis
⚫ Amniotic fluid volume imbalance
⚫ Fetal malformations
⚫ Cord entanglement

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

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, 2000
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,
2000

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)
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.
SOGC, Management of twin pregnancy (Part 1), July,
2000
http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-‐14weeks/images-‐centrus/gem-‐dicor-‐dia-‐01.jpg
http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-‐14weeks/images-‐centrus/gem-‐mono-‐01.jpg
KESEHATAN
JJE-‐20091119
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

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
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.

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

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

Sonographic determination of chorionicity and
amnionicity in first trimester twins gestations
Placentation Gestational 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

MONOCHORIONIC & DICHORIONIC
http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-‐14weeks/chapter-‐05/images/fig05-‐04b.jpg

TRIPLETS

QUADRUPLET
http://www.youtube.com/watch?v=PN3e7nyExqc
Complications and
Abnormality in
twins pregnancy

http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-‐14weeks/images-‐thefetus/conj-‐01.jpg
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
Sumber: Dr. dr. Adityawarman, SpOG(K)
CONJOINED
TWINS
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 Jeanty –
www.thefetus.net )
http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-‐14weeks/images-‐thefetus/conj-‐01.jpg
ECTOPARASITIC TWINS
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-‐para-‐01.jpg

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.htm

SYNDROME
NEJM, July 2004

http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-‐14weeks/chapter-‐05/images/fig05-‐10.gif
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
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

TTT
S
http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-‐14weeks/chapter-‐05/images/fig05-‐11a.jpg

STUCK
TWINS

Twin reversed arterial perfusion
sequence(TRAP)
⚫ TRAP (acardiac twin): 1 : 35,000 pregnancies
⚫The most extreme manifestation of TTTS  ± 1% of
MC twin  is acardiac twinning (acardius
chorioangiopagus parasiticus).
⚫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)

sequence(TRAP)
⚫50% of donor twins die due to congestive heart
failure or severe preterm delivery, the consequence
of polyhydramnios (Van Allen MI et al, 1983; Moore TR, 1990)
⚫All perfused twins die due to the associated multiple

malformations. (Nicolaides KH et al, 2001)
⚫Acardiac twins: hydrops, heart beat +/-‐ (rudimentary

pulsatile cardiac structure), reversed perfusion via SUA (Kurt
Hecher et al. 2009)
sequence(TRAP)
http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-‐14weeks/images-‐thefetus/trap-‐01.jpg
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)

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)

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.
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, 2000
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)

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)

SONOGRAPHIC CERVICAL ASSESSMENT
⚫There is good evidence that transvaginal sonographic
measurement of cervical length predicts preterm birth in
twins. (II-‐1 A)
 There are no intervention studies that have evaluated

cervical length measurement in the prevention of preterm
birth,  the role of sonographic clinical cervical assessment
in the prenatal period has not been determined. (C)

Trust Your Vaginal Ultrasound
http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-‐14weeks/images-‐thefetus/incom-‐cervical/cx-‐draw-‐01.gif

Measurement of the cervical length
http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-‐14weeks/images-‐thefetus/incom-‐cervical/cx-‐draw-‐01.gif

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
http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-‐14weeks/images-‐centrus/colo/grap-‐01q.jpg
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)

MISCARRIAGE AND PERINATAL
MORTALITY
http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-‐14weeks/images-‐centrus/gemelar/gem-‐01.jpg
Dichorionic and Diamniotic pregnancy at 9+2 weeks
gestation, with a discrepancy of to embryos size

ULTRASOUND MANAGEMENT
① Performed in 1st trimester: number, amnionicity, chorionicity, and NT (10
– 14 W)
② Detailed US examination: 18 – 20 W, fetal gender, number of placenta,

the thickness and number of layers in membrane, and lambda (twin peak) sign
③ Dichorionic pregnancy: fetal growth (FG) evaluation every 3 – 4 W (if

FG and AFV normal)
④ Monochorionic diamniotic: evaluation every 2 – 3 W, TTTS, fetal

echocardiography

ULTRASOUND MANAGEMENT
⑤ Dichorionic or monochorionic: if IUGR, discordant fetal
growth, discordant AFV NST, Biophysical Profile, Doppler
studies
⑥ Monoamniotic: daily NST starting from 24 – 26 W (risk of

sudden IUFD from cord entanglement)  variable deceleration
 delivery?

FETAL LOSS & DELIVERY TIME
Cumulative fetal loss rates in monochorionic (solid line) and Gestational age distribution at delivery of monochorionic (solid bars) and
dichorionic (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

JJE-‐20091119
KESEHATAN
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)

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

CASE REPORT
⚫Mrs F, 33th years old, G2P1A0:
DIZYGOTIC TWINS
⚫ IVF
⚫ Two embryo
⚫ fetal variability (2nd fetus)
⚫CS at 36 W: F 2480 grams, AS 9/9; B
2082 grams, AS 9/9. Two placenta, two
amnion and two chorion. The
placenta for the 2nd baby is smaller

1. Female, 2480 gr, AS 9/9
2. Boy, 2082 gr, AS 9/9

JJE-‐20091119
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

TAKE HOME MESSAGES
① Early diagnose of twin pregnancy (ultrasound !)
② Determination of zygosity: !! Conjoined twins
③ Screening for fetal anomaly and growth
disturbances
④ When the best time to delivery?
⑤ Confident diagnosis of zygosity may require
detailed examination of the placenta after
delivery

REFERENCES
① Tarsa M, Moore TR. Multifetal gestation and malpresentation.
In: Essentials of obstetrics and gynecology, 5th Ed, 2010;160-‐172
② Hecher K, Diehl W. Multiple pregnancies. In: Ultrasound in

obstetrics and gynaecology. European practice in Gynecology and
obstetrics. Edited by JW Wladimiroff, SH Eik-‐Nes,2009,247-‐258
③ Young Mi Lee et al. Multiple pregnancy. In: Management of

High-‐ Risk Pregnancy. An Evidence-‐based Approach, 2007,304-‐315
④ Egan JFX, Borgida AF. Ultrasound evaluation of multiple pregnancies.

In: Ultrasonography in obstetrics and gynecology, Callen, 5th Ed, 2008;181-‐
224

THANK
YOU
http://www.youtube.com/watch?v=50JO-‐YtGshw
http://www.facebook.com/judi.j.endjun?ref=profile
judijanuadi@hotmail.com http://www.scribd.com/Judi%20Endjun


Twin Pregnancy

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Twin Pregnancy

Uploaded by

Copyright:

Available Formats

Judi Januadi Endjun

Gatot Soebroto Army Central Hospital/

ISUOG Meeting, Bali,

⚫Dizygotic twins : a pregnancy of 2 fetuses derived from

HANYA UNTUK PENDIDIKAN DAN

⚫Lambda sign : sonographic sign resulting from the

HANYA UNTUK PENDIDIKAN DAN

⚫ USA (2003): 67% twins; 500% triplets and high-­‐order

HANYA UNTUK PENDIDIKAN DAN

⚫ IUFD: 4x (ACOG, 2004)

⚫ Twin-­‐speciﬁc problems: TTTS, MCMA, conjoined

HANYA UNTUK PENDIDIKAN DAN

⚫Monozygotic: identical, same genetic make up, the rate is

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

HANYA UNTUK PENDIDIKAN DAN

HANYA UNTUK PENDIDIKAN DAN

HANYA UNTUK PENDIDIKAN DAN

Twinning rate (per 1000 pregnancies)

HANYA UNTUK PENDIDIKAN DAN

Frequency and mortality according to

DA-­‐DC DA-­‐DC DA-­‐MC MA-­‐MC

Frequency 35% 27% 36% 2%

⚫FIRST TRIMESTER ULTRASOUND: number of GS and

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

⚫ Detection of complication such as :

HANYA UNTUK PENDIDIKAN DAN

⚫There is consensus that serial

HANYA UNTUK PENDIDIKAN DAN

⚫Precision may also be obtained by using sex and

⚫In clinical practice, however, these diﬀerences are

⚫Both must be interpreted in the light of the

HANYA UNTUK PENDIDIKAN DAN

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

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

 The optimal time to determine chorionicity is 10-­‐14

 While these recommendations apply to diagnosis of twin

NICU > 28 days 8.7% 15.7% 43.8%

Neurodevelopment 3.3% 8.0% 9.7%

Pregnancy Comparable with

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

⚫The procedure should be performed in a tertiary

⚫Transportation and out‐of-

HANYA UNTUK PENDIDIKAN DAN

⚫Ultrasound is very useful in determining

HANYA UNTUK PENDIDIKAN DAN

HANYA UNTUK PENDIDIKAN DAN

* Amnionicity cannot be determined by this ﬁnding

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

HANYA UNTUK PENDIDIKAN DAN

HANYA UNTUK PENDIDIKAN DAN

HANYA UNTUK PENDIDIKAN DAN

In this case what appears to be an

(Courtesy Glynis Sack, MD,

HANYA UNTUK PENDIDIKAN DAN

⚫This phenomenon of a shared circulation between

HANYA UNTUK PENDIDIKAN DAN

NEJM, July 2004

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

IV As above As above Abnormal Yes, either No

HANYA UNTUK PENDIDIKAN DAN

HANYA UNTUK PENDIDIKAN DAN

HANYA UNTUK PENDIDIKAN DAN

⚫ USA (2003): 67% twins; 500% triplets and high-‐order

⚫ Twin-‐speciﬁc problems: TTTS, MCMA, conjoined

DA-‐DC DA-‐DC DA-‐MC MA-‐MC

 The optimal time to determine chorionicity is 10-‐14

⚫Acardiac twins: hydrops, heart beat +/-‐ (rudimentary

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

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