Multifetal pregnancy

Dr. HANI MAHDI

Sep. 2018
Multifetal pregnancy
• The overall incidence of multiple gestations in the United States is
3.5%
• The natural rate of twinning is approximately 1 in 80 and is slightly
higher in African Americans than in whites.
• The multiple birth rate is rising as a result of an increase in maternal
age and the more frequent use of assisted reproductive technologies
(ARTs) and ovulation induction agents.
• It is estimated that 43% of triplet and higher order gestations result
from ART procedures and 38% from ovulation induction; spontaneous
conception accounts for the remainder.
Multifetal pregnancy
• Two fetuses (twins) ,twins gestations can made of a singleton viable fetus & a
complete mole.
• Three fetuses (triplets) .
• Four fetuses (quadruplets).
• Five fetuses (quintuplets).
• Six fetuses (sextuplets).
• Seven offspring - septuplets
• Eight offspring - octuplets
• Nine offspring - nonuplets
• Ten offspring - decuplets
Quintuplet girls delivered in Oxford in 2007
Multifetal pregnancy
• Twin gestations can be characterized as dizygotic (fraternal) or monozygotic
(identical).
• Dizygotic twins occur when two separate ova are fertilized by two separate
sperms.
• Monozygotic twins result from the division of the fertilized ovum after
conception.
• The incidence of monozygotic twinning is approximately 1 in 250 pregnancies.
• Increasing maternal age and increasing parity are independent risk factors for
dizygotic twinning, and rates are higher among mothers of families with
twins.
Dizygotic , Binovular Fraternal,
Nonidentical
Dizygotic pregnancies originate from
the fertilization of two separate ova
by two sperms and are therefore
genetically dissimilar.
Monozygotic ,Uniovular, identical
NATURAL HISTORY
• Zygosity refers to the genetic make-up of the pregnancy.
• Chorionicity refers to the placental make-up of the
pregnancy.
• Chorionicity is determined by the mechanism of twinning
and, in MZ twins, by the timing of embryo division.
• Early determination of chorionicity is very important since
the risks associated with monochorionic twins are much
higher and must be managed differently from dichorionic
twins.
Zygocity and chorionicity
in twin pregnancies
Chorionicity
• Diamnionic/dichorionic (30%): If division of the conceptus occurs within 3 days of
fertilization, each fetus will be surrounded by an amnion and chorion. There may be
two separate placentas or one “fused” placenta.
• Diamnionic/monochorionic (70%) : If division occurs between the fourth and
eighth day following fertilization, the chorion has already begun to develop, whereas
the amnion has not. Therefore, each fetus will later be surrounded by an amnion, but
a single chorion will surround both fetuses.
• Monoamnionic/monochorionic: In 1% of monozygotic gestations, amnion and the
chorion, and the twins will share a common sac.
• Division thereafter is incomplete, resulting in the development of conjoined twins.
The fetuses may be fused in a number of ways, with the most common involving
the chest and/or abdomen. This rare condition is seen in approximately 1 in 70,000
deliveries. This condition is associated with a mortality rate of greater than 50%.
Chorionicity in twin pregnancies.
(A) Two placentas, two amnions, two chorions:diamniotic/dichorionic.
(B) One placenta, two amnions, two chorions: diamniotic/dichorionic.
(C) One placenta, two amnions, one chorion: diamniotic/monochorionic.
(D) One placenta, one amnion, one chorion:
monoamniotic/monochorionic.
One placenta, one amnion, one One placenta, two amnions, one
chorion: monoamniotic/monochorionic chorion: diamniotic/monochorionic.

One placenta, two amnions, two

chorions: diamniotic/dichorionic Two placentas, two amnions, two
chorions:diamniotic/dichorionic
Classification/Distribution of
Monozygotic Twins
 Conjoined twins
Conjoined twins are
classified according to
the anatomical site of
union (eg, chest, head)
with the suffix "pagus"
(meaning fixed, eg
thoracopagus).
Conjoined twins
Maternal Adaptation to Multifetal
Gestation
• Increased risk for gestational diabetes due to increase in human
placental lactogen (hPL)
• A greater risk for hyperemesis
• Increased dependent edema and a greater propensity for pulmonary
edema
• By 25 weeks’ gestation, the average twin gestation uterine size is
equal to a term singleton pregnancy.
RISKS OF MULTIFETAL GESTATION
• Compared with singleton pregnancies:
• 6 times more preterm birth
• 13 times more birth before 32 weeks
• twins are delivered at an average of 35 weeks
• triplets at 32 weeks
• quadruplets at an average of 30 weeks
• With each additional fetus, the length of gestation is decreased by approximately 2 to
3 weeks
• Fivefold increased risk of stillbirth
• Sevenfold increased risk of neonatal death, which primarily is due to complications of
prematurity
Perinatal Morbidity and Mortality
• Higher rates of low birth weight (LBW), very low birth weight (VLBW)
• One in 8 twins and 1 in 3 triplets are born before 32 weeks’ gestation
compared with only 2 in 100 singletons.
• Twins are more than 4 times, triplets 10 times, and quadruplets more
than 20 times as likely to die in infancy.
• Rates of cerebral palsy have been estimated to be 4 to 8 times higher
in twins than in singletons and as much as 47 times higher in triplets
• Twofold increased risk for congenital anomalies in twins versus
singletons, with most of this risk occurring in MZ twins.
 Other associated maternal and fetal/neonatal morbidities include
• Hyperemesis
• Spontaneous abortions: twice as
common in multiple gestations
• Anemia
• Intrauterine growth restriction
• Hydramnios (in approximately 10% of
multiple gestations, predominantly
monochorionic gestations)
• Preeclampsia (three times more
frequent in twin gestations)
• Gestational diabetes mellitus
• Congenital anomalies: twice as
common in multiple gestations.
• Cesarean delivery
• Postpartum hemorrhage
• Placental abruption
• Umbilical cord accidents
• Postpartum depression.
MATERNAL COMPLICATIONS IN
MULTIPLE GESTATIONS
DIAGNOSIS
• Vomiting may be more marked in early pregnancy.
• Twin pregnancy should be suspected when the uterine size is large for the calculated
gestational age. A difference of 4 cm or more between the weeks of gestation and
the measured fundal height should prompt evaluation with ultrasound to detect the
cause
• Chorionicity should be determined
• Chorionicity can be determined by ultrasound with almost 100% certainty as early as
8 to 9 weeks of gestational age
• The optimal timing for determination of chorionicity is in the first trimester or
early second trimester.
• Findings of dichorionic twins:
• the twin peak (or lambda) sign,
• a thick dividing membrane (>2 mm), and
• discordant genders.
Ultrasound of dichorionic twins in early pregnancy showing the
lambda sign.
The twin peak sign is a triangular projection of tissue that extends beyond the
chorionic surface of the placenta
Ultrasound determination of chorionicity during first trimester. A: Lambda sign,
B: T-sign, C: Two different placental masses.
Prediction of chorionicity and amnionicity
• After the early second trimester, determination of chorionicity and
amnionicity becomes less accurate
• The sonographic prediction of chorionicity and amnionicity should be
systematically approached by determining the number of placentae
and the sex of each fetus and then by assessing the membranes that
divide the sacs.
Chorionicity should be determined and
documented
• This is because chorionicity is relevant to:
• Counseling parents in relation to the risk of perinatal morbidity and
mortality
• Counseling parents in relation to their risk of genetic and structural
abnormalities
• Invasive testing and the management of discordant congenital anomaly;
• Feasibility of multiple fetal pregnancy reduction
• Risk of complications that may occur in a multiple pregnancy and potential
sequelae that may ensue
• Early detection and management of feto‐fetal transfusion syndrome.
Determination of Zygosity
• If a twin set is monochorionic, monozygosity can be inferred. If twins
are different genders, with very rare anecdotal exceptions, they can
be assumed to be DZ.
• It is estimated that based on these two findings, about 55% of all
twins’ zygosity can be determined by examination of the babies and
placentae.
• Conversely, 45% of all twins (same-sex dichorionic twins) would need
further genetic testing to determine zygosity.
Algorithm for determination of
chorionicity and amnionicity in
the second and third trimesters.
Systematic Labelling of Twins

• This is to ensure that biometry from longitudinal growth scans are consistently allocated
to the same twin at each visit.
• Additionally, when screening for aneuploidies is undertaken, there must be a reliable and
accurate system in place to ensure that invasive prenatal diagnosis or selective fetal
reduction is carried out on the at-risk or affected twin
• Each fetus within the twin pregnancy can be orientated at the 11–14 week ultrasound
assessment, the fetus contained in the gestational sac closest to the maternal cervix is
designated as twin one.
• The relative orientation of the fetuses to each other is then defined as either lateral
(left/right) or vertical (top/bottom). Lateral fetal orientation is associated with an
intertwine membrane running vertically along the longitudinal axis of the uterus and a
vertical fetal orientation is associated with an intertwin membrane running horizontally
across the longitudinal axis of the uterus
Diagrammatic representation of twin orientation
relative to the longitudinal axis of the uterus. The twins
may (A) top/bottom [T/B, vertical] or (B) right/left [R/L,
lateral] orientation.
 Poor Growth
• Poor intrauterine growth, because the human uterus appears less capable of adequately
nurturing more than one fetus to term.
• The percentage of small–for–gestational age (SGA) babies (birth
weight < the 10th percentile of singleton nomograms) is about 27% in twins and 46% in triplets.
• Growth curves for singletons, twins and triplets are similar up to 28 weeks’ gestation, when the
growth velocity of multiplets begins to fall.
• The chance of both fetuses being SGA is twice as high in monochorionic (17%) as in dichorionic
(8%) twins.
• The degree of discordant growth:
• Severe growth discordancy is defied as a weight difference of 25% or more, (12% of twins and
34% of triplets)
• Factors that influence growth in monochorionic twins: the division of the single placenta
between the fetuses, the vascular anastomoses and the effectiveness of invasion of each
placental portion into the spiral arteries
Monoamniotic Twins
• In 1% of monozygotic twins, division occurs between 9 and 12 days following
fertilization, both fetuses occupy a single sac composed of inner amnion and
outer chorion.
• The risk of entanglement of the umbilical cords, with subsequent fetal death,
is considerable.
• Recent management:
• Hospitalization at 24 to 26 weeks,
• Steroid administration, and
• Fetal heart rate monitoring several times daily
• Delivery is recommended early, at 32 to 34 weeks (after steroids), by cesarean delivery.
• UK guidance is for birth by 36 weeks’ gestation.
• The historic perinatal mortality rate for monoamniotic twins was >50%, but
now <10% with current management
Cord entanglement and knotting at birth in a
monoamniotic twin pregnancy.
Summary of Antepartum Management

• First trimester scan at 11–14 weeks:

• assessing gestational age,
• chorionicity,
• labelling and
• aneuploidy.
• In monochorionic pregnancies 2 weekly ultrasound assessments
from 16 weeks is indicated to screen TTTS.
• As a screening method of preterm labor routine cervical length assessment
is not recommended for multiple pregnancies as there is no effective
treatment to prevent preterm labor.
• Serial 4 weekly ultrasound fetal growth case of suspected TTTS
and discordant fetal growth >25%, referral to a regional referral center is
recommended.
 Complications of monochorionicity
• Twin–twin transfusion syndrome (TTTS)
• Twin anemia polycythemia sequence (TAPS) occurs where there are marked hemoglobin
differences between MC twins but in the absence of the liquor volume changes characteristic of
TTTS. Occurring as a consequence of small placental anastomoses, it can follow incomplete laser
ablation for TTTS.
• Criteria for diagnosis: a difference in hemoglobin concentration between the twins of > 8 g/dl
and reticulocyte count ratio > 1.7 or small vascular anastomoses (<1 mm in diameter) in the
placenta.
• Twin reversed arterial perfusion (TRAP) is a rare abnormality of MC twins. An abnormal, often
acardiac fetus is perfused by a normal ‘pump’ twin, which is therefore at risk of cardiac failure.
• Intrauterine growth restriction
• Co-twin death
• Other vascular abnormalities absence of an umbilical artery:
Seen in approximately 3% to 4% of twins, compared with 0.5% to 1% of singletons
Associated in 30% of cases with other congenital problems, especially renal agenesis.
TAPS is believed to be due to the presence of miniscule
arteriovenous anastomoses (<1 mm)
Twin-Twin Transfusion Syndrome
• Complicates approximately 10% to 15% of monochorionic diamnotic pregnancies.
• In almost all MC twins, there is a shared circulation in the placenta with different
anastomoses. These could be arterial to venous (A–V), venous to venous (V–V) and
arterial to arterial (A–A) anastomoses.
• Through arteriovenous anastomoses, there is net flow from one twin to another.
• The so-called donor twin can have impaired growth, anemia, hypovolemia.
• The recipient twin can develop hypervolemia, hypertension, polycythemia, and
congestive heart failure as a result of this preferential transfusion.
• A secondary manifestation involves amniotic fluid dynamics.
• The hypervolemia in the recipient twin leads to an increase in urinary output and, in turn,
to an increase in amniotic fluid volumes (hydramnios).
• The opposite effect may occur in the donor twin— hypovolemia leads to decreased
urinary output and, possibly, a decrease in amniotic fluid volume (oligohydramnios).
Staging system for FFTS/TTTS.
Staging of TTTS Based on Sonographic
and Doppler Findings (Quintero et al.)

The prognosis is better in early-stage disease (stages I and

II) and worse in more advanced disease (stages III and IV)
Twin-Twin Transfusion Syndrome
• Traditionally, serial removal of amniotic fluid from the sac of the
recipient twin has been the only treatment option associated with
improved survival.
• When available, fetoscopic laser photocoagulation has largely
replaced serial amnioreduction as first-line therapy for TTTS with
greater success in treating this difficult problem.
• With laser, approx. 50% both twins survive; 80% one twin survives
Death of One Fetus
• Multiple gestations, especially high-order gestations, are at increased
risk for losing one or more fetuses remote from delivery.
• No fetal monitoring protocol has been shown to predict most of these
losses.
• Whereas some advocate immediate delivery of the remaining
fetus(es), if the death was the result of an abnormality of the fetus
itself (i.e., rather than maternal or uteroplacental pathology) and the
pregnancy is remote from term, expectant management may be
appropriate.
• In DC twins: The healthy twin should not be compromised in the
event of a co-twin death, as they have two different placental vascular
systems.
Death of One Fetus
• In MC twins:
• Because virtually 100% of monochorionic placentas contain vascular
anastomoses that link the circulations of the two fetuses, the
surviving fetus is at significant risk for sustaining damage caused by
the sudden, severe, and prolonged hypotension that occurs at the
time of the demise or by embolic phenomena that occur later.
• By the time the demise is discovered, the greatest harm has most
likely already been done, allowing the pregnancy to continue may
provide the most beneficial outcome
Timing of Delivery

• Perinatal mortality of twins starts to become significantly high after 38

weeks and after 35 weeks for the triplets.
• Uncomplicated dichorionic twins should be managed expectantly and
delivery can be arranged around 38 weeks.
• Elective birth from 35 weeks 0 days is recommended for uncomplicated
triplets after a course of antenatal corticosteroids has been offered
Vaginal Twin Birth

• Mono-amniotic twins should be delivered by elective CS.

• Approximately 40% of twins will present at birth as vertex–vertex, 40% as vertex–
non-vertex and 20% with the fist twin non-vertex.
• A recent systematic review was unable to find support for a view that CS should
be recommended practice where the first twin is non-cephalic.
• Interlocking of twins is extraordinarily rare (1/600–800) and should not be used to
influence choice of mode of birth.
• Where the second twin is significantly larger than the first (20–25% larger or
where the absolute difference is more than 250 g) , CS might be considered.
• Available evidence suggests that vaginal birth of twins after CS does not carry
additional risk compared with vaginal birth after CS in singleton pregnancies
• Preterm Breech and Twin Birth: CS is recommended if gestational age is < 32
weeks
Conduct of Labor
• Birth of Twin1: Where the first twin is cephalic, then birth should
follow the usual guidance for the length of the second stage and the
indications for operative birth
• Birth of Twin 2: The presentation of the second twin should be
sought by abdominal palpation followed by digital vaginal
examination. Ultrasound is more widely available and should be
used in addition where practicable, and its use should be
mandatory where there is any doubt
• Twin 2 Cephalic: Where the head is not fully engaged in the pelvis it
should be stabilized by an assistant.
• ‘Active management’ of the second twin results in better outcomes
Conduct of Labor
• Twin 2 Non-cephalic: External cephalic version (ECV) is used with
success of less than 50%
• Internal podalic version(IPV) with breech extraction is used
• For ECV and IPV to be successful and safe, the uterus needs to be
relaxed.
• Tocolytic is terbutaline, either as 250 mcg subcutaneously, or given
intravenously over 5 min.
• Where the membranes are already ruptured and the lie is transverse
or oblique, ECV is unlikely to succeed, CS should be undertaken.
Algorithm for
twin birth