MMCON

Clinical teaching on

Twin Pregnancy
SUBMITTED TO : SUBMITTED BY:

MISS DEEPSHIKHA EKTA RAJPUT

MAM
(Assistant Professor) 1918024
 MULTIPLE PREGNANCY

• When more than one fetus simultaneously develops in the

uterus,it is called multiple pregnancy.

• Simultaneuosly, development of two fetuses (twins) is the most

common ; although rare, development of three fetuses (triplets), four
fetuses (quadruplets), five fetuses (quintuplets or six fetuses
(sextuplets) may also occur.
 INCIDENCE
• According to Hellin’s (1895)
rules;

Incidence of Twin pregnancy = 1 in 80 pregnancy

Incidence of Triplets = 1 in 80²

Incidence in quadruplets = 1 in 80³

 Twins
• Simultaneous development of two fetuses in the uterus is the most
common variety of multiple pregnancy.
 Types of Twin Pregnancy or varieties

DIZYGOTIC (DZ) MONOZYGOTIC

TWINS (MZ) TWINS
1.) Dizygotic twins or fraternal twins or non-
identical twins (binovular):- (80%)
• Results from fertilization of two ova, most likely ruptured from two
distinct graafian follicles usually of the same or one from each ovary, by
the two sperms during a single ovarian cycle.

2.) Monozygotic twins or identical twins (uniovular) :-

(20%)

• The twinning (cleavage of fertilized ovum) may occur at different periods

after fertilization and this markedly influences the process of implantation
and the formation of the fetal membranes.
 Dizygotic twins Monozygotic twins
 Dizygotic twins are more common.  SAME
 Sex – same or different  Sex
 Dizygotic twins vary from country to  Genotype (Chromosomal makeup)
country.  Phenotype/looks
 Highest incidence of dizygotic twins =  Blood
NIGERIA ( 1 in 20 Pregnancy)  HLA typing
 Lowest = JAPAN ( 1 in 200)  Different finger printing
 INDIA = 1 in 80 Pregnancy  Incidence:- remains constant
throughout the world – 1 in 250
pregnancies
 RISK FACTORS
I Maternal family history of twinning
.
II. Increased maternal age 30-35 yrs)

III. Increased Parity ( female>5th Gravida )

IV. LATROGENIC : Use of drugs (Ovulation inducing drugs- like

Clomiphene Citrate or procedures like In Vitro Fertilization
(IVF)
Always two Number of fetal
fetuses Number of membrane
Always have placenta
separate cord
Chorion and
Amnion

Depends on
2 umbilical cords dizygotic /
monozygotic
 Important terms

Number of placenta
Number of membranes

MONOZYGOT DICHORIONI
DIZYGOTIC MONOZYGOTIC C
IC
 In case of Dizygotic twins

ZYGOTE-1 ZYGOTE-2

They are Diachorionic and Diamniotic (DCDA) 2 Placentas

 In case of Monozygotic twins

No. of Chorion and Amnion and placenta depends on the time of division
CHORION: formed roughly by Day 7-8 after fertilization.
AMNION: formed roughly by Day 10 after fertilization.
 TYPES OF MONOZYGOTIC
TWINS

<72 hours after

Days 4-7 Days 8-12 Day >13
fertilization

DICHORIONC MONOCHORIONIC CONJOINED TWINS

DIAMNIOTIC MONOCHORIONIC
DIAMNIOTIC MONOAMNIOTIC (SIAMESE)
CONJOINED TWINS (Siamese Twins)
Some body part of the twins is fused with each other.

Depending upon the part of twins fused

T- thoracopagus(Thorax fused twins) most common
O- Omphalopagus (Abdomen fused)
P- Pyopagus (buttocks fused) Posterior fusion
I- Ischiopagus (Pelvic bone fused) Caudal (Heads
C- Craniopagus are fused) Cephalic

LEAST COMMON : RACHIPAGUS ( Head to buttocks all parts fused ) Dorsal

THORACOPAGUS OMPHALOPAGUS
PYOPAGUS ISCHIOPAGUS
CRANIOPAGUS RACHIPAGUS
Prognosis depends on: CHORIONICITY

• Best investigation to know Chorionicity : Ultrasound (TVS)

• Time: 11-14 weeks

 SEX: Same/Difference

 No. of placenta = 2  SEX: Same

 No. of layers of membrane between twins = 4  No. of placenta = 1

 Thickness of membrane = >2mm thick  No. of layers of membrane between twins = 2

 Thickness of membrane = <2mm thick

 SIGN: Twin Peak sign or Lambda sign (positive)
 FETAL COMPLICATIONS
1.) TWIN TO TWIN TRANSFUSION SYNDROME (TTTS)

2.) ACARDIUS TWIN (TRAP)

3.) PREMATURITY

4.) CONGENITAL MALFORMATION

5.) ABORTIONS

6.) DEATH OF ONE FETUS

- Vanishing twins
- Fetus compressus or Fetus Papyraceous
7.) IUGR

8.) DISCORDANT TWIN GROWTH

9.) HYDATIDIFORM MOLE

1.) TWIN-TWIN TRANSFUSION SYNDROME
( TTTS)
It is a clinic-opthalmological state, exclusively met within monozygotic twins, where one
twin appears to bleed into the other through some kind of placental vascular anastomosis
such that blood blows in one direction.
 TWIN-A TWIN-B
 The twin which reiceves blood is Donor twin (Twin A)  The twin which receives the blood is recipient twin (Twin B)

 Anemia in Donor twin

 Polycythemia
 Pale look
 Pink colour
 Macosomia

 Less growth  Microsomia

 More growth
 Renal blood flow (decreases)
 Increased Renal blood

Increased urine output

 GFR
 POLYHYDRAMINOS
Urine output (decreases)
 Blood increases
( plethoric twin)
 OLIGOHYRAMINOS

 Renal failure
CONGESTIVE HEART
FAILURE
 Management of TTT syndrome

a.) Laser photocoagulation

b.) Repeated amniocentesis to control polyhydramnios in the recipient twin is done.

c.) Septostomy ( making a hole in the diving amniotic membrane)

d.) Selective reduction

 2.)Twin reversed arterial perfusion (TRAP)
OR Acardius twin
It is characterized by an “acardiac perfused twin“having blood supply from a normal co-twin via large arterio-
arterial or vein to vein anastomosis.

One twin has heart other twin does not have heart.

In twin 2nd due to gravity; blood reaches lower extremities

Lower part of body is developed

But because there is no heart

So blood cannot reach upper part of body

So upper part of body is not formed

Called as Acardius Ancephalus

Sometimes in Acardiac twin

No part of body can be identified

Called as Acardius Amorphus

3.) Death of 1 fetus

1st trimester death: VANISHING TWIN

2nd trimester death: FETUS COMPRESSUS

VANISHING COMPRESSUS:

Initial USG shows twin pregnancy one fetus dies before 14 weeks and simply
disappears on USG. Later on USG only one fetus visible, other vanishes.

FETUS COMPRESSUS / PAPYRACEOUS:

One twin dies after 1st trimester after twin which is alive grows and compressus the
dead twin against the walls of uterus .More common in monozygotic twins.
4.)Discordant growth:
one twin grows less other twin grows more.

5.) Abortions: If both fetus die

6.) Prematurity

7.) Cord prolapse

8.) Hydatidiform Mole (Vesicular mole):

It is an abnormal condition of the placenta where there are partly degenerative

and partly proliferative changes in the young chorionic villi. Discordant Growth
Maternal complications of twin pregnancy

During pregnancy

1.) Nausea and vomiting

2.) Height of uterus is more than period of gestation.

3.) Anemia

4.) GFR increases

5.) Malpresentation

6.) Increased weight gain and increases cardiac output as compared to singleton
pregnancy.
All complications of pregnancy and which start with letter “P”

Placenta previa HTN

Abruptio Placentae Folic acid defeciency

PIH

Polyhydraminos

PPH

Preterm Labor

PROM

Pre-eclampsia

Except: Post-term Pregnancy

During labor

1.) Early rupture of membranes and cord prolapse

2.)Prolonged labor

3.)Increased operative interference

4.)Bleeding ( intrapartum)

5.PPH
During Puerperium

Increased incidence of:

1.) Subinvolution – because of bigger size of the uterus

2.) Infection because of increased operative inference, pre-existing anemia and blood loss during
delivery.

3.)Lactation failure – this is minimized by reassurance and giving her additional support
ANTENATAL MANAGEMENT
Complications are higher in monozygotic twins compared to dizygotic twins.Complications
are further higher in monochorionic diamniotic twins and highest in monochorionic
monoamniotic twins

Twin pregnancy is High risk pregnancy which needs extra care

Mother needs extra calories, extra rest, extra iron,vitamins and more frequent antenatal visits

Increased rest

Fetal surveillance is maintained by serial sonography at every 3-4 weeks interval or earlier at
every 2 weeks in monochorionic twins

Non –stress test

Most common cause of perinatal mortality in twins – PREMATURITY

Most common cause of maternal morality in twins – PPH

Most common complication of twin pregnancy – PRETERM LABOR

In all twin pregnancies – Give injection DEXAMETHASONE to mother

between
(32-34 weeks)

To prevent preterm delivery , routine use of tocolytics, progesterone therapy

SUPERFECUNDATION

It is the fertilization of two different ova released in the same cycle , by separate acts of
coitus within a short period of time.

SUPERFETATION

It is the fertilization of two ova released in different menstrual cycles.

 MANAGEMENT (Mode of Delivery of twin)
Vaginal Delivery Cesarean section

 Dichorionic Diamniotic  Congenital twins

Monochorionic Diamniotic Monochorionic Monoamniotic twins
Any complication like:
 vaginal delivery depends on presentation of 1st twin
TTTS
Vaginal delivery is possible : IUGR
Only if 1st twin is CEPHALIC or 2nd will be BREECH  If 1st twin is breech or transverse lie.
otherwise perform cesarean section.
 If first twin is cephalic (Vertex)

There can be 3 conditions/ situations

1ST situation 2nd situation 3rd Situation

 1st – cephalic  1st – cephalic  1st – cephalic

2nd - cephalic 2nd – Breech 2nd – Transverse lie

1 condition
st
1st twin = vaginal delivery

 After delivery of 1st twin do not give injection Methyl ergometrine to mother

 CORD CLAMP : 1st twin ; use clamps and cut in between them

 Now check fetal heart sound, lie of second baby

 Usual time of delivery of 2nd baby = 15 minutes maximum wait untill 30 minutes

 2nd the baby : vaginal delivery

Now you can give injection Methyl ergometrine to the mother

2 Situation
nd

1st twin -Vaginal delivery

2nd twin – Vaginal breech delivery

3 Situation
rd

1st twin : vaginal delivery

Now shift the patient to OT and give general anesthesia to mother

Take your hand inside uterus ,hold feet of your baby and bring it
down Internal podalic version
Internal podalic version
Done under general anesthesia

only indication: if a twin is transverse lie

Take hands inside uterus

chances of uterine rupture

DELIVERY = Good prognosis in 1st twin

 Indications of cesarean section

Obstetric indications

For twins
OBSTETRIC FOR TWINS
 Placenta previa Both the fetuses or even the first fetus with noncephalic
(breech or transverse) presentation
 Severe pre-eclampsia
Twins with complications: IUGR, conjoined twins.
 Previous LSCS
Monoamniotic twins
 Cord prolapse of the first baby
Monoamniotic twins with TTTS
 Abnormal uterine contractions
Collision of both the heads at brim preventing engagement
 Contracted pelvis of either head
SELECTIVE FETAL REDUCTION
PURPOSE: To reduce multifetal pregnancy into single pregnancy or twin pregnancy.

DRUG USED: Potassium Chloride intracardiac injection

TIME: 11- 13 weeks

 Research article
ABSTRACT
A pregnant woman (Gravida 2, Abortion 1, twin pregnancy with
microinjection, Gestational Age: 23 weeks and 3 days) was referred to a tertiary
referral hospital with complaints of fever, dry cough and dyspnea. She was
admitted with a diagnosis of COVID-19. During her hospitalization, O2
saturation progressively declined, which required acute respiratory care and
support leading to intubation and mechanical ventilation. Gradual recovery
occurred through treatment processes and finally the patient was extubated.
However, there was another episode of respiratory failure leading to
reintubation after 5 days. Meanwhile, serum liver enzymes increased
significantly and leaded to intrauterine death of both fetus followed by a critical
decline in cardiac output to less than 10% and cardiac arrest followed by
unsuccessful resuscitation within hours.
Conclusion :
Pregnancy is undoubtedly a risk factor for
immune system defense against COVID-19. There is
robust evidence that these patients need much more
sophisticated care.
 BIBLIOGRAPHY
DC DUTTA TEXTBOOK OF OBSTETRICS

PAGE NO. 189-198

POST EVALUATION
Q.1 what is superfecundation?
Q.2 what is the difference between Dizygotic and Monozygotic twins ?
Image based question
Q.3 Identify the most rare type of conjoined twins pregnancy

CRANIOPAGUS RACIPHAGUS

THORACOPAGUS
ISCHIOPAGUS
Q.4 Embryo reduction of multiple pregnancy is done at

or

Best time for detecting chorionicity twin pregnancy on USG is-

Ans. a.) 8-10 weeks

b.) 11-14 weeks

c.) 14-15 weeks

d.) 16-18 weeks

Q.5 In multiple pregnancy, fetal reduction is done by:

Ans. a.) Mifepristone

b.) PgF2 – Alpha

c.) KCL

d.) Methotrexate
Q.6 A abnormal condition in which one fetus is dead in early pregnancy before 14
weeks and dead fetus is simply reabsorb during IUL than pregnancy is continue
with only one fetus is known as-

Ans. A.) Fetus papyraceous

B.) Fetus acardius

C.) Vanishing syndrome

D.) TTTsyndrome
Q.7 A monochorionic and diamniotic twins develop TTT syndrome which of the
following condition seen by nurse in donor twins except -

Ans. A.) Macrosomia

B.) Microsomia

C.) Hypovolemia

D.) Less liquor amnii

Q.8 Twin peak sign seen in –

Ans. A.) Monochorionic diamniotic

B.) monochorionic monoamniotic

C.) Conjoined twins

D.) Dichorionic diamniotic

Q.9 Lowest frequency of twin pregnancy is seen in-

Ans. A.) Nigeria

B.) Philippines

C.) India

D.) Japan