Scanning Twin Pregnancies

Gerald Hackett

East Anglian Ultrasound Course July 2013

 Learning Objectives

To determine number of fetuses ;

chorionicity and amnionicity
To establish position of each fetus and
placenta
To detect congenital anomaly in
association with monochorionic multiple
pregnancies
 DIAGNOSIS

• THE DIAGNOSIS OF TWIN

PREGNANCY CAN BE MADE
TRANSVAGINALLY AS EARLY AS
5 WEEKS OF GESTATION:
 TWO YOLK SACS
AS EARLY AS 6 WEEKS:
 TWO BEATING HEARTS
 CHORIONICITY

CHORIONICITY: DIVISION BETWEEN

THE TWO AMNIOTIC CAVITIES

DICHORIONIC: TWO CHORIONIC AND

TWO AMNIOTIC MEMBRANES
MONOCHORIONIC: ONLY TWO
AMNIOTIC MEMBRANES
Chorionicity and Amnionicity

Di-chorionic, di-
amniotic

Mono-chorionic,
di-amniotic

Mono-chorionic,
mono-amniotic

Conjoined twin
 ZYGOSITY

ZYGOSITY: NUMBER OF FERTILISED

OOCYTES GIVING RISE TO A
MULTIPLE PREGNANCY

MONOZYGOUS: GENETICALLY
IDENTICAL

 DIZYGOUS:GENETICALLY
DIFFERENT
 ZYGOCITY AND CHORIONICITY
• ALL DIZYGOTIC TWINS HAVE ONE
INTER-TWIN DICHORIONIC
MEMBRANE

• MONOZYGOTIC TWINS MAY HAVE

DIFFERENT TYPES OF INTER-TWIN
MEMBRANES
 Placentation in monozygous twin
pregnancies

33% 65% 2%
DICHORIONIC

Placentae MONOCHORIONIC

Sacs MONOAMNIOTIC

Fetuses SIAMESE

Days 0 3 9 12 15
• DISTINCTION BETWEEN A
MONOCHORIONIC AND
DICHORIONIC INTER-TWIN
MEMBRANE CAN BE MADE
DURING THE FIRST TRIMESTER
OF PREGNANCY
 11-14 wk scan

Monochorionic Dichorionic
One placenta, always - sign Two separate placentas or sign


• MONOCHORIONICITY IS
ESTABLISHED BY THE PRESENCE
OF A SINGLE PLACENTA,
ABSENCE OF THE LAMBDA SIGN,
THIN DIVIDING MEMBRANE AND
SAME GENDER
 Chorionicity Determination
• First trimester
100% accuracy
thickness of
septum
‘T’ or ‘λ’

• Second trimester
80-90% accuracy
genitalia placental
site
thickness of septum
A-V anastomoses on
the chorionic
 Epidemiology of Multiple
pregnancy
• “Natural” rate of twinning varies
worldwide (age, race, nutrition, geography)
– Japan 7/1000 pregnancies
– Europe 11/1000 ( ~ 1/80)
– Nigeria 40/1000 (~1/25)

– But this applies to dizygous twinning as monozygous

twinning is constant 3-5/1000 births.
Fetal risks of multiple pregnancy
• Increased risk of stillbirth
– Throughout gestation
– Even at term, risk is 3x higher than singletons
• Some of these deaths are due to difficulties in labour & delivery

• Single fetal demise

– May have implications for ‘surviving twin’
– e.g. high risk of cerebral palsy in MC twins

• Preterm labour and delivery

• Intrauterine growth restriction

• “Failure to achieve growth potential”
Fetal risks of multiple pregnancy
• Congenital abnormalities
– At least twice risk of singletons
– Higher if monochorionic pregnancy

• Complications of
– monochorionicity (MCDA)
– monoamnionicity (MCMA)
• Twin-twin transfusion syndrome in MCDA
• Congenital abnormalities inc. conjoined twins
• Cord entanglement in MCMA
 The vanishing twin

• Affects 50% multiple pregnancies before 10 weeks

• A twin pregnancy is associated with increased risk of
preterm delivery and small for dates compared to
singletons
• May contribute a small proportion of total cases of
cerebral palsy
• If CRL of vanishing twin is measured will increase
PAPP-a level so use NT alone
• ESHRE 2011 Prof M Davies an increased risk of
structural abnormalities
 Twin Pregnancies

MISCARRIAG DC MC
E
12-24 wks 1.8% 12.2%
Monochorionic 20%
PERINATAL DEATH DC MC

>24 wks 1.6% 2.8%

GROWTH RESTRICTION DC MC

Total fetuses 12% 21%

PRETERM DELIVERY DC MC

Gestation <32 wks 5.5% 9.2% Dichorionic 80%
 Excess loss in MC twins
• Higher at all gestations
• Higher risk of prematurity
• But 8x greater beyond 32 wks
• 2-3% risk of IUD
if no TTTS, or IUGR
• Neuro-morbidity increased
irrespective of TTTS, or single IUD

Barigye et al 2005,
Hack et al 2007
 Chorionicity relevant to;
• Risk of perinatal morbidity and mortality
• Risk of genetic or structural abnormality
• Invasive testing and management of
discordant anomalies
• Feasibility of fetocide or MFPR
• Early detection of risks to MC twins
• Risk of sequelae if fetal compromise
 Prenatal diagnosis
• Risk of structural malformation reduced
• Risk of anencephaly and CHD increased
• Nt sensitivity same but FPR increased
• Procedure related loss no higher
• Beware contamination rates(5%) with CVS
• Option of late karyotype for discordant
anomalies +/- late fetocide (5-10% risk of
loss of healthy twin if fetocide in 1st/2nd T)
Complications in twin
pregnancies
 Complications of MC twins
• Feto-fetal (Twin-Twin) transfusion syndrome

• Death of co-twin

• Twin reversed arterial

perfusion sequence (TRAP)

• Monoamniotic twins

• Conjoined twins
 Twin-Twin-Transfusion
Syndrome
• About 50% of MCDA twins show some discrepancy for growth,
amniotic fluid or Doppler

• 10-15% of monochorionic twin pregnancy develop TTTS (1: 3200

pregnancies)

• TTTS usually develops in 2nd trimester (16-22 weeks)

• Accounts for 17% of perinatal death among twins overall

5-10% of survivors have long-term neurodevel’ sequelae

50% risk of CP in survivor in event of twin death
What causes TTTS?
• Shared placental vessels or
anastomoses.

• May connect
– arteries to arteries (AAA),
– arteries to veins (AVA),
– or veins to veins (VVA)

• Some anastomoses protect against

haemodynamic imbalance
Hypervolemia Hypovol’
– others allow ‘transfusion’. Polyuria

- the relative flow through these Oliguria

vessels determines the risk.
Hyperosmolality

Maternal Plasma
TWIN-TWIN TRANSFUSION SYNDROME
J Egan A Borgida; Ed Callen, 2007
Normal paired branch vessels from umbilical cord (left) and
arterio-venous anastomosis in monochorionic twin placenta
(right) J Egan & A Borgida; Ed Callen, 2007
 TWIN-TWIN TRANSFUSION
SYNDROME

• INCIDENCE: appr 15%

• ETIOLOGY: RESULT OF A NET UNBALANCED

FLOW BETWEEN TWO MONOCHORIONIC
FETUSES THROUGH PLACENTAL VASCULAR
COMMUNICATIONS
Twin-Twin Transfusion Syndrome
USS findings
• Acute 2nd trimester polyhydramnios
(16-24 weeks)
• Monochorionic pregnancy

SIZE AF BLADDER
DONOR o
RECIPIENT
 Twin-Twin-Transfusion Syndrome

• Sonographic staging by Quintero

– Stage I: Bladder donor visible, Doppler normal

– Stage II: Bladder donor not visible, Doppler not critically
abnormal
– Stage III: Doppler critically abnormal in either twin
– Stage IV: Ascites, pericardial or pleural effusion, hydrops
– Stage V: One or both babies are dead

Quintero et al
J Perinatol 1999
 Anhydramnios / polyhydramnios

Associated donor
Doppler
findings in recipient

TTTS
Absent / Reverse EDF in Absent / Reverse ‘a’ wave in
umbilical artery of ductus venosus of recipient
donor
 Nuchal translucency (NT)
Aneuploidy
Increased nuchal translucency (e.g. trisomy 21)
Genetic syndromes
Structural heart disease Very
early feature of TTTS
 Twin-Twin-Transfusion
Syndrome
• Treatment options:

• Serial amnioreduction
• +/- septostomy
• LASER
• Selective fetocide/cord occlusion

• Overall survival with treatment 54.8%

• Alternative conservative management in severe

TTTS associated with 90-100% mortality
 Amniodrainage Vs Laser ablation in
severe TTTS
Laser Amni
Pregnancies (116) 73 o 43
Gestation 20 (17-25)
Survival fetuses 79% 60%
Death both fetuses 3% 19%
Delivery (wks) 33.7 30.7
Abnormal NN brain 6% 18%
Hecher et al 1999

Laser Amni
Pregnancies (142) 72 o 70
Gestation 20 (17-25)
Survival fetuses 76% 51%
Death both fetuses 24% 49%
Delivery (wks) 33.3 29.0
Abnormal NN brain 7% 20%
Senat et al NEJM 2004
 Further complications of MC twins
• TRAP
– Acardiac twin receives blood from A-A anastomosis
with Pump twin. 50% mortality for Pump
twin unless mechanical separation of
twins (bipolar diathermy)

• Death of a co-twin
– 25% risk of death in healthy co-twin
– 25% risk of neurological/renal
lesions in co-twin

Management dependant on time elapsed, gestation, pre-

event health of survivor.
Further complications of MC twins

Conjoined twins
– Rare. 1/100,000 births
– Outcome dependant on
gestation and anatomy
Mortality certain if cardiac
connection
 Further complications of MC twins
• Monoamniotic twins
– 1% of MC twins.
Entangled cords
inevitable
– NSAIDS to reduce
polyhydramnios and
FM
• Delivery
– 30-32 wks caesarean
 Ultrasound and the
Management of Twin
Pregnancy
• Chorionicity best determined before 14 weeks
• Risk of chromosomal problems –
Nuchal (NT) scan before 13+6
• NT also for assessment of risk of TTTS and
cardiac anomalies
• Growth assessment:
– Scans every 2/40 for MC twins, every 4/40 for DC
twins
– Check growth, amniotic fluid and Doppler studies
Prevention of
multiple
pregnancy
• No. embryos replaced

• Multifetal pregnancy reduction (MFPR)

– Reduce to two at 11-12 weeks
– Nt and anomaly scan
– 7.5% risk miscarriage (Yaron et al 1999)
– Reduced risks of prematurity, miscarriage, PNMR, and
adverse neurodevelopmental
outcomes
successful twins
 Take home messages (I)
• Distinction between a monochorionic and
dichorionic inter-twin membrane can be
made during the first trimester of
pregnancy;
• Monochorionicity is established by the
presence of a single placenta, absence of the
lambda sign, a thin dividing membrane, and
same gender.
 Take home messages (II)
• Complications of monochorionicity (MCDA)
and monoamnionicity ( MCMA) are:
• Twin-twin transfusion syndrome in MCDA;
• Congenital abnormalities incl. conjoined twins;
• Cord entanglement in MCMA;

• A twin pregnancy is associated with increased

• risk of prenatal death and fetal growth restriction
compared to singletons.
 Take home messages (III)
• Complications of monochorionic twins are:
• Fetal-fetal ( twin-twin ) transfusion
syndrome;
• Death of co-twin;
• Twin reversed arterial perfusion sequence
(TRAP);
• Monoamniotic twins;
• Conjoined twins.
•

• Thank you