Twin gestation

Multiple gestation or twins continues to increase in

the US secondary to assisted reproductive techniques
and an advancing maternal age at childbirth .
Maternal and perinatal morbidity are higher in
multiple gestations, as well as congenital anomalies.
Prenatal visits are more frequent with multiple
gestations, since they are at increased risk for
complications. Many of these women require care
by trained specialist. In twins, normal physiologic
changes are increased compared with a singleton
pregnancy. There is an increase in cardiac output, iron
requirements, plasma volume , blood volume,
glomerular filtration rate, and caloric requirements
Maternal Adaptations
Maternal physiologic changes are more exaggerated compared to
a singleton pregnancy
Cardiac:
-rise heart rate , increased stroke volume, high cardiac output is
more secondary to the raised myometrial contractility and blood
volume
-Rise in uterine volume / weight
Respiratory : Further raise in tidal volume and oxygen
consumption
Renal: high in renal size
Nutrition:
-Calories: Average to consume 3000-4000 kcal/day compared to
2400 kcal/ day in singletons
-Weight gain: Avg/ week is 1-1.5 pounds; total gain: 35-45 pounds
Types of Twins
A zygote is the result of fertilization of an
ovum with a spermatozoan
-Dizygotic twins are the result of two ova
fertilized by two different sperm. Risk
factors include fertility drugs, race ,
advanced maternal age, and parity. These
are fraternal twins
-Monozygotic twins are the result of a single
ovum fertilized by one sperm which
subsequently divides. The frequency of 1 in
250 pregnancies . These are identical twins
Division of the ovum between days O and 3:
Dichorionic, diamniotic monozygotic twins
* Division between 4 and 8 days. Monochorinoic,
Diamniotic monozygotic twins
* Division between 9 and 12 days: Monochorionic ,
monoamniotic monozygotic twins
* Division after 13 days: Conjoined twins
-Monochorionic twins have more complications than
dichorionic
-Monoamniotic twins have more complications than
diamniotic
Prenatal Diagnosis
-Diagnosis and genetic counseling is important
because of the high risk of congenital anomalies
-Both monozygotic and dizygotic twins are at up/
raise for structural amnoalies
-Multiple gestation have an increased risk of
aneuploidy
 * Firs-trimester serum markers not as valid of
multiple gestation
 * Nuchal translucency is the preferred first -
trimester marker
Diagnosis and Management of twins
-Physical exam may show a uterine size /gestational
age (GA) difference with size greater than expected fro
mGa
-Ultrasound is used for the following in multiple
gestations:
* Confirm diagnosis
* Determine chorionicity
* Detect fetal anomalies
*Measure cervical lenth
*Evaluate for fetal growth
* Guide invasive procedures
* Confirm fetal well-being
Determining chorionicity is important :
 * Chorionicity can best be deteremined in the first or
early second trimester by ultrasound (US)
* Monoschorionic twins should undergo US
examination to look for fetal growth every 4 weeks,
while dichorionic twins can be scanned every 6-8
weeks for growth
* Growth restriction rates are higher among the
monochorionic in comparison to the dichorionic twin
gestation
*Monochorionic twins may also be at risk for twin-
twin transfusion syndrome
*
*Induction of labor of twins should be strongly
considered when 38 weeks gestation has been reached
, as the rate of stillbirth and growth restriction
increases after this GA
*Determining the route of delivery (vaginal versus
cesarean ) should be based on the experience of the
obstetrician and the presentation of both twins
* Breech presentation of Twin A and cephalic
presentation of Twin B may causes interlocking
twins, and cesarean delivery should be undertaken in
this cause
 Twin-Twin Transfusion
-A serious complication of monochorinoic multifetal
gestation in which blood / intravascular volume is
shunted from one twin to another
-The major risk is intrauterine fetal demise, in which
one twin develops complications of due to under-
perfusion and the other due to over perfusion
-The theoretical cause in unbalanced vascular
anastomoses
-US is needed for diagnosis
- Treatement is laser coagulation of the anastomoses