obstetrics & gynecology,

1. TWIN PREGNANCYTWIN PREGNANCY
By Sophia BanoBy Sophia Bano
0808 -- 186186
Batch-LBatch-L
Final Year MBBSFinal Year MBBS

2. Definition and TypesDefinition and Types
Twin pregnancy means that woman is carryingTwin pregnancy means that woman is carrying
two fetuses at a timetwo fetuses at a time ..
TYPES.TYPES.
1.1. Dizygotic twins/binovular/fraternalDizygotic twins/binovular/fraternal
2.2. Monozygotic twins/uniovular /identicalMonozygotic twins/uniovular /identical

3. Dizygotic TwinsDizygotic Twins
 They result when two oocytes areThey result when two oocytes are
simultaneously released from the same orsimultaneously released from the same or
both ovaries and fertilized by two separateboth ovaries and fertilized by two separate
spermatozoa derived at the same coitus.spermatozoa derived at the same coitus.
 Account for 75% of all twins.Account for 75% of all twins.
 WWithin the uterus the two zygotes implantithin the uterus the two zygotes implant
separately each having its own set ofseparately each having its own set of
placenta and membranes( dichorionicplacenta and membranes( dichorionic
diamniotic(diamniotic(

4. Monozygotic TwinsMonozygotic Twins
 Ovum is fertilized by a sperm & a zygote isOvum is fertilized by a sperm & a zygote is
formedformed
 If cell mass of zygote gets divided in first 3If cell mass of zygote gets divided in first 3
days after fertilization - dichorionicdays after fertilization - dichorionic
diamniotic twidiamniotic twins23%ns23%

5.  Division between 3 &Division between 3 & 88 days after fertilization -days after fertilization -
monochorioinic diamnioticmonochorioinic diamniotic twins75%twins75%
 Division betweenDivision between 88 && 1313 days after fertilization -days after fertilization -
monochorioinic monoamniotic twinsmonochorioinic monoamniotic twins
 Division afterDivision after 1313 days -days - conjoint twinsconjoint twins

6. Twins
Monozygotic
Dichorionic/Monochorion
ic depending on time of
cleavage
Same gender ,blood
Group and karyotype.
Dizygotic
Dichorionic/Diamniotic.
same or different blood .
groups and gender.
Different Karyotype.

7. TwinTwin PregnancyPregnancy AetiologyAetiology
 IncidenceIncidence
 Monozygotic twins - 3.5-5%Monozygotic twins - 3.5-5%
 Dizygotic twins; depends on -Dizygotic twins; depends on -
 RaceRace
 ParityParity
 AgeAge
 Family historyFamily history
 BuiltBuilt
 RecurrenceRecurrence

8.  In Vitro fertilizationIn Vitro fertilization
– Intrauterine inseminationIntrauterine insemination
– Assisted HatchingAssisted Hatching
– Frozen Embryo Transfer, Blastocyte EmbryoFrozen Embryo Transfer, Blastocyte Embryo
TransferTransfer
 Fertility DrugsFertility Drugs
– Clomiphene citrate (clomid, serrophene)Clomiphene citrate (clomid, serrophene)
– Gonadotropins (Gonadotropins (GonalF, follistim,GonalF, follistim,
 Role of LH and FSHRole of LH and FSH

9. What contributes to the perils of twin pregnancyWhat contributes to the perils of twin pregnancy
MaternalMaternal RisksRisks
 Exaggerated early symptomExaggerated early symptom) hyperemesis) hyperemesis
gravidarumgravidarum))
 Pregnancy induced hypertensionPregnancy induced hypertension
 AnemiaAnemia
 Urinary tract infectionsUrinary tract infections
 Placental abruptionPlacental abruption
 Increased minor disorders of pregnancy (back-ache,Increased minor disorders of pregnancy (back-ache,
leg pain, inability to walk properlyleg pain, inability to walk properly,supine,supine
hypotension syndrome dyspnoea and dyspepsiahypotension syndrome dyspnoea and dyspepsia))

10.  preterm labourpreterm labour
 Need for antenatal hospitalizationNeed for antenatal hospitalization
 Risk of operative deliveryRisk of operative delivery
 Increased risk for C/SIncreased risk for C/S
 Postpartum hemorrhage (PPH)Postpartum hemorrhage (PPH)
 Postnatal problemsPostnatal problems

11. Concerns – Higher Fetal RisksConcerns – Higher Fetal Risks
Congenital MalformationsCongenital Malformations::
Unique toUnique to twintwin pregnancy arepregnancy are
conjoined twins,fetal acardia,exstrophyconjoined twins,fetal acardia,exstrophy
OOf cloaca.f cloaca.
Malformations more frequent to twinMalformations more frequent to twin
pregnancy but not unique to it includepregnancy but not unique to it include
AAnencephaly,encephalocele,hydrocephalusnencephaly,encephalocele,hydrocephalus
BBowel atresia, cardiac anomalies congenitalowel atresia, cardiac anomalies congenital
dislocation of hip jt.dislocation of hip jt.
Acardiac twin

12. MiscarriagesMiscarriages
Vanishing twin syndromeVanishing twin syndrome
Loss of both twinsLoss of both twins
Intrauterine death of one twin inIntrauterine death of one twin in early pregnancyearly pregnancy
Fetus PapyraceousFetus Papyraceous
Single fetal death during 2nd half ofSingle fetal death during 2nd half of GGestationestation
PPrognosis of surviving twin varies with chorionicity.rognosis of surviving twin varies with chorionicity.
DDichorionic surviving twin has good prognosis .ichorionic surviving twin has good prognosis .
MMonochorionic may develop renal cortical cystsonochorionic may develop renal cortical cysts
and lesions in brain called multicystic encephalo-and lesions in brain called multicystic encephalo-
malacia.malacia.
Intrauterine growth restrictionIntrauterine growth restriction
Twin reversed arterial perfusion sequenceTwin reversed arterial perfusion sequence
MMonozygotic twins ,umbilical cords are linked by large arterio arterialonozygotic twins ,umbilical cords are linked by large arterio arterial

13. anastomosis and twin with high arterial pressureanastomosis and twin with high arterial pressure
pumps blood in other twin with low pressurepumps blood in other twin with low pressure
former is called pump twin and latter perfusedformer is called pump twin and latter perfused
twin.lower part of perfused fetus shows varyingtwin.lower part of perfused fetus shows varying
development while cephalic pole fails to developdevelopment while cephalic pole fails to develop
.Heart is absent and presented by large pulsating.Heart is absent and presented by large pulsating
vessel thus called ACARDIAC MONSTER.Perfusedvessel thus called ACARDIAC MONSTER.Perfused
twin has CONFIRMED MORTALITY while pumptwin has CONFIRMED MORTALITY while pump
twin has high risk of polyhydraminos.twin has high risk of polyhydraminos.

14. Malpresentations:Malpresentations:
Of all types are seen.At time of labour firstOf all types are seen.At time of labour first
twin presents with vertex in 70 % of casestwin presents with vertex in 70 % of cases
and 30% of fetuses haveand 30% of fetuses have
malpresentation.Malpresentationmalpresentation.Malpresentation
IIncrease incidence of cord prolapse, intrapartumncrease incidence of cord prolapse, intrapartum
asphyxia and hence perinatal mortality.asphyxia and hence perinatal mortality.

15. Risks specific to MonoamnioticRisks specific to Monoamniotic
 2/3 monozygotic are2/3 monozygotic are
monochorioinicmonochorioinic
 2% monozygotic are monoamniotic2% monozygotic are monoamniotic
 Risk of cord accidents is increasedRisk of cord accidents is increased
 Twin to twin transfusion syndromeTwin to twin transfusion syndrome
 Interlocking at birthInterlocking at birth

16.  INTERLOCKING TWINSINTERLOCKING TWINS

17. Twin to twin transfusion syndrome (TTTS)Twin to twin transfusion syndrome (TTTS)
 Placental vascular anastomosis between both fetal placentaePlacental vascular anastomosis between both fetal placentae
 76-98% of monochorioinic twins76-98% of monochorioinic twins
 Discordant fetal size & amniotic fluidDiscordant fetal size & amniotic fluid
volume between both fetusesvolume between both fetuses
 Recipient twin - Polycythemia ,Recipient twin - Polycythemia ,
hypervolemia ,polyhydramnioshypervolemia ,polyhydramnios
 Donor twin - anemia/ hypovolemia/ oligohydramnios &IUGRDonor twin - anemia/ hypovolemia/ oligohydramnios &IUGR
 Ascites, pleural effusion, pericardial effusion may develop inAscites, pleural effusion, pericardial effusion may develop in
both twinsboth twins
 Mortality if syndrome occurs early at 18-26 weeks - 79-100%Mortality if syndrome occurs early at 18-26 weeks - 79-100%

18. TTTS ManagementTTTS Management
 Serial therapeutic amniocentesisSerial therapeutic amniocentesis
 Pregnancy terminationPregnancy termination
 Indomethacin to reduce amniotic fluidIndomethacin to reduce amniotic fluid
 Selective feticideSelective feticide of donor twinof donor twin
 Laser ablation of placental vascular anastomosisLaser ablation of placental vascular anastomosis
 Fetal phlebotomy & transfusionFetal phlebotomy & transfusion

19. ManagementManagement of Twin pregnancyof Twin pregnancy
 PrepregnancyPrepregnancy - discuss twin pregnancy risk with- discuss twin pregnancy risk with
ART etcART etc
 PrenatalPrenatal
 Frequent visits (every 2 weeks or more often)Frequent visits (every 2 weeks or more often)
 Folate supplementationFolate supplementation
 Iron supplements in early second trimesterIron supplements in early second trimester
 Anomaly scan at 18-20 weeksAnomaly scan at 18-20 weeks
 Check Chorionicity / amniocityCheck Chorionicity / amniocity
 Educate the patientEducate the patient

20.  Frequent USG evaluations every 3-4 weeksFrequent USG evaluations every 3-4 weeks
 Umbilical artery Doppler etc as requiredUmbilical artery Doppler etc as required
 Rest in lateral decubitus for min 2 hrs each morning &Rest in lateral decubitus for min 2 hrs each morning &
afternoon ; sleep for 10 hrs atleast each nightafternoon ; sleep for 10 hrs atleast each night
 Frequent vaginal examinationFrequent vaginal examination
 Careful monitoring throughout antenatal periodCareful monitoring throughout antenatal period
DETERMINATION OF CHORIONICITYDETERMINATION OF CHORIONICITY::
USG in first trimester with thick intertwin septumUSG in first trimester with thick intertwin septum
comprising of two amnion and two chorion measuringcomprising of two amnion and two chorion measuring
MMore than 2mm indicates dichorionic twinsore than 2mm indicates dichorionic twins

21.  A Single extraembryonic coelom with two yolk sacsA Single extraembryonic coelom with two yolk sacs
separated by a thin septum comprising only of twoseparated by a thin septum comprising only of two
amnions and measuring less than 2mm isamnions and measuring less than 2mm is
monochorionic diamniotic placentation.monochorionic diamniotic placentation.
 A Single coelom with single yolk sac and no dividingA Single coelom with single yolk sac and no dividing
septum indicates monochorionic monoamnioticseptum indicates monochorionic monoamniotic
placentation.placentation.

22. Optimal time of delivery ?Optimal time of delivery ?
 Singleton pregnancy mostly deliver between 39 – 40Singleton pregnancy mostly deliver between 39 – 40
weeksweeks
 Twins deliver between 37 - 38 weeksTwins deliver between 37 - 38 weeks
 Fetal lung maturity occurs at an earlier gestation inFetal lung maturity occurs at an earlier gestation in
twintwin pregnancypregnancy at 32 weeksat 32 weeks
 Fetal monitoring should be performed betweenFetal monitoring should be performed between
35 – 38 weeks in case of twins35 – 38 weeks in case of twins
 Postmaturity is uncommonPostmaturity is uncommon

23. Concerns about labour/ delivery managementConcerns about labour/ delivery management
 Induction of labor in cases of : PIH, IUGRInduction of labor in cases of : PIH, IUGR
 Preterm labour/PPROM -Steroids for lung maturityPreterm labour/PPROM -Steroids for lung maturity
 Risk of APH (Ante partum hemorrhage)Risk of APH (Ante partum hemorrhage)
 Risk of PPH (Postpartum hemorrhage)Risk of PPH (Postpartum hemorrhage)
 Continuous fetal heart monitoring for both twinsContinuous fetal heart monitoring for both twins
 Epidural analgesiaEpidural analgesia
 Mode of delivery depending on presentations & otherMode of delivery depending on presentations & other
associated risk factors.associated risk factors.

24. How to avoid perils of deliveryHow to avoid perils of delivery
 Careful consideration ofCareful consideration of
 Gestational ageGestational age
 Weight of twinsWeight of twins
 ChorionicityChorionicity
 Presentation of twins :Presentation of twins :
Nine possible combinationsNine possible combinations
1. Vertex-vertex1. Vertex-vertex
2. Vertex-2. Vertex-breechbreech
3.3. BreechBreech – vertex– vertex
4. Breech –4. Breech – breechbreech
5. Vertex - transverse5. Vertex - transverse
Others….Others….

25. MODE OF DELIVERYMODE OF DELIVERY
ELECTIVE CAESAREAN SECTION IFELECTIVE CAESAREAN SECTION IF
 PPregnancy induced hypertesionregnancy induced hypertesion
 Diabetes mellitusDiabetes mellitus
 Antepartum haemorrhageAntepartum haemorrhage
 RRh-isoimmunisationh-isoimmunisation
 IIntrauterine growth restrictionntrauterine growth restriction
 MMalpresentation of 1st twinalpresentation of 1st twin
 CConjoined twinsonjoined twins
 MMonoamniotic twinsonoamniotic twins

26.  PPolyhydramniosolyhydramnios
 SScarred uteruscarred uterus
Vaginal DeliveryVaginal Delivery
 RRoute of choice for uncomplicated twinoute of choice for uncomplicated twin
pregnancy with 1st twin in cephalicpregnancy with 1st twin in cephalic
presentationpresentation

27. Prerequisites for SafePrerequisites for Safe VaginalVaginal DeliveryDelivery
 Knowledge of lie, presentation & weight of each fetusKnowledge of lie, presentation & weight of each fetus
 Portable ultrasound scanner & a CTG with dual monitorsPortable ultrasound scanner & a CTG with dual monitors
 Preferable to monitor one fetus externally & other internallyPreferable to monitor one fetus externally & other internally
by scalp electrodeby scalp electrode
 Intravenous accessIntravenous access
 Availability of cross matched bloodAvailability of cross matched blood
 Two skilled obstetricians & neonatologistsTwo skilled obstetricians & neonatologists
 Continuous epidural analgesia is a good option due toContinuous epidural analgesia is a good option due to
frequent manipulative proceduresfrequent manipulative procedures
 Lithotomy positionLithotomy position

28. Management of first stage of LabourManagement of first stage of Labour
 If facilities avaliable labour in twin is monitoerd byIf facilities avaliable labour in twin is monitoerd by
continuous electronic fetal heart rate monitoring .continuous electronic fetal heart rate monitoring .
 LLatent phase of labour is often short due toatent phase of labour is often short due to
increased pre labour cervical dilatation.Active phaseincreased pre labour cervical dilatation.Active phase
maybe prolonged and dysfunctional labour patternmaybe prolonged and dysfunctional labour pattern
of all types are more common.of all types are more common.
 Epidural is the ideal mode of analgesiEpidural is the ideal mode of analgesiaa in labour inin labour in
twins as it allows safe manipulation of second twin .twins as it allows safe manipulation of second twin .

29. Management of 2nd stageManagement of 2nd stage
 Delivery of 1st twinDelivery of 1st twin;;
VVertex presentation delivery same as singeltonertex presentation delivery same as singelton
PPregnancy need for episiotomy and forceps are same.regnancy need for episiotomy and forceps are same.
AAt delivery of 1st twin placental side of cord must bet delivery of 1st twin placental side of cord must be
SSecured to avoid hemorrhage from 2nd twin ifecured to avoid hemorrhage from 2nd twin if
MMonochorionic.onochorionic.
 Delivery of 2nd twin ;Delivery of 2nd twin ;
2nd twin is at high risk due to placental separation.2nd twin is at high risk due to placental separation.
Recommended is that 2nd twin better be delivered withRecommended is that 2nd twin better be delivered with

30. IIn 15 min.of delivery of first.If uterine contractionsn 15 min.of delivery of first.If uterine contractions
donot resume by this time oxytocin infusion may bedonot resume by this time oxytocin infusion may be
started an ARM is then performed and delivery of 2ndstarted an ARM is then performed and delivery of 2nd
twin is contemplated.twin is contemplated.
SSpecial circumstances for 2nd twinpecial circumstances for 2nd twin
deliverydelivery
 IIf 2nd twin in vertex presentation fails to descend –f 2nd twin in vertex presentation fails to descend –
high vaccum extraction applicationhigh vaccum extraction application

31.  AAbnormal lie uncorrectable at ext.version,internalbnormal lie uncorrectable at ext.version,internal
podalic version may be usedpodalic version may be used
 CCaserean indicated ifaserean indicated if: Abnormal lie not corrected at: Abnormal lie not corrected at
ECV and internal podalic version not feasibleECV and internal podalic version not feasible
 ROM+Abnormal lie with or without cord prolapseROM+Abnormal lie with or without cord prolapse
 FFetal distress due to bolus of oxytocin administeredetal distress due to bolus of oxytocin administered
by mistke between delivery of two twins.by mistke between delivery of two twins.

32. Internal podalic versionInternal podalic version
• Experienced operatorExperienced operator
 EFW > 1500 gmEFW > 1500 gm
 Adequate liquorAdequate liquor
 Available anesthesia forAvailable anesthesia for
effective uterine relaxationeffective uterine relaxation
 Simultaneous preparationSimultaneous preparation
for emergency C/Sfor emergency C/S

33. Management of 3rd stageManagement of 3rd stage
 Most dangerousMost dangerous
 Risk of PPHRisk of PPH
 Large placenta – longer time to separateLarge placenta – longer time to separate
 More profuse bleedingMore profuse bleeding
 May occupy lower segment ( insufficient retraction )May occupy lower segment ( insufficient retraction )
 Uterine inertia following over distention of uterusUterine inertia following over distention of uterus
 Active management of 3Active management of 3rdrd
stage, use of oxytocistage, use of oxytocin andn and
even ergometrine if patient is normotensive.even ergometrine if patient is normotensive.

34. Special CasesSpecial Cases
Twins with previous scarTwins with previous scar
 Trial of scar if twins has a first vertexTrial of scar if twins has a first vertex should not be anshould not be an
absolute contraindicationabsolute contraindication
 Judicious external or internal manipulations are notJudicious external or internal manipulations are not
contraindicatedcontraindicated
 Prefer caesarean if tranverse / breech ?Prefer caesarean if tranverse / breech ?
 Success rate 30-75%Success rate 30-75%
 Risk of uterine rupture is the same as VBAC in aRisk of uterine rupture is the same as VBAC in a
singleton pregnancysingleton pregnancy

35. Management of Mono Amniotic TwinsManagement of Mono Amniotic Twins
Timing / mode of delivery !!!!!!Timing / mode of delivery !!!!!!
 Antenatal hospitalizationAntenatal hospitalization
 Fetal heart monitoring & cord entanglement diagnosisFetal heart monitoring & cord entanglement diagnosis
Greatest risk for intrauterine fetal death is at < 30 wksGreatest risk for intrauterine fetal death is at < 30 wks
 Labor / vaginal delivery do not increase perinatal deathLabor / vaginal delivery do not increase perinatal death
 Risk of cord of twin B being inadvertently clamped duringRisk of cord of twin B being inadvertently clamped during
delivery of twin A in case of vaginal deliverydelivery of twin A in case of vaginal delivery
 Patient should be informed about complicationsPatient should be informed about complications
 Best delivered by elective caesarean sectionBest delivered by elective caesarean section

36. Demise of One Fetus in TwinsDemise of One Fetus in Twins
 Management depends on –Management depends on –
 Gestational age at the time of deathGestational age at the time of death
 Cause of deathCause of death
 ChorionicityChorionicity
 If dichorionic & cause of death is intrinsic to affectedIf dichorionic & cause of death is intrinsic to affected
twin - well being of survivor twin is not jeopardizedtwin - well being of survivor twin is not jeopardized
 Monitoring of maternal platelets & fibrinogen ??Monitoring of maternal platelets & fibrinogen ??
 If cause of death is unknown; very close observation ofIf cause of death is unknown; very close observation of
survivor twin !survivor twin !

37. Death of One of theDeath of One of the
Twins when MonochorioinicTwins when Monochorioinic
Leads to -Leads to -
 Microcephaly / hydrocephalyMicrocephaly / hydrocephaly
 Cerebral palsy / atrophyCerebral palsy / atrophy
 Limb reduction deformitiesLimb reduction deformities
 Intestinal atresiaIntestinal atresia
 Renal necrosisRenal necrosis
 Pulmonary / Hepatic / splenic infarctsPulmonary / Hepatic / splenic infarcts

38. Conjoined twinsConjoined twins
Result when zygote divided after 13 days fom time ofResult when zygote divided after 13 days fom time of
fertilization.TWO groupsfertilization.TWO groups
 EEqual conjoined twinsqual conjoined twins
 ThoracophagusThoracophagus
 PyophagusPyophagus
 CraniophagusCraniophagus
 IIschiophagus.schiophagus.
 UUnequal conjoined twinsnequal conjoined twins

39. Post Natal ManagementPost Natal Management
 Prolonged hospitalProlonged hospital
staystay
 Breast feedingBreast feeding
encouragedencouraged
 Discuss and stressDiscuss and stress
on use ofon use of
contraceptioncontraception

40. THANK YOUTHANK YOU