done by our Ho for Ho CME

1. By: Dr Syuhadah
Mentor: Dr Hasniza

2.  Definition: Any Pregnancy in which 2 or more
embryos or fetuses occupy the uterus
simultaneously
 Increased incidence (assisted reproductive
technology)
 Twins account for about 1% of pregnancies
 Hellins law (80 n-1)
- Twins → 1 in 80
- Triplets → 1 in 802
- Quadruplets → 1 in 803

3. ↑maternal age and parity
Assisted reproduction techniques
- Ovulation induction agents
(gonadotropins)
- In-vitro fertilization (IVF)
Family history

4. Monozygotic VS Dizygotic

5.  Monozygotic twins (identical)
 Originate by fertilization of
single ovum by single sperm.
 The twinning may occur at
different periods after
fertilization and this influences
the process of implantation and
the formation of the fetal
membranes.

6. Monozygotic/
identical/uniovular
(1 zygote divide into 2)
~33%
Dichorionic
Diamniotic
(cleavage of
embryonic egg
<3days )
~30%
MONOchorionic
Diamniotic
(4-8days)
~69%
MONOchorionic
MONOamniotic
(9-12days)
~1%

8.  Dizygotic twins
(non-identical )
 Results from
fertilisation of
two ova by two
sperms.
 Dichorionic and
diamniotic twins.

9. A. History Taking
 Family history of multiple
pregnancy
 Recent infertility treatment
 Excessive nausea and vomiting
 Excessive lower limb swelling
and varicosities
 Excessive fetal movement and
abdomen overdistension
 Extremely fatigue

10. B. Physical Examination
 Anaemia & oedema
 Raised BP
 Uterus larger than dates
 Polyhydramnios (> in monozygotic
twins)
 Multiple fetal parts & poles
 > 1 heart sound with different rates
 Abnormal weight gain

11.  Zygosity
 Ultrasound-
=> Gender discordance = dizygotic
 DNA fingerprinting, from amniotic fluid sample
(amniocentesis), placental tissue (chorionic
villi sampling) and fetal blood (cordocentesis)
 Chorionicity
 Characteristic of membrane(US)-

12. A: Thick amnion-
chorion septum, Twin-
peak sign (lamda sign)
~dichorionic
B: Thin amnion-chorion
septum, The "T sign"
~monochorionic

13. Why so important to
differentiate???
Prenatal diagnosis of chorionicity is important as
monochorionic pregnancies have increased rates and
severity of all types of obstetric complications when
compared with dichorionic pregnancies.

14. Maternal
• ↑ Sx of early pregnancy (↑HCG)
• Miscarriage
• Anaemia (↑ Fe,folate & B12 )
• Polyhydramnios (uniovular twins)
• PIH (↑3-5x)
• APH (placenta praevia)
• PPH (uterine atony d2 over
stretching)
• GDM (↑diabetogenic placental
hormones)
• Ineffective labour (malpresentation)
• Thromboembolic ds (↑pelvic vein
compression)
Fetal
• Single fetal death
• Preterm labour (d2
overdistended uterus, polyH,
intrauterine infection)
• IUGR (discordant growth)
• Stillbirth
• Congenital abnormality
• Twin to twin transfusion
syndrome
• Asphyxia (cord entanglement)
• Intrauterine death

16.  TTTS is found in MCMA as well as MCDA
pregnancies.
 TTTS is more common in MCDA pregnancies than
MCMA pregnancies, possibly reflecting that there
are more protective artery–artery anastomoses in
the latter.
 Rarely (in approximately 5% of cases), the
transfusion may reverse during pregnancy, with the
donor fetus demonstrating features of a recipient
fetus and vice versa
 Unequal placental sharing and peripheral,
‘velamentous’ cord insertions are common in TTTS

17.  Affects 10-15% of monochorionic twin
pregnancies.
 Pathophysiology:
 Result of transfusion of blood from donor to
recipient twin through abnormal artery-to-
vein anastomoses in the placenta
 The donor suffers hypovolaemia and hypoxia →
IUGR, smaller in size, oligohydramnios & high
output cardiac failure
 The recipient fetus exhibit hypervolemia →
large size, polyhydramnios, cardiomegaly, CCF

20.  More than 90% ends in miscarriage/severe preterm
delivery
 To monitor:
 US doppler 2 weekly
 Management:
I. Laser coagulation – occlude the vascular
anastomosis between twins (presenting prior to
26weeks of gestation)
II. Amnioreduction every 1 - 2/52, drain amniotic
fluid from recipient sac
III. Septotomy (cord entanglement risk)
IV. Anticipate preterm delivery – corticosteroid
(promote fetal lung maturity

21.  Occur in monochorionic twin
 Fetal demise <14weeks-not increase risk on
the survivor twin
 Confers risk to survivor twin if fetal
demise after 14 weeks.
 Dt transfer of thromboplastin from dead
twin > produce thrombotic arterial occlusion
> occlusions of ant & mid cerebral arteries >
multicystic encephalomalacia & neurologic
damage.
 Induce consumptive coagulopathy in mother.

22.  Antenatal
 Intrapartum

23. • All women with a multiple pregnancy should be
offered an ultrasound examination at 10–13weeks
of gestation to assess:
I. viability
II. chorionicity
III. major congenital malformation
IV. nuchal translucency for designation of risk of
aneuploidy and twin-to-twin transfusion
syndrome.

24. 1. Ultrasound at 10–13 weeks: (a) viability; (b)
chorionicity; (c) NT: aneuploidy
2. Structural anomaly scan at 20–22 weeks.
3. Serial fetal growth scans e.g 24, 28, 32 and then
two- to four-weekly.
4. BP monitoring and urinalysis at 20, 24, 28 and
then two-weekly.
5. 34–36 weeks: discussion of mode of delivery and
intrapartum care.
6. Elective delivery at 37–38 completed weeks.
7. Postnatal advice and support (hospital- and
community-based) to include breastfeeding and
contraceptive advice

25. 1. Ultrasound at 10–13 weeks: (a) viability; (b)
chorionicity; (c) NT: aneuploidy/TTTS
2. Ultrasound surveillance for TTTS and discordant
growth: at 16 weeks and then two-weekly.
3. Structural anomaly scan at 20–22 weeks (including
fetal ECHO).
4. Fetal growth scans at two-weekly intervals until
delivery.
5. BP monitoring and urinalysis at 20, 24, 28 and then
two-weekly.
6. 32–34 weeks: discussion of mode of delivery and
intrapartum care.
7. Elective delivery at 36–37 completed weeks (if
uncomplicated).
8. Postnatal advice and support (hospital- and
community-based) to include breastfeeding and
contraceptive advice.

26.  Dietary advice: adequate caloric intake to meet
increased demands, supplement of iron (60-80
mg /day), folic acid, calcium, vitamins
 Monitor for infection, anaemia, PIH, preterm
labour & malpresentation
 Corticosteroid if strong possibility of preterm
labour (for lung maturity)

27. 1. Leading twin is cephalic

28. INTRAPARTUM MANAGEMENT OF TWINS
Criteria for vaginal delivery fulfilled
Deliver the 1st twin
Clamp and cut the cord
Note lie of 2nd twin
Transverse lie Longitudinal lie
Attempt External Cephalic
Version and vaginal delivery
under GA
If unsuccessful C-section
Amniotomy with controlled oxytocin
infusion if there is uterine inertia
Note presentation
Vertex Breech
Vaginal delivery or optionally
outlet forceps or ventouse
Breech extraction
or assisted breech
delivery

29. In PIH and cardiac disease: give oxytocin 10
unit i.m
Syntometrine 1 ml (5 unit oxytocin and 500
mcg ergometrine i.m) with delivery of anterior
shoulder of 2nd baby
Placenta delivered with controlled cord traction
In high risk of uterine atony and PPH, i.v
infusion 40 units oxytocin over 6 hours after
delivery)
Episiotomy/perineal repair if needed

30. i) ELECTIVE
 1st baby non-cephalic
especially shoulder
 Conjoined twins
 Congenital abnormality
precluding safe vaginal
delivery
 IUGR in dichorionic twin
 Chronic TTTS
 Monoamniotic twin
 Placenta praevia
 Triplets or more
 Contracted pelvis
 Previous C-section
 Pre-eclampsia
ii) EMERGENCY
 Fetal distress
 Cord prolapse in 1st
baby
 Non-progress of
labour
 Collision of both
twins
 2nd twin transverse,
version failed after
1st delivery of twin