Multiple Pregnancy

Ryan Saktika Mulyana

Multiple Pregnancy/ Multifetalpregnancy
The presence of more than one fetus in the gravid
uterus is called multiple pregnancy
• Two fetuses (twins)
• Three fetuses (triplets)
• Four fetuses (quadruplets)
• Five fetuses (quintuplets)
• Six fetuses (sextuplets)
 INCIDENCE
Hellin’s Law:
Twins: 1:89
Triplets: 1:892
Quadruplets: 1:893
Quintuplets: 1:894
Conjoined twins: 1 : 60,000
 Demography
• Race: most common in Negroes
• Age: Increased maternal age
• Parity: more common in multipara
• Heredity - family history of multifetal gestation
• Nutritional status – well nourished women
• ART - ovulation induction with clomiphene
citrate, gonadotrophins and IVF
Superfecundation
Fertilization of two different ova released in
the same cycle
Superfetation
Fertilization of two ova released in different
cycles
 Types of twins

Monozygotic (1/3 rds) Dizygotic (2/3 rd)

Results from fertilization Results from fertilization
a single ova of of two ovum

Monozygotic twins Dizygotic twins

(syn: Identical, uniovular) (syn: Fraternal, binovular)
 Monozygotic twins (syn: Identical, uniovular):
• Upto 3 days - diamniotic-dichorionic
• Between 4th & 7th day - diamniotic
monochorionic - most common type
• Between 8th & 12th day- monoamniotic-
monochorionic
• After 13th day - conjoined / Siamese twins.
DIZIGOTIC TWINS
MONOZIGOTIC TWINS
 Conjoined twins
Ventral:
1) Omphalopagus
2) Thoracopagus
3) Cephalopagus
4) Caudal/ ischiopagus
Lateral:
1) Parapagus
Dorsal:
1)Craniopagus,
2)Pyopagus
THORACOPAGUS CRANIOPAGUS ISCHIOPAGUS

OMPHALOPAGUS PYOPAGUS RACHYPAGUS

 Born May 11, 1811
Samutsongkram, Siam (now Thailand)

Died January 17, 1874 (aged 62)

Mount Airy, North Carolina, U.S.

Cause of death Stroke

Heart attack
Resting place White Plains Baptist Church Cemetery

Citizenship Siamese
American
Occupation Cotton Plantation
Years active 1834-1874

Chang and Eng Bunker

INVESTIGATION
Chorionocity
 Differences in zygocity
Monozygotic Dizygotic
• 1 ova + 1 sperm • 2 ova + 2 sperm
• Same sex • Same or opposite sex
• Identical features • Fraternal resemblance
• Single or double placenta • Double or s/t fused
• Same genetic features • Different genetic features
• DNA microprobe -same • DNA microprobe - different
Differences in chorionicity with single placenta
D / D ( fused placenta ) M/D
• Monozygotic or dizygotic • Monozygotic
• Thick dividing membrane • Thin dividing membrane
> 2mm 2mm or less
• Twin peak / lambda sign • T sign
Chorionicity should be determined at the time the twin pregnancy is detected by
ultrasound based upon the number of placental masses, the appearance of the membrane
attachment to the placenta and the membrane thickness. This scan is best performed
before 14 weeks of gestation.[New 2016] (B)
On ultrasound, the fetuses in twin pregnancies should be assigned
nomenclature (i.e. upper andlower, or left and right) and this should be clearly
documented in the woman’s case notes to ensureconsistency throughout
pregnancy. [New 2016] (C)
Dating
 Dating
When twin pregnancy is the result of IVF, accurate
determination of gestational age should be made from the
date of embryo transfer. (II-1A)

To avoid missing a situation of early IUGR in one twin, most

experts agree that the clinician may consider dating
pregnancy using the larger fetus. (III-C)
Screening for Abnormality
 Aneuploidy Screening in 1st T
Nuchal transluscency and maternal age.
 Using the average NT:
NT in conjunction with maternal age: 75% sensitivity
 Useful in the early detection or prediction of TTTS.
An NT threshold at the 95th percentile had a
PPV:43%
NPV: 91%

Women with monochorionic twins who wish to have aneuploidy screening should be offered
nuchal translucency measurements in conjunction with first trimester serum markers
(combined screening test) at 11+0 weeks to 13+6 weeks of gestation (crown–rump length 45–
84 mm). [New 2016] (C)
 Aneuploidy Screening in the 2nd T
Soft markers of Down syndrome
 Nonossified nasal bone
 linear arrangement of the tricuspid and mitral valves within the heart
 thickened nuchal skin fold
 slightly short humerus relative to head size
 slightly short femur relative to head size
 echogenic intracardiac focus
 fetal hydronephrosis

In women with monochorionic twin pregnancies who ‘miss’ or who have unsuccessful first
trimester screening for aneuploidy, second trimester screening by the quadruple test should be
offered. [New 2016] (D)
 Congenital Malformations
 Incidence:
 1.2 to 2 times more common in twin.
 Dizygotic twins
 Rate/fetus is the same as in singletons
 Monozygotic twins
 rate is 2 to 3 times higher.
 The most common structural abnormalities
 cardiac
 neural tube and brain
 facial clefts
 gastrointestinal
 anterior abdominal wall

All monochorionic twins should undergo a routine detailed ultrasound scan between 18 and
20+6 weeks of gestation which includes extended views of the fetal heart anatomy (as
recommended in the Fetal Anomaly Screening Programme screening of a singleton fetus). (C)
Screening for Preterm Birth
How:
Cervical length

When:
21-24 w
{correlates highly with PTL at < 32 to 33 w}
 Risk of PTL is increased 3- to 5-fold from baseline prevalence.
 PPV: 22% to 38 %.
 NPV: high: 94% to 96%.

CL > 35 mm at mid 2nd T: probability of reaching 34-35w is quite high (88% -98%).

Rate of cervical shortening

 2.5 mm/w predicted PTL (positive likelihood ratio of 10.8).
 Progressive shortening greater than expected may indicate a higher risk of PTL.
 There is still insufficient data to recommend screening twin
pregnancies with TVS cervical length, but this might change soon!
(Schuit et al. 2014)
Assesment of Fetal Growth
Assesment of Fetal Well Being
 RCOG recommendation
• Fetal ultrasound assessment should take place every 2 weeks in uncomplicated
monochorionic pregnancies from 16+0 weeks onwards until delivery (D)
• At every ultrasound examination, liquor volume in each of the amniotic sacs should be
assessed and a deepest vertical pocket (DVP) depth measured and recorded, as well as the
umbilical artery pulsatility index (UAPI). Fetal bladders should also be visualised. (Appendix
III). [New 2016] (GPP)
• From 16+0 weeks of gestation, fetal biometry should be used to calculate an estimated fetal
weight (EFW) and the difference in EFW calculated and documented. As the risk of selective
growth restriction (sGR) extends to delivery, this should be performed at 2-weekly intervals
until delivery. [New 2016] (D)
COMPLICATION
 Maternal Complications
During pregnancy
 Miscarriages
 Hyperemesis gravidorum
 Anaemia
 Pre-eclampsia (25%)
 Hydramnios ( 10 % )
 GDM ( 2 – 3 times)
 Antepartum hemorrhage – placenta previa and placental abruption
 Cholestasis of pregnancy
 Malpresentations
 Preterm labour (50%) twins – 37 weeks, triplets – 34 weeks, quadruplets – 30 weeks
 Mechanical distress such as palpitation, dyspnoea, varicosities and haemorrhoids
 Obstructive uropathy
During Labour:
 Prelabour rupture of the membranes
 Cord prolapse
 Incoordinate uterine contractions
 Increased operative interference
 Placental abruption after delivery of 1st baby
 Postpartum haemorrhage

During puerperium:
 Subinvolution
 Infection
 Lactation failure
 Fetal Complications
 Preterm delivery
 IUGR
 Congenital Abnormalities
 Cord abnormalities :
 Single umbilical artery
 Velamentous insertion
 Cord entanglement
 Cord prolapse
 Monochorionic twins :
 Discordant growth
 Twin to twin syndrome
 Single fetal Demise
MONOCHORIONIC
DIAMNIOTIC TWIN
• Both babies share one placenta
• 1/3 of twins in the UK have MC placentas Recent
increase in multiple pregnancies due to ART
• Particular challenges: vascular placenta anastomoses that are
almost universal and connect umbilical circulation of both twins

All women with a twin pregnancy should be offered an ultrasound

examination between 11+0 weeks and 13 +6 weeks of gestation
(crown–rump length 45–84 mm) to assess fetal viability, gestational age
and chorionicity, and to exclude major congenital malformations (B)
If unable to determine chorionicity, treat as
monochorionic until proven otherwise
 Subsequent Management
Aim
◦ Timely detection of TTTS
◦ Detection of other complications such as selective
IUGR,TOPS,TRAPS, single fetal demise
TTTS
• 95% monochorionic placentas have these but only 10-
15% suffer adverse outcomes
• TTTS and TRAP are the most well recognised
complications
• Suggested aetiology: deep anastomoses within
placental mass are usually btwn arteries and veins
which allow unidirectional blood flow

Screening for TTTS by first trimester nuchal translucency measurements should not be offered.
[New 2016] (C)

Screening for TTTS should be by ultrasound examination from 16+0 weeks onwards, at 2-weekly
intervals, noting and recording fetal biometry and liquor volumes (DVP). Fetal bladders should
also be visualised.
TTTS
ARTERY VS VEIN ANASTOMISIS
DIAGNOSIS TTTS
STAGE TTTS
PROGNOSIS TTTS
In severe early TTTS, the prominent feature is
discordant liquor

Growth may not be significantly

affected in early pregnancy
Management options of early severe TTTS

Amnioreduction
Septostomy
Selective laser ablation of communicating vessels
 Amnioreduction
• Amnioreduction: survival rates 60-65%
• Septostomy: decrease in need to rpt procedure and
survival rate similar, however risk of inter-twin cord
entanglement
• Laser ablation: most logical therapeutic approach,
placental vessels traced endoscopically from origins and
ablate all anastomoses, survival rate 70-81%,consider in
ALL stages of TTTS to improve perinatal outcome
 Recommendation (RCOG)

Severe TTTS presenting < 26 weeks should be treated by laser

ablation rather than amnioreduction or septostomy Little
information about maternal morbidity after laser (A)
Delivery of monochorionic twin pregnancies previously complicated
by TTTS and treated should be between 34+0 and 36+6 weeks of
gestation. [New 2016] (D)
 Complications of laser ablation
Most common: PROM (9%)
Placental abruption 1%
Miscarriage 8%

NICE March 2006

TAPS (Twin Anaemia Polychytemia Sequence)
• Monochorionic Twin (5%)
• Spontaneous or after incomplete Laser
treatment for TTTS
• Same pathology as TTTS (Milder form)
• Large intertwin hemoglobin differences in the
absence of amniotic fluid discordances
• Usually in 3rd trimester.
Presence of arterial-arterial anastomoses is protective against TTTS
In TAPS: either less A-V anastomoses or more A-A
anastomoses

TAPS should be screened for following fetoscopic laser ablation for TTTS and in
other complicated monochorionic pregnancies requiring referral to a fetal medicine
centre (such as those complicated by sGR) by serial middle cerebral artery peak
systolic velocity (MCA PSV). [New 2016] (GPP)
 TAPS: Antenatal Diagnosis
No apparent growth and liquor discordance
Main feature: discordance in MCA blood flow
MCA Peak systolic velocity measurement
(PSV)
– Moderate to severe anemia : PSV MoM > 1,5
– Polycythaemia: PSV MoM < 0.8

Even in apparently uncomplicated MCDA, it is advised

to do MCA doppler in every patient after 24 weeks
TRAPS (Twin Reversed Arterial Perfusion Sequence)
• Also called acardiac twinning
• High perinatal mortality of the normal ‘pump’ twin due to
CCF and hydrops
• Treatment:
– Expectant
– Cord occlusion of the acardiac twin if show evidence of
heart failure in the pump-twin
PUMP TWIN

ACARDIAC TWIN
Selective Growth Restricted (sGR)
• Differentiate from TTTS by absence of
polyhydramnios in one of the amniotic sacs,
although the small twin may have
oligohydramnios owing to placental insufficiency
• Scans after 24 weeks to detect fetal growth
restriction
 Discordant Growth*
• Abdominal Circumference difference >20 mm
• EFW difference > 20%** (Larger twin as a reference)
• BPD > 6 mm
• FL > 6 mm
* Usually accompanied with abnormal UA doppler
** Latest evidence suggests that difference by 18% is significant

At each scan from 20 weeks of gestation (at 2-weekly intervals) onwards, calculate EFW discordance
using two or more biometric parameters. Calculate percentage EFW discordance using the following
formula: ([larger twin EFW – smaller twin EFW]/larger twin EFW) x 100. Liquor volumes as DVP should
be measured and recorded (to differentiate from TTTS). [New 2016] (C)
Umbilical artery Doppler evaluation in monochorionic twins with sGR allows definition of prognosis and
potential morbidity. In particular, those with absent or reversed end-diastolic velocities (AREDV) and
‘cyclical’ umbilical artery Doppler waveforms (intermittent AREDV) are at increased risk of perinatal
mortality and morbidity (Appendix IV). [New 2016] (C)
 Abnormal ductus venosus Doppler waveforms (reversed flow during
atrial contraction) or computerised cardiotocography short-term
variation should trigger consideration of delivery. [New 2016]

In type I sGR, planned delivery should be considered by 34–36 weeks of

gestation if there is satisfactory fetal growth velocity and normal umbilical
artery Doppler waveforms. [New 2016] (GPP)

In type II and III sGR, delivery should be planned by 32 weeks of gestation,

unless fetal growth velocity is significantly abnormal or there is worsening of
the fetal Doppler assessment. [New 2016] (GPP)
 Why is MCDA different compared to DCDA?
• Death in one twin may lead to death of the other twin
• Neurological sequelae in surviving twin
Importance of close monitoring and timely decision for delivery!!!
• try to achieve good survival of both fetuses
• at least survival of one fetus with minimal neurological sequelae

In cases of early-onset sGR in association with poor fetal growth

velocity and abnormal umbilical artery Doppler assessments,
selective reduction may be considered an option. [New 2016] (C)
Single fetal demise
Risks are not restricted to MC pregnancies with a prior diagnosis
of TTTS
Caused by acute haemodynamic changes around time of death, as
survivor haemorrhaging part of its circulating volume into the
circulation of the dying twin leading to hypotension and low
perfusion and eventually ischaemic end organ damage

After a single fetal death in a monochorionic pregnancy, clinicians should be

aware that the risks to the surviving twin of death or neurological abnormality
are of the order of 15% and 26%, respectively. [New 2016] (B)
 Tromboplastin Release

Thrombotic Arterial Occlusion of anterior & Middle

Cerebral arteries

Multicystic Ensephalomalacia
Detailed counselling and record in case notes
Rapid delivery is unwise unless there are significant CTG
abnormalities or evidence of anaemia in the survivor
(MCA doppler) or if fetal death occurs late in pregnancy
Evidence of fetal compromise could represent
continuing damage to the brain and other organs,
therefore conservative management is often
appropriate
Plan for brain imaging by 4 weeks to establish whether serious
cerebral morbidity has occurred as such manifestation on CNS are
variable and takes up to 4 weeks to occur
Fetal MRI provides earlier and more detailed information about brain
lesions than USG

Fetal magnetic resonance imaging of the brain may be performed 4 weeks

after co-twin demise to detect neurological morbidity if this information would
be of value in planning management.(D)
 Intervention to prevent concordant fetal demise or
neurological sequelae?
• If single fetal demise is diagnosed early: intrauterine fetal blood
transfusion of the surviving twin may be considered

Fetal anaemia may be assessed by measurement of the fetal MCA PSV using
Doppler ultrasonography. (D)
Early in pregnancy:
prognosis for the surviving fetus is excellent.

2nd and 3rd T

2% to 5% of twin pregnancie
 Timing of delivery
Deliver at 36-37, does not appear to be a/w increased risk of
serious adverse outcomes
Appropriate to aim for vag birth unless there are accepted, specific
clinical indications for CS eg twin one lying breech or previous CS
60% of twins: spontaneous birth before 37 weeks
Prolonging pregnancy beyond 38 weeks increases risk
of fetal death
If elective birth declined, offer weekly appointment with specialist
obstetrician, offer USG at each visit and perform biweekly
biophysical profile assessments, fortnightly fetal growth scans
Management depends on
1. Chorionicity
2. Gestation age
3. Time since death.

Sequels of Death of Co-twin DC MC

Fetal Demise 3% 15%
Preterm Birth 54% 68%
Abnormal Postnatal Cranial Imaging 16% 34%
Neuro-developmental Impairment 2% 26%
 MCDA: its all about discordance!!
TTTS
Discordant liquor

Selective IUGR
Discordant growth

TAPS
Discordant MCA PSV

TRAPS/discordant fetal discordant fetal anomalies

anomalies
Assessment in uncomplicated
monochorionic twin pregnancy
 Timing and mode of delivery in
uncomplicated monochorionic pregnancies
optimal timing and method of delivery for
otherwise uncomplicated monochorionic pregnancies
(without TTTS, sGR or TAPS)

Women with monochorionic twins should have timing of birth discussed and
be offered elective delivery from 36+0 weeks with the administration of
antenatal steroids, unless there is an indication to deliver earlier. [New 2016]
(C)

It is appropriate to aim for vaginal birth of monochorionic diamniotic

twins unless there are other specific clinical indications for caesarean
section.(A)
 MONOCHORIONIC
MONOAMNIOTIC TWIN
Cord entanglement
 specific problems of MCMA pregnancies and how should they
be managed

MCMA twins almost always have umbilical cord entanglement when

visualised using colour flow Doppler. Such a finding has not consistently
been demonstrated to contribute to overall morbidity and mortality. [New
2016] (D)

MCMA twins have a high risk of fetal death and should be delivered by
caesarean section between 32+0 and 34+0 weeks. [New 2016] (D)