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Twins

Dr Manal Behery 2014

Defintion When more than one fetus simultaneously develops in the UTERUS3 fetuses : triplets4 fetuses : quadruplets5 fetuses : quintuplets6 fetuses : sextuplets

HELLINS RULETwins 1 in 80Triplets 1 in 80^2Quadruplets 1 in 80^3

Types of twins Monozygotic (1/3 rds) Dizygotic (2/3 rd) Results from fertilization Results from fertilization of a single ova of two ovum

Dizygotic

amnion

amnion2 chorionsAlways dichorionic & diamnionic

Factors affecting dizygotic twinningEthnic groupIncreasing maternal age

Increasing parityFamily h/o twinning, esp maternal

Ovulation induction

ART

Monozygotic twinning is independent of race, heredity,age & Parity.INCIDANCE 1/25O

MONOZYGOTIC

4-7 days

>8days

>DAY 13

THORACOPAGUSISCHIOPAGUSCRANIOPAGUSRACHYPAGUSPYOPAGUSOMPHALOPAGUS

MONOZYGOTIC TWINS

Diagnosis

History

Previous history of twinning; high parity

Older maternal age > 37yrs

History of ovulation induction or pregnancy following ART

Family history of twinning

Clinically Symptoms Exaggerated pregnancy symptoms.

Fetal activity is greater and more persistent in twinning than in singleton pregnancy.

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Signs (1) Uterus > dates of amenorrehea .

(2) Excessive maternal weight gain that is not explained by edema or obesity.

(3)palpation of 2 fetal heads/presence of three fetal poles.

4) Simultaneous recording of different fetal heart rates, each asynchronous with the mothers pulse and with each other and varying by at least 8 beats per minute.

Ultrasound Determination of ChorionicityNumber of sacs. [ before 10 weeks ] 2 sacs dichorionic Single sac - monochorionic

Placenta

Sex

Intertwin membrane

thicker and more echogenic in dichorionic.

Ideal time for assessing of chorionicity is before 14 weeks

Dizygotic

Lambda sign

MONOCHORIONIC & DIAMNIONICT sign

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Importance of chorionicity ?????

Problems Specific to Monochorionic twins Nearly 100% of monochorionic twin placentas have vascular anatomizes2 patterns of vascular anastomosis twin-to-twin transfusion syndrome (TTTS) acardiac twinning or twin reversed arterial perfusion (TRAPS)

Maternal ComplicationAntenatal :Hyperemesis gravidarumchances of abortionhydramnios PIH Placenta previa, abruptioAnemiaExaggerated minor problems: pressure symptoms, etc

Intrapartum complicationsProlonged labor (uterine inertia)Malpresentation Cord prolapseAbruptio placenta for 2nd twinInterlocking of twinsPPH

Fetal complicationsPreterm deliveryIUGRCongenital AbnormalitiesCord abnormalities : Single umbilical artery Velamentous insertion Cord entanglement Cord prolapseMonochorionic twins : Discordant growthTwin to twin syndromeSingle fetal Demise

Cord entanglement

TTTS:Arterio venous anastomoses with net flow in one direction..

Donor(arterial side)

recipient

Severe IUGRpoor renal perfusionAnuriasevere oligohydramnios

HypervolemiaPolyuria with polyhydramniosCCF..hydropsdeath

Serial amnio reduction,fetoscopic laser ablation of anastomosis

Ultrasound in TTS Stuck Twin Sign

Vanishing twinCessation of cardiac activity in a previously viable foetus

Fetus papyraceous

TRAP sequence

PUMP TWINACARDIAC TWIN

Acardiac twins

APARNA P2009 MBBSManagement

1.Prenatal care

More frequent antenatal visits.

prophylactic iron 60-100mg and folic acid 1mg daily should be given.

Nutritional advice-calorie req is 300kcal/day more than that recommended for uncomplicated pregnancy.

Restriction of activity and increased rest at home.

Prophylactic steroids risk for preterm labour or IUGR.

2.Ultrasound scanAt 9-11 wks : confirmation, chorionicity determination, assessment of gestational age and nuchal translucency.

anomaly scan at 20 wks

4 weekly scans in 3rd trimester to assess fetal growth, diagnose complications like TTS

Nuchal Translucency

Mid Trimester Amniocentesis is the gold standard

Delivery prereqistsCTG with dual monitoring capabilityForceps or vacuum Oxytocin infusion Tocolytic agent for uterine relaxation Methergin, 15-methyl PGF2 alpha Immediate availability of blood Access for emergency C/S

1.Place of delivery- Fully equipped hospital having intensive neonatal care unit.

2.Timing of deliveryRCOG recommends elective termination of pregnancy at 37-38 weeksMonochorionic pregnancy best delivered at 36-37 weeks

Mode of deliveryDepend on presentation of 1st twinBoth vertex / 1st twin vertex vaginal deliveryIndication for Elective LSCS-More than 2 fetuses -1st twin malpresentation, CPD-Scarred uterus-MCMA-Conjoint twin-IUGR in dichorionic twin-TTTS

Delivery of 1st twin twin

Delivery Of Second TwinPalpate abdomen immediately to ensure lie,presentation.

If required-ultrasound examination done.

Vaginal examination is also done to exclude cord prolapse.

Acceptable interval between deliveries 30 mins

Longitudinal lie

2ND Twins

Internal podalic versionTo do or not to do ?? Experienced operator EFW > 1500 gm Adequate liquor Available anesthesia for effective uterine relaxation Simultaneous preparation for emergency C/S

Rapid Delivery BY emergancy CS

Severe vaginal bleeding

Cord prolapse in second twin

Inadvertent use of IV ergometrine with delivery of anterior shoulders of first baby2nd twin is transverse, version failed after delivery of 1st twin

Fetal distress

Third StageCross matched blood should be readily available.

Risk of atonic PPH is more.

Oxytocin infusion & i/v ergometrine 0.25mg or methergine 0.2mg given following delivery of anterior shoulder of second baby.

Prostaglandins-15 methyl PG F2alpha can also be used.

Placenta examined for completeness, confirm chorionicity.

Selective fetal reduction-one fetus in a multiple gestation is abnormal

Multifetal reduction-in higher order pregnancy

Iatrogenic fetal death us guided fetal heart puncture or inj kcl

One member of monochorionic pair should never be selected

Multifetal and selective pregnancy reduction

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