Multiple gestation

1. Incidence
a. Twins1 in 30 births
b. Higher order multiples 1 in 500 births
2. Increased incidence
a. Advanced maternal age, increased likelihood
b. Use of ART (assisted reproduction technique)
i. 8-15% ovuation induction
ii. 25-50%--> IVF
3. Importance
a. Prematurity
b. NICU admission
c. Prolonged hospital stay
4. Zygosity (embryological term- less frequently used by clinician because
zygocity is difficult to be determined by US)
a. Monozygotic Identical twins Shared placenta 2/3 incidence
i. 1 sperm, 1 eggSplitting of one embryonic mass
ii. Same set of chromosomeForm 2 or more fetus who are
genetically IDENTICAL
b. Dizygotic Fraternal twins Separate placenta 1/3 incidence
i. 2 sperms, 2 eggsFertilization of more than 1 oocyte
ii. Different set of chromosomeForm 2 or more fetus who are
genetically DIFFERENT
iii. Due to high FSH
5. For monozygotic, it is Important to know about chorionicity &
amnionicity!!!!!!--> determined by time at which zygot splits, or cleaves
a. 25%-If cleavage occurs by day 3 (DD)
i. 2 separate blastocyte 2 sites of implantationdichorionic-
diamniotic twins IDENTICAL (come from SAME ZYGOTE)
b. 75%- If cleavage after day 3 (day 4- day 8) (MD)
i. Blastocyst already formed result in each has own inner sac
(amnion) but surrounded byone outer sac (chorion)
monochorionic pregnancy (1 placenta)
c. 2%- If cleavage occurs between day 8 and 13 MM
i. Too late for amnion to form separately
ii. 1 outer sac (chorion); 1 inner sac (amnion) MM
iii. 2% of monozygotic twins-
iv. High risk due to umbilical cord entanglement
d. If cleavage occurs after day 13
i. MM
ii. Embryo has no time to separate completely produce
conjointed twins
6. Dizygotic twins ALWAYS DD!!!!!!
7. How to tell chorionicity/amnionicity in 1st trimester
a. MM
i. 1 chorion; 1amnion
ii. Both embryos in the same amnion
iii. There should be 1 yolk sac since there is only one amnion
 iv. High risk 50% mortality confirmation of absence of
membrane is crucial!!
v. Must exclude CONJOINT TWINS especially if the twins appear to
be facing each other
vi. Twin transfusion , congenital anomaly, death of 1 co-twin
vii. To decide on selective termination
viii. =Interwined fetal parts (arms, legs)
ix. =interwined cords
x. =2 different heart rate
b. MD
i. 1 sac with both embryo in uterus
ii. 1 placenta; 1 chorion; 2 amnion
iii. 2 yolk sacs
iv. Separating membrane which can be difficult to find
v. Safely tell they are IDENTICAL TWINS- nearly all monochorionic
is monozygotic!!
vi. Even though thin membrane separating, at higher risk than
dichorionic!!!!!bcz some degree of shared vascular connection in
single placenta
c. DD
i. 2 sacs in uterus
ii. Can be both identical (if split so early after conception) and
fraternal
iii. Each sac contains an embryo with a yolk sac
iv. Each sac has a chorion and one amnion
v. 2 discrete placentas or one fused placenta
vi. Thick membrane seen between twins (4 layers of dichorionic
membrane)
vii. Lamda sign/chorionic peak sign- diagnostic of dichorionicity
8. Chorionicty and amnionicity determination in FISRT trimester is almost 100%
accurate.
9. While more difficult in 2nd trimester, can look ofr membrane thickness and
presence or absence of lamda sign
10.Outcomes
a. Perinatal
b. Maternal
11.Management
a. Antepartum
b. Intrapartum
12.Problems unique to management of multiple pregnancy