OBSTETRICS 2 MULTIFETAL

2S-7 | CEU-SOM A & B PREGNANCY

MAYNILA E. DOMINGO, MD, DPOGS, FPSMFM, FPSUOG

OUTLINE rate for twins was more than four times the rate for single births. In
the same year, the infant mortality rate for triplets was nearly 12
I. INCIDENCE AND EPIDEMIOLOGY times the rate for singletons, and for quadruplets, it was a
II. MECHANISMS OF MULTIFETAL GESTATIONS staggering 26 times that for singletons!
A. Superfetation
B. Superfecundation
C. Factors affecting twinning
D. Sonographic Assessment of Chorionicity
E. Determining Chorionicity
III. DIAGNOSIS OF MULTIFETAL GESTATION
IV. MATERNAL PHYSIOLOGICAL ADAPTATIONS
V. COMPLICATIONS
A. Pregnancy/Maternal
B. Fetal/Neonatal
C. Unique Fetal Complications
VI. PRENATAL CARE OF MULTIPLE GESTATION
VII. LABOR AND DELIVERY
VIII. REFERENCES
Table 1. Selected Outcomes in Singleton and Twin Pregnancies Delivered
LEGEND: PRESENTER’S NOTES
II. MECHANISMS OF MULTIFETAL GESTATIONS
COURSE OBJECTIVES
Ø To understand the mechanism of multifetal gestations
Ø To know how to make an accurate diagnosis of multifetal gestation
Ø To recognize the maternal and fetal complications associated with
multifetal gestations
Ø To elucidate how to manage multifetal gestations and their
complications
I. INCIDENCE AND EPIDEMIOLOGY
Ø The risk of infant death rose proportionally with the number of
fetuses in the pregnancy
• Twins: 4x increased risk compared to singletons
• Triplets: 12x increased risk Figure 2. Fertilization two separate ova = Dizygotic or Fraternal twins
• Quadruplets: 26x increased risk

Figure 3. Fertilization of a single ovum that then divides = Monozygotic or

Identical twins

Figure 1. Multifetal birth rate incidence and epidemiology
- Fueled largely by infertility therapy, both the rate and the number
of twins and higher-order multifetal births grew dramatically during
the 1980s and 1990s in the United States. National data from
Martin and coworkers (2017) presented here is informative. The
twinning rate rose 76 percent from 18.9 per 1000 live births in 1980
to 33.2 in 2009. During the same time, the number of higher-order
multifetal births peaked in 1998 at a rate of 1.9 per 1000 total births.
- In 2015, the overall multifetal birth rate was 34.5 per 1000, with
twins representing nearly 97 percent of these births.
- These rates of multifetal pregnancies have a direct effect on the
rates of preterm birth and its comorbidities. In addition, the risks for
congenital malformation and its consequences are greater with
multifetal gestations. Importantly, this increased risk applies to
each fetus and is not simply the result of more fetuses. In sum, in
2013 in the United States, multifetal births accounted for 3 percent
of all live births but for 15 percent of all infant deaths. Moreover, the
risk of infant death rose proportionally with the number of fetuses
in the pregnancy (Matthews,2015). Specifically, the infant mortality
SUPERFETATION
Ø An interval as long as or longer than a menstrual cycle intervenes
between fertilizations
Ø Requires ovulation and fertilization during the course of an
established pregnancy
• Theoretically possible until the uterine cavity is obliterated
by fusion of the decidua capsularis to the decidua parietalis
Ø Although known to occur in mares, superfetation is not known to
occur spontaneously in humans.
- In superfetation, an interval as long as or longer than a menstrual
cycle intervenes between fertilizations. Superfetation requires
ovulation and fertilization during the course of an established
pregnancy, which is theoretically possible until the uterine cavity is
obliterated by fusion of the decidua capsularis to the decidua
parietalis. Although known to occur in mares, superfetation is
not known to occur spontaneously in humans.
SUPERFECUNDATION
Ø Refers to fertilization of two ova within the same menstrual cycle
but not at the same coitus, nor necessarily by sperm from the
same male

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 Ø Heteropaternity INFERTILITY TREATMENT
Ø Ovulation induction
- Superfecundation refers to fertilization of two ova within the same o FSH + hCG = 28.6%
menstrual cycle but not at the same coitus, nor necessarily by o Clomiphene citrate = 9.3%
sperm from the same male. An instance of superfecundation or Ø IVF
heteropaternity, documented by Harris (1982). The mother o For women < 35 years old à single-embryo transfer
delivered a black neonate whose blood type was A and a white
neonate whose blood type was O. The blood type of the mother - As the number of fetuses per pregnancy increases, the
and her husband was O. More recent cases have been reported in percentage of male conceptus declines
the setting of paternity lawsuits (Girela, 1997). Given that - Mortality rates are lower in females
superfecundation may also occur with ART, women should be - Female zygotes have a greater tendency to divide.
advised to consider avoiding intercourse after embryo transfer
(McNamara, 2016; Peigné, 2011).

FACTORS AFFECTING TWINNING

Race
Hereditary
Maternal age
DIZYGOTIC Parity
Fertility treatment
Documented tubal pathology
Generally independent of demographic
MONOZYGOTIC factors
Table 2. Overview of the Incidence of Twin Pregnancy Zygosity and Corresponding
ART Twin-Specific Complications
Table 3. Different Factors affecting Twinning
- Chorionicity, not zygosity, determines the risk for
RACE
twin-specific complications
Ø Due to racial variations in the levels of FSH - Monochorionic > Dichorionic
o Black > White > Hispanic, Asian, Native American

MATERNAL AGE SONOGRAPHIC ASSESSMENT OF CHORIONICITY

Ø Rises 4x between ages 15-37 years
Ø Declining fertility but increasing twinning with advancing maternal FIRST TRIMESTER
age Ø Number of gestational sacs =
number of chorions
Ø Visualization of 2 separate
placentas à dichorionicity
Ø Intervening membrane – thickness
of 2mm has been used as threshold
o LAMBDA SIGN
Figure 5. Visualization of 2 Separate
§ Dichorionic
Placentas Confirming Dichorionicity
o T-SIGN
§ Monochorionic

Figure 4. Multifetal birth rates according to maternal age and race

Table 4. Sonographic Determination of Chorionicity and Amnionicity in First

PARITY
Trimester Twin Gestations
Ø á Parity = á Twinning rate
o < 4 = 8x rise in multifetal gestation rates
o > 5 = 20x rise in multifetal gestation rates

HEREDITARY
Ø Maternal > Paternal
Ø Chromosome 6, 7, 9 and 16
NUTRITION
Ø Nutritional sufficiency = á Twinning rate
o Black > White > Hispanic, Asian, Native American

PITUITARY GONADOTROPIN
Figure 6. Intervening membrane – thickness of 2mm has been used as threshold
Ø FSH

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 1
DETERMINING CHORIONICITY
Placental masses
2 Thickness of the membrane dividing the sacs (Figure 6)
3 Presence of an intervening membrane
4 Fetal gender

Figure 7. Lambda sign represents chorionic tissue wedged between layers of the
intervening membrane (separating the gestational sacs of twins A and B) where it
meets the fetal surface of the abutting placentas. This finding is not always Figure 9. Dichorionic diamnionic twin placenta. The membrane partition that
present, but when seen it is a useful indicator of dichorionicity. separated twin fetuses is elevated and consists of chorion between two amnions

III. DIAGNOSIS OF MULTIFETAL GESTATION

HISTORY SYMPTOMS PHYSICAL

EXAMINATION
History of ovulation
inducing drugs Hyperemesis Maternal weight gain
especially gravidarum
gonadotrophins
Family history of Tendency of swelling Fundic height à
twinning of the legs larger than expected
(maternal side) for age of gestation
Figure 8. T-sign formed by the thin inter-twin membrane (composed of two layers
Varicose veins Leopold’s Maneuver
of amnion, separating the sacs A and B) where it meets perpendicular to the fetal
surface of the single shared placenta - indicating a monochorionic diamniotic twin à palpation of 2
pregnancy. heads/ too many fetal
small parts
- Early in the first trimester, the number of gestational sacs equals Hemorrhoids Detection of 2 distinct
the number of chorions. heart tones
- Late in the first trimester, the visualization of two separate Excessive abdominal
placentas can be used to diagnose dichorionicity. In cases with a enlargement
single placenta or adjacent Excessive fetal
- apparently “fused” placentas, evaluation of the intervening movements
membrane can help distinguish between monochorionic and Table 5. Summary of Findings in Multifetal Gestation
dichorionic placentation.
- Membrane thickness, number of membrane layers, and presence DIAGNOSTICS
of either the lambda sign or T-sign at the base on the intervening Ø Ultrasound
membrane can be evaluated using ultrasound imaging. In Ø Radiography
dichorionic twins, the separating membrane tends to be thicker, as Ø Biochemical tests: ELEVATED but not diagnostic
it is composed of two layers of amnion and two layers of chorion, o Maternal serum chorionic gonadotrophin
compared to only two layers of amnion in monochorionic twins. o Alpha fetoprotein
Although a membrane thickness of 2 mm has been used as a o Unconjugated estriol
threshold to distinguish between dichorionic and monochorionic
twins, it does not perform reliably as a diagnostic test.18 IV. MATERNAL PHYSIOLOGICAL ADAPTATIONS
- The lambda sign, consisting of a small triangular wedge of
echogenic chorionic tissue observed between layers of the
- intervening membrane at its base, where it meets the fetal surface
of the placenta, is diagnostic of dichorionicity19 (Figs. 7-9 and 7- First Second Third
10). The lambda sign is best visualized in the late first and early trimester trimester trimester
second trimesters of pregnancy. It is important to remember that
this sign does not necessarily persist on follow-up scans later in
pregnancy, but when seen, it helps confirm dichorionicity. FIRST TRIMESTER SECOND THIRD TRIMESTER
- The T-sign, which appears as a thin linear structure, composed of TRIMESTER
two opposing layers of amnion, forming a perpendicular angle Higher serum β-hCG Greater blood Greater degree of
where it intersects the fetal surface of the shared placenta, is à nausea and volume explansion increase in BP at
characteristic of monochorionic placentation vomiting term
Lower blood Greater iron and Greater uterine
BEYOND THE FIRST TRIMESTER pressure folate requirements growth
1. Placental number à Anemia
Ø If 2 distinct placentas seen = dichorionic Lower vascular
Ø If 1 placenta seen = may be monochorionic or dichorionic resistance
2. Fetal Genitalia Increased cardiac
Ø If different gender = dichorionic output
Ø If same gender = may be monochorionic or dichorionic Table 6. Physiological Changes by Trimester
3. Membrane Characteristics
Ø Lambda sign and T sign

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 V. COMPLICATIONS MONOAMNIONIC TWINS
PREGNANCY/MATERNAL Ø 1% of all monozygotic twin gestations
Ø 1 in 20 monochorionic twin gestations
SPONTANEOUS ABORTION Ø < 16 weeks: 50% mortality rate
Ø 7.3% risk in multifetal gestation vs 0.9% risk in singleton Ø > 20 weeks: 15% mortality rate
Ø ART > spontaneous conception o Congenital anomalies, TTTS, preterm
Ø Incidence of twins in 1st trimester (1 in 8) is greater than the birth, cord entanglement
incidence of twins at birth (1 in 80) à due to loss of 1 of the twin Ø Congenital anomaly rate: 18-28%
Ø “Vanishing Twin” à spontaneous reduction o High risk of cardiac anomaly à fetal
o 10-40% of all twin pregnancies 2D ECHO
o Monochorionic > Dichorionic Ø Monozygotic à genetically identical EXCEPT for
some cases of discordance
HYPERTENSION
Ø More likely to develop with multifetal gestation
o Overall: 20% of all multifetal gestation will develop
pregnancy-induced hypertension
Ø Twins: 8%
Ø Triplets: 11%
Ø Quadruplets: 12%

Fetal number and placental mass are involved in the

preeclampsia pathogenesis

PRETERM BIRTH
Ø The duration of gestation shortens with accruing fetal number
o Twins: 6x increased risk
o Triplets: 10x increased risk
Ø 60% are indicated preterm delivery
Ø 30% result from spontaneous preterm labor
Ø 10% follow premature rupture of membranes

FETAL/NEONATAL

CONGENITAL MALFORMATIONS
Ø 406 / 10,000 twins compared to 238/10,000 singletons
Ø Monochorionic > Dichorionic
Ø Monozygotic > Dizygotic

LOW BIRTH WEIGHT

Ø The degree of growth restriction increases with fetal number
Ø Monozygotic > Dizygotic
Ø Monochorionic:
o Allocation of blastomeres are unequal
o Vascular anastomoses within the placenta à unequal
distribution of nutrients and oxygen
o Discordant structural anomalies

LONG-TERM INFANT DEVELOPMENT

○ Cognitive outcomes between twins and singletons are similar Figures 10-17. Actual Monoamnionic Twins
○ Cerebral palsy risk is higher in multifetal gestations
○ Singleton: 2.3/1000 CONJOINED TWINS
○ Twins: 12.6/1000 Ø “Siamese Twins”
○ Triplets: 44.8/1000 o Chang and Eng Bunker of Siam
Ø Joining of the twins may begin at either pole and
UNIQUE FETAL COMPLICATIONS produce characteristic forms depending on
which body parts are joined
CLASSIFICATION Ø Ultrasound and MRI
Monoamnionic Twins Ø Surgical separation of an almost completely
joined twin pair may be successful if essential
Conjoined Twins organs are not shared
External Parasitic Twins
Figure 18. Cephalopagus conjoined twins
Fetus-in-Fetu
Twin-Twin Transfusion Syndrome (TTTS)
Twin Anemia-Polycythemia Sequence (TAPS)
Twin Reversed-Arterial-Perfusion Sequence (TRAP)
Hydatidiform Mole with Coexisting Normal Fetus
Discordant Growth of Twin Fetuses
Fetal Demise
Table 7. Unique Fetal Complications Examples
Figure 19. Types of conjoined twins.
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 EXTERNAL PARASITIC TWIN
Ø Grossly defective fetus or merely fetal parts, attached externally to
a relatively normal twin
Ø PARASITIC TWIN
o Externally attached supernumerary limbs, often with
some viscera
o Absent functional heart or brain
o Result from demise of the defective twin, with its
surviving tissue attaching and receiving vascular supply
from the normal cotwin

Figure 23. Schematic representation of an AV anastomosis in twin-twin

transfusion syndrome that forms a “common villous district” or “third circulation”
Figures 20-21. External Parasitic Twins deep within the villous tissue.

FETUS – IN – FETU
Ø One embryo may be enfolded within its twin
Ø Development usually arrests during the 1st trimester
o Normal spatial arrangement and many organs are lost
Ø Fetiform mass:
o (+) vertebral or axial bones
o (-) brain and heart
Ø Monozygotic, mono-di
Ø Supported by a large parasitic vessel
Table 8. TTTS Staging system / Quintero Staging (See Appendix)
TWIN–TWIN TRANSFUSION SYNDROME (TTTS)
Ø All monochorionic placentas likely share some anastomotic
connections Ø MANAGEMENT:
Artery-to-artery anastomoses are most frequent: 70% o Expectant management: close monitoring
Vein-to-Vein anastomoses and Artery-to-Vein o Amnioreduction of the recipient twin,
anastomoses: 50% o Intrauterine blood transfusion for the donor twin,
Deep arteriovenous anastomoses à “third circulation” à o Selective fetal reduction,
fetofetal transfusion o Fetoscopic laser ablation of placental anastomosis
Ø 1-3 per 10,000 births o Septostomy à no longer recommended
Ø Blood is transfused from a DONOR twin to its RECIPIENT co-twin
Ø Donor àanemic and growth restricted  More than three fourths of stage I cases have been reported
Ø Recipient àpolycythemic and may develop circulatory overload to remain stable or regress without intervention. Conversely,
à hydrops outcomes in those identified at stage III or higher are much
o Hypervolemia àcardiac failure àhydrops worse, and the perinatal loss rate is 70 to 100 percent
o Hyperviscosity àthrombosis without intervention (Society for Maternal-Fetal Medicine,
o Polycythemia àhyperbilirubinemia and kernicterus 2013). At Parkland Hospital, among expectantly managed
pregnancies with TTTS, most had early disease at
diagnosis, and 50 percent of stage I cases progressed
(Duryea, 2016).

TWIN ANEMIA-POLYCYTHEMIA SEQUENCE (TAPS)

Ø Significant hemoglobin difference between donor and recipient
twins
Ø NO discrepancy in the amniotic fluid volumes
Ø Diagnosed by MCA PSV:
o 1.5 MoM in DONOR twin
o < 1.0 MoM in RECIPIENT twin
Ø Spontaneous (3-5%) vs Iatrogenic (13% after laser
photocoagulation)
Figure 22. Mechanism of TTTS
TWIN REVERSED-ARTERIAL-PERFUSION SEQUENCE (TRAP)
Ø Occur in 20-25% of monochorionic twins Ø ACARDIAC TWIN
Ø Diagnosis: 2 criteria Ø 1 in 35,000 births
o Monochorionic-Diamnionic Ø There is a normally formed donor twin that shows features of heart
o Oligohydramnios-Polyhydramnios failure and a recipient twin that lacks a heart and other structures
Ø Caused by a large artery-to-artery placental shunt, often also
accompanied by vein-to-vein shunt

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 Figure 24. Acardiac Twin
Figure 27. Possible outcomes of monozygotic twinning. The asymmetrical
category contains twinning types in which one twin complement is substantially
smaller and incompletely formed

HYDATIDIFORM MOLE WITH COEXISTING NORMAL FETUS

Ø one of twin is a normal fetus, while the cotwin is a complete molar
pregnancy
Ø 1 in 22,000 to 1 in 100,000 pregnancies
Ø Differentiate with PARTIAL MOLAR PREGNANCY
o Anomalous singleton fetus àtriploid
Ø Associated with complications:
o Thyrotoxicosis
o Preeclampsia, early-onset
o Hyperemesis gravidarum

Figure 25. Twin Reversed Arterial Perfusion Sequence. Within the single, o
o
Preterm labor
Vaginal bleeding
shared placenta, perfusion pressure of the donor twin overpowers that in the
recipient twin, who thus receives reverse blood flow from its twin sibling. The
“used” arterial blood that reaches the recipient twin preferentially goes to its iliac DISCORDANT TWINS
vessels and thus perfuses only the lower body. This disrupts growth and Ø 15% of twin gestations
development of the upper body. Ø As the weight difference increases, the perinatal mortality rate
increase proportionately
Ø Classification: Ø SELECTIVE FETAL-GROWTH RESTRICTION
o Acardius anceps / myelacephalus – when the head is poorly Ø Monochorionic : unequal placental sharing
formed
Ø Dichorionic: suboptimal placentation of one placenta, different
o Acardius acephalus – if the head is absent genetic potential
o Acardius acormus – presence of head only
o Acardius amorphous – unrecognizable anatomy

Figure 28. Discordant Twins

Figure 26. Classifications of Acardiac Twin

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 VI. PRENATAL CARE OF MULTIPLE GESTATION

Ø DIET
o 37 to 54 lbs weight gain for women with twin gestation and
normal pre-pregnant BMI
o Supplement: calcium, magnesium, zinc, vitamins C, D, and
E
o Daily recommended caloric intake: 40-45 kcal/kg

Ø ANTENATAL FETAL SURVEILLANCE

o Serial ultrasound àgrowth, amniotic fluid
o Biophysical profile
o Non-stress test
o Doppler velocimetry studies

Figure 29. Formula for the computation of Difference in Discordant Twins. Ø PREDICTION OF PRETERM BIRTH
o Cervical length measurement à NOT proven
Ø Difference of 20
o 20 mm difference in abdominal circumference Ø PREVENTION OF PRETERM BIRTH
o 20% weight difference o Bed rest àdoes NOT prolong pregnancy
Ø 25-30% difference: adverse perinatal outcomes o Prophylactic tocolysis àUNWARRANTED
o Progesterone therapy
Ø FETAL SURVEILLANCE:
• Intramuscular: 17 alpha-hydroxyprogesterone caproate
o Biometry every 2 weeks àassess growth
(150mg)
o Biophysical profile
• Vaginal: micronized progesterone (100-200mg)
o NST
o Cervical cerclage
o Doppler velocimetry studies
o Cervical pessary
Ø SELECTIVE IUGR: CATEGORIES
Ø MANAGEMENT OF PRETERM LABOR
o Type I: (+) end-diastolic flow, smaller degree of
discordance, benign clinical course o Treatment of Preterm Labor
o Type II: persistently absent end-diastolic flow, high risk of • Tocolysis
deterioration and demise • Glucocorticosteroids for lung maturity
o Type III: intermittently absent or reversed end-diastolic flow, • Magnesium for neuroprotection
large artery-to-artery shunt, lower risk of deterioration and
demise o Preterm Premature Rupture of Membranes
• Expectant management
FETAL DEMISE
Ø One or more fetus/es may die but the pregnancy continues with o Delayed Delivery of Second of Twin
one or more live fetus/es • Infrequently, after preterm birth of the presenting fetus, it
Ø Early in pregnancy: may be advantageous for undelivered fetus(es) to
o Vanishing twin remain in utero
o Fetus compressus • If asynchronous birth is attempted, there must be careful
o Fetus papyraceus evaluation for infection, abruption, and congenital
Ø Risk of stillbirth is related to gestational age anomalies.
Ø Higher for monochorionic pregnancies  If asynchronous birth is attempted, there must be careful
Ø Prognosis of surviving twin: evaluation for infection, abruption, and congenital
o age of gestation at the time of demise anomalies. The mother must be thoroughly counseled,
o Duration between demise and delivery of surviving twin particularly regarding the potential for serious, life-
o Neurological prognosis threatening infection. The range of gestational age in
• < 34 weeks age of gestation: 5x increased neurologic which the benefits outweigh the risks for delayed delivery
morbidity in monochorionic twins is likely narrow. Avoidance of delivery from 23 to 26
• > 34 weeks age of gestation: monochorionic = weeks would seem most beneficial.
dichorionic
Ø Maternal complications: DIC VII. LABOR AND DELIVERY
TIMING OF DELIVERY
Ø Factors affecting timing:
o Gestational age
o Fetal growth
o Lung maturity
o Presence of maternal complications
Ø 37 to 40 weeks
Ø Monochorionic twin gestation: deliver at 32-34 weeks

Ø ACOG GUIDELINES
o Uncomplicated dichorionic twin pregnancies:
• 38 weeks
o Uncomplicated monochorionic diamnionic twin pregnancies:
• between 34 and 37 6/7 weeks
o Monoamnionic twin pregnancies:
• 32 to 34 weeks
Figure 30. Factors to consider in the management of Fetal Demise

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 MODE OF DELIVERY o External Cephalic Version (ECV) vs breech extraction
Ø In general, cephalic presentation of the first fetus in a laboring for the delivery of 2nd twin
woman with twins may be considered for vaginal delivery §  Fetal distress necessitating CS more frequent with
(American College of Obstetricians and Gynecologists, 2016) ECV (18%) compared to breech extraction (0.5%)
 This is especially true following delivery of the first twin. Importantly,
related to delivery method, second twins at term have worse
composite neonatal outcomes compared with outcomes of their
cotwin regardless of delivery method (Muleba, 2005; Smith, 2007;
Thorngren-Jerneck, 2001).

Ø Regardless of fetal presentation during labor, obstetricians must

be ready to deal with any change of fetal position during delivery.

Figure 31. Presentations seen in twin pregnancy

Figure 34. (A) External Cephalic Version. (B) Internal Podalic Version

Ø External Cephalic Version

1. Forward roll of the fetus is attempted
2. Each hand grasps one fetal pole, and fetal buttock are
elevated from the maternal pelvis and displaced laterally
3. Buttocks are gently guided toward the fundus while the head
is directed toward the pelvis

Figure 32. Evidence-based Algorithm for the delivery of Multifetal gestation (See
Appendix)
Ø Delivery of Twins: Vertex/Nonvertex
o Preterm nonvertex 2nd twin weighing <1500 g grams
§ inconsistent perinatal outcome of different studies
regarding the mode of delivery
§ allow a trial of labor with breech extraction
§ reasonable to offer CS due to the possible neonatal
risks
o Nonvertex 2nd twin (>32 wks) > 1500g & < 3500 g
§  Concordance or discordance with 2nd twin smaller
SVD
§ Discordance with 2nd twin larger SVD or CS

Figure 35. External Cephalic Version

Ø Internal Podalic Version

Figure 33. Twins in vertex/nonvertex presentation Upward pressure on the head by one hand as the other hand is
introduced into the vagina grasping both feet and applying gentle
downward traction. Total breech extraction follows

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 VIII. REFERENCES
Ø Williams Obstetrics, 25th Edition (Cunningham et al)
Ø Dr. Domingo’s PPT
Ø Notes and Recordings of OB2 Trans Team

IX. APPENDIX

Fueled Mechanism of monozygotic twinning. Black boxing and blue arrows in columns A, B, and C indicate timing
of division.
A. At 0-4 days postfertilization, an early conceptus my divide into two. Division at this early stage
creates two chorions and two amnions (dichorionic, diamnionic). Placentas may be separate or
fused.
B. Division between 4 and 8 days leads to formation of a blastocyst with two separate embryoblasts
(inner cell masses). Each embryoblast will form its own amnion within a shared chorion
(monochorionic, diamnionic).
C. Between 8 and 12 days, the amnion and amnionic cavity form above the germinal disc. Embyonic
division leads to two embryos with a shared amnion and shared chorion (monochorionic,
monoamnionic.
D. Differing theories explain conjoined twin development. One describes an incomplete splitting of one
embryo into 2. The other describes fusion of a portion of one embryo from a monozygotic pair onto
the other.

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