Complications of Twin

Pregnancy
Twin pregnancies can be both exciting and stressful. In this presentation, we will discuss the maternal
and fetal complications that can arise in a twin pregnancy.

by Harsh Sharma
Comparison of Twin Pregnancy
Complications
Here's a quick overview of the maternal and fetal complications that can arise in twin pregnancy. We
compare the likelihood of these complications occuring in monozygotic (identical) versus dizygotic
(fraternal) twins.

Monozygotic(monochorioni Dizygotic
c)

Maternal Complications Higher risk Lower risk

Fetal Complications Higher risk Lower risk

Maternal Complications
in Twin Pregnancy
Twin pregnancy can increase the risk of several maternal complications,
including:

Nausea and vomiting

Anemia

Pre-eclampsia and pregnancy-induced hypertension

Polyhydramnios or oligohydramnios

Preterm labor

Malpresentation

Antepartum hemorrhage

Mechanical distress, such as dyspnea and palpitation

Prolonged labor

Cesarean delivery

Postpartum hemorrhage

Thromboembolism

Early prenatal screening can help detect these complications, allowing for
prompt intervention to reduce the risk of adverse outcomes and improve
overall health for both mother and babies.
Fetal Complications in Twin
Pregnancy
When carrying twins, there are various fetal complications that may arise, including:

Vanishing twin/fetus papyraceous

Preterm birth

Low birth weight babies

Fetal anomalies (genetic)

Discordant growth

Increased risk of cerebral palsy

Intrauterine death of one fetus

Twin transfusion syndrome

Cord prolapse / cord entanglement

Locked twins

These complications can result in perinatal mortality, with a higher risk in monochorionic twins.
During pregnancy
Nausea and vomiting are more frequent and severe due to increased hcG levels. Can lead to
hyperemesis gravidarum

Anemia is common due to increased iron and folate requirement by two fetuses. Folate deficiency
can lead to megaloblastic anaemia.

Pre-eclampsia is increased three times over single pregnancy, and may lead to antepartum
hemorrhage.

Placenta previa occurs more often in twin pregnancy due to the bigger size of the placenta
encroaching on to the lower segment, which can cause bleeding. The separation of normally
situated placenta may be due to (1) increased incidence of preeclampsia, (ii) sudden escape of
liquor following rupture of the membranes of the hydramniotic sac, (iii) deficiency of folic acid and
(iv) following delivery of the first baby due to sudden shrinkage of the uterine wall adjacent to the
placental attachment
■Malpresentation is quite common. Malpresentation is thus more common in the second baby. It can
be breach of transverse .Fortunately, the babies are usually smaller and do not pose much of a
problem.

■ Preterm labor (50%) frequently occurs and the mean gestational period for twins is 37 weeks.
Overdistensionof the uterus, polyhydramnios and premature rupture of the membranes are
responsible for preterm labor.

■Mechanical distress, such as palpitation, dyspnea, varicosities and hemorrhoids, may be increased
compared to a singleton pregnancy
During labor
Twin pregnancies have a higher risk of early rupture of membranes and cord prolapse(5 times)
due to an increased prevalence of malpresentation.

Prolonged labor is less common in twin pregnancies because parous women tend to have smaller
babies.

Bleeding following the birth of the first baby may be due to separation of the placenta.

Postpartum hemorrhage is a real danger in twin pregnancies due to several factors a) atony of
uterus due to overdistension b) longer time taken by big placenta to seperate c) bigger surface
area of placenta exposing more sinuses d) implantation of part of placenta in lower segment
which is less retractile
During puerperium
1 Subinvolution 2 Infection

Because of bigger size of the uterus Because of increased operative

interference, preexisting anemia and blood
loss during delivery

3 Lactation failure 4 Thromboembolism

This is minimized by reassurance and giving

her additional support
Fetal complications
Miscarriage rate is increased, especially with monochorionic monoamniotic twins , due to cord
entanglement

Premature birth rate is very much increased.

Discordant twin growth (20%): some degree of discordant growth is normal in dizygotic twins, but
true pathological discordance involves estimated weight difference of 25% or more due to twin-
twin transfusion syndrome, placental insufficiency, IUGR, or structural anomalies occurring in one
fetus

Vanishing twin (21%): loss of one fetus of a multiple pregnancy is common and may occur
spontaneously in triplets or quadruplets

Intrauterine death of one fetus (3-7%) is more common in monozygotic twins and may result in the
affected fetus "vanishing" by resorption, forming a fetus papyraceous or compressus, or causing
death of the other fetus in the presence of vascular anastomosis or even DIC (rare). The deaths
are due to cord entanglement, TTTS or Twin Anemia-Polycythemia Sequence (TAPS), chromosomal
or structural anomalies, or congenital malformation.
Fetal complications
Appearing twin: where diagnosis of twin pregnancy is missed on initial USG but diagnosed as twins
in a later scan. This is common in monozygotic twins.

Fetal anomalies are increased by 2-4% compared to a singleton pregnancy, more in monozygotic
twins. They are in the form of anencephaly, holoprosencephaly, neural tube defects, symmelia,
microcephaly, cardiac anomalies or Down's syndrome.

Complications are higher in monozygotic twins compared to dizygotic twins. Complications are
further higher in monochorionic diamniotic twins and highest in monochorionic monoamniotic
twins.
 Monozygotic twins run the higher risk compared to dizygotic of twins. These are:

• Pregnancy complications:

• Preterm births.

• Low birth weight.

• Intrauterine and neonatal deaths. Fetal anomalies.

Monochorionicity rather than monozygocity is the

determining factor.

Other complications in monochronic twins: TTTS, Dead fetus syndrome, TRAP, TAPS,
 PROGNOSIS

Maternal mortality is increased in twins than in a singleton pregnancy. Death is mostly due to
hemorrhage (before, during and after delivery), pre-eclampsia and anemia.

Perinatal outcome: Perinatal mortality is markedly increased mainly due to prematurity. It is 4-5
times higher than in a singleton pregnancy. It is extremely high in monoamniotic monozygotic twins
due to cord entanglement. One third loss is due to stillbirth and two- thirds due to neonatal death.
During delivery the second baby is more at risk (50%) than the first one due to: (i) retraction of uterus
leading to placental insufficiency, (ii) increased operative interference and (iii) increased incidence of
cord prolapse.

Because of increased risk to both the mother and the baby, compared to that of a singleton
pregnancy, the twin pregnancy is considered 'high-risk' and as such should be delivered in a hospital
COMPLICATIONS OF MONOCHORIONIC TWINS

(i) Twin-Twin Transfusion Syndrome (TTTS): Occurs in Monochorionic Diamniotic (MCDA) twins , where
one twin (donor) appears to bleed into the other (recipient) through three types of deep placental
vascular anastomosis. (a) Artiovenous (AV), (b) Arterioarterial (AA) and (c) Venovenous (VV). Clinically ,
the recipient twin becomes larger with hydramnios, polycythemic, hypertensive polyuric and
hypervolemic, at the expense of the donor twin which becomes smaller (IUGR) with oligohydramnios
(Poly-Oli syndrome), anemic, hypotensive, oliguric and hypovolemic

This leads to anemia-polycythemia syndrome. The donor twin may appear 'stuck' due to severe
oligohydramnios. The difference of hemoglobin concentration between the two, usually exceeds 5 g%
and estimated fetal weight discrepancy is 25% or more.

Management: Antenatal diagnosis is made by ultrasound with Doppler blood flow study in the
placental vascular bed at 16-18 weeks. Increased nuchal translucency can also be seen on USG
Treatment methods

(a) Laser photocoagulation to interrupt the anastomotic vessels on the chorionic plate can give
some success.

(b) Repeated amniocentesis to control polyhydramnios in the recipient twin is done.

(c) Septostomy (making a hole in the dividing amniotic membrane).

(d) Selective reduction (feticide) of one twin is done when survival of both the fetuses is at risk.
The smaller twin generally has got better outcome. The plethoric twin runs the risk of
congestive cardiac failure and hydrops.
(i)Twin Anemia-Polycythemia Sequence (TAPS): TAPS is an important association in complicated
monochorionic pregnancies, occurring in 2% of uncomplicated Monochorionic Diamniotic (MCDA) and
up to 13% of monochorionic twins post-laser ablation. -It is a complication of monochorionic
diamniotic twin pregnancy due to chronic and severe hemoglobin discordance. It is seen in the
absence of other features of TTTS.

It is diagnosed by using Middle Cerebral Artery (MCA) Doppler PSV≥ 1.5 MOM in one and in the
other twin MCAPSV <0.8 MOM without any amniotic fluid discordance. Postnatal diagnosis of
anemia, hemoglobin <11 g/dL in the donor and hemoglobin >20 g/dl. in the recipient. -The TAPS may
be due to small AV anastomoses which allows a slow transfusion of blood from the donor to the
recipient. The management of TAPS is done with intrauterine transfusion (intraperitoneal or IV) and
with laser treatment. Expectant management is also an option.

(ii) Dead fetus syndrome: Death of one twin (2-7%) is associated with poor outcome of the cotwin
(25%) especially in monochorionic placenta. The surviving twin runs the risk of cerebral palsy,
multicystic encephalomalacia, microcephaly, renal cortical necrosis and DIC. This is due to acute
hypotension and thromboplastin liberation from the dead twin that crosses via placental anastomosis
to the living twin.
(iii) Twin Reversed Arterial Perfusion (TRAP) is characterized by an 'acardiac perfused twin' having
blood supply from a normal cotwin via large arterioarterial or vein to vein anastomosis .

In majority the cotwin dies (in the perinatal period) due to high output cardiac failure. -The arterial
pressure of the donor twin being high, the recipient twin receives the 'used' blood from the donor.
The perfused twin is often chromosomally abnormal. The anomalous twin may appear as an
amorphous mass. -Management of TRAP is controversial. Coagulation or ligation of the umbilical
cord (laser or RFA) of the acardiac twin under fetoscopic guidance has been done.

(iv) Monoamniocity (1-2% of all MZ twins) in monochorionic twins leads to high perinatal mortality
(50%) due to preterm delivery, LBW, congenital anomalies and mostly due to cord problems .

Increased fetal surveillance, antenatal corticosteroids, planned early delivery (34 weeks) improve
perinatal outcome. Cesarean delivery is commonly done.

(v) Conjoined twin is rare (1.3 per 100,000 births). Perinatal survival depends upon the type of joint .
Paraphagus> thoracophagus . Major cardiovascular connection leads to high mortality.
(vi) Selective Growth Restriction (SGR): SGR is defined when Estimated Fetal Weight (EFW) difference
is >20% between the fetuses. It is over 50% in monochorionic twins complicated by TTTS. In cases with
SGR, staging is done based on severity of affection.

Stage I: Growth discordance but positive diastolic velocities in both fetal umbilical arteries. Stage II:
Growth discordance with Absent or Reversed End-Diastolic Velocities (AREDV) in one or both fetuses.
Stage III: Growth discordance with cyclical umbilical artery diastolic waveforms over several minutes
(intermittent AREDV; AREDV).

Stage IsGR is preferably delivered by 34-36 weeks. Stage II and Stage III by 32 weeks. Antenatal
corticosteroids are give prior.
Fetal Complications

Twin-to-twin Twin Anemia- Twin Reversed

transfusion Polycythemia Arterial Perfusion
syndrome (TTTS) Syndrome (TAPS) (TRAP)

A serious condition that can
occur when blood flows
unequally between identical
twins sharing a placenta
A rare form of chronic inter-
twin transfusion, where blood
from one twin flows into the
other, leading to anemia in
one and polycythemia in the
other twin
A rare complication that can
occur in monozygotic
pregnancies, where one twin
lacks a functioning heart and
receives blood supply from
its healthy counterpart