TWIN PREGNANCY

Tigist B

By the end of this session, the student be able to:

Describe the patho-physiology of multiple pregnancy
List risk factors of multi-fetal gestation
Describe complications to mother and fetus
Propose management options in multi-fetal pregnancy

II. Monozygotic twins

i. one oocyte is fertilized by one spermatozoa
ii. the zygote splits between 2 cells stage and 2 nd week,
thus having common placenta and chorionic cavity, but
separate amniotic cavities.
If the separation occurs as late as at the bilaminar germ
disc stage, just before formation of the primitive
steak/node, also the amniotic cavity is common.
If separation fails to complete the twins will be
conjoined.
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Twin pregnancy
Occur when two or more ova are released and
fertilized (dizygotic)
A single fertilized ovum divides early to form
two identical embryos at the inner cell mass
stage or earlier (monozygotic)
Either or both processes may be involved in
the formation of higher numbers

Dizygotic
The two ova may be produced by one or the two
ovaries
Each fetus has its own membrane (both chorion and
amnion) and its own placenta (dichorionic
diamniotic placentation
Some times the two placentas may become fused if
the implantation site is close
Fetus may have similar or opposite sex
Differ in genetic constitution as any other children
born to the same couples
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Contd.
Superfecundation 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
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
as yet unproven in humans
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Contd.

Monozygotic
The varieties are determined by the time (days
after fertilization) when splitting occurs in the
embryo
The exact cause of monozygotic twinning is
unclear

Incidence
The incidence of monozygotic twinning is fairly
constant through out the world at a rate of about
4/1000 LB
Where as dizygotic twinning is affected by
several factors
Race :- low in Asians, intermediate in Caucasians &
high in blacks e.g. Nigeria 45/1000 LB
Age :- increase with age
Infertility treatment:- using clomiphen, HMG,

Placentation
In dizygotic twinning the placentas are always
diamniotic and dichorionic
Intimate fusion of the placentas may occur, if they
implant side by side
The type of placentation in monozygotic twin
pregnancy is determined by the time at which
cleavage of fertilized ovum occurs

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Contd.
Cleavage in the 1st 2-3 days 2 chorions & 2
amnions are formed
Cleavage between 3rd and 8th day diamniotic
monochorionic placenta forms
Cleavage between 8th and 13th monoamniotic
monochorionic placenta
13th 15th the process of twinning cant
completely occur (conjoined twins )

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Diagnosis
History/physical examination
Family history of twins
Exaggerated pregnancy symptoms
Positive discrepancy(large for date uterus)
Abdominal examination usually reveals
multiple fetal parts(in 3rd Tm)
Two different fetal heart beats identified
at the same time
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Contd.
Increased availability of US imaging has
improved the possibility of early diagnosis
An x-ray of the maternal abdomen
After 16 weeks of gestation
Diagnosis late in pregnancy, Intrapartum
or even late after the delivery of the first
twin is not rare

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Determination of zygosity
Rate of twin-specific complications varies in

relation to zygosity and chorionicity, with the

latter being the more important determinant
Sonographic Evaluation
Chorionicity can sometimes be determined
sonographically in the first trimester
presence of two separate placentas and a thick
generally 2 mm or greaterdividing membrane
supports a presumed diagnosis of dichorionicity
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Contd.
Twins of opposite sex are almost always DZ
Monochorionic placentation indicates MZ
Dichorionic twins of similar sex may be DZ or MZ
Placental Examination
After delivery
PCR

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 Pregnancy Outcome
Abortion
Congenital Malformations
Defects resulting from twinning itself, a
process that some consider to be a teratogenic
event
conjoined twinning
Defects resulting from vascular interchange
between monochorionic twins
Defects may develop from fetal crowding
talipes equinovarus (clubfoot)
congenital hip dislocation.
Dizygotic twins are also subject to these.
Birth weight
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Contd.

Duration of pregnancy
As the number of fetuses increase, the duration
of gestation and birth weight decrease
The mean duration of gestation for twins is 37
weeks and for triplets 35 weeks
Prolonged gestation is considered at 40 weeks (2
weeks earlier than singleton )
Twin stillborn neonates delivered at 40 weeks or
beyond had features similar to those of
postmature singletons
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Maternal Complications of twin

pregnancy
Hyperemesis gravidarum
PIH
Maternal anemia
APH
PPH
Dysfunctional labor
Operative delivery

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Unique Complications

Monoamnionic Twins
1 % of monozygotic twins are monoamnionic
Diamnionic twins can become monoamnionic if the
dividing membrane ruptures
high fetal death rate
cord entanglement
congenital anomaly,
preterm birth,
twin-twin transfusion syndrome

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Contd.
Conjoined twins
incomplete splitting of an embryo into two
separate twins
Craniopagus
Thoracopagus
Ischiopagus
omphalopagus
parapagus = the most common lower limp
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Conjoined Twins

Thoracopagus, Pygopagus and Craniopagus twins

Conjoined twins can be separated only if they have
no vital parts in common

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Contd.

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Contd.
Viable conjoined twins should be
delivered by cesarean
For pregnancy termination, however,
vaginal delivery is possible because
the union is most often pliable
if the fetuses are mature, vaginal
delivery may be traumatic to the
uterus or cervix
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Twin-Twin-transfusion syndrome
Almost always in association with monochorial placenta
The transfusion syndrome is there if there is A-V
communication
One fetus becomes a donor that transfuses its co-twins
The donor becomes anemic & growth retarded
The recipient becomes polycythemic and can suffer from CHF
Hydramnios in the sac of the larger twin due to increased
urine production
Oligohydramnios in the co-twin
Perinatal mortality as high as 70 %

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Contd.

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Prenatal care
Early detection
More frequent visits
To early diagnose and treat associated
complications
Advice about additional diet
Ferrous sulfate supplementation
Antepartum fetal surveillance
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Intrapartum management
Mode of delivery is CS if the first twin is nonvertex
Complications anticipated
Preterm delivery (asphyxia)
Uterine dysfunction
Malpresentation
Cord prolapse
Abruptio placenta
PPH
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Delivery of the second twin

As soon as the 1st twin is delivered the
presentation, lie and position of the
second fetus determined
If the presenting part is fixed in the
birth canal, fundal pressure is applied,
membrane is ruptured and PV
repeated to R/O cord prolapse
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Contd.
If contraction does not resume within 10
minutes start augmentation
Intrapartum external version of the noncephalic second twin can be done if
membrane is intact and presenting part not
engaged
Interval between deliveries of the 2 twins
is ideal if between 15-30 minutes
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Contd.
CS for the second twin may be
necessary because of
Fetal macrosomia
cervix retracting and not dilating
Fetal distress
Cord prolapse
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