ANOMALIES ASSOCIATED

WITH
MULTIPLE GESTATION

AGUS ABADI

FETOMATERNAL DIVISION
DEPT. OF OBGYN
DR. SOETOMO HOSPITAL
SURABAYA
 INCIDENCE

TWIN 1,1 - 1,2 % SPT. PREG.

TRIPLETS 1: 8000 (n) ,,

QUADRUPLETS 1: 729.000 (n²) ,,

QUINTIPLETS 1: 65.610.000 (n³) ,,

 TWIN PREGNANCY

MONOZYGOTIC TWIN DIZYGOTIC TWIN

( IDENTICAL ) ( FRATERNAL)
 (MONOZYGOTE)
DICHORION MONOCHOR
DIFF. SEX SAME SEX
35% 20%
1st Qtr
( DIZYGOTIC ) DICHORION 2nd Qtr
(MONOZYGOTE)
SAME SEX
3rd Qtr
10%
4th Qtr
DICHORION
SAME SEX
35%
( DIZYGOTIC )
 USG
CHORIONICITY

PLACENTA
MEMBRANE
SEX

1ST 2nd 3rd TRIMESTER

ACCURACY ≤ 83% 98%

T - sign
Lamda - sign
 PERINATAL OUTCOME

CHORIONICITY

3% MONOCHORIONIC
PERINATAL LOST RATE 1,5% DICHORIONIC

12% MONOCHORIONIC
FETAL LOST RATE 2% DICHORIONIC
 PERINATAL OUTCOME

VANISHING TWIN
< 14 WKS
3% MONOCHORIONIC
6% DICHORIONIC

MONOCHORIONIC BOTH TWIN †

1ST TWIN DISAPPEAR

DICHORIONIC ABORTION
2ND TWIN PRETERM
TERM
PERINATAL OUTCOME

PRETERM DELIVERY

TWIN 36 WKS

TRIPLET 33 WKS

QUADRUPLET 29 WKS
TWIN PREGNANCY

INCREASED RISK OF
CHROMOSOMAL AND
FETAL ANOMALIES

DIZYGOTIC
MONOZYGOTIC
MONOCHORIONIC > DICHORIONIC
 COMPLICATIONS IN MONOCHORIONIC TWIN

MONOCHORIONIC-DIAMNIOTIC
1. TWIN EMBOLIZATION SYNDROME. - Embolization or ischemic injury
following in utero demise of
a co-twin
2. TWIN-TWIN TRANSFUSION SYNDR. - Unequal shunting of blood
secondary to anastomotic of
placental vessels

MONOCHORIONIC-MONOAMNIOTIC.
1. CONJOINED TWIN - Partial fusion of twin
2. ACARDIAC TWIN - Absent or rudimentary non -
( TWIN REVERSED ARTERIAL functional heart in resipient
PERFUSION SYNDROME) twin
TWIN EMBOLIZATION SYNDROME

FETAL THROMBOPLASTIN
FRAGMENT PLAC. NECROSIS
1ST TWIN †
DIC

16-20 WKS 2ND TWIN † 2%

PORENCEPHALY
VENTRICULOMEGALY
2ND – 3RD TRIMESTER MICROCEPHALY
CEREBRAL ATROPHY
CYSTIC ENCEPH. MALACIA
PORENCEPHALY
VENTRICULOMEGALY
MICROCEPHALY
TWIN-TWIN TRANSFUSION SYNDROME

MONOCHORIONIC

TWIN-TWIN TRANSF. SYNDROME

ANASTOMOSIS OF PLACENTAL VESSELS

25% MILD
15% SEVERE
USG MONOCHORIONIC-DIAMNIOTIC TWIN
T
T 1ST TR.
S NUCHAL TRANSLUSION
SENS.95% - PPV 40% - NPV 90%

2ND TR
RESIPIENT DONOR

POLYHYDR NORMOHYDR.
HYDROPS OLIGOHYDR.
CONGEST. HEART IUGR & HIPOXIC
URINE BLADDER >> URINE BLADDER<<
Twin-twin
Transfusion
Syndrome
MONOAMNIOTIC TWIN

1% - TWIN PREGNANCY
INCIDENCE 2 3% - MONOCH. TWIN

ULTRASONOGRAPHY

1ST TR : 1 YOLKSAC

2ND TR : 1 PLACENTA
1 AMNION
 MONOAMNIOTIC TWIN

PARTIAL FUSION OF TWIN ANASTOMOSIS OF

PLAC. GREAT VESSELS

CONJOINED TWIN ACARDIAC TWIN

 CONJOINED TWIN

1 : 50.000 1 : 200.000 PREGNANCY

INCIDENCE
FEMALE > MALE

ORGAN ANOMALIES 50%

ASSOCIATED CARDIAC DEFECT 20 – 30%

ANOMALIES

POLYHYDRAMNIOS 50 - 75%
 CONJOINED TWIN

CEPHALOPAGUS
CRANIOPAGUS
VENTRAL THORACOPAGUS
ISCHIOPAGUS

DITHORACIC PARAPAGUS
CLASSIF. LATERAL DICEPHALIC PARAPAGUS
DIPROSOPIC PARAPAGUS

DORSAL CRANIOPAGUS
PYGOPAGUS
RACHIPAGUS
 THORACOPAGUS
WITH SHARED HEART

SIGN OFNON-OPERABILITY
TWO FACES
SEEN AT THE SAME
LEVEL
OMPHALOPAGUS
WITH TWO STOMACH
IN DIAGONAL POSISION
DICEPHALIC
PARAPAGUS
ACARDIAC TWIN

1 % OF MONOCHORIONIC TWIN
INCIDENCE 1 : 35.000 OF ALL PREGNANCY

ANASTOMOSIS PLAC. VESSELS

(LARGE DIAMETER)

MOST EXTREEM
TWIN-TWIN TRANSFUSION SY
 PATOPHYSIOLOGY

NORMAL TWIN

RETROGRADE TRANSFER OF
POORLY OXYGENATED BLOOD

SLOW DEVELOPED TWIN

RUDIMENTARY
NON FUNCTIONAL HEART
(ACARDIAC TWIN)
ACARDIAC TWIN

MALFORMATION DESCRIPTION

ACEPHALUS No cephalic structure

ANCEPS Some cranial and / or

neural structure

ACORNUS Cephalic structure but

no truncal structure

AMORPHUS No distinguishable rostral

or caudal structure
 ACARDIAC TWIN
AT 14 WEEKS
( 2,9 CM )

ACARDIAC TWIN
AT 15 WEEKS
( 5 CM )
AMORPHUS

ACEPHALUS
FETUS IN FETU