Complications of all Multiple pregnancies

Fetal Complications: Maternal complications

• Each is smaller than a singleton
fetus- Growth restriction • Preeclampsia
• Prematurity
• Increased incidence of growth • Placenta abruption
retardation and anomalies
• For the second twin to be • Placenta previa
delivered – prenatal mortality of
10-15% prolapsed cord, anoxia • APH & PP
 Vanishing twins
Demise < 15weeks GA.
 Twin – Twin Transfusion Syndrome

• Occur in 15-30% of all Monochorionic pregnancies

• TTTS results from an unbalanced arterio-venous
(AV) communication in the placenta with
increasing evidence implicating asymmetric
anastomotic patterns in its etiology.
• One fetus “steals” blood from the other
• Poor prognosis, especially for the smaller fetus
 Twin-Twin Transfusion Syndrome
Ultrasound Findings
• Variable Presentation
• Full blown
- One fetus larger and hydropic
- Other fetus smaller and “growth restricted”
• If Di-amniotic Twinning
- Larger fetus with polyhydramnious
- Smaller fetus with oligohydramnious
• The smaller twin with oligohydramnious which also called
"stuck twin" that pumps away blood is termed the donor twin
• The larger twin receiving extra blood is termed the recipient
twin.
 Features of the Recipient twin
• Recipient twin is larger in size and will have an
increased estimated fetal weight (EFW)
• Polyhyramnios
• Large urinary bladder
• Evidence of fetal polycythaemia
• Fetal hydrops
• Fetal cardiomegaly
– in certain cases fetal echocardiography may also show
AV valve incompetence
 Features of the Donor twin
• Donor twin (pump twin / stuck twin)the small
twin (with decreased EFW) can appear
"pinned" to side of gestational sac
• Evidence of fetal anemia
• Oligohydramnios
• Small/absent urinary bladder
 TTTS
US: twin growth

discordance between the two twins

(>20%)

•Monochorionic twins with

asymmetric fluid distribution and

growth.

•Oligohydramnios, stuck twin”

 Doppler in TTTS
• Absent or reversed diastolic flow in the
umbilical artery is an indication of worsening
twin-to-twin transfusion syndrome
• Abnormal Ductus venosus waveform pattern
suggests possibility of cardiac diastolic
dysfunction 
Twin –twin transfusion
 Acardiac Twinning

• Rare Complication of Monochorionic

Pregnancies
• One Normal Fetus
• Acardiac twin – lacking development of heart,
head & upper extremities. Marked
edematous changes.
• Doppler – Shared Blood Supply
- Artery to Artery – Toward Acardiac Twin
- Vein to vein – Away from Acardiac Twin
 Stuck twin
• The stuck twin ( arrow) is “ plastered” to
the uterine wall and is much smaller.
• It is a result of twin to twin transfusion.
• The donor twin is small with
oligohydramnios. The receptor twin is
large with Polyhyramnios and hydrops.
• The cause of trans fusion is a shares
placenta with connecting blood vessels.
• The receptor twin steals blood form the
donor twin.
• The receptor twin is also at risk of cardiac
failure due to the volume overload.
• The donor twin is at a higher risk of dying
due to hypovolemia
 Conjoined (Siamese) Twinning

• Monochorionic – Monoamnoitic
• Thoracopagus – most common – joined at chest
• Conjoining anywhere from head to hip
• Conjoining does not have to be symmetric
• Does not affect survival.
• Affects mode of delivery and chance of separation
•Conjoined twins happens when one fertilized egg fails to divide
completely to create two distinct individuals.
•1:50,000 to 1:200,000.
 Cord entanglement
Monochorionic-monoamniotic twins have a further increased
incidence of Cord entanglement.