Undergraduate course lectures in Obstetrics&Gynecology prepared by DR Manal Behery,Professor of OB&Gyne,Faculty of medicine,Zagazig University

1. Dr Manal Behery
2014

2. Defintion
• When more than one fetus simultaneously
develops in the UTERUS
• 3 fetuses : triplets
• 4 fetuses : quadruplets
• 5 fetuses : quintuplets
• 6 fetuses : sextuplets

3. HELLIN’S RULE
Twins 1 in 80
Triplets 1 in 80^2
Quadruplets 1 in 80^3

4. Types of twins
•
• Monozygotic (1/3 rds) Dizygotic (2/3 rd)
Results from fertilization Results from fertilization of
a single ova of two ovum

6. Dizygotic
amnion amnion
2
chorions
Always dichorionic & diamnionic

7. Factors affecting dizygotic twinning
Ethnic group
Increasing
maternal age

8. Increasing parity
Family h/o twinning, esp
maternal
Ovulation induction
ART

9. • Monozygotic twinning is independent of
• race,
• heredity,
• age &
• Parity.
• INCIDANCE 1/25O

10. MONOZYGOTIC
4-7 days

11. >8days

12. >DAY 13

13. THORACOPAGUS
ISCHIOPAGUSCRANIOPAGUS
RACHYPAGUSPYOPAGUSOMPHALOPAGUS

14. MONOZYGOTIC
TWINS

15. Diagnosis

16. History
Previous history of twinning; high parity
Older maternal age > 37yrs
History of ovulation induction or pregnancy
following ART
Family history of twinning

17. Clinically Symptoms
• Exaggerated pregnancy symptoms.
• Fetal activity is greater and more persistent in
twinning than in singleton pregnancy.

18. Signs
• (1) Uterus > dates of amenorrehea .
• (2) Excessive maternal weight gain that is not explained
by edema or obesity.
• (3)palpation of 2 fetal heads/presence of three fetal
poles.
• 4) Simultaneous recording of different fetal heart rates,
each asynchronous with the mother’s pulse and with
each other and varying by at least 8 beats per minute.

19. Ultrasound Determination of Chorionicity
• Number of sacs. [ before 10 weeks ]
 2 sacs – dichorionic
 Single sac - monochorionic
• Placenta
• Sex
• Intertwin membrane
 thicker and more echogenic in dichorionic
.
Ideal time for assessing of chorionicity is before 14 weeks

20. Dizygotic

21. Lambda sign

22. MONOCHORIONIC & DIAMNIONIC
T sign

23. Importance of chorionicity ?????

24. Problems Specific to Monochorionic twins
Nearly 100% of monochorionic twin placentas
have vascular anatomizes
2 patterns of vascular anastomosis
•twin-to-twin transfusion syndrome (TTTS)
acardiac twinning or twin
•reversed arterial perfusion (TRAPS)

25. Maternal Complication
Antenatal :
1.Hyperemesis gravidarum
2.↑chances of abortion
3.hydramnios
4.PIH
5.Placenta previa, abruptio
6.Anemia
7.Exaggerated minor problems: pressure symptoms,
etc

26. • Intrapartum complications
1.Prolonged labor (uterine inertia)
2.Malpresentation
3.Cord prolapse
4.Abruptio placenta for 2nd twin
5.Interlocking of twins
6.PPH

27. Fetal complications
1.Preterm delivery
2.IUGR
3.Congenital Abnormalities
4.Cord abnormalities :
1. Single umbilical artery
2. Velamentous insertion
3. Cord entanglement
4. Cord prolapse
5.Monochorionic twins :
1. Discordant growth
2. Twin to twin syndrome
3. Single fetal Demise

29. Cord entanglement

30. TTTS:Arterio venous anastomoses
with net flow in one direction..

31. Donor(arterial side)
recipient
•Severe IUGR
•poor renal perfusion
•Anuria
•severe oligohydramnios
•Hypervolemia
•Polyuria with polyhydramnios
•CCF…..hydrops…death
Serial amnio reduction,fetoscopic laser ablation
of anastomosis

32. Ultrasound in TTS – Stuck Twin Sign

33. Vanishing twin
Cessation of cardiac activity in a
previously viable foetus
Fetus
papyraceous…

34. TRAP sequence
PUMP TWIN ACARDIAC TWIN

35. Acardiac twins

36. APARNA P
2009 MBBS

37. 1.Prenatal care
 More frequent antenatal visits.
 prophylactic iron 60-100mg and folic
acid 1mg daily should be given.
 Nutritional advice-calorie req is
300kcal/day more than that
recommended for uncomplicated
pregnancy.
 Restriction of activity and
increased rest at home.
 Prophylactic steroids – risk for
preterm labour or IUGR.

38. 2.Ultrasound scan
 At 9-11 wks :
confirmation, chorionicity
determination,
assessment of gestational
age and nuchal
translucency.
 anomaly scan at 20 wks
 4 weekly scans in 3rd
trimester to assess fetal
growth, diagnose
complications like TTS

39. Nuchal Translucency
Mid Trimester
Amniocentesis is
the gold standard

40. Delivery prereqists
CTG with dual monitoring capability
Forceps or vacuum
 Oxytocin infusion
 Tocolytic agent for uterine relaxation
 Methergin, 15-methyl PGF2 alpha
 Immediate availability of blood
 Access for emergency C/S

41. 1.Place of delivery-
Fully equipped
hospital having
intensive neonatal
care unit.
2.Timing of delivery
RCOG recommends
elective termination
of pregnancy at 37-
38 weeks
Monochorionic
pregnancy best
delivered at 36-37
weeks

42. Mode of delivery
Depend on presentation of 1st twin
Both vertex / 1st twin vertex –
vaginal delivery
Indication for Elective LSCS
-More than 2 fetuses
-1st twin malpresentation, CPD
-Scarred uterus
-MCMA
-Conjoint twin
-IUGR in dichorionic twin
-TTTS

43. Delivery of 1st twin twin
Deliver the first baby vaginally
Cord is divided in between 2 clamps to prevent acute
intrapartum transfusion.
No methergin is given at this point as it can cause
entrapment and asphyxia of second twin.

44. Delivery Of Second Twin
• Palpate abdomen
immediately to ensure
lie,presentation.
• If required-ultrasound
examination done.
• Vaginal examination is
also done to exclude
cord prolapse.
• Acceptable interval
between deliveries – 30
mins

45. Longitudinal lie
A.R.M + oxytocin if necessary…. If delay
Vertex- Low down->forceps or ventose;
High up->internal version
Breech- breech extraction

46. 2ND Twins
Transverse lie
External version- cephalic or IF FAILS
Internal version under G.A

47. Internal podalic version
To do or not to do ??
 Experienced operator
 EFW > 1500 gm
 Adequate liquor
 Available anesthesia for
• effective uterine relaxation
 Simultaneous preparation
• for emergency C/S

48. Rapid Delivery BY emergancy CS
Severe vaginal bleeding
Cord prolapse in second twin
Inadvertent use of IV ergometrine with
delivery of anterior shoulders of first
baby
2nd twin is transverse, version failed
after delivery of 1st twin
Fetal distress

49. Third Stage
 Cross matched blood should be
readily available.
 Risk of atonic PPH is more.
 Oxytocin infusion & i/v
ergometrine 0.25mg or
methergine 0.2mg given
following delivery of anterior
shoulder of second baby.
 Prostaglandins-15 methyl PG
F2alpha can also be used.
 Placenta examined for
completeness, confirm
chorionicity.

50.  Selective fetal reduction-one
fetus in a multiple gestation is
abnormal
 Multifetal reduction-in higher
order pregnancy
 Iatrogenic fetal death –us
guided fetal heart puncture or
inj kcl
 One member of monochorionic
pair should never be selected
Multifetal and selective pregnancy reduction

51. THANK
YOU