Prof. Turgut Aydın M.D.

Multiple Acibadem University School of

Gestatio Medicine
Department of Obstetrics and
Gynecology
ns
Multiple Gestations

• Learning Objectives

• Epidemiyology
• Diagnosis
• Zygosity, placentation and mortality
• Complications
• Antenatal management of multiple gestations
• Delivery
 Multiple Gestations

• This is a pregnancy in which more than one fetus is present. 3 % of live

births in worldwide

Prematurity 10 % of Neonatal Deaths

Low birth weight
Congenital Anomalies 11 % of Perinatal Mortality
Epidemiology

● Monozygotic 4/1000
Dizygotic 10-40/1000
● Heredity (From Mom)
● Race(Increased rate in the black race)
● Maternal age(over 35)
● High maternal BMI
● Ovulation induction and multiple ET
● Rarely micromanupilation in IVF lab
● Risk of twinning is up to 10 % with CC
and up to 30 % with hMG
Diagnosis

• Diagnosis is confirmed by sonogram most accurately in the first trimester when separate
gestational sacs are easily seen to determine chorionicity.
• In later gestations, sonogram can detect the “twin-peak” sign also known as the “lambda sign”
for dichorionic twins and the T sign for monochorionic diamnionic twins.
• Uterine size is greater than expected for gestational age
• Multiple fetal heart rates are detected
• Multiple fetal parts are felt
• Human chorionic gonadotropin (hCG) and maternal serum alpha- fetoprotein
• Pregnancy is a result of ART
Dichorionic Placenta
• Lambda sign
Ultrasound
• lambda sign; for dichorionic twins
• T sign; for monochorionic diamnionic twins
Conjoined Twins

● Very rare form of MC twins

● It formed by division of embryonal disk after 13th and 15th day after
fertilization.
• Thorakophagus (most common)
• Xyphophagus
• Pyophagus
• Craniophagus
• İshiophagus
Conjoined Twins
Vanishing Twin
• One gestational sac does not growth of cardiac activity is not visualized by ultrasound
• Relatively frequent, 10-30 %
• 80 % of cases < before 9th GW
• Risk of IUGR , PTD increase
• Confused or controversial screening tests even cf-DNA tests
Zygosity, placentation, and
mortality

• Dizygotic dichorionic/diamnionic twins

• 70% to 80% of all twins
• Result from the fertilization of two ova.
• Each fetus has its own placenta and a complete and separate
amnion-chorion membrane.
• Monozygotic twins
• 20% to 30% of all twins
• Result from cleavage of a single, fertilized conceptus.
• The timing of cleavage determines the placentation.
 Monozygotic twins (20% to 30% of all
twins)
• Dichorionic/diamnionic monozygotic twins (8% of all twins)
• They are produced by cleavage in the first 3 days after fertilization.
• They will have separate amnions and chorions, just like dizygotic twins.
• They have the lowest perinatal mortality rate (<10%) of all monozygotic twins.

• Monochorionic/diamnionic twins (14% to 20% of all twins)

• They are produced by cleavage between days 4 and 8 after fertilization.
• They share a single placenta but have separate amnionic sacs.
• The mortality rate for monochorionic/diamnionic twins is approximately 25%.
•
• Monochorionic/monoamnionic twinning (<1% of cases)
• They occurs after the eighth day.
• The fetuses share a single placenta and a single amnionic sac because both amnion and chorion were
formed before cleavage.
• Later, cleavage is even rarer and results in conjoined fetuses.
• Monoamnionic gestations have a 50% to 60% mortality rate, usually occurring before 32 weeks.
Embryonic Division

Placentation and Membranes Based on Timing of Embryonic Division. (A) Two amnions, two chorions, and separate
placentas from the division of either a dizygotic or monozygotic embryo within 3 days of fertilization. (B) Two amnions,
two chorions, and one fused placenta from the division of either a dizygotic or monozygotic embryo within 3 days of
fertilization. (C) Two amnions, one chorion, and one placenta from monozygotic embryonic cleavage, days 4–8 after
fertilization. (D) One amnion, one chorion, and one placenta from a monozygotic embryo splitting, days 8–13 after
fertilization. (Modified from Gibbs R, Karlan B, Haney A, et al. Danforth’s Obstetrics & Gynecology, ed. 10, Philadelphia;
Lippincott, Williams & Wilkins, 2008.)
Monozygotic Placentation

Types of Monozygotic Placentation. (A) Dichorionic diamniotic pregnancy. (B) Monochorionic diamniotic
pregnancy. (C) Monochorionic monoamniotic pregnancy. (Adapted from Hall JG. Twinning. Lancet.
2003;362:735–743; and Benirschke K, Kim CK. Multiple pregnancy. 1. N Engl J Med. 1973; 288:1276–1284.
 • Miscarriage
• Nausea and vomiting
• Congenital anomalies and malformations
• Preeclampsia
• Polyhydramnios
Complicatio • Preterm delivery
• Intra uterine growth retardation (IUGR)
ns • Discordant twin growth
• postpartum hemorrhage
• Intrapartum complications
• Twin-to-twin transfusion syndrome (TTTS)
Miscarriage
• Miscarriage is at least twice as common in multiple gestations,
compared with singleton pregnancies.
• Fewer than 50% of twin pregnancies diagnosed by ultrasonography in
the first trimester result in live birth of twins.

Nausea and vomiting

• Nausea and vomiting are often worse in multiple gestations
• Although the etiology is unclear, higher levels of hCG may be the
cause
Congenital anomalies and
malformations

• Congenital anomalies and malformations are about

• Twice as common in dizygotic twins
• Three times more common in trizygotic triplets compared to
singletons
• Because the risk of chromosomal anomalies increases with each
additional fetus
• Monozygotic twins have a 2% to 10% risk of developmental defects,
about twice the rate for dizygotic twins
Preeclampsia
• Preeclampsia is more common, occurs earlier, and is more severe in
multiple gestations
• Approximately 40% of twin pregnancies and 60% of triplet
pregnancies are affected.

Polyhydramnios
• Polyhydramnios occurs in 5% to 8% of multiple pregnancies,
particularly with monoamnionic twins.
• Acute polyhydramnios before 28 weeks’ gestation has been
reported in 1.7% of twin pregnancies.
• The perinatal mortality in those cases approaches 90%.
Morbidity and Mortality
by Fetal Number
Incidence of Twin Pregnancy
Zygosity
and Chorionicity
With Corresponding
Complications
Discordant twin growth

• Discordant twin growth is defined as a discrepancy of more than 20% in

the estimated fetal weights.
• It is calculated as a percentage of the larger twin’s weight.
• TTTS
• Chromosomal or structural anomalies in either twin
• Discordant viral infection
• Unequal division of the placenta mass
• When discordance exceeds 25%, the fetal and neonatal death rates
increase 6.5-fold and 2.5-fold, respectively.
 Twin-to-twin
transfusion syndrome (TTTS)
● Deep A-V anastomosis
● It occurs in 12 % of MC twins.
● Recipient;
● Polycythemia, Hypertansion, polyuria,
polyhydramnios, circulatory overload, heart
failure, hydrops fetalis, fetal demise
● Donor;
● Anemia,hypotansion, oliguria, oligohydramnios,
circulatory insuffient, growt restricrion, renal
failure, fetal demise
● First sign could be NT difference between 11th and
14th GW during nuchal scan.
Twin-to-twin transfusion syndrome (TTTS)
Twin reversed arterial perfusion
(TRAP)

• TRAP is a sequence, seen in monochorionic twin pregnancies with poor

prognosis and with a 1/100.000 incidence.
• It is characterized with a recipient fetus exhibiting lethal anomalies
including acardia and a pump fetus supplying blood by vascular
communications in the placenta.
• Mortality of acardiac twin is inevitable.
• Pump twin has the mortality rate of 50% and death is usually due to
heart failure or premature labor caused by polihydramnios.
Twin reversed arterial perfusion
(TRAP)
Intrapartum Complications

• Malpresentation
• Cord prolapse
• Cord entanglement
• Dysfunctional labor
• Fetal distress
• Urgent cesarean delivery are more common for multiple gestations
compared with singletons
Antenatal management of multiple
gestations

• Antenatal management of multiple gestations includes

• adequate nutrition (300 additional calories per day per fetus),
• more frequent prenatal visits,
• Periodic ultrasound assessment of fetal growth and well-being
• prompt hospital admission for preterm labor or obstetric complications
• No evidence supports bed rest or prophylactic tocolytics in multiple gestations
• In addition, neither prophylactic cerclage or progesterone therapy have been
shown to reduce preterm birth rates in multiples
Ultrasonography

• Ultrasonographic assessments should be conducted every 3 to 4 weeks

from 23 weeks’ gestation to monitor fetal growth and detect
discordance.
• Monochorionic placentation may warrant ultrasonography every 2
weeks to evaluate for evidence of TTTS.
Amniocentesis

• Amniocentesis should be performed for both fetuses, if indicated, for

prenatal diagnosis of genetic disorders or alloimmunization
• One to 5 mL of indigo carmine is injected into the first sac following fluid
aspiration to ensure that both sacs are sampled
• To establish lung maturity, amniotic fluid evaluation from one fetal sac is
adequate
• For discordant twins, amniotic fluid should be obtained from the larger
twin, which usually reaches pulmonary maturity later
Multifetal pregnancy reduction

• Multifetal pregnancy reduction may be offered to reduce risk in higher

order pregnancies
• Because the presence of three or more fetuses is associated with such
increased maternal and perinatal mortality and morbidity, fetal
reduction may be appropriately offered.
• The risk of subsequent pregnancy loss is 5% to 10%.
• Selective termination refers specifically to the termination of one or
more specific fetuses with structural or chromosomal anomalies.
Delivery

• The optimal route of delivery for twins remains controversial and should
be assessed on a case-by-case basis
• Decisions about delivery must consider the
• presentations,
• gestational age,
• maternal or fetal complications,
• the experience of the obstetrician,
• the availability of anesthesia and neonatal intensive care support.
Presentation of Fetus at Term
• Vtx-Vtx 40%
• Vtx-Breech 26%
• Breech-Vtx 10%
• Breech-Breech 10%
• Vtx-Trans 8%
• Other 6%
 Take Home Messages

• The multiple birth rate has increased by 76% in the past three decades.
• Increased utilization of assisted reproductive technologies and women delaying childbearing are the
main contributors to the increase in multiples.
• Multiple gestations are at high risk for both maternal and fetal morbidity and mortality, which increase
as fetal number increases.
• Zygosity and chorionicity are important predictors of perinatal morbidity, with monochorionic
diamniotic and monochorionic monoamniotic twins at higher risk.
• The risk of monozygotic twinning is increased in in vitro fertilization (IVF); etiologies may include zona
pellucida manipulation and extended in vitro culture.
• Most neonatal complications in multiple gestations are sequelae of prematurity, including low
birthweight, respiratory distress syndrome, intraventricular hemorrhage, and necrotizing enterocolitis.
Take Home Messages

• Up to 80% of women with multiple gestations experience antepartum complications, which

include preterm labor, preterm premature rupture of membranes (PPROM), and placental
abruption.
• Women carrying multiples are at increased risk for the three major causes of maternal
mortality: postpartum hemorrhage, venous thromboembolism, and hypertensive disorders.
• Multiple gestations are associated with increased financial and psychosocial costs.
• Strategies for decreasing the rate of multiples resulting from assisted reproductive
technology (ART) include increasing the number of single embryo transfers performed in
IVF and using “low and slow” protocols for superovulation cycles with gonadotropins.
• Multifetal pregnancy reduction can be performed to decrease the fetal number and lower
the risk of morbidity, although the procedure does involve some medical and psychological
risk.
Teşekkür Ederim