1. Muhammad Redzwan Bin Abdullah
081303583 Batch 25 Group E2

2. References
 http://www.rcog.org.uk/files/rcog-corp/uploaded-
files/T51ManagementMonochorionicTwinPregnancy2008a.pdf
 http://emedicine.medscape.com/article/977234-overview
 Obstetric Today
 Hacker and Moore’s Essentials of Obstetrics and Gynecology

3. Definition
 Simultaneous development of more than one fetus in
the uterus
 2 fetuses –twins (commonest)
 Triplets, quadruplets etc

4. Incidence
 Hellin’s Law – Twin = 1:80
Triplets = 1:80²
Quadruplets = 1:80³
 Monozygotic = 3-5/1000 births
 Dizygotic = varies depending on
maternal age, race and geographical
distribution

5. Aetiology
 Assisted reproduction techniques
 Increase parity
 Increase maternal age
 Family history
 Previous multiple pregnancy
 African race

6. Type of multiple pregnancy
Dizygotic / binovular / fraternal
2. Monozygotic / Uniovular / identical
1.

7. Types of Monozygotic twins
1. Dichorionic Diamniotic :
i. Division occurs with in 72 hrs of fertilization
ii. May have 2 diff placentas/ single fused placenta
iii.Difficult to differentiate form dizygotic twins
iv.Both babies have same sex
2. Monochorionic Diamniotic:
I. Division occurs with in 4 – 8 days of fertilization

8. 3. Monochorionic Monoamniotic:
I. Division occurs 9-12 days of fertilization
4. Conjoined twins:
I. Division occurs after 13th day
II. Incomplete division of embryonic disc
III. Types: -thoracopagus
- omphalophagus
-craniopagus
-pyopagus
-ischiopagus

9. Monozygotic / Uniovular / Identical
Dizygotic / binovular / fraternal
1.1/3 twins
1.2/3 twins
2.1 sperm and 1 ovum
2.2 sperms and 2 ova
3.Identical
3.Dichorionic Diamniotic
twins
4.Type of placenta depends
on the time of splitting of
embryo
4.Presence of chorionic tissue
between 2 amniotic sac
5.Incidence is dependent of
5.Incidence is independent of race, age, parity, and
race, age, parity
ovulation inducing drugs

10. Clinical presentation
Symptoms :
• ↑ nausea, vomiting
• ↑ pressure symptoms:


•
•
•
•
•
constipation, pedal edema, varicosity of veins,
palpitations, precordial pain
Fatigue, indigestion, backache, sleeplessness
H/O overdistension
H/O premature labor
Excessive fetal movements
F/H, H/O ovulation inducing drugs

11. SIGNS :
• Anemia
• Edema
• Abnormal Weight Gain
• Uterine Height > POG
It may be normal size in case of binovular twins/ when 1 of
the babies die in utero
Palpation:
Feel 2 separate heads/ > 2 poles
Auscultation :
2 FHS with difference of at least 10 beats heard on 2 sides of
uterus by 2 people, at least 6 inches away

12. Role of ultrasound
 Confirmation of chorionicity
 Twin peak sign / Lambda sign = dichorionic placenta
 Identify the number and site of placenta, fuse or
separate
 Lie and presentation of twin
 Amniotic fluid assessment

13. 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

14.  Intrapartum :
1. Prolonged labor (uterine inertia)
2. Malpresentation
3. Cord prolapse
4. Abruptio placenta for 2nd twin
5. PPH

15. 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

16. Twin to Twin Trasfusion Syndrome

17. Twin to Twin Transfusion
Syndrome
 Occur in 10-15% of monochorionic twins
 Mostly during 2nd trimester
 Due to imbalance of blood flow across placental
AV anastomosis
 Symptoms : sudden increase girth a/w extreme
discomfort
 Signs : tense uterus with excessive
liquor volume
 Ultrasound : Polyhydramnios in
recipient.Oligohydramnios in donor

18. Donor twin
Recipient twin
Hypovolemic & oliguric/anuric
Hypervolemic & polyuric
Result in stuck twin phenomenon
where the twin appears in a fixed
position against uterine wall
Can also develop HTN,hypertrophic
cardiomegaly,disseminated
intravascular coagulation,and
hyperbilirubinemia after birth
Ultrasound may fail to visualize fetal
bladder because of absent urine
Both twin can develop hydrops foetalis
Donor can become hydropic because of
anemia and high output heart failure
Recipient becomes hydopic because of
hypervolemia

19. Single Fetal Demise
 > in Monochorionic twin
 If one twin dies after 14wk,there is high risk of
neurological damage to survivor twin : due to
thromboplastin release  thrombotic arterial
occlusion of ant & middle cerebral arteries
multicystic encephalomalacia

20. Management of multiple
pregnancy
Antenatal care :
Extra attention & diet: at least 300 kcal more than in
normal pregnancy
Routine iron and folic acid
Detailed anomaly scan followed by serial growth scan
at 28, 32 and 36 week
Hospitalization if suspected pretem

21. RCOG recommended antenatal
care
Dichorionic
Monochorionic
-Lead clinician with multidisciplinary
team
-Lead clinician with multidisciplinary
team
-US at 10-13wk :
viability,chorionicity,NT:aneuploidy
US at 10-13wk :
viability,chorionicity,NT:aneuploidy/T
TTS
-Structural anomaly scan at 20-22wk
-US surveillance for TTTS and
discordant growth at 16wk and then
2weekly
-Serial fetal growth scan eg:24,28,32
then 2-4weekly
-Structural anomaly scan 20-22wk
(including fetal ECHO)
-BP monitoring and urinalysis at
20,24,28 and then 2weekly
-fetal growth scan 2wkly interval until
delivery
-Discussion of mother’s/family needs
relating to twins
-BP monitoring and urinalysis at
20,24,28 then 2weekly

22. Timing of delivery
 Uncomplicated dichorionic – by
38 week
 Uncomplicated monochorionic –
by 37 week
 TTTS – depend on current
situation
 MCMA – 32 week, by LSCS

23. 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

24.  Emergency LSCS :
-Fetal distress
-cord prolapse in 1st baby
-Non progress of labor
-2nd twin is transverse, version failed after
delivery of 1st twin

25. Management during labour 1st
stage
1.
2.
3.
4.
5.
6.
Determine the presentation of 1st twin
Maintain partogram
Keep NBM and establish IV line
Blood grouping and cross matched
Continous intrapartum twin CTG monitoring
Analgesic

26. Management during labour 2nd
stage
1. Delivery of 1st twin
2. Clamp and cut the cord
3. Note lie of the 2nd twin (delivered within 20 min)
4. Longitudinal lie (abdominally & vaginally) :
Start 2 units of pitocin IV drip
Cephalic  Fix the head into pelvisARM &
deliver the fetus
Breech  Assisted breech delivery, Breech
extraction

27. If 2nd twin has transverse lie :
•
•
•
•
Assistant performs ECV.
Fix the head in lower pole of the uterus and accoucher
performs controlled ROM (rupture of membrane)
If this fails: do IPV (internal podalic version) followed
by breech extraction
Or proceed with emergency LSCS

28. Thank You
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