- Multiple pregnancies require enhanced antenatal monitoring including serial ultrasounds to check for complications which are more common than singletons such as prematurity and fetal growth issues. - Determining chorionicity and amnionicity is important for management since monochorionic twins carry higher risks like twin-to-twin transfusion syndrome. - Monitoring involves regular ultrasounds to check fetal size, growth, and Doppler studies of the umbilical artery depending on if there is size discordance or a small fetus. High risk monochorionic twins require every 2 week scans.

1. HIGH RISK PREGNANCY CME
PART III
ANTENATAL SURVEILLANCE AND MANAGEMENT OF MULTIPLE
PREGNANCY – RECENT ADVANCES
Speaker : Dr Seema Gupta

2. DR. SEEMA GUPTA

3. • Multiple Pregnancies require enhanced antenatal visits and serial
ultrasound examination
• The awareness and timely detection of complications and early
referral to fetal medicine specialist and prompt intervention are
essential for a successful management and outcome.

4. AMNIOCITY, CHORIONICITY, ZYGOSITY
• DETERMINING CHORIONICITY AND AMNIONICITY
• FORMS THE MAINSTAY OF MANAGEMENT AND SURVEILLANCE

5. MATERNAL RISKS AND COMPLICATIONS
As compared to singleton ,complications like
Hyperemesis
Anemia
Hypertensive Disorders
Gestational Diabetes Mellitus
Haemorrhage
Are more and severe in multiple pregnancy and management is similar as
for singleton pregnancy.

6. FETAL COMPLICATIONS
Fetal Risks are more in Multiple Pregnancy.
Are related to CHORIONICITY
As compared to Dichorionic , Monochorionic twins have higher
complications;
Congenital Anomalies
Prematurity
TTTS
FGR

11. MONITORING DICHORIONIC TWIN PREGNANCY

12. FETAL WEIGHT DISCORDANCE
• EFW larger fetus – EFW smaller fetus / EFW larger fetus
• Starting 20 weeks every 4 weeks
• If Discordance 20% or more
• EFW of any fetus below 10th centile
• Do weekly umbilical artery doppler
• If EFW discordance 25% or more and EFW of any twin below 10th
centile(sFGR) refer to fetal medicine centre.

13. MONOCHORIONIC MULTIPLE PREGNANCY
• Ultrasound every 14 days from16 weeks till delivery . Evaluate for Feto-
fetal Transfusion Syndrome, Fetal growth restriction, advanced stage
Twin Anemia Polycythemia (TAPS) sequence.
• Screen for sFGR/Fetal discordance by EFW and DVP of liquor for each
fetus.
• Do umbilical artery Doppler if
• -EFW discordance 20% or more
• -EFW of any fetus below 10th centile
• Refer to fetal medicine centre if discordance 25% or more and EFW of
any below 10th centile.

15. MONOAMNIOTIC MULTIPLE PREGNANCY
• Monoamniotic fetuses are rare(less than 1% of all twin
pregnancy)and associated with high perinatal loss due to
• Congenital malformations
• Twin Reverse Arterial Perfusion Sequence(TRAPS)
• Cord accidents
• Recommendation (NICE 2019)is to deliver between 32 and 33+6
weeks by Caesarean section rather than recommending a specific
monitoring strategy.

17. FETO –FETAL TRANSFUSION SYNDROME
Feto-Fetal Transfusion Syndrome or Twin-Twin Transfusion
Syndrome(TTTS) is seen in 10-15% of Monochorionic twins so
screening is important.
Screening by ultrasound doppler assessment of umbilical artery
done weekly if
-difference in DVP of liquor is 4cm or more
-EFW discordance is 20% or more or EFW any twin is
below 10th centile

19. TWIN ANEMIA POLYCYTHEMIA SEQUENCE
• Weekly ultrasound monitoring for TAPS from 16 weeks using Middle
Cerebral Artery Peak Systolic Velocity (MCA-PSV)is advised in:
• TTTS treated by laser
• Selective FGR
• Monochorionic pregnancy with complications like fetal
hydrops,cardiomegaly,unexplained isolated polyhydramnios, abnormal
umbilical artery.
• All such cases require fetal medicine specialist referral.

20. SCREENING FOR PRETERM BIRTH
• Multiple pregnancies are at a higher risk of preterm birth.
• Transvaginal cervical length measurement is a good predictor of
preterm birth.
• However despite the good predictive value NICE guidelines do not
recommend routine measurement as there was no evidence based
intervention to reduce the subsequent risk of spontaneous
preterm birth.

21. TIMING OF DELIVERY IN MULTIPLE PREGNANCY
• UNCOMPLICATED DICHORIONIC DIAMNIOTIC TWINS – Plan delivery at 37
weeks as continuing beyond 37+6 increases risk of fetal death.
• UNCOMLICATED MONOCHORIONIC DIAMNIOTIC TWINS – Plan delivery at 36
weeks.
• UNCOMPLICATED MONOCHORIONIC MONOAMNIOTIC TWINS – Plan delivery
by Caesarean Section between 32+0 and 33+6 weeks.
• UNCOMPLICATED TRIPLETS – Plan at 35 weeks by Caesarean Section.

22. MODE OF DELIVERY IN MULTIPLE PREGNANCY
•Can offer Vaginal Delivery if:
1. Pregnancy uncomplicated and beyond 32 weeks.
2. First twin is Cephalic.
3. No obstetric contraindication for labour.
4. No significant discordance in size between the twins.

23. TAKE HOME MESSAGE
• Careful dating and determination of chorionicity and amnionicity
is essential for formulation of management plan.
• Dichorionic twins require monitoring by serial ultrasound
examinations every 4 weeks.
• Monochorionic twins have higher chance of complications like
TTTS, SFGR, TAPS and hence require ultrasound monitoring every
2 weeks.
• Successful outcome depends on awareness, timely detection and
referral to fetal medicine expert .

24. THANK YOU