TWIN PREGNANCY

Ahmad Kurdi Syamsuri

TWIN PREGNANCY
Multiple pregnancy rates vary world wide Insidence of monozygotic twin is relatively constant : 3 5/1000 births Dizygotic twinning rates vary by age, parity, ethnic group and assisted reproduction : 1,3 49/1000 births

Incidence
More than 3 % in US
Martin and colleques, 2002

1.4 per 100 birth in Korea

1996

Korean birth certificate,

M ultiple pregnancy rates 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% 1997 1998 1999 2000 2001 2002 2003 2004 2.1% 2.4% 2.3% 2.4% 1.9% 3.7% 3.9% 4.3%

2007

Twins - Chorionicity
100 Twins

Dizygotic
n = 70

Monozygotic
n = 30

Dichorionic n=80

Monochorionic n=20

Types and Genesis of Twining

Dizygotic Monozygotic

By timing of division
< 3 day
4- 8 day > 8 day > 12 day

Dichorionic Diamnionic

Dichorionic Diamnionic

Monochorionic Diamnionic

Monochorionic Monoamnionic

Conjoined

Superfetation Superfecundation Vanishing twin

Determination of Chorinicity
6 weeks 1. If one fetus in two chorionic sacs 2. If two fetus in one chorionic sac 3. If as in 2. and one yolk sac Conjoined 8 weeks 4. If as in 2. and separate amniotic sacs 5. If as in 2. and one amniotic sac DC MC

MC/DA MC/MA

Determination of Chorinicity
10-14 weeks Twin peak or Lambda sign - projection of placental tissue into the inter-twin membrane : DC >14 weeks Count placentae Sex of fetuses ?Dividing membrane >2mm

MATERNAL RISKS WITH TWINS

Increased minor complaints of pregnancy Increased risk of miscarriage Increased anaemia, pre-term delivery Hypertension Antepartum Haemorrhage

MATERNAL RISKS WITH TWINS (contd.)

Hydramnios Need for hospitalisation Single fetal death in twins Operative Delivery Caesarean Section Postpartum Haemorrhage

Pre-term Labour/Delivery

Pre-term birth (<37 weeks) 43.6% Very pre-term (<32 weeks) 6.0%

Hypertension

Pre-eclampsia 5 times more likely in twin pregnancy.

Perinatal Mortality

Up to 10 times higher than singletons

Single Fetal Death in Twins

Early single demise : trim I
Relatively common No Increased risk of fetal loss in suviving twin

Single Fetal Death in Twins

Late single fetal demise Inceased risk of death of surviving twin of 20% Chorionicity very important

Monoamniotic Twins
1% of monozygotic pregnancies Mortality up to 50% Cord entanglement

Twin-Twin Transfusion
Monochorionic twins Vascular Anastomoses Up to 30% Mortality 30% Severe morbidity in survival

2. Twins with two separate placental masses can still be monochorionic and therefore have vascular anastomoses

pathogenesis of bipartite placentation in MC twinning not clear

American Journal of Obstetrics and Gynecology 2006

Dichorionic Twins
Management in specialised unit Scan for growth monthly Aim for vaginal delivery

Monochorionic Twins
Specialised clinic Scan fortnightly Aim for vaginal delivery

Management in Pre-Pregnancy
Women who are offered ART should be provided with adequate counseling about the increased risk of multiple pregnancy and the potential complication

All pregnant women should be advised to take periconceptual folate supplementation to reduce the risk of fetal neural tube defects

Antepartum Management

Ultimate goals
to to to to prevent the delivery of markedly preterm fetuses identify growth restriction in 1 or both fetuses deliver the fetuses atraumatically have expert anesthesia and neonatal care available

Antepartum Management

Determination of chorionicity
Best performed in the first trimester with Ultrasound 1. Numbers of G-sac 2. Detection of the lambda sign or twin peak ; best seen between 10-14 weeks, disappear after 20 weeks 3. Measurement of membrane thickness, using a cut-off value of 2 mm

Describe as DCDA / MCDA / MCMA twin

Antepartum Management

Antenatal screening

Increased hypertensive disorders in pregnancy

5 times greater in primigravid women 10 times greater in multiparous women than singleton pregnancy

-> frequent antenatal attendance allows the early detection of hypertension

Gestational diabetes screening; conflicting evidence to support the practice

Increased risk of antepartum hemorrhage from both placenta previa and abruption

Antepartum Management

Routine fetal anomaly ultrasound at 1820 weeks

Twins have an increased risk of congenital abnormalities

->midtrimester ultrasound examination between 18 and 20 weeks gestation. ; A retrospective review of 245 women with a twin pregnancy -> congenital malformation in 4.9% of cases
Edwards M, Ultrasound in Obstetrics and Gynecology, 1995

Antepartum Management

Preterm labor
1. Cervical assessment
Cervical length of less than 25 mm at 24 weeks in twins; ; predictor of spontaneous preterm birth at < 32 weeks (OR 6.9), < 35 weeks (OR 3.2), and < 37 weeks (OR 2.8) ; its clinical usefulness as a routine evaluation is questionable because of the lack of proven treatments affecting outcome

2. Fetal fibronectin The presence of fetal fibronectin in cervical secretions ; ; positive test at 28 weeks to predict preterm birth before 35 weeks => 50% sensitivity, 92% specificity, 62.5% positive predictive value, 87.3% negative
predictive value

it is unclear if this knowledge can result in effective interventions that could reduce preterm labor and birth

Labor and Delivery

Timing of birth
The lowest risk of perinatal mortality and morbidity; between 36 and 38 weeks
After 38 weeks gestation, the perinatal death rate and intrauterine growth restriction of twin pregnancies increase substantially In a single RCT from Japan, Women were randomised at 37 weeks gestation either to induction of labor or to continued expectant management ; No statistically significant differences The ideal time of delivery for an uncomplicated twin pregnancy is still uncertain. However, the literature appears to support delivery by 38 weeks of gestation

Antepartum Management

Mode of birth
Women with a twin pregnancy are more likely to give birth by caesarean, with gestational age and fetal presentation influencing this decision
First twin vertex/second twin vertex
the most common presentation of twins the general recommendation is for vaginal birth, even for infants of estimated very low birthweight (less than 1500 g)

First twin vertex/second twin non-vertex

no consensus as to the most appropriate mode of birth The only small RCT, planned vaginal or planned caesarean birth showed no differences in neonatal outcome For the second non-vertex twin of birthweight less than 1500 g, some reports recommend caesarean birth to reduce the risk of birth trauma

First twin non-vertex

Caesarean section is often performed