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RACHANA CHIBBER
MBBS; DGO ; MD ; MRCOG (UK) ; FRCOG (UK)
OBJECTIVES:
•Definition.
•Incidence and epidemiology.
•Clinical characteristics.
•Classification.
•Diagnosis.
•Complications.
•Abnormalities of the twinning process.
•Management.
DEFINITION
1 40 weeks
2 36 weeks
3 33 weeks
4 29 ½ weeks
Incidence & epidemiology
Twins 1 in 80
Triplets 1 in 80^2
Quadruplets 1 in 80^3
-
Types of twins………
DIZYGOTIC MONOZYGOTIC
DIZYGOTIC 2
chorions
amnion amnion
Ethnic group
Ovulation induction
MONOZYGOTIC
MONOZYGOTIC
>8days
MONOZYGOTIC
4-7 days
Chorionicity
Type of placentation
Prenatal detection by USS
Number of sacs
Placenta
Sex
Intertwin membrane
T SIGN
Antepartum
hyperemesis
hydramnios
Pre eclampsia(3 fold times),eclampsia(6 fold
times)
Pressure symptoms
Anaemia
Dysfunctional labour
Malpresentations
Increased chance for operative delivery
Post partum hemorrhage
Retained placenta
FETAL COMPLICATIONS…………
Antepartum complications
I. Prematurity
2. IUGR
monochorionic
Shift of blood
Normal
Death of one twin twin
A/c or C/c…
•Severe IUGR
•Stuck Twin
Donor(arterial side) •poor renal perfusion
•Anuria
•severe oligohydramnios
•Hypervolemia
•Polyuria with polyhydramnios
recipient •CCF…..hydrops…death
Management Options
Serial amnio reduction,
fetoscopic laser ablation of
anastomosis
Uss of TTS….STUCK TWIN
6. Vanishing twin
Identification of a multifetal gestation with
subsequent disappearance of one or more fetuses.
Cessation of cardiac activity in a previously viable Fetus papyraceous…
foetus. In vanishing twin syndrome, there may be
complete reabsorption of a fetus, formation of a fetus one of twin fetuses that has died and
papyraceus (ie, a "mummified" or compressed fetus), been pressed flat against the uterine
or development of a subtle abnormality on the wall by the growth of the living fetus
placenta such as a cyst, subchorionic fibrin, or
amorphous material.[
7. Congenital anomalies
Structural Chromosomal
malformations anomalies
Acardiac fetus
Anencephaly
Talipes
Dislocation of hip
etc..
Conjoint twins
Always monozygotic
classification
Thoracopagus
Craniopagus
omphalopagus
Pygopagus
ischiopagus
•One twin is normally developed and referred to as the 'pump' twin. He pumps blood for himself as well as
for the other twin. The other twin is not fully developed and often lacks any personable features. This twin
does not have a heart and is referred to as the 'acardiac' or abnormal twin.
•The term 'reversed perfusion' is used because the blood enters the undeveloped twin through the vessels
in the opposite direction.
•This sequence of events places the normal twin at risk for heart failure. Left untreated, there is a 50%-75%
chance of mortality for the normal twin. The cause of TRAP is unknown.
•What testing is recommended during the pregnancy?
•Ultrasound examination can confirm the diagnosis and will be used to monitor the pregnancy. The size of
both babies is an important determinant for the outcome of the normal twin. If the estimated weight of the
abnormal twin is greater than 75% of the normal twin, the survival for the normal twin is about 10%.
Pump twin
Umb
De oxygenated
blood
.A
Interlocking of twins
ANTEPARTUM MANAGEMENT
Diet
• Biophysical profile
• Preterm labour
• Uterine dysfunction
• Abnormal presentations
• Postpartum hemorrhage
Intrapartum Management
• Appropriately trained obstetrical attendant
• cephalic-breech 27%
• cephalic-transverse 18%
• Breech-breech 5%
Mode of delivery
• vaginal for cephalic-cephalic
• Controversial for cephalic-non cephalic
(breech) especially
if prematurity is a concern
• Controversial for breech-cephalic because of
rare risk of
Locked Twins
Locked Twins
Delivery of the Second Twin
• Interval between first and second twins can be prolonged
more than 30 minutes if continuous fetal monitoring is
employed
• Cesarean delivery rate is increased if interval is > 15
minutes
• Intrapartum external version of the noncephalic second
twin may be used for non fixed presenting part
• Internal Podalic Version: The fetus is turned so as to
deliver the feet first to effect delivery by breech
extraction
Multiple gestation with more than two fetuses
Management options:
1) Multifetal reduction may be offered:
Reduce the risk to the mother & the remaining fetuses.
Performed only in the setting of dichorionic /diamniotic
gestation.
2) Selective termination:
Termination of one or more fetuses with structural or
chromosomal anomalies.