Twins for undergraduate

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Information about Twins for undergraduate

Published on March 26, 2014

Author: MBHRY



Undergraduate course lectures in Obstetrics&Gynecology prepared by DR Manal Behery,Professor of OB&Gyne,Faculty of medicine,Zagazig University

Dr Manal Behery 2014

Defintion • When more than one fetus simultaneously develops in the UTERUS • 3 fetuses : triplets • 4 fetuses : quadruplets • 5 fetuses : quintuplets • 6 fetuses : sextuplets

HELLIN’S RULE Twins 1 in 80 Triplets 1 in 80^2 Quadruplets 1 in 80^3

Types of twins • • Monozygotic (1/3 rds) Dizygotic (2/3 rd) Results from fertilization Results from fertilization of a single ova of two ovum

Dizygotic amnion amnion 2 chorions Always dichorionic & diamnionic

Factors affecting dizygotic twinning Ethnic group Increasing maternal age

Increasing parity Family h/o twinning, esp maternal Ovulation induction ART

• Monozygotic twinning is independent of • race, • heredity, • age & • Parity. • INCIDANCE 1/25O



>DAY 13




History Previous history of twinning; high parity Older maternal age > 37yrs History of ovulation induction or pregnancy following ART Family history of twinning

Clinically Symptoms • Exaggerated pregnancy symptoms. • Fetal activity is greater and more persistent in twinning than in singleton pregnancy.

Signs • (1) Uterus > dates of amenorrehea . • (2) Excessive maternal weight gain that is not explained by edema or obesity. • (3)palpation of 2 fetal heads/presence of three fetal poles. • 4) Simultaneous recording of different fetal heart rates, each asynchronous with the mother’s pulse and with each other and varying by at least 8 beats per minute.

Ultrasound Determination of Chorionicity • Number of sacs. [ before 10 weeks ]  2 sacs – dichorionic  Single sac - monochorionic • Placenta • Sex • Intertwin membrane  thicker and more echogenic in dichorionic . Ideal time for assessing of chorionicity is before 14 weeks


Lambda sign


Importance of chorionicity ?????

Problems Specific to Monochorionic twins Nearly 100% of monochorionic twin placentas have vascular anatomizes 2 patterns of vascular anastomosis •twin-to-twin transfusion syndrome (TTTS) acardiac twinning or twin •reversed arterial perfusion (TRAPS)

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

• Intrapartum complications 1.Prolonged labor (uterine inertia) 2.Malpresentation 3.Cord prolapse 4.Abruptio placenta for 2nd twin 5.Interlocking of twins 6.PPH

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

Cord entanglement

TTTS:Arterio venous anastomoses with net flow in one direction..

Donor(arterial side) recipient •Severe IUGR •poor renal perfusion •Anuria •severe oligohydramnios •Hypervolemia •Polyuria with polyhydramnios •CCF…..hydrops…death Serial amnio reduction,fetoscopic laser ablation of anastomosis

Ultrasound in TTS – Stuck Twin Sign

Vanishing twin Cessation of cardiac activity in a previously viable foetus Fetus papyraceous…


Acardiac twins


1.Prenatal care  More frequent antenatal visits.  prophylactic iron 60-100mg and folic acid 1mg daily should be given.  Nutritional advice-calorie req is 300kcal/day more than that recommended for uncomplicated pregnancy.  Restriction of activity and increased rest at home.  Prophylactic steroids – risk for preterm labour or IUGR.

2.Ultrasound scan  At 9-11 wks : confirmation, chorionicity determination, assessment of gestational age and nuchal translucency.  anomaly scan at 20 wks  4 weekly scans in 3rd trimester to assess fetal growth, diagnose complications like TTS

Nuchal Translucency Mid Trimester Amniocentesis is the gold standard

Delivery prereqists CTG with dual monitoring capability Forceps or vacuum  Oxytocin infusion  Tocolytic agent for uterine relaxation  Methergin, 15-methyl PGF2 alpha  Immediate availability of blood  Access for emergency C/S

1.Place of delivery- Fully equipped hospital having intensive neonatal care unit. 2.Timing of delivery RCOG recommends elective termination of pregnancy at 37- 38 weeks Monochorionic pregnancy best delivered at 36-37 weeks

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

Delivery of 1st twin twin Deliver the first baby vaginally Cord is divided in between 2 clamps to prevent acute intrapartum transfusion. No methergin is given at this point as it can cause entrapment and asphyxia of second twin.

Delivery Of Second Twin • Palpate abdomen immediately to ensure lie,presentation. • If required-ultrasound examination done. • Vaginal examination is also done to exclude cord prolapse. • Acceptable interval between deliveries – 30 mins

Longitudinal lie A.R.M + oxytocin if necessary…. If delay Vertex- Low down->forceps or ventose; High up->internal version Breech- breech extraction

2ND Twins Transverse lie External version- cephalic or IF FAILS Internal version under G.A

Internal podalic version To do or not to do ??  Experienced operator  EFW > 1500 gm  Adequate liquor  Available anesthesia for • effective uterine relaxation  Simultaneous preparation • for emergency C/S

Rapid Delivery BY emergancy CS Severe vaginal bleeding Cord prolapse in second twin Inadvertent use of IV ergometrine with delivery of anterior shoulders of first baby 2nd twin is transverse, version failed after delivery of 1st twin Fetal distress

Third Stage  Cross matched blood should be readily available.  Risk of atonic PPH is more.  Oxytocin infusion & i/v ergometrine 0.25mg or methergine 0.2mg given following delivery of anterior shoulder of second baby.  Prostaglandins-15 methyl PG F2alpha can also be used.  Placenta examined for completeness, confirm chorionicity.

 Selective fetal reduction-one fetus in a multiple gestation is abnormal  Multifetal reduction-in higher order pregnancy  Iatrogenic fetal death –us guided fetal heart puncture or inj kcl  One member of monochorionic pair should never be selected Multifetal and selective pregnancy reduction


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