F.

Kahlo

Multiple pregnancy
- diagnosis and follow up-
Dr. Ilinca Gussi

Spitalul Clinic Dr I Cantacuzino

Multiple pregnancy- context

• aprox 1% of all pregnancies

• Incidence rising due to age at procreation

and ART (assisted reproduction
techniques)
• Appears from the fertilisation of different
oocytes (polizygotic)
• or from the division of one oocyte
(monozygotic)
Multiple pregnancy - context
• Associated with an increased risk of:

– Spontaneous abortion
– Premature birth
– Preeclampsia
– IUGR (intrauterine growth restriction)
– IUFD (in utero fetal demise) of one twin
– C/S
– Postpartum hemmorage
– Fetal perinatal mortalitaty and morbidity
– TTTS (twin-to-twin transfusion syndrome)
Multiple pregnancy- management
• Diagnosis
• Prenatal follow up
• Treatament of complications
• Delivery
• Postpartum
Multiple pregnancy- management
• Diagnosis
• Prenatal follow up
• Treatament of complications
• Delivery
• Postpartum
 Zygotism & chorionicity
• Monozygotic versus poli-/dizygotic
1/3 2/3

poli-/di-chorionic
 Zygotism & chorionicity
• Monozygotic versus poli-/dizygotic
1/3 2/3

any type poli-/di-chorionic

depending on
timing of division
Monozygotism & chorionicity

...chorionicity depends on the timing of oocyte division

Nicolaides et al, 11-13 wks scan, FMF 2005

Monozygotism and chorionicity

T.W. Sadler, Langman Embriology, 7th ed, 1995

Incidence of twin pregnancy
• Monozygotic versus poli-/dizygotic
1/3 2/3
No f (race) X5 Africa,
/2 Asia
No f (maternal age) 2% at 35 yrs
No f (parity) 2% >4P
x 2-3 IVF ART 20% ovulation
induction
Nicolaides et al, 11-13 wks scan, FMF 2005
Incidence of twin pregnancy
• Monozygotic versus poli-/dizygotic
1/3 2/3
No f (race) X5 Africa,
/2 Asia
No f (maternal age) 2% at 35 yrs
No f (parity) 2% >4P
x 2-3 IVF ART 20% ovulation
induction
Nicolaides et al, 11-13 wks scan, FMF 2005
Incidence of twin pregnancy
• Monozygotic versus poli-/dizygotic
1/3 2/3
No f (race) X5 Africa,
/2 Asia
No f (maternal age) 2% at 35 yrs
No f (parity) 2% >4P
x 2-3 IVF ART 20% ovulation
induction
Nicolaides et al, 11-13 wks scan, FMF 2005
Incidence of twin pregnancy
• Monozygotic versus poli-/dizygotic
1/3 2/3
No f (race) X5 Africa,
/2 Asia
No f (maternal age) 2% at 35 yrs
No f (parity) 2% >4P
x 2-3 IVF ART 20% ovulation
induction
Nicolaides et al, 11-13 wks scan, FMF 2005
Incidence of twin pregnancy
• Monozygotic versus poli-/dizygotic
1/3 2/3
No f (race) X5 Africa,
/2 Asia
No f (maternal age) 2% at 35 yrs
No f (parity) 2% >4P
x 2-3 IVF ART 20% ovulation
induction
Nicolaides et al, 11-13 wks scan, FMF 2005
Incidence of twin pregnancy
• Monozygotic versus poli-/dizygotic
1/3 2/3
No f (race) X5 Africa,
/2 Asia
No f (maternal age) 2% at 35 yrs
No f (parity) 2% >4P
x 2-3 IVF ART 20% ovulation
induction
Nicolaides et al, 11-13 wks scan, FMF 2005
Incidence of twin pregnancy
• Monochorionic versus dichorionic
4/1000 7-10/1000

1/250 1/80-100

Nicolaides et al, 11-13 wks scan, FMF 2005

 Zygotism & chorionicity
- diagnosis-
• diagnosis of zygotism is genetic
(prenataly invasive methods are needed)

• diagnosis of chorionicity is by ultrasound,

could be done very early, is the most
important regarding the prognosis
 Prognosis f(chorionicity)
S Di ch Mono ch
Spontaneous abortion
1% 2% 10%
(prior to 24 SA)
Perinatal mortality 2% 5%

Severe prematurity 1% 5% 10%

IUGR < 5 P on one fetus 5% 20% 30%

IUFD of one fetus 5-10% 30%

Preeclampsia x4
 Ultrasound diagnosis of
chorionicty
• Ultrasonography detects:
– Fetal sex: diferent = ALWAYS dichorionic
– Nr and position of placenta: when distinc (rarely)
is sign of dichorionicity
– Interamniotic membrane aspect: thicker in
dichorionic twins
» Detectable at 6-9 wks
» Lambda sign at the insertion up to 12 wks
 Ultrasound diagnosis of
chorionicty
• Ultrasonography detects:
– Fetal sex: diferent = ALWAYS dichorionic
– Nr and position of placenta: when distinc (rarely)
is sign of dichorionicity
– Interamniotic membrane aspect: thicker in
dichorionic twins
» Detectable at 6-9 wks
» Lambda sign at the insertion up to 12 wks
 Ultrasound diagnosis of
chorionicty
• Ultrasonography detects:
– Fetal sex: diferent = ALWAYS dichorionic
– Nr and position of placenta: when distinc (rarely)
is sign of dichorionicity
– Interamniotic membrane aspect: thicker in
dichorionic twins
» Detectable at 6-9 wks
» Lambda sign at the insertion up to 12 wks
 Diagnosing chorionicity
in the first trimester

Dichorionic, lambda sign Monochorionic, T sign

Sepulveda et al, FMF 1996-97

Monteagudo et al, FMF 2000
Monochorionic monoamniotic
- case presentation-
Monochorionic monoamniotic
- case presentation-
Monochorionic monoamniotic
- case presentation-
Monochorionic monoamniotic
- case presentation-
 Key points

• 1/3 of twins are identical and 2/3 are fraternal

• ½ have discordant sex

• Chorionicity is the most important prognosis factor

• Expected growth in twins is identical to singletons

until 28 wks
 Prognosis and follow up
-key points-
• chorionicity > zygotism
• complication rate is increased in monochorionic
twins
• specific complications exist (e.g. TTTS, TAPS)
• Prenatal screening is different (e.g. cautious use of
serum markers for fetal aneuploidies)

• Intense ultrasound follow up benefits the prognosis

:
– every 4 wks for dichorionic, every 2 wks for monochorionic
Multiple pregnancy- management
• Diagnosis
• Prenatal follow up
• Treatament of complications
• Delivery
• Postpartum
 Twins prenatal follow up
• Monochorionic vs dichorionic
every 2 wks 4 wks

• Screening for aneuploidy (e.g. Down Sdr) difficult

– Materal serum markers are not validated for twins
– US markers are the most predictive

• Clinically repeted vaginal examinations are

unnecessary, cervix is measured by US
 What risks are screened ?

• Increased incidence of:

– Sp abortion (prior to 24 wks) 10% vs 2%
– Perinatal mortality 5% vs 2%
– Premature birth 10% vs 5%
– IUGR < 5P on one twin 30% vs 20%
– IUFD of one twin

• Specific complications:
TTTS (twin-to-twin transfusion sy.) appears in
30% cases and in ½ is severe
 What risks are screened ?

• Increased incidence of:

– Sp abortion (prior to 24 wks) 10% vs 2%
– Perinatal mortality 5% vs 2%
– Premature birth 10% vs 5%
– IUGR < 5P on one twin 30% vs 20%
– IUFD of one twin

• Specific complications:
e.g. TTTS (twin-to-twin transfusion sy.)
appears in 30% cases and in ½ is severe
 • Functional cervical length
< 26 mm = threatened Premat
Birth
Iams et al, NEJM 1996

• Screened by US at every visit after 16

wks

normal threatened PB
www.fetalmedicine.com
 Distribution of Subjects among Percentiles for Cervical Length Measured by Transvaginal
Ultrasonography at 24 Weeks of Gestation (Solid Line) and Relative Risk of Spontaneous Preterm
Delivery before 35 Weeks of Gestation According to Percentiles for Cervical Length (Bars)

26 mm

Iams, J. D. et al. N Engl J Med 1996;334:567-573

 What risks are screened ?

• Increased incidence of:

– Sp abortion (prior to 24 wks) 10% vs 2%
– Perinatal mortality 5% vs 2%
– Premature birth 10% vs 5%
– IUGR < 5P on one twin 30% vs 20%
– IUFD of one twin

• Specific complications:
TTTS (twin-to-twin transfusion sy.) appears in
30% cases and in ½ is severe
• US follow up key points:

– Dgn chorionicity before 12 wks

– Every 2-4 weekly : fetal biometry, doppler on UA and
MCA, AF aspect and presence of urinary bladder.
– Cervix measurement at every visit (after 16 wks)
– Structural anomalies scan at 12 wks, 22 wks, 32 wks
• US follow up key points:

– Dgn chorionicity before 12 wks

– Every 2-4 weekly : fetal biometry, doppler on UA and
MCA, AF aspect and presence of urinary bladder.
– Cervix measurement at every visit (after 16 wks)
– Structural anomalies scan at 12 wks, 22 wks, 32 wks
 What risks are screened ?

• Increased incidence of:

– Sp abortion (prior to 24 wks) 10% vs 2%
– Perinatal mortality 5% vs 2%
– Premature birth 10% vs 5%
– IUGR < 5P on one twin 30% vs 20%
– IUFD of one twin

• Specific complications:
TTTS (twin-to-twin transfusion sy.) appears in
30% cases and in ½ is severe
 Prognosis f(chorionicity)
S Di ch Mono ch
Spontaneous abortion
1% 2% 10%
(prior to 24 SA)
Perinatal mortality 2% 5%

Severe prematurity 1% 5% 10%

IUGR < 5 P on one fetus 5% 20% 30%

IUFD of one fetus 5-10% 30%

Preeclampsia x4
• Fetal hypoxia screening:

– Dgn chorionicity before 12 wks

– Every 2-4 weekly : fetal biometry, doppler on UA and
MCA, AF aspect and presence of urinary bladder.
– Cervix measurement at every visit (after 16 wks)
– Structural anomalies scan at 12 wks, 22 wks, 32 wks
 What risks are screened ?

• Increased incidence of:

– Sp abortion (prior to 24 wks) 10% vs 2%
– Perinatal mortality 5% vs 2%
– Premature birth 10% vs 5%
– IUGR < 5P on one twin 30% vs 20%
– IUFD of one twin

• Specific complications: TTTS (twin-to-twin

transfusion sy.) appears in 30% cases and in ½
is severe, TAPS, TRAP
Topics in Twins- discordances
• Complications in monoch twins
TTTS TAPS (twin anemia TRAP (twin reversed
policytemia sdr) arterial perfusion)
= hemodinamic = hematologic criteria = acardiac twin

= hydramnios = PSV MCA > 1,5 MoM

(deepest AF pool + PSV MCA < 0,8 MoM = acardiac twin,
over 8 cm) + structural discordance
oligoamnios (under
2 cm)
Multiple pregnancy- management
• Diagnosis
• Prenatal follow up
• Treatament of complications
• Delivery
• Postpartum
 Manage complications
• Threatened premature birth
• Cerclage not mandatory a priori
• Tocolysis: preffer calcium channel blockers to beta-
mimetics
• IUGR follow up as for singletons
• IUFD is not complicated by coagulopathy
• Preeclampsia more frequent, unrelated to
chorionicity

• Discusion of selective feticide in certain cases

• TTTS : selective laser coagulation of placental
anastomosis or repeated amnioreductions
 TTTS- hemodinamic criteria
• Monochorionic
• Same sex
• Max AF pouch
>8cm and <2cm

> 8 cm
Neonatal criteria do not apply!
< 2 cm
= growth or Hb discordance are
not relevant for diagnosis
Monochorionic- diamniotic pregnancy
complicated with TTTS
• TTTS appears in 30% cases and in ½ is severe

Unbalanced inter-twin
blood transfer through
placental shunts

Quintero et al, Ultrasound

Obstet Gynecol 2004
Fisk, Galea NEJM 8 Jul 2004
 TTTS- Quintero evolution stages

Severly
UB donor UB donor modified
visible un visible Dopplers Hidrops IUFD

I II III IV V

Evolution is unpredictable.
!!!! Fetal distress and fetal anemia!!!

Quintero et al, J perinatology 1999

Quintero et al, Ultrasound Obstet 2002
 Treatment for TTTS

• Natural history = 95% perinatal mortality

• selective laser coagulation of placental

anastomosis = 80% survival rate of one twin

Senat et al NEJM 2004

Manage specific complications
TTTS TAPS (twin anemia TRAP (twin reversed
policytemia sdr) arterial perfusion)
= hemodinamic = hematologic criteria = acardiac twin
Fetoscopic laser Follow-up Reduction of acardiac
photocoagulation vs twin (cord
amniodrenage coagulation)

= hidramnios = PSV MCA > 1,5 MoM

(deepest AF pool + PSV MCA < 0,8 MoM = acardiac twin,
over 8 cm) + structural discordance
oligoamnios (under
2 cm)
 Treatment for fetal anemia
complicating TTTS or other conditions

• TIU intra-uterine transfusions

 Monoamniotic monochorionic
- specificities-
- Low incidence and High mortality rate (20%)
- Specific complication = IUFD due to mechanical
compression of the cord (sub acute event)

- Follow up timing controversial

- In- patient intensive screening believed to be
best option = 2-3 CTG 60 min/d after 28 wks
 Monochorionic monoamniotic
- case presentation-
- I G I P, 29 yrs, FH twins
- dgn mono-mono bedore 12 wks
- Ultrasound F/U 2-3 weekly:
no discordances
- NT T1 + structural anomalies scan 2nd trim: no
abnormalities
- No maternal complications (except relative
trombocitopenia)

- Admitted at 38 wks
 2465g
Cord entanglement
2788g
GN 2650g=2650g

C/S 38 w+ 3 d after PROM

Multiple pregnancy- management
• Diagnosis
• Prenatal follow up
• Treatament of complications
• Delivery
• Postpartum
 Multiple pregnancy- delivery
• No arguments for a priori C/S
• Elective delivery discussed at 38 completed
wks for dich and 36-37 completed wks for
monoch
• Complete team (obstetrician, midwife,
pediatrician on site, and anesthesiologist
available)
• First twin delivered as a singleton
• 2nd twin in the following 5 minutes
• Breach = great extraction
• Transverse = internal version with great extraction
• Vertex that does not descend = internal version with great
extraction
Multiple pregnancy- management
• Diagnosis
• Prenatal follow up
• Treatament of complications
• Delivery
• Postpartum
 Post partum
• Major risc of hemorage
• Sistematic uterine revision
• Recommended breast-feading
• Postnatal support needed
Triplets and high-order pregnancy

• Intensive follow-up
• Early admission
• Multifetal pregnancy reduction to twins should
be offered
• C/S rate 70%
• MAJOR post-partum bleeding risk
• Breast feeding extremly difficult
• Support (both psychological and material)
must be organised in advance