Your SlideShare is downloading. ×
Multiple Pregnancy - Diagnosis ,Clinical Features & Complications
Upcoming SlideShare
Loading in...5

Thanks for flagging this SlideShare!

Oops! An error has occurred.


Saving this for later?

Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime - even offline.

Text the download link to your phone

Standard text messaging rates apply

Multiple Pregnancy - Diagnosis ,Clinical Features & Complications


Published on

1 Comment
  • thanks for accepting me to join the, my pleasure, I hope it will give me great opportunity to learn more than before.
    Are you sure you want to  Yes  No
    Your message goes here
No Downloads
Total Views
On Slideshare
From Embeds
Number of Embeds
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

No notes for slide


  • 1. Hari Dev2008 MBBS
  • 2. MULTIPLE PREGNANCY• Presence of more than one fetus in the gravid uterus• 1% of all pregnancies• Hellin’s Rule – Twins : 1 in 80 – Triplets : 1 in 80 × 80 – Quadruplets : 1 in 80 × 80 × 80….• Gemellology : Study of twins
  • 3. • ZYGOSITY - Refers to the Type of Conception. - only determined by DNA testing• CHORIONICITY - Type of Placentation - prenatally by ultrasound - postnatally by examining membranes.
  • 4. 1. ZYGOSITYDizygotic TwinsMonozygotic Twins
  • 5. 1.DIZYGOTIC TWINS/ BINOVULAR75%Fertilisation of 2 ova by different spermatozoa.Each twin has its own placenta, chorion , amnion.Hence always dichorionic, diamniotic.Factors affecting - ethnic group - increasing maternal age - increasing parity - Family history of twinning - ovulation induction with clomiphene citrate/gonadotrophins resulting in multiple ovulation.
  • 7. 2.MONOZYGOTIC / BINOVULAR/ IDENTICAL25%Result from splitting of a single fertilized ovumAlways same sex and look alike. [ IDENTICAL ]Rate of monozygotic twinning is relatively constant , not affectedby any factors.True etiology unknown.Type of placentation is determined by the time of splitting
  • 10. 2.CHORIONICITY• Type of Placentation• Postnatally- Examination of Membranes• Prenatally- By Ultrasound• Ideal time for assesment is before 14 weeks
  • 11. Which is more important –zygosity or chorionicity??
  • 12. CHORIONICITY………Why????• Dichorionic twins can be either mono/dizygotic.• Dichorionic twins develop as two distinct organs. – so no risk.
  • 13. CHORIONICITY………Why????• Monochorionic twins have increased vascular anastomoses between the two circulation – so high risk!!
  • 14. 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.
  • 15. • Twin peak / Lambda sign - characteristic of dichorionic pregnancies - chorionic tissue between 2 layers of intertwin membrane at the placental origin• T Sign – in monochorionic , no chorionic tissue• If no membrane is seen in between – monochorionic monoaniotic
  • 16. Ultrasound differentiation of chorionicity Criterion Monochorionic DichorionicPlacenta Single DoubleFetal Sex -------- DiscordanceMembrane <2 mm >2 mmNo: of layers in 2 layers 4 layersmembraneTwin peak sign Absent Present
  • 17. Maternal ComplicationsAntepartum Intrapartum1.Hyperemesis 1.Dysfunctional labour2.Hydramnios 2.Malpresentation3.Pre-eclampsia 3.Operative delivery4.Pressure symptoms 4.Postpartum hemorrhage5.Anaemia 5.Retained Placenta6.Antepartum 6.Premature separationhemorrhage of placenta
  • 18. Maternal Complications - Antepartum Hyperemesis – increased β- hCG Hydramnios – monoamniotic pregnancies, Twin transfusion syndrome, major cause of prematurity Pre- eclampsia – 3 times commoner compared to singleton Pressure symptoms Anaemia – increased plasma volume expansion , fetoplacental demand for iron increased. APH – Placenta praevia , Abruptio placenta.
  • 19. Fetal ComplicationsAntepartum Intrapartum1.Prematurity 1.PROM2.IUGR 2.Cord Prolapse3.Single fetal demise 3.Abruption in second twin4.Twin to Twin transfusion 4.Interlocking (rare)syndrome5.Vanishing Twin/abortion6.Cong.anomalies7.Conjoined twins
  • 20. FETAL COMPLICATIONS Perinatal mortality: 6 times Morbidity: 2- 3 times Mono chorionic - morbidity/mortality twice as that of dichorionic. - additional risk from TTS Monoamniotic twins - 50% mortality. Main cause of adverse outcome is 1. Prematurity 2. IUGR Cerebral palsy, neurodevelopmental impairment, lower IQ scores. Monochorionic twins: 1. TTTS 2 .Monoamniotic twinning 3. Conjoined twinning 4. Acardiac fetus
  • 21. 1. Prematurity• Single most important cause of perinatal mortality and morbidity.• Ensure delivery in a tertiary care centre.!!
  • 22. 2. IUGRCan affect one or both fetuses.Monochorionic > Dichorionic.UPTO 30-32 Weeks twins grow with same velocity , afterthat reduction in abdominal circumference.Poor growth – poor placentation , unequal placentalsharing, fetal anomalies.
  • 23. 3. SINGLE FETAL DEMISEDeath of one twin NEUROLOGICAL DAMAGE in surviving TWIN Sudden acute shift of blood from surviving twin to dead fetus
  • 24. 3. SINGLE FETAL DEMISEMonochorionic - 25% risk of twin death, 25% risk ofneurological damage in surviving twin.• Dilemma exists whether to deliver early or not• Terminated as soon as other twin is capable of extra uterine survivalDichorionic – no such risk• Conservative management
  • 25. 4.Monochorionic Monoamniotic twinningSeen in less than 1% of all twin pregnanciesLate intrauterine death due to cord entanglement.Best diagnosed in 1st trimester – absence of intervening membrane.Colour doppler – cord entaglementFetal loss – 50-70%Hence elective CS at 36 weeks.
  • 26. 5. Twin – twin Transfusion Syndrome [ TTS]Occurs in monochorionic placentation due toAV anastomoses with resultant flow in onedirection.
  • 27. 5. Twin – twin Transfusion Syndrome [ TTS]
  • 28. Ultrasound in TTS – STUCK TWIN SIGN
  • 29. • Management after delivery – Exchange transfusion• Chronic TTS – Serial amnio reduction – - Reduces preterm labour - Reduce hydrostatic pressure – - improves circulation and urine production.• Fetoscopic laser ablation of anastomoses
  • 30. • Acute TTS can occur in 3rd trimester or in labour – sudden death of one twin• Overall mortality is 70%• High incidence of CP and neurological abnormalities in survivors.
  • 31. 6. Vanishing Twin & Abortion Incidence of abortion more in multiple pregnancy Spontaneous cessation of cardiac activity in a previously viable fetus of a multiple gestation. – VANISHING TWIN When fetal death occur after the first trimester, results in a thin parchment – like body called FETUS PAPYRACEOUS Diagnosis made after delivery No effect on mother or the viable fetus.
  • 32. 7. Congenital AnomaliesSTRUCTURAL MALFORMATIONS• Unique to twins – conjoined twins , Acardiac fetus• Non specific but common in twins – CHD , Anencephaly• Postural deformities – Talipes & Congenital dislocation of HipCHROMOSOMAL ANOMALIES• Dizygotic – independent risk, but both will not be involved• Monozygotic – same risk as that of singleton, both affected• Down’s syndrome
  • 33. Nuchal Translucency Mid Trimester Amniocentesis is the gold standard
  • 34. Management of Anomalies SelectiveDICHORIONIC If one fetus is feticide usingPREGNANCY abnormal KCl
  • 35. Conjoined TwinsAlways monozygoticIncomplete division occuring after 13 days.Very rareThoraco pagus, craniopagus, omphalopagus, pyopagus, ischiopagus..Prenatal diagnosis important – for termination , for planning operationSevere cases detected early – TerminationSurgical separation only in some cases – sharing of brain and heart – unsuccessful operationCaesarean preferred
  • 37. Acardiac FoetusVery rareBizarre form of monochorionic twinningOne fetus is normalThe other twin is severely malformed – no heart , absentdevelopment of upper part of body
  • 39. Twin Reversed Arterial Perfusion Sequence [ TRAP]•Pump twin – high output cardiac failure, hydrops, poly hydramnios and death •Overall perinatal mortality of pump twin is 50%
  • 41. THANK YOU