Twins pregnancy and delivery in Obstetrics

1. Multiple pregnancy
Assist.prof. Andrii Berbets

2. Multiple pregnancy
Multiple pregnancy involves more than one
embryo (fetus) in any one gestation.
Two independent mechanisms may lead to
multiple gestation:
• segmentation of a single fertile ovum
(identical, monovular, or monozygotic)
• or fertilization of separate ova by different
spermatozoa (fraternal or dizygotic)

3. BENSON & PERNOLL’S
HANDBOOK OF OBSTETRICS AND GYNECOLOGY

4. Maternal complications
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anemia;
urinary tract infection;
preeclampsia-eclampsia,
hydramnios,
uterine inertia (overdistention);
hemorrhage (before, during, and after
delivery).

5. Fetal complications
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prematurity
fetal growth retardation
congenital anomalies (18% higher)
abnormal presentations
cord prolapse (5 times increased)
collision of twins
fetus-fetus tranfusion syndrome

7. Clinical findings
• A uterus larger than expected for the duration
of pregnancy (4 cm than anticipated);
• Excessive maternal weight gain not explained
by eating or edema;
• Hydramnios;
• Iron deficiency anemia;
• Maternal reports of increased fetal activity;

8. Clinical findings
• Uterus containing 3 large parts or multiple
small parts;
• Simultaneous auscultation or recording of two
fetal hearts varying 8 beats per min and
asychronous to the maternal heart
• Ultrasound confirmation

9. Two-vertex twins presentation

10. One vertex and one breech
presentation

11. Locked twins

12. Feto-fetal transfusion syndrome
• This condition affects approximately 1 in 5
(20%) of all twins that share the same
placental mass (monochorionic).
• This is a highly pathological condition, which if
untreated will lead to fetal or newborn death
in excess of 95% of cases.

13. Feto-fetal transfusion syndrome
• The underlying abnormality is that the
placenta contains vascular connections that
connect the twins, in effect, making them
connected together by a continuous blood
supply.

14. Feto-fetal transfusion syndrome
• The vascular (blood supply) connection
between twins within the placenta leads to a
haemodynamic (blood flow) imbalance
between the twins, with one, the recipient,
having a relative high perfusion of blood and
the other, the donor, being under perfused
with blood.

15. Feto-fetal transfusion syndrome

16. Severity classification
• Stage 1. There is a difference in the amounts
of amniotic fluid surrounding the twins. The
recipient often is complicated by
polyhydramnios (excess amniotic fluid with a
maximum pool depth of around 8cms) and the
donor is complicated by oligohydramnios
(reduced amniotic fluid with a maximum pool
depth of around 2cms).

17. Severity classification
• Stage 2. In addition to the discrepancy of
amniotic fluid volumes, there is a difference in
size between the two babies (the recipient is
often larger than the donor).

18. Severity classification
• Stage 3. There are haemodynamic differences
between the twins. The recipient has evidence of
abnormal blood flow and right-sided heart strain.
The donor often demonstrates absent or reversed
blood flow in the umbilical arterial (cord) circulation.
• Stage 4. One twin shows signs of severe right-sided
heart failure.
• Stage 5. One of twin has already died.

19. Feto-fetal transfusion syndrome

20. Treatment
Fetoscopy and placenta laser ablation

21. Delivery
• Cesarean section is recommended for monoamniotic
twins because of the 10% delivery loss from cord
entanglement.
• Other standard indications for cesarean include: any
birth number exceeding twins (e.g., triplets), or if the
first twin is nonvertex.
• The first twin may be delivered vaginally if it presents
by the vertex.

22. Delivery
• A vaginal examination immediately after the
first delivery is performed to identify a
possible forelying or prolapsed cord

23. Delivery
• If 2nd fetus has continued as a vertex, a second
vaginal delivery may be performed.

24. Delivery
If the second fetus is anything but vertex there
are three alternatives.
● Bringing the head into the inlet by external
guidance (version); if successful, allows labor
to proceed for another vertex vaginal delivery.
● Perform cesarean section
● Complete a vaginal breech delivery

25. Delivery
• Rupture of the second sac (if present) is
accomplished as late as possible to avoid
prolapse of the cord.

26. Thank You!