This document discusses multiple pregnancy, specifically twins. It begins by outlining Hellin's Rule which describes the statistical likelihood of having multiples based on maternal factors. It then differentiates between dizygotic and monozygotic twins and describes the key differences. Factors that can increase the chances of dizygotic twins are also outlined. The rest of the document details various maternal and fetal complications that can arise in twin pregnancies such as preeclampsia and preterm birth. Specific complications of monozygotic twins like twin-twin transfusion syndrome are also explained.

1. Multiple
pregnancy…

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

3. Types of twins………
DIZYGOTIC MONOZYGOTIC

4. DIZYGOTIC 2
chorions
amnion amnion
Always dichorionic & diamnionic

5. Factors affecting dizygotic
twinning
Ethnic group
Increasing
maternal age

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

7. MONOZYGOTIC
4-7 days

9. >8days

10. Chorionicity
Type of placentation
Prenatal detection by USS
Clinical implications in antepartum & intrapartum
management…
Monochorionic MZ
Dichorionic+discordant
sex DZ
Dichorionic+concordant
sex MZ or DZ

11. USS DETERMINATION OF CHORIONICITY
Number of sacs
Placenta
Sex
Intertwin membrane
Lambda sign & T sign
Ideal time for assessing of chorionicity is before 14
weeks

12. DIZYGOTIC

13. LAMBDA SIGN

14. MONOCHORIONIC & DIAMNIONIC
T SIGN

15. MONOCHORIONIC MONOAMNIOTIC

16. Importance of chorionicity ?????

17. MATERNAL COMPLICATIONS
Antepartum
hyperemesis
hydramnios

18. Pre eclampsia(3 fold times),eclampsia(6 fold times)
Pressure symptoms
Anaemia
Ante partum hemorrhage-
Abruption
Placenta preavia

19. Intrapartum complications
Dysfunctional labour
Malpresentations
Increased chance for operative delivery
Post partum hemorrhage
Retained placenta

20. FETAL COMPLICATIONS…………
Antepartum complications
I. Prematurity

21. 2. IUGR
Poor placentation,unequal placental
sharing,fetal anomalies……

22. 3. Single fetal demise
monochorionic
Shift of blood
Normal
Death of one twin
twin
25% risk of co-twin death /25% risk of neurological
damage in surviving twin

23. 4. Cord entanglement

24. 5. TWIN-TWIN TRANSFUSION SYNDROME

25. Arterio venous anastomoses with net
flow in one direction..
A/c or C/c…
•Severe IUGR
•poor renal perfusion
Donor(arterial side) •Anuria
•severe oligohydramnios
•Hypervolemia
recipient •Polyuria with polyhydramnios
•CCF…..hydrops…death

26. Uss of TTS…. STUCK TWIN

27. Serial amnio reduction,fetoscopic laser ablation of
anastomosis
6. Vanishing twin
Cessation of cardiac activity in a
previously viable foetus
Fetus papyraceous…

28. 7. Congenital anomalies
Structural Chromosomal
malformations anomalies
Conjoint twins Down’s syndrome
Acardiac fetus
Anencephaly
Talipes
Dislocation of hip
etc..

29. Conjoint twins
Always monozygotic
classification
Thoracopagus
Craniopagus
omphalopagus

30. Pygopagus
ischiopagus
Prenatal diagnosis-to counsel the parents for mtp / to
plan site & mode of delivery…

31. Acardiac foetus
A-A anastamoses Umb. A
in placenta
Umb
De oxygenated
.A
blood
Minimal oxy. extracted by lower
Normal fetus/pump twin part of Acardiac fetus
Fully de oxygenated
Umb.V V-V anastomoses Umb.V Upper part of fetus ,no growth
in placenta

33. Acardiac twins

34. Anencephaly

35. Intrapartum complications
PROM & cord
prolapse
Abruption in the 2nd
twin
Interlocking of twins