863

C H A PT E R 45

M u lt ifeta l Pregn a n cy

MECHANISMS OF M U LTI FETAL GESTATIONS . . . . . . . . 864 unknown. These pregnancies may result from two or more fer­
tilization events, from a single fertilization followed by a split­
DIAGNOSIS OF M U LTIFETAL GESTATION . . . . . . . . . . . 869 ting of the zygote, or from a combination of both. Multifetal
MATERNAL PHYSIOLOGICAL ADAPTATIONS . . . . . . . . 870
gestations were problematic during those times and remain so
today for both the mother and her fetuses. For examp le, in
PREGNANCY COMPLICATIONS . . . . . . . . . . . . . . . . . . . . 871 this country, approximately a fourth of very-low-birthweight
neonates-those born weighing < 1 500 g-are from multifetal
U N IQUE FETAL COM PLICATIONS . . . . . . . . . . . . . . . . . . 873 gestations (Martin, 20 1 7) .
DISCORDANT GROWTH OF TWI N FETUSES . . . . . . . . . . 88 1
Fueled largely b y infertility therapy, both the rate a n d the
number of twins and higher-order multi fetal births grew dra­
FETAL DEMISE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 882 matically during the 1 980s and 1 990s in the United States.
National data from Martin and coworkers (20 1 7) presented
PRENATAL CARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 884 here is informative. he twinning rate rose 76 percent from
PRETERM BIRTH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 885
1 8 .9 per 1 000 live births in 1 980 to 33.2 in 2009. During
the same time, the number of higher-order multifetal births
LABOR AND DELIVERY . . . . . . . . . . . . . . . . . . . . . . . . . . 887 peaked in 1 998 at a rate of 1 .9 per 1 000 total births. Since
then, however, evolving infertility management has lowered
SELECTIVE REDUCTION OR TERM I NATION . . . . . . . . . . 891 rates of higher-order multifetal births-especially among non­
Hispanic white women. For example, the rate of triplets or
more declined by more than 50 percent from 1 998 to 20 1 5 in
this demographic group. And, in 20 1 5 , the overall m ultifetal
birth rate was 34. 5 per 1 000, with twins representing nearly
97 percent of these births.
In single-ovum twins, there is always a certain area of the These rates of multi fetal pregnancies have a direct efect on
placenta in which there is anastomosis between vascular sys­ the rates of preterm birth and its comorbidities. In addition,
tems which is never present in the fused placenta ofdouble­ the risks for congenital malformation and its consequences are
ovum twins. Thus, if at an eary period the heart of one greater with multifetal gestations. Importantly, this increased
embryo is consideraby stronger than that of the other, a risk applies to each fetus and is not simply the result of more
gradualy increasing area of the communicating portion of fetuses. In sum, in 20 1 3 in the United States, multifetal births
the placenta is monopolized by the ormer, so that its heart accounted for 3 percent of all live births but for 1 5 percent of
increases rapidy in size, whilst that ofthe latter receives less all infant deaths. Moreover, the risk of infant death rose propor­
blood and eventualy atrophies. tionally with the number of fetuses in the pregnancy (Matthews,
-J. Whitridge Williams ( 1 903) 20 1 5) . Speciically, the infant mortality rate for twins was more
than four times the rate for single births. In the same year, the
In Williams' time, a great deal concerning the embryological infant mortality rate for triplets was nearly 1 2 times the rate for
and morphological development of multifetal pregnancies was singletons, and for quadruplets, it was a staggering 26 times that
864 Obstetrical Compl i cations

two does not necessarily result in equal sharing of protoplasmic

TABLE 45-1 . Selected Outcomes i n S i n g leton a n d Twi n
material. Monozygotic twins may actually be discordant for
Preg nancies Del ivered a t Parkland H os pital
genetic mutations because of a postzygotic mutation, or may
from 1 988 t h ro u g h 20 1 6
have the same genetic disease but with marked variability in
Outcome Sing letons (No.) Twins (No.) expression. In female fetuses, skewed lyonization can produce
P reg n a n cies 202,306 241 2 diferential expression of X-linked traits or diseases. Further,
B i rt h sa 202,306 4824 the process of monozygotic twinning is in a sense a teratogenic
Sti l l bi rths 1 01 1 (5 .0) 1 14 (23 .6) event, and monozygotic twins have a higher incidence of often
N eo nata l death s 590 (2.9) 92 ( 1 9.5) discordant malformations (Glinianaia, 2008) . For example, in
Peri nata l deaths 1 60 1 (7.9) 206 (42 . 7) one study of 926 monozygotic twins, the prevalence of con­
Ve ry l ow b i rthweig ht 1 927 (9.6) 507 ( 1 07.6) genital heart defects was 1 2-fold greater than the general popu­
« 1 500 g) lation rate, but 68 percent of afected infants had a normal
sibling (Pettit, 20 l 3) . From any of these mechanisms, dizygotic
a B i rt h data a re re prese nted as n u m ber (per 1 000) .
b De n o m i nator for neonata l deaths a nd very low b i rth­ twins of the same sex may appear more nearly identical at birth
than monozygotic twins.
wei g h t i s l iveborn i nfa nts.
Data from D r. Don Mci nti re.
• Genesis of Monozygotic Twins
The developmental mechanisms underlying monozygotic twin­
for singletons! From Parkland Hospital, a comparison of single­
ning are poorly understood. The incidence of monozygotic
ton and twin outcomes is shown in Table 45- 1 . These risks are
twins is increased two- to fivefold in pregnancies conceived
magnified further with higher-order births.
using assisted reproductive technology (ART) . he predispo­
he mother may also experience higher obstetrical morbid­
sition to splitting may stem from specimen handling, growth
ity and mortality rates. hese rates lso rise with the number of
media, or sperm DNA microinjection or may arise from intrin­
fetuses (Mhyre, 20 1 2; Young, 20 1 2) . In one study of more than
sic abnormalities associated with infertility (McNamara, 20 1 6) .
44,000 multifetal pregnancies, the risks for preeclampsia, post­
The outcome o f the monozygotic twinning process depends
partum hemorrhage, and maternal death were twofold higher
on when division oCCuts. If zygotes divide within the irst
than these rates in singleton gestations (Walker, 2004) . The risk
for peripartum hysterectomy is also greater. Francois and associ­ 72 hours after fertilization, two embryos, two amnions, and
two chorions develop, and a diamnionic, dichorionic twin
ates (2005) reported this to be threefold for twins and 24-fold
pregnancy evolves (Fig. 45- 1 ) . Two distinct placentas or a
for triplets or quadruplets. Last, compared with women with
single, fused placenta may develop. If division occurs between
a singleton pregnancy, these mothers are at increased risk for
the fourth and eighth day, a diamnionic, monochorionic twin
depression as well as parental divorce (Choi, 2009; Jenna, 20 1 1) .
pregnancy results. By approximately 8 days after fertilization,
the chorion and the amnion have already diferentiated, and
M ECHAN I SMS OF MULTI F ETAL G ESTATIONS division results in two embryos within a common amnionic
sac, that is, a monoamnionic, monochorionic twin pregnancy.
Twin fetuses usually result from fertilization of two separate Conjoined twins result if twinning is initiated later.
ova, which yields dizygotic or ratenal twins. Less often, twins It has long been accepted that monochorionicity incon­
arise from a single fertilized ovum that then divides to create trovertibly indicated monozygosity. Rarely, however, mono­
monozygotic or identical twins. Either or both processes may be chorionic twins may in fact be dizygotic (Hackmon, 2009) .
involved in the formation of higher numbers. Quadruplets, for Mechanisms for this are speculative, but in one review of 1 4
example, may arise from as few as one to as many as four ova. cases, nearly all had been conceived after ART procedures (Eke­
These traditional models of twinning discussed in the next sec­ lund, 2008) . McNamara and colleagues (20 1 6) ofer an excel­
tions have been taught for more than 50 years and remain the lent review of the mechanisms and evidence for both typical
widely accepted theory. More recently, Herranz (20 1 5) ofered and atypical twinning.
a provocative alternative hypothesis, which posits that mono­
zygotic twinning occurs with splitting at the postzygotic two­ • Superfetation and Superfecundation
cell stage. Notably, data are not robust in support of either the
traditional or the newly proposed model (Denker, 20 1 5). In supeetation, an interval as long as or longer than a men­
strual cycle intervenes between fertilizations. Superfetation
requires ovulation and fertilization during the course of an
• Dizygotic versus Monozygotic Twinning established pregnancy, which is theoretically possible until the
Dizygotic twins are not in a strict sense true twins because they uterine cavity is obliterated by fusion of the decidua capsularis
result from the maturation and fertilization of two ova during to the decidua parietalis. Although known to occur in mares,
a single ovulatory cycle. Moreover, from a genetic perspective, superfetation is not known to occur spontaneously in humans.
dizygotic twins are like any other pair of siblings. Lantieri and associates (20 1 0) reported a case ater ovarian
On the other hand, monozygotic or identical twins, although hyperstimulation and intrauterine insemination in the presence
they have virtually the same genetic heritage, are usually not of an undiagnosed tubal pregnancy. Most authorities believe
identical. Namely, the division of one fertilized zygote into that alleged cases of human superfetation result from markedly
 M u ltifeta l P reg n a n cy 865

2-cell stage

0-4 days

! ! ! 4-8 days

Amnionic
cavity
� Shared
! 8-1 2 days

> 1 3 days

Separate Fused
placenta � placenta

Dichorionic Monochorionic Monochorionic Monochorionic

d iam nionic d iamn ionic monoamnionic monoamn ionic
conjoi ned twins
F I G U R E 45- 1 Mecha nism of monozygotic twi n n i ng . Black box i n g a n d b l u e a rrows in col u m ns A, B, a n d C i nd icates t i m i ng of d ivisio n .
A . A t 0 t o 4 d ays postferti l ization, a n early conceptus m a y d ivide i nto two. Division a t t h i s ea rly stage creates two chorions a n d two a m n ions
(d ichorion ic, d ia m n io n ic). Placentas may be sepa rate or fused. B. Division between 4 to 8 d ays l eads to formation of a blastocyst with two
sepa rate e m b ryoblasts ( i n n e r ce l l m asses). Each embryoblast wi l l form its own a m n io n wit h i n a s h a red chorion (monochorion ic, d i a m n i­
on ic). C. Between 8 a n d 1 2 d ays, the a m n ion and a m nionic cavity form a bove the germ i n a l d isc. E m b ryon i c d ivision l eads to two e m b ryos
with a shared a m nion a nd s h a red c h orion (monoc horion ic, monoa m n io n ic). D. Difering theories expla i n conjoined twi n development. One
descri bes a n incomplete splitti n g of one e m b ryo into two. The other d escri bes fu sion of a portion of one e m b ryo from a monozygotic pair
onto the other.

unequal growth and development of twin fetuses with the same setting of paternity lawsuits (Girela, 1 997) . Given that superfe­
gestational age. cundation may also occur with ART, women should be advised
Supeecundation refers to fertilization of two ova within the to consider avoiding intercourse after embryo transfer (McNa­
same menstrual cycle but not at the same coitus, nor neces­ mara, 20 1 6; Peigne, 2 0 1 1 ) .
sarily by sperm from the same male. An instance of superfe­
cundation or heteropaternity, documented by Harris ( 1 982),
is demonstrated in Figure 45-2. he mother was delivered of • Factors Afecting Twinning
a black neonate whose blood type was A and a white neonate Dizygotic twinning is much more common than monozygotic
whose blood type was O. The blood type of the mother and her splitting of a single oocyte, and its incidence is infl u enced by
husband was O. More recent cases have been reported in the race, heredity, maternal age, parity, and, especially, fertility
866 Obstetrica l Com p l ications

200 • Non-Hispan ic white

• Non-Hispanic black
• Hispanic

1 60
)
c
::
0
)
�
0
0
0 1 00
5
.

�
)

50

F I G U R E 45-2 An exa mple o f d izygotic twi n boys as the con se­

q u en ce of superfec u ndation.

treatment. By contrast, the frequency of monozygotic twin o ---�

births is relatively constant worldwide-approximately 1 set � )J
per 250 births, and this incidence is generally independent �� ��

of demographic factors. One exception is that rates of zygotic Age (years)

splitting are increased following ART (Aston, 2008) . F I G U R E 45-3 M u ltifetal birth rates in the U n ited States accord i n g
t o maternal age a nd race, 20 1 5 . (Data from M a rtin, 2 0 1 7.)
Demog ra p h ics
Among diferent races and ethnic groups, the frequency of mul­
tifetal births varies significantly. In one analysis of more than cautioned that greater use ofRT may be partially contributory.
8 million births in the United States between 2004 and 2008, the In a two-year study from Nigeria, where such technology is not
rate of twinning was 3.5 percent in black women and 3 percent commonly available, Olusanya (20 1 2) calculated the efects of
in whites (Abel, 20 1 2) . Hispanic, Asian, and Native merican multiparity compared with primiparity. They found an eight­
women had comparatively lower rates than white women. In one fold rise in multifetal gestation rates when parity was ;4, and a
rural community in Nigeria, twinning occurred once in every 20-fold rise when parity was : 5 .
20 births (nox, 1 960)! hese marked diferences in twinning
frequency may be the consequence of racial variations in levels of H e red ity
follicle-stimulating hormone-FSH (Nylander, 1 973) . As a determinant of twinning, the family history of the mother
Maternal age is another important risk factor for multife­ supersedes that of the father. One study of 4000 genealogical
tal pregnancies (Fig. 45-3) . Dizygotic twinning frequency rises records showed that women who themselves were a dizygotic
almost fourfold between the ages of 1 5 and 37 years (Painter, twin gave birth to twins at a rate of 1 set per 58 births (White,
20 1 0) . As such, there is a paradox of declining fertility but 1 964) . Women who were not a twin, but whose husbands were
increasing twinning rates with advancing maternal age (Beem­ a dizygotic twin, gave birth to twins at a rate of 1 set per 1 1 6
sterboer, 2006) . Another explanation for the dramatic rise in pregnancies. Painter and associates (20 1 0) performed genome­
twinning with advancing maternal age may be a higher use of wide linkage analyses on more than 500 families of mothers of
ART in older women (Ananth, 20 1 2) . Paternal age has also dizygotic twins and identified four potential linkage peaks. he
been linked to twinning frequency, but its efect is felt to be h ighest peak was on the long arm of chromosome 6, and other
small (Abel, 20 1 2) . Although twin pregnancy is associated with suggestive peaks were on chromosomes 7, 9, and 1 6. That said,
greater risks for most adverse perinatal outcomes, McLennan the contribution of these variants to the overall incidence of
and associates (20 1 7) did not find advanced maternal age to be twinning is likely small (Hoekstra, 2008) .
an additional risk factor for fetal and infant death. From this
population-based study of the United States, they concluded N utrition
that women in their 30s may be counseled that their age is not In animals, the litter size number grows in proportion to nutri­
a major additional risk factor for adverse obstetric outcomes in tional suiciency. Evidence from various sources indicates that this
the setting of twin pregnancy. occurs in humans as well. Nylander ( 1 97 1 ) showed an increas­
Increasing pariy independently raises the incidence of twin­ ing gradient in the twinning rate related to greater nutritional
ning in all populations studied. During a 30-year period, Antsak­ status as relected by maternal size. Taller, heavier women had a
lis and coworkers (20 1 3) noted a progressively increasing positive twinning rate 25 to 30 percent greater than short, nutritionally
correlation between multiparity and twinning. However, they deprived women. Likewise, Reddy and associates (2005) found
 Mu ltifeta l P reg n a n cy 867

an association of maternal weight and dizygotic twinning in the hese practices have efectively lowered multifetal rates, and the
United States, in the absence of fertility drugs. Indeed, the influ­ rate of triplet or higher-order multifetal pregnancy has declined
ence of maternal weight s a factor for twinning will continue to every year since 2009 (Kulkarni, 20 1 3; Martin, 20 1 7) .
rise in importance s the percentage of obese women in the United
States continues to grow.
• Sex Ratios i n Multifetal Pregnancies
Evidence acquired during and after World War II suggested
that twinning correlated more with nutrition than with body In humans, as the number of fetuses per pregnancy rises, the per­
size. Widespread undernourishment in Europe during those centage of male conceptuses declines. Strandskov and coworkers
years was associated with a marked fall in the dizygotic twin­ ( 1 946) found the percentage of males in 3 1 million singleton
ning rate (Bulmer, 1 959). Several investigators have reported a births in the United States was 5 1 .6 percent. For twins, it was
greater prevalence of twinning among women who have taken 50.9 percent; for triplets, 49.5 percent; and for quadruplets,
supplementary folic acid (Ericson, 200 1 ; Haggarty, 2006) . 46. 5 percent. Swedish birth data spanning 1 35 years reveals
Conversely, in a systematic review, Muggli and Halliday (2007) the number of males per 1 00 female newborns was 1 06 among
were unable to demonstrate a significant association. Analysis singletons, 1 03 among twins, and 99 among triplets (Fellman,
of twinning rate in Texas after folic acid fortiication of cereal­ 20 1 0) . Females predominate even more in twins from late twin­
grain products also failed to demonstrate an independent ning events. For example, 68 percent of thoracopagus conjoined
increase in twinning rates (Waller, 2003). twins are female (Mutchinick, 20 1 1 ) . Two explanations have
been ofered. First, beginning in utero and extending through­
Pitu ita ry Gonadotro p i n out the life cycle, mortality rates are lower in females. Second,
he common factor linking race, age, weight, and fertility to female zygotes have a greater tendency to divide.
multifetal gestation may be FSH levels (Benirschke, 1 973) .
This theory is supported by the fact that greater fecundity and a • Determining Zygosity
higher rate of dizygotic twinning have been reported in women
Twins of opposite sex are almost always dizygotic. In rare
who conceive within 1 month after stopping oral contracep­
instances, due to somatic mutations or chromosome aberra­
tives, but not during subsequent months (Rothman, 1 977) .
tions, the karyotype or phenotype of a monozygotic twin ges­
This may be due to the sudden release of pituitary gonadotro­
tation can be diferent (Turpin, 1 96 1 ) . Most reported cases
pin in amounts greater than usual during the irst spontaneous
describe postzygotic loss of the Y chromosome in one 46,XY
cycle after stopping hormonal contraception. Indeed, the para­
twin resulting in a phenotypically female twin with T urner
dox of declining fertility but increasing twinning with advanc­
syndrome (45,X) . Zech and coworkers (2008) found a rare
ing maternal age can be explained by an exaggerated pituitary
case of a 47,Y zygote that underwent postzygotic loss of
release of FSH in response to decreased negative feedback from
the X chromosome in some cells and loss of the Y chromo­
impending ovarian failure (Beemsterboer, 2006) .
some in other cells. The phenotype of the resultant twins was
I nfe rti l ity Thera py
one male and one female. Karyotype analyses revealed both to
be 46,XXJ46,XY genetic mosaics.
Ovulation induction with FSH plus human chorionic gonado­
tropin (hCG) or clomiphene citrate remarkably enhances the
likelihood of multiple concurrent ovulations. In their review • Determining Chorion icity
of this practice, McClamrock and coworkers (20 1 2) reported he risk for twin-speciic complications varies in relation to
rates of twins and higher-order multifetal pregnancies as high both zygosity and chorionicity-the number of chorions.
as 28.6 percent and 9.3 percent, respectively. Rates this high Shown in Table 45-2, the latter is the more important determi­
remain a major concern. Two ongoing multicenter trials­ nant. Speciically, perinatal mortality and neurological i nj ury
Assessment of Multiple Gestations from Ovarian Stimulation rates are greater in monochorionic diamnionic twins compared
(AMIGOS) and Pregnancy in Polycystic Ovary Syndrome II with dichorionic diamnionic pairs (Hack, 2008; Lee, 2008). In
(PPCOSII)-are designed to provide guidance on achieving one retrospective analysis of more than 2000 twins, the risk of
maximum pregnancy rates while minimizing multifetal gesta­ fetal demise in one or both monochorionic twin(s) was twice
tion rates (Diamond, 20 1 5 ; Legro, 20 1 4) . that in dichorionic multifetal gestations (McPherson, 2 0 1 2) .
I n general with i n vitro fertilization (IVF), the greater the Moreover, the prospective risk o f antepartum stillbirth i s higher
number of embryos that are transferred, the greater the risk for monochorionic than for dichorionic twins at all preterm
of twins and other multifetal gestations. In 20 14, ART con­ gestational ages. he highest risk is before 28 weeks' gestation
tributed to 1 .6 percent of all newborns in the United States (Glinianaia, 20 1 1 ) . In contrast, chorionicity diferences do not
and to 1 8.3 percent of all neonates in multifetal gestations signiicantly afect maternal outcomes (Carter, 20 1 5) .
(Sunderam, 20 1 7) . The American Society for Reproductive
Medicine (20 1 7) recently revised their age-related guidelines S o n og ra p h i c Determ i nation
regarding the number of cleavage-stage embryos or blastocysts This has become an integral tool to assist in multifetal preg­
to transfer during IVF. This efort aims to reduce the incidence nancy management. Indeed, the diagnosis and evaluation of
of higher-order multifetal pregnancies. Based on these new rec­ a multifetal gestation is now considered a recognized indica­
ommendations, women younger than 35 years are encouraged tion for irst-trimester sonography (Reddy, 20 1 4) . In addition,
to receive a single-embryo transfer, regardless of embryo stage. the North American Fetal Therapy Network (NAFTNet)-a
868 Obstetrica l Com pl ications

TABLE 45-2. Overview of the I ncidence of Twi n P regna ncy Zygosity a n d Correspond i n g Twi n-Specific Com p l i cations
Rates of Twin-Specific Complications i n Percent
Placental
Fetal-G rowth Preterm Vascular Perinatal
I Type of Twinn ing Twins Restriction Del iverya Anastomosis Morta lity
D izygotic 80 25 40 0 1 0- 1 2
Monozygotic 20 40 50 1 5- 1 8
Dia m n io n ic/d ichorionic 6-7 30 40 0 1 8-20
D ia m n io n ic/monochorionic 1 3- 1 4 50 60 1 00 30-40
Monoa m n ion ic/monochorion ic <1 40 60-70 80-90 58-60
Conj o i ned 0.002 to 0.008 70-80 1 00 70-90

a De l ivery before 3 7 weeks.

Data from M a n n i ng, 1 995.

consortium of 30 medical institutions in the United States and the point of origin of the dividing membrane on the placental
Canada-have provided recommendations for determination surface. he peak appears as a triangular projection of placen­
of chorionicity using sonography (Emery, 2 0 1 5). tal tissue extending a short distance between the layers of the
Sonographic features used to evaluate chorionicity vary dividing membrane (Fig. 4 5-4) .
according to gestational age. Accuracy is greatest in the irst
trimester and diminishes as gestational age advances. Namely,
chorionicity can be determined sonographically with 98-percent
accuracy in the irst trimester but may be incorrect in up to
1 0 percent of second-trimester examinations (Emery, 20 1 5;
Lee, 2006) . Moreover, for sonographic evaluations between
1 5 and 20 weeks' gestation, the odds of chorionicity misclas­
siication rise by approximately 1 0 percent for each week of
advancing gestational age in pregnancies compared with those
completed before 14 weeks (Blumenfeld, 20 1 4) . Overall, cho­
rionicity can be correctly determined with sonography before
24 weeks in approximately 95 percent of cases (Lee, 2006) .
Early in the first trimester, the number of chorions equates
to the number of gestational sacs. A thick band of chorion
separating two gestational sacs signals a dichorionic pregnancy,
whereas monochorionic twins have a single gestational sac. If
the gestation is monochorionic diamnionic, it may be diicult
to visualize the thin intervening amnion before 8 weeks' A
gestation (Emery, 20 1 5) . If the intervening membrane is
diicult to visualize, the number of yolk sacs usualy correlates
with the number of amnions. However, the number of yolk
sacs as a predictor of amnionicity may not always be accurate
(Shen, 2006) . Although uncommonly seen early, cord entan­
glement identifies a monoamnionic gestation. When chorionic­
ity is uncertain, additional later sonographic examinations are
performed.
Ater 1 0 to 14 weeks' gestation, sonographic assessment of
chorionicity may be determined using four features. These are
the number of placental masses, thickness of the membrane
dividing the sacs, presence of an intervening membrane, and
fetal gender (Emery, 20 1 5) . First, two separate placentas sug­ B
gest dichorionicity. The converse is not necessarily true, such as
cases with a single fused placental mass. Second, identiication F I G U R E 45-4 A. Sonogra p h i c i m ag e of the "twin-pea k" sign, a l so
termed the "la m bda sign," in a 24-week g estatio n . At the top of
of a thick dividing membrane-generally �2 mm-supports
this sonog ram, tissue from the a nterior place nta is seen exte n d i n g
a presumed diagnosis of dichorionicity. In a dichorionic preg­ downwa rd between the a m n i o n layers. T h i s sign confi rms d ichori­
nancy, this visualized membrane is composed of a total of four onic twi n n ing. B. The "tWin-pea k" sign is seen at the bottom of this
layers-two amnion and two chorion. Also, the twin peak schematic diagra m . The tria n g u l a r portio n of placenta insin uates
sign-also called lambda or delta sign-is seen by examining between the a m n iochorion l ayers.
 M u ltifetal P re g n a ncy 869

A FIGURE 45-6 Dichorio n ic d i a m n i o n i c twi n placenta. The m e m ­

bra n e partition t h a t separated twi n fetu ses is elevated a n d c o n sists
of chorion (c) between two a m n ions (0).

cord. Cord blood is generally not collected until after deliv­

ery of the other twin. As the second neonate is delivered, two
damps are placed on that cord, and so on as necessary. lter­
natively, in higher-order deliveries, color-tagged damps can be
simpler. Until the delivery of the last fetus, each cord segment
must remain damped to prevent fetal hypovolemia and anemia
caused by blood leaving the placenta via anastomoses and then
through an undamped cord. At this time, evidence is insuicient
to recommend for or against delayed umbilical cord damping
in multifetal gestations (American College of Obstetricians and
B
Gynecologists, 20 1 7a) . At Parkland Hospital, we currently do
F I G U R E 45-5 A. Sonogra phic image of the '" sig n in a m o n o­ not perform delayed cord damping in these pregnancies.
chorion ic d ia m n i o n i c gestation at 30 weeks. B. Schematic d iagram The placenta is carefully delivered to preserve the attach­
of the ' " sign. Twi n s a re sepa rated only by a membra ne created by
ment of the amnion and chorion. With one common amnionic
the j u xta posed a m nion of each twi n . A '" is formed at the point at
which a m n io n s meet the pl acenta.
sac or with juxtaposed amnions not separated by chorion, the
fetuses are monozygotic (see Fig. 45- 1 ) . If adjacent amnions
are separated by chorion, the fetuses could be either dizygotic
In contrast, monochorionic pregnancies have a dividing or monozygotic, but dizygosity is more common (Fig. 4 5-6) .
membrane that is so thin (generally <2 mm) that it may not I f the neonates are of the same sex, blood typing o f cord blood
be seen until the second trimester. The relationship between samples may be helpful. Diferent blood types conirm dizy­
the membranes and placenta without apparent extension of gosity, although demonstrating the same blood type in each
placenta between the dividing membranes is called the T sign fetus does not conirm monozygosity. For deinitive diagnosis,
(Fig. 45-5) . Evaluation of the dividing membrane can establish more complicated techniques such as DNA ingerprinting can
chorionicity in more than 99 percent of pregnancies in the first be used. However, these tests are generally not performed at
trimester (Miller, 20 1 2) . Lack of a dividing membrane signals birth unless medical indications dictate a need.
a monochorionic monoamnionic gestation.
Last, twins with difering gender indicates a dichorionic
(and dizygotic) gestation (Emery, 20 1 5) . A rare exception to DIAGNOSIS OF M U LTIF ETAL G ESTATION
this scenario would be a heterokaryotypic monochorionic ges­
tation, described earlier (p. 867) . If both twins are the same • Clinical Evaluation
gender, additional measures are necessary. During physical examination, accurate fundal height mea­
surement, described in Chapter 9 (p. 1 64), is essential. With
P l ace nta l Exa m i nation multifetal pregnancies, uterine size is typically larger during
A carefully performed visual examination of the placenta and the second trimester than expected for a singleton. Rouse and
membranes ater delivery serves to establish zygosity and cho­ associates ( 1 993) reported fundal heights in 336 well-dated
rionicity promptly in approximately two thirds of cases. The twin pregnancies. Between 20 and 30 weeks' gestation, fundal
following systematic examination is recommended. As the irst heights averaged approximately 5 cm greater than expected for
neonate is delivered, one damp is placed on a portion of its singletons of the same fetal age.
870 Obstetrica l C o m p l i cations

FIGURE 45-7 Sonograms of first-trimester twi n s. A. Dichorionic d i a m nionic twi n preg n a ncy at 6 weeks' g estation. N ote the thick d ivid i n g
chorion (yellow arrow). One o f the yol k s a c s i s i n d i cated (blue arrow). B. Monoc horionic d i a m n ionic twi n preg n a ncy at 8 weeks' gestation.
N ote the th i n a m n ion encirc l i ng each e m b ryo, resu lting i n a t h i n d ivid i n g mem bra ne (blue arrow).

Diagnosing twins by palpation of fetal parts before the third • Other Diagnostic Aids
trimester is diicult. Even late in pregnancy, this may be chal­ Abdominal radiography can be used if fetal number in a higher­
lenging, especially if one twin overlies the other, if the woman order multifetal gestation is uncertain. However, radiographs
is obese, or if there is hydramnios. Palpating two fetal heads, generally have limited utility and may lead to an incorrect diag­
often in diferent uterine quadrants, strongly supports a twin nosis if fetuses move during the exposure or if exposure time is
diagnosis. Late in the first trimester, two fetal heartbeats may inadequate. Additionally, fetal skeletons before 1 8 weeks' gesta­
be diferentiated with Doppler ultrasonic equipment if their
tion are insuiciently radiopaque and may be poorly seen.
rates are clearly distinct from each other and from that of the
Although not typically used to diagnose multifetal preg­
mother.
nancy, magnetic resonance (MR) imaging may help delineate
Overall, however, using clinical criteria alone to diagnose complications in monochorionic twins (Hu, 2006) . In one
multifetal gestations is unreliable. For example, in the Rou­ review of 1 7 complicated twin gestations evaluated by both
tine Antenatal Diagnostic Imaging with Ultrasound (RADIUS) sonographic and MR imaging, the latter provided a more
trial, for 37 percent of women who did not have a screen­ detailed assessment of twin pathology (Bekiesinska-Figatowska,
ing ultrasound examination, their twin pregnancies were not
20 1 3) . This was particularly helpful in cases of conjoined twins.
diagnosed until 26 weeks' gestation. And, in 1 3 percent of No biochemical test reliably identifies multifetal gestations.
unscanned women, their multifetal gestations were only diag­ Serum and urine levels of 3-hCG and maternal serum levels of
nosed during their admission for delivery (American College of alpha-fetoprotein (MSAFP) are generally higher with twins
Obstetricians and Gynecologists, 20 1 6; LeFevre, 1 993). compared with those in singletons. However, levels may vary
considerably and overlap with those of singletons.
• Sonog raphy
Sonographic examination should detect practically all sets MATERNAL PHYSIOLOGICAL ADAPTATIONS
of twins. And, given the increased frequency of sonographic
examinations during the fi r st trimester, early detection of a he various physiological burdens of pregnancy and the like­
twin pregnancy is common. Sonography can also be used to lihood of serious maternal complications are typically greater
determine fetal number, estimated gestational age, chorionic­ with multifetal gestations than with a singleton pregnancy.
ity, and amnionicity. With careful examination, separate gesta­ his is considered, especially when counseling a woman whose
tional sacs, if present, can be identiied early in twin pregnancy health is compromised and in whom a multifetal gestation is
(F ig. 4 5-7) . Subsequently, each fetal head should be seen in recognized early. Similar consideration is given to the woman
two perpendicular planes so as not to mistake a cross section who is not pregnant but is considering infertility treatment.
of the fetal trunk for a second fetal head. Ideally, two fetal Beginning in the first trimester, and temporarily associated
heads or two abdomens should be seen in the same image with higher serum 3-hCG levels, women with a multifetal ges­
plane to avoid scanning the same fetus twice and interpreting tation oten have nausea and vomiting in excess of that with a
it as twins. singleton pregnancy. In women carrying more than one fetus,
Higher-order multifetal gestations are more challenging blood volume expansion is greater and averages 50 to 60 per­
to evaluate. Even in the irst trimester, it can be diicult to cent compared with 40 to 50 percent in those with a singleton
identiY the actual number of fetuses and their position. This (Pritchard, 1 965). This augmented hypervolemia teleologically
determination is especially important if pregnancy reduction or ofsets blood loss with vaginal delivery of twins, which is twice
selective termination is considered (p. 89 1 ) . that with a single fetus. Although red cell mass also accrues, it
 M u ltifetal P reg n a n cy 87 1

does so proportionately less in twin pregnancies. Combined with the irst trimester is much greater than the incidence of twins
greater iron and folate requirements, this predisposes to anemia. at birth. It has been estimated that 1 in 80 births are multifetal,
Women carrying twins also have a typical pattern of arte­ whereas 1 in 8 pregnancies begin multifetal but are spontane­
rial blood pressure change. MacDonald-Wallis and coworkers ously reduced (Corsello, 20 1 0) . Sonography studies in the fi r st
(20 1 2) analyzed serial blood pressures in more than 1 3,000 trimester have shown that one twin is spontaneously reduced or
singleton and twin pregnancies. As early as 8 weeks' gestation, "vanishes" before the second trimester in up to 1 0 to 40 p ercent
the diastolic blood pressure in women with twins was lower of all twin pregnancies (Brady, 20 l 3) . The incidence is higher
than that with singleton pregnancies but generally rose by a following ART conception. Also, monochorionic twins have a
greater degree at term. An earlier study demonstrated that this significantly greater risk of spontaneous reduction than dicho­
rise was at least 1 5 mm Hg in 95 percent of women with twins rionic twins (Sperling, 2006) . Undoubtedly, some threatened
compared with only 54 percent of women with a singleton abortions are the result of death and resorption of one embryo
(Campbell, 1 986) . from an unrecognized twin gestation.
Hypervolemia along with decreased vascular resistance has Dickey and associates (2002) described spontaneous reduc­
an impressive efect on cardiac function. In one study of 1 1 9 tion in 709 multifetal pregnancies. Before 1 2 weeks, one or
women with a twin pregnancy, cardiac output rose another 20 more embryos died in 36 percent of twin pregnancies, in 53
percent above that in women with a singleton pregnancy (Kam­ percent of triplet pregnancies, and in 65 percent of quadru­
etas, 2003) . Similarly, Kuleva and coworkers (20 1 l ) using serial plet pregnancies. Interestingly, ultimate pregnancy duration
echocardiography found a greater increase in cardiac output in and birthweight were inversely related to the initial gestational
20 women with uncomplicated twin pregnancies. Both studies sac number regardless of the fi n al number of fetuses at deliv­
found the augmented cardiac output was predominantly due ery. This efect was most pronounced in twins who started as
to greater stroke volume rather than higher heart rate. Vascular quadruplets. Chasen and coworkers (2006) reported that spon­
resistance was signiicantly lower in twin gestations through­ taneous reduction of an IVF twin pregnancy to a singleton
out pregnancy compared with singleton ones. In a study of 30 pregnancy was associated with perinatal outcomes intermediate
uncomplicated twin pregnancies, this same group of investiga­ between those for IVF singleton and IVF twin pregnancies that
tors using echocardiography later identified progressive diastolic did not undergo spontaneous reduction. Evidence for adverse
dysfunction from the irst to third trimester. The dysfunction immediate and long-term efects of twin spontaneous reduction
subsequently normalized after delivery (Ghi, 20 1 5) . on the remaining pregnancy is conflicting (MeN amara, 2 0 1 6) .
Uterine growth i n a multifetal gestation is substantively Notably, spontaneous reduction of a twin gestation may
greater than in a singleton pregnancy. The uterus and its non­ afect prenatal screening results. In one study of ART-conceived
fetal contents may achieve a volume of 10 L or more and weigh gestations, Gjerris and colleagues (2009) compared 56 twin
in excess of 20 pounds. Especially with monozygotic twins, pregnancies with a single early demise and 897 singleton ges­
excessive amounts of amnionic luid may rapidly accumulate. tations. They found no diferences in irst-trimester serum
In these circumstances, maternal abdominal viscera and lungs marker concentrations as long as the embryonic loss was iden­
can be appreciably compressed and displaced by the expanding tiied before 9 weeks' gestation. If diagnosed ater 9 weeks, the
uterus. As a result, the size and weight of the large uterus may serum markers were higher and less precise in gestations with
preclude more than a sedentary existence for these women. an early demise of one twin than in the singleton gestations.
Ifhydramnios develops, maternal renal function can become With a vanishing twin, first-trimester maternal serum levels of
seriously impaired, most likely as the consequence of obstruc­ the pregnancy associated plasma protein-A (PAPP-A) can be
tive uropathy (Quigley, 1 977) . With severe hydramnios, thera­ elevated. Second-trimester MSAFP and dimeric inhibin A lev­
peutic amniocentesis may provide relief for the mother, may els can also be higher (Huang, 20 1 5) . his phenomenon may
improve obstructive uropathy, and possibly may lower the pre­ also afect noninvasive prenatal testing using cell-free D NA
term delivery risk that follows preterm labor or prematurely (cDNA) . In one report, this efect was thought to be responsi­
ruptured membranes. Unfortunately, hydramnios is often char­ ble for 1 5 percent of the false-positive results from quantitative
acterized by acute onset remote from term and by rapid reac­ counting methods (Futch, 20 l 3) . The recent development of
cumulation despite amniocentesis. single nucleotide polymorphism technology for cDNA test­
ing appears to hold promise in better identiYing these cases
(Curnow, 20 1 5) . Regardless, the diagnosis of a spontaneously
PREGNANCY COMPLICATIONS reduced abortus is ideally excluded to help avoid confusion
with results from aneuploidy and neural-tube defect screening.
• Spontaneous Abortion
Miscarriage is more likely with multifetal gestation. In one
1 6-year study, the spontaneous abortion rate per live birth • Congenital Malformations
in singleton pregnancies was 0.9 percent compared with 7.3 As noted earlier, the incidence of congenital malformatio ns is
percent in multifetal ones (Joo, 20 1 2) . Also, twins achieved appreciably higher in multifetal gestations compared with that
through ART are at greater risk for abortion compared with in singleton pregnancies. In one survey-based study, the con­
those conceived spontaneously (Szymusik, 20 1 2) . genital malformation rate was 406 per 1 0,000 twins compared
In some cases, one fetus may be spontaneously lost rather with 238 per 1 0,000 singletons (Glinianaia, 2008) . The mal­
than the entire gestation. As a result, the incidence of twins in formation rate in monochorionic twins was almost twice that
872 O bstetrica l Co m p l i cations

of dichorionic twin gestations. This increase has been attributed

to the higher incidence of structural defects in monozygotic
twins. Indeed, one large population-based study between 1 998
and 20 1 0 found that twins had a 73-percent greater risk of
congenital heart disease than singletons. The risk was substan­
tially higher among monochorionic twins (Best, 20 1 5). But,
from a 30-year European registry of multifetal births, struc­
tural anomaly rates rose steadily from 2. 1 6 percent in 1 987 to
3.26 percent in 2007 (Boyle, 20 1 3) . Yet, during this time, the
proportion of dizygotic twins grew by 30 percent, whereas the
proportion of monozygotic twins remained stable. his higher
risk of congenital malformations in dizygotic twins over time
correlated with increased availability of AR. An increase in
rates of birth defects related to ART has been reported repeat­
edly (Boulet, 20 1 6; Talauliker, 20 1 2) .

• Low Birthweight
Multifetal gestations are more likely to be low birthweight than F I G U R E 45-9 Ma rked g rowth d iscord a n ce in monochorionic
twi n s. (Used with perm ission from Dr. La u ra Greer.)
singleton pregnancies due to restricted fetal growth and preterm
delivery. From 1 988 to 20 1 2 at Parkland Hospital, data were
collected from 357,205 singleton neonates without malforma­ he degree of growth restriction in monozygotic twins is
tions and from 37 1 4 normal twins who were both liveborn. likely to be greater than that in dizygotic pairs (Fig. 4 5-9) .
Birthweights in twins closely paralleled those of singletons until With monochorionic embryos, allocation o f blastomeres may
28 to 30 weeks' gestation. Thereafter, twin birthweights progres­ not be equal, vascular anastomoses within the placenta may
sively lagged (Fig. 45-8) . Beginning at 35 to 36 weeks' gestation, cause unequal distribution of nutrients and oxygen, and dis­
twin birthweights clearly diverge from those of singletons. cordant structural anomalies resulting from the twinning event
In general, the degree of growth restriction increases with itself may afect growth. For example, the quintuplets shown in
fetal number. The caveat is that this assessment is based on Figure 4 5- 1 0 represent three dizygotic and two monozygotic
growth curves established for singletons. Several authori­ fetuses. When delivered at 3 1 weeks, the three neonates from
ties argue that fetal growth in twins is diferent from that of separate ova weighed 1 420, 1 530, and 1 440 g, whereas the two
singleton pregnancies. And thus, abnormal growth should be derived from the same ovum weighed 990 and 860 g.
diagnosed only when fetal size is less than expected for multie­ In the third trimester, the larger fetal mass leads to acceler­
tal gestation. Accordingly, twin and triplet growth curves have ated placental maturation and relative placental insuiciency. In
been developed (Kim, 20 1 0; Odibo, 20 1 3; Vora, 2006) . At dizygotic pregnancies, marked size discordancy usually results
Parkland, we use the standards of birthweight in twin gesta­ from unequal placentation, with one placental site receiving
tions stratified by placental chorionicity for identifi c ation of more perfusion than the other. Size diferences may also reflect
suspected fetal-growth restriction (Ananth, 1 998). diferent genetic fetal-growth potentials. Discordancy can also
result from fetal malformations, genetic syndromes, infection,
or umbilical cord abnormalities such as velamentous insertion '
5000 marginal insertion, or vasa previa (Chap. 44, p. 849) .

4000
• Hypertension

E 3000 Pregnancy-related hypertensive disorders are more likely to

) develop with multifetal gestations. The exact incidence attrib­
'5
€ 2000 utable to twin pregnancy is diicult to determine because these
gestations are more likely to deliver preterm and before pre­
O
eclampsia usually develops. Also, women with twin pregnan­
1 000
cies are often older and multiparous, qualities associated with
lower rates of preeclampsia (Francisco, 20 1 7) . The incidence
o --- of pregnancy-related hypertension in women with twins is
25 30 35 40
Gestational age (weeks) 20 percent at Parkland Hospital. In their analysis of 5 1 3 twin
pregnancies, Fox and coworkers (20 1 4) identified 1 5 percent
F I G U R E 45-8 B i rthweig ht percentiles (25th to 75th) for 3 5 7,205
of parturients with preeclampsia. Another study compared
sing leton neonates compared with the 50th b i rthweig ht percentile
for 3 7 1 4 twi n s, Parkland Hospita l 1 988-20 1 2. I nfa nts with m ajor
257 women with twins and gestational diabetes against 277
ma lformations, preg n a n cies com pl i cated by sti l l bi rth, a nd twi n nondiabetic women carrying twins. hese researchers found a
gestations with > 2 5 percent discordance were a lso exc l uded. (Data twofold greater risk of preeclampsia in women diagnosed with
from Dr. Don Mci ntire.) gestational diabetes (Gonzalez, 20 1 2) . Conversely, no specific
 M u ltifeta l P reg n a n cy 873

10 percent follow prematurely ruptured mem­

branes (Chauhan, 20 1 0) . In another analysis of
almost 300,000 live births, the proportion of
preterm birth associated with premature mem­
brane rupture rose with gestational plurality
from 1 3 percent with singletons to 20 p ercent
with triplets or more (Pakrashi, 20 1 3) .
Although the causes o f preterm delivery in
twins and singletons may be diferent, neona­
tal outcome is generally the same at similar
gestational ages (Kilpatrick, 1 996; Ray, 2009;
Salem, 20 1 7) . However, outcomes for preterm
twins who are markedly discordant may not be
comparable with those for singletons because
whatever caused the discordance may have
long-lasting efects (Yinon, 2005) .

FIGURE 45- 1 0 Davis q u i ntuplets at 3 weeks fol l owing del ivery. The first, second, • Long-Term Infant Development
and fou rth newborns from the left each a rose from sepa rate ova, whereas the third Historically, twins have been considered cog­
a n d fifth neonates a re from the same ovu m. nitively delayed compared with singletons
(Record, 1 970; Ronalds, 2005). However, in
zygosity confers a greater rate of hypertensive disorder in twin cohort studies evaluating normal-birthweight term newborns,
pregnancies (Lucovnik, 20 1 6) . Finally, from the National Cen­ cognitive outcomes between twins and singletons are s imilar
ter for Health Statistics, Luke and associates (2008) analyzed (Lorenz, 20 1 2) . Christensen and associates (2006) found simi­
3 1 6,696 twin, 1 2, 1 93 triplet, and 778 quadruplet pregnancies. lar national standardized test scores in the ninth grade in 34 1 1
hese investigators noted that the risk for pregnancy-associated twins and 7796 singletons born between 1 986 and 1 988.
hypertension was significantly increased for triplets and qua­ In contrast, among normal-birthweight neonates, the cere­
druplets ( 1 1 and 1 2 percent, respectively) compared with that bral palsy risk is higher among twins and higher-order mul­
for twins (8 percent) . tiples. For example, the cerebral palsy rate has been reported
hese data suggest that fetal number and placental mass are to be 2.3 per 1 000 in singletons, 1 2.6 per 1 000 in twins, and
involved in preeclampsia pathogenesis. Women with twin preg­ 44. 8 per 1 000 in triplets (Giufre, 20 1 2) . Greater risks of fetal­
nancies have levels of antiangiogenic soluble fms-like tyrosine growth restriction, congenital anomalies, twin-twin transfusion
kinase- 1 (sFlt- 1 ) that are twice that of singletons. Levels are syndrome, and fetal demise of a cotwin are suggested contribu­
seemingly related to greater placental mass rather than primary tors to these diferences (Lorenz, 20 1 2) .
placental pathology (Bdolah, 2008; Maynard, 2008) . Rana and
coworkers (20 1 2) measured antiangiogenic sFlt- 1 and proan­
giogenic placental growth factor (PIGF) in 79 women with UNIQUE FETAL COMPLICATIONS
twins referred for evaluation of preeclampsia. In the 58 women
Several unique complications arise in multifetal pregnancies.
identiied with either gestational hypertension or preeclampsia,
These are described in twins but can be found in higher-order
there was an incremental rise in sFlt- 1 concentrations, decline
multifetal gestations. Most fetal complications due to the twin­
in PIGF levels, and increase in sFlt- l IPIGF ratios compared
ning process itself are seen with monozygotic twins. heir
with normotensive twin pregnancies. With multifetal gestation,
pathogenesis is best understood after reviewing the possibilities
hypertension not only develops more often but also tends to
shown in Figure 45- 1 .
develop earlier and be more severe. In the analysis of angiogenic
factors mentioned above, more than half of afected women
presented before 34 weeks, and their sFlt- l IPIGF ratio rise was • Monoam nionic Twins
more striking (Rana, 20 1 2) . This relationship is discussed in
Only about 1 percent of all monozygotic twin gestations will
Chapter 40 (p. 7 1 6) .
share an amnionic sac, and approximately 1 in 20 monocho­
rionic twin gestations are monoamnionic (Hall, 2003; Lewi,
• Preterm Birth 20 1 3) . Diamnionic twins can become monoamnionic if the
The duration of gestation shortens with accruing fetal number. dividing membrane spontaneous or iatrogenically ruptures.
More than five of every 1 0 twins and nine of 1 0 triplets born Their morbidity and mortality rates then mirror those of mono­
in the United States in 20 1 5 were delivered preterm (Mar­ amnionic twins.
tin, 20 1 7) . Prematurity is sixfold and tenfold greater in twins Historical mortali ty rates in monoamnionic twins were
and triplets, respectively (Giufre, 20 1 2) . One review showed reported to be as high as 70 percent. Contemporary outcomes
that approximately 60 percent of preterm births in twins are are improved, yet the demise rate after viability remains elevated
indicated, about a third result from spontaneous labor, and (Post, 20 1 5) . Of those fetuses alive before 1 6 weeks' gestation,
874 Obstetrica l Compl ications

less than half survive until the neonatal period. Fetal abnor­ umbilical vessel constnctton are unknown. A consequence
malities and spontaneous miscarriage contribute to most losses is that fetal death from cord entanglement is unpredictable.
(Prefumo, 20 1 5) . After 20 weeks, the perinatal mortality rate Unfortunately, monitoring for this is relatively inefective. In
for monoamnionic twin pregnancies approximates 1 5 percent one study, after analysis of more than 1 0,000 hours of fetal
(Shub, 20 1 5) . A high fetal death rate is attributable to preterm tracing from 1 7 sets of monoamnionic twins, Quinn and
birth, congenital anomalies, twin-twin transfusion syndrome, colleagues (20 1 1 ) concluded that monitoring was physically
or cord entanglement.
Congenital anomaly rates in monoamnionic twins reach
1 8 to 28 percent (Post, 20 1 5) . Since concordance of anoma­
lies is found in only approximately one quarter of cases, the
fi n ding of normal anatomy in one twin does not negate the
need for a thorough evaluation in the second. Also, because of
the higher risk of cardiac anomalies, fetal echo cardiography
is indicated in these pregnancies. Of note, monoamnionic
twins are by definition monozygotic and thus presumed to
be genetically identical. Consequently, either both or none
of the fetuses have chromosomal abnormalities except in rare
cases of discordance (Zwijnenburg, 20 1 0) . Indeed, the risk
for Down syndrome in each fetus of the monozygotic pair
is similar to or lower than the risk in maternal age-matched
singletons (Sparks, 20 1 6) . he standard methods for Down
syndrome screening in these pregnancies can be applied
(Chap. 1 4 , p. 28 1 ) .
The rate o f twin-twin transfusion syndrome i n monoamni­
onic twins is lower than the rate reported in monochorionic
diamnionic pregnancies. This may be due to the near universal
presence in monoamnionic twins of arterioarterial anastomo­
ses, which are presumed to be protective (Hack, 2009b; Post,
20 1 5) . Nonetheless, twin-twin transfusion syndrome surveil­
lance is recommended and described on page 879.
Umbilical cords frequently entangle (Fig. 4 5- 1 1 ) . lorbid
cord entanglement appears to occur early, and monoamnionic
pregnancies that have successfully reached 30 to 32 weeks' ges­
tation are at reduced risk. In one Dutch series, the incidence
of intrauterine demise dropped from 1 5 percent after 20 weeks
to 4 percent at gestational ages >32 weeks (Hack, 2009a) .
Although color-low Doppler sonography i s used t o diagnose
entanglement (Fig. 45- 1 2) , factors that lead to pathological

FIGURE 45- 1 2 Monochorionic monoa m n ionic cord enta nglement.

A. Despite marked knotti ng of the cords, vigorou s twi ns were del iv­
F I G U R E 45- 1 1 Monozygotic twi n s in a single a m n i o n i c sac. The ered by cesarean. B. Preoperative sonogra m of this preg nancy shows
s m a l l e r fetu s a p pa re ntly d ied first, a n d the second su bseq uently entwi ned cords. C. This fi nding is accentuated with appl ication of
succum bed when u m bi l ica l cords entwi ned. color Doppler. (Used with perm ission from Dr. J u l ie Lo.)
 M u ltifeta l Preg na ncy 875

Monozygous twins

Sym metrical Asymmetrical

I
I I I
External External I nternal
Separate Conjoi ned
Acardiac (TRAP) Parasitic Fetus in fetu

F I G U R E 45- 1 3 Possible outcomes of monozygotic twi n n i ng . The a symmetrical category conta i n s twi n n i n g types in which one twi n
complement is s u bsta ntia l ly s m a l ler a n d incomp lete ly formed.

possible in only 50 percent of cases. An abnormal fetal heart embryos are either symmetrical or asymmetrical, and the spec­
rate tracing prompted delivery in only six cases. trum of anomalies is shown in Figure 45- 1 3 .
One proposed management scheme is based on a study
by Heyborne and coworkers (2005), who reported no still­ Conjoi ned Twi n s
births in 43 twin pregnancies of women admitted at 26 to In the United States, united or conjoined twins have been
27 weeks' gestation for daily fetal surveillance. However, in 44 referred to as Siamese twins-after Chang and Eng Bunker of
women managed as outpatients and admitted only for obstet­ Siam (Thailand) , who were displayed worldwide by P. T. Bar­
rical indications, there were 1 3 stillbirths. Because of this num. Joining of the twins may begin at either pole and produce
report, women with monoamnionic twins are recommended characteristic forms depending on which body parts are j oined
to undergo 1 hour of daily fetal heart rate monitoring, either or shared (Fig. 4 5- 1 4) . Of these, thoracopagus is the most com­
as an outpatient or inpatient, beginning at 26 to 28 weeks' mon (Mutchinick, 20 1 1 ) . he frequency of conjoined twins is
gestation. With initial testing, a course of betamethasone is not well established. In Singapore, Tan and coworkers ( 1 97 1 )
given to promote pulmonary maturation (Chap. 42, p. 823). identified seven cases o f conjoined twins among more than
If fetal testing remains reassuring and no other intervening 400,000 deliveries-an incidence of 1 in 60,000.
indications arise, cesarean delivery is performed at 32 to Conjoined twins can frequently be identiied using s onog­
34 weeks. A second course of betamethasone can be given raphy at midpregnancy (McHugh, 2006) . his provides an
before this (American College of Obstetricians and Gynecolo­ opportunity for parents to decide whether to continue the preg­
gists, 20 1 6) . his management scheme is used at Parkland nancy. As shown in Figure 45- 1 5 , identification of cases d uring
Hospital and resulted in the successful 34-week delivery of the the first trimester is also possible. During sonographic interroga­
twins depicted in Figure 45- 1 2. tion, fetal poles are closely associated and do not change relative
position from one another. A targeted examination, including
a careful evaluation of the organs involved, is necessary b efore
• Unique and Aberrant Twinning counseling can be provided. As shown in Figure 45- 1 6, MR
Of monoamnionic twins just described, one interesting sub­ imaging is a valuable adjunct to clariY shared organs. Compared
set derives from embryonic splitting on postfertilization day 9. with sonography, MR imaging can provide superior views, espe­
These "mirror image twins" are genetically identical but have cially in later pregnancy when amnionic luid is diminished and
mirror image features such as handedness and hair whorls (Post, fetal crowding is greater (Hibbeln, 20 1 2) .
20 1 5) . Surgical separation o f a n almost completely joined twin pair
More seriously, several aberrations i n monozygotic twinning may be successful if essential organs are not shared (O'Brien,
result in a spectrum of fetal malformations. hese are tradi­ 20 1 5 ; Tannuri, 20 l 3) . Conjoined twins may have discordant
tionally ascribed to incomplete splitting of an embryo into two structural anomalies that further complicate decisions about
separate twins. However, it is possible that they may result from whether to continue the pregnancy. Consultation with a pedi­
early secondary fusion of two separate embryos. These separated atric surgeon often assists parental decision making. A recent
876 Obstetrica l Compl ications

Ventral Dorsal

I I

Rostral Caudal Lateral

. Parapagus Parapagus
Omphalopagus Thoracopagus Cephalopagus Ischiopagus ' Craniopagus Rachipagus Pygopagus
d IproSOpus dicephalus

F I G U R E 45- 1 4 Types of conj o i ned twi n s. (Mod ified with permission from Spencer R: Theoretical a n d a n a lytica l e m b ryology of conjoi ned
twi ns: pa rt I: e m b ryoge nesis, ( l i n A nat. 2000; 1 3 ( 1 ):36-5 3 .)

series in Seminars in Pediatric Surgey with a preface by Spitz Fetu s-i n- Fetu
(20 1 5) provide an excellent reference regarding postnatal man­ Early in development, one embryo may be enfolded within its
agement. twin. Normal development of this rare parasitic twin usually
Viable conjoined twins should be delivered by cesarean. arrests in the first trimester. As a result, norml spatial arrange­
For the purpose of pregnancy termination, however, vaginal ment of and presence of many organs is lost. Classically, vertebral
delivery is possible because the union is most often pliable or xial bones are found in the fetiform mass, whereas a heart and
(Fig. 45- 1 7) . Still, dystocia is common, and if the fetuses are brain are absent. hese masses are believed to represent a monozy­
mature, vaginal delivery may be traumatic to the uterus or cervix. gotic, monochorionic diamnionic twin gestation and are typically
supported by large parasitic vessels to the host (McNamara, 20 1 6;
Exte r n a l Pa ra s itic Twi n s
Spencer, 2000). Malignant degeneration is rare (Kaufman, 2007) .
his is a grossly defective fetus or merely fetal parts, attached
externally to a relatively normal twin. A parasitic twin usually
consists of externally attached supernumerary limbs, often with • Monochorionic Twins and
some viscera. Classically, however, a functional heart or brain Vascular Anastomoses
is absent. Attachment mirrors those sites described earlier for All monochorionic placentas likely share some anastomotic
conjoined twins (see Fig. 45- 1 4) . Parasites are believed to result connections. And, with rare exceptions, anastomoses between
from demise of the defective twin. Its surviving tissue attaches
to and receives vascularity from the normal cotwin (Spencer,
200 1 ) . In one large epidemiological study, parasitic twins
accounted for 4 percent of all conjoined twins and occurred
more frequently in male fetuses (Mutchinick, 20 1 1 ) .

FIGURE 45- 1 6 Mag netic resona nce i m ag i ng of conjoi ned twins.

This T2-weig hted HASTE sag itta l i mage demonstrates fusion from
the level of the xiphoid process to j u st below the level of the
u m b i l icus, that is, omphalopagus twi ns. Below the fu sed liver (L)/
there is a m i d l i ne cystic mass (arrow) wit h i n the tissue con necting
F I G U R E 45- 1 5 Sonog ra m of a conjoi n ed twi n preg na n cy at the twins. An ompha lomesenteric cyst was favored g iven the
1 3 weeks' g estation. These thoracoo m p h a lopa g u s twi n s h ave two location wit h i n the shared tissue. (Used with permission from
heads but a s h a red chest a nd abdomen. Dr. Apri l Bailey.)
 M u ltifeta l P re g n a n cy 877

F I G U R E 45-1 7 Conjoi ned twi n s a borted at 1 7 weeks' gestation.

(Used with perm ission from Dr. Jonathan Wi l l ms.)

twins are unique to monochorionic twin placentas. However,

the number, size, and direction of these seemingly haphazard
connections vary markedly (Fig. 4 5- 1 8) . In one analysis of more
than 200 monochorionic placentas, the median number of anas­
tomoses was 8, with an interquartile range of 4 to 14 (Zhao, ----
20 1 3) .
Artery-to-artery anastomoses are most frequent and are F I G U R E 45- 1 9 Anastomoses between twi n s may be a rtery-to­
identiied on the chorionic surface of the placenta in up to 75 vei n (AV), a rtery-to-artery (AA), or vei n-to-vei n (W). Schematic
percent of monochorionic twin placentas. Vein-to-vein and representation of a n AV a nastomosis i n twi n-twin tra n sfu sion syn­
d rome that forms a "co m m o n villous district" or "th i rd c i rculation"
artery-to-vein communications are each found in approxi­
deep wit h i n the vi l lous tissue. Blood from a donor twi n may be
mately half. One vessel may have several connections, some­ tra nsferred to a reci pient twi n t h ro u g h t h is shared c i rc u lation . Th is
times to both arteries and veins. In contrast to these supericial tra nsfer leads to a g rowth-restricted d iscordant donor twi n with
vascular connections on the surface of the chorion, deep artery­ m a rked ly red u ced a m n i o n i c fl u id , causing it to be "stuc k."
to-vein communications can extend through the capillary
bed of a given villus (Fig. 4 5- 1 9) . hese deep arteriovenous Whether these anastomoses are dangerous to either twin
anastomoses create a common villous compartment or "third depends on the degree to which they are hemodynamically
circulation" that has been identiied in approximately half of balanced. In those with signiicant pressure or low gradients,
monochorionic twin placentas. a shunt will develop between fetuses. his chronic fetofetal

F I G U R E 45- 1 8 S h a red p l a centa from preg na ncy com p l icated by twi n-twin tra n sfu sion syn d rome. The fol l owing color code was a p p l ied
for i njection. Left twi n : yel low a rtery, b l u e vei n ; rig ht twi n : red = a rtery, g reen vein. A. Pa rt of the a rteri a l network of the rig ht twi n is
= = =

fi lled with yel l ow dye, due to the presence of a small a rtery-to-artery a nastomosis (arrow) . B. Close- u p of the l ower portion of the placenta
displays the yel low dye-fi l led a nastomosis. (Reprod uced with permission from De Paepe M E, DeKo n i n c k P, Friedma n RM: Vasc u l a r d istri bu­
tion patterns i n monochorionic twi n placentas, Placenta. 2005 J u l;26(6):47 1 -475 .)
878 Obstetrica l Com p l icatio n s

F I G U R E 45-20 These seri a l sonog rams depict a n i nterventri c u l a r hemorrhage with parenchymal extension a nd eventu a l porencephaly
that developed fol lowi n g cotwin dem ise i n a m onochorion i c preg n a n cy. From left to rig ht, these i mages were obtai n ed 1 week, 5 weeks,
a n d 8 weeks fol lowi ng dem ise of the cotwin.

transfusion may result in several clinical syndromes that include amnionic fluid imbalance is associated with growth restriction,
twin-twin transfusion syndrome (TTTS), twin anemia poycythe­ contractures, and pulmonary hypoplasia in the donor twin,
mia sequence (TAPS), and acardiac twinning. and premature rupture of the membranes and heart failure in
the recipient.
Twi n-Twi n Tra n sfu s i o n Syn d rome
In this syndrome, blood is transfused from a donor twin to its Feta l Bra i n Damage. Cerebral palsy, microcephaly, porenceph­
recipient sibling such that the donor may eventually become aly, and multicystic encephalomalacia are serious complications
anemic and its growth may be restricted. In contrast, the recipi­ associated with placental vascular anastomoses in multifetal
ent becomes polycythemic and may develop circulatory over­ gestation. he exact pathogenesis of neurological damage is
load manifest as hydrops. Classically, the donor twin is pale, not fully understood but is likely caused by ischemic necro­
and its recipient sibling is plethoric. Similarly, one portion of sis leading to cavitary brain lesions (Fig. 45-20) . In the donor
the placenta often appears pale compared with the remain­ twin, ischemia results from hypotension, anemia, or both. In
der. The recipient neonate may also have circulatory overload the recipient, ischemia develops from blood pressure instabil­
from heart failure and severe hypervolemia and hyperviscosity. ity and episodes of profound hypotension (Lopriore, 20 1 1 ) .
Occlusive thrombosis is another concern. Finally, polycythe­ Cerebral lesions may also b e due t o postnatal injury associated
mia in the recipient twin may lead to severe hyperbilirubinemia with preterm delivery (Chap. 34, p. 639) . In one review of 3 1 5
and kernicterus (Chap. 33, p. 626) . he prevalence of TTTS liveborn fetuses from pregnancies with TTTS, cerebral abnor­
approximates 1 to 3 cases per 1 0,000 births (Society for Mater­ malities were found in 8 percent (Quarello, 2007) .
nal-Fetal Medicine, 20 1 3) . If one twin of an afected pregnancy dies, cerebrl pathology
Chronic TTTS results from unidirectional low through in the survivor probably results from acute hypotension. A less
deep arteriovenous anastomoses. Deoxygenated blood from a likely cause is emboli of thromboplastic material originating from
donor placental artery is pumped into a cotyledon shared by the the dead fetus. Fusi and coworkers ( 1 990, 1 99 1 ) observed that
recipient (see Fig. 45- 1 9) . Once oxygen exchange is completed with the death of one twin, acute twin-twin anastomotic transu­
in the chorionic villus, the oxygenated blood leaves the cotyledon sion from the high-pressure vessels of the living twin to the low­
via a placental vein of the recipient twin. Unless compensated­ resistance vessels of the dead twin leads rapidly to hypovolemia
typically through superficial arterioarterial anastomoses-this and ischemic antenatal brain damage in the survivor. In one review
unidirectional low leads to an imbalance in blood volumes of 343 twin pregnancies complicated by single fetal demise, the
(Lewi, 20 1 3) . Clinically important TTTS frequently is chronic risk of neurodevelopmental morbidity in monochorionic twins
and results from significant vascular volume diferences between was 26 percent compared with 2 percent in dichorionic twins
the twins. Even so, the pathogenesis is more complex than a net (Hillman, 20 1 1) . This morbidity was related to the gestational age
transfer of red blood cells from one twin to another. Indeed, at the death of the cotwin. If the death occurred between 28 and
in most monochorionic twin pregnancies with the syndrome, 33 weeks' gestation, monochorionic twins had an almost eightfold
hemoglobin concentrations between the donor and recipient risk of neurodevelopmental morbidity compared with dichorionic
twin do not difer (Lewi, 20 1 3) . twins of the same gestational age. With fetal death ater 34 weeks,
TTTS typically presents i n midpregnancy when the the likelihood dramaticlly decreased-odds ratio 1 .48.
donor fetus becomes oliguric from decreased renal perfusion he acuity of hypotension following the death of one twin
(Society for Maternal-Fetal Medicine, 20 1 3) . This fetus devel­ with TTTS makes successful intervention for the survivor nearly
ops oligohydramnios, and the recipient fetus develops severe impossible. Even with delivery immediately ater a cotwin demise
hydramnios, presumably due to increased urine production. is recognized, the hypotension that occurs at the moment of
Virtual absence of amnionic fluid in the donor sac prevents death has likely already caused irreversible brain damage (Langer,
fetal motion, giving rise to the descriptive term stuck twin 1 997; Wada, 1 998) . s such, immediate delivery is not consid­
or poyhydramnios-oligohydramnios syndrome- 'poy-oli. This " ered beneficial in the absence of another indication.
 M u ltifeta l Preg na ncy 879

Diagnosis. he criteria used to diagnose and classiy varying intervention. One system for evaluating cardiac function-the
severities of TTTS have dramatically changed. Previously, myocardial peormance index (MPI) or Tei index-is a Dop­
weight discordancy and hemoglobin diferences in monocho­ pler index of ventricular function calculated for each ventricle
rionic twins were calculated. However, in many cases, these (Michelfelder, 2007) . lthough scoring systems that include
are late fi n dings. According to the Society for Maternal-Fetal assessment of cardiac function have been developed, their
Medicine (20 1 3) , TTTS is diagnosed based on two so no­ usefulness to predict outcomes remains controversial (Society
graphic criteria. First, a monochorionic diamnionic pregnancy for Maternal-Fetal Medicine, 20 1 3) .
is identified. Second, hydramnios defined by a largest vertical
pocket > 8 em in one sac and oligohydramnios defined by a Ma nagement and Prog nosis. h e prognosis for mulrifetal
largest vertical pocket < 2 em in the other twin is found. Only gestations complicated by TTTS is related to Quintero stage
1 5 percent of pregnancies complicated by lesser degrees of luid and gestational age at presentation. More than three fourths
imbalance progress to TTTS (Huber, 2006) . Although growth of stage I cases have been reported to remain stable or regress
discordance or growth restriction may be found with TTTS, without intervention. Conversely, outcomes in those identi­
these per se are not considered diagnostic criteria. ied at stage III or higher are much worse, and the perinatal
Organizations that include the American College of Obste­ loss rate is 70 to 1 00 percent without intervention (Society for
tricians and Gynecologists (20 1 6) , Society for Maternal-Fetal Maternal-Fetal Medicine, 20 1 3) . At Parkland Hospital, among
Medicine (20 1 3) , and North American Fetal herapy Network expectantly managed pregnancies with TTTS, most had early
(Emery, 20 1 5) recommend sonography surveillance of pregnan­ disease at diagnosis, and 50 percent of stage I cases progressed
cies at risk for TTTS. To aid earlier identification of amnionic (Duryea, 2 0 1 6) .
luid abnormalities and other complications of monochorionic Several therapies are available for TTTS and include amnio­
twins, these examinations begin at approximately 16 weeks' reduction, laser ablation of vascular placental anastomoses,
gestation, and subsequent studies are considered every 2 weeks. selective feticide, and septosromy. Described further in Chap­
Once identiied, TTTS is typically classiied by the Quintero ter 1 1 (p. 230), amnioreduction describes needle drainage of
( 1 999) staging system (Fig. 4 5-2 1 ) : excess amnionic fluid. Septostomy is intentionally creating a
hole in the dividing amnionic membrane but has largely been
• Stage I-discordant amnionic fluid volumes as described in
abandoned as treatment (Society for Maternal-Fetal Medicine,
the earlier paragraph, but urine is still visible sonographically
20 1 3) . Comparative data from randomized trials for some of
within the bladder of the donor twin
these other techniques are discussed below.
• Stage II-criteria of stage I, but urine is not visible within the
The Eurofetus trial included 1 42 women with severe TTTS
donor bladder
diagnosed before 26 weeks. Participants were randomly assigned
• Stage III-criteria of stage II and abnormal Doppler studies
to laser ablation of vascular anastomoses or to serial amniore­
of the umbilical artery, ductus venosus, or umbilical vein
duction (Senat, 2004) . A higher survival rate to age 6 months
• Stage IV-ascites or frank hydrops in either twin
for at least one twin was found in pregnancies undergoing laser
• Stage V-demise of either fetus.
ablation-76 versus 5 1 percent, respectively. Moreover, analyses
In addition to these criteria, evidence suggests that cardiac of randomized studies confirm better neonatal outcomes with
function of the recipient twin correlates with fetal outcome laser therapy compared with selective amnioreduction (Roberts,
(Crombleholme, 2007) . Although fetal echocardiographic ind­ 2008; Rossi, 2008, 2009) . In contrast, Crombleholme and asso­
ings are not part of the Quintero staging system, many centers ciates (2007) , in a randomized trial of 42 women, found equiva­
routinely perform fetal echocardiography for TTTS. heo­ lent rates of 30-day survival of one or both twins treated with
retically, earlier diagnosis of cardiomyopathy in the recipient either amnioreduction or selective fetoscopic laser ablation-75
twin may identiy pregnancies that would beneit from early versus 65 percent, respectively. Furthermore, evaluation of

FIGURE 45-21 A. Sonog ram of stage I ms at 1 9 weeks' gestation. Oligohyd ra m nios in the donor twi n sac ca uses the mem bra n e to
essentia l ly wra p around the "stuck twi n " and suspend it from the a nterior uteri ne wa l l . B. In this same preg na n cy, hyd ra m n ios is seen in the
reci pient twi n sac. The mea s u red pocket exceeds 1 0 cm. C. Stage I I ms i n a donor twi n at 1 7 weeks' gestation . Color Doppler high lig hts
the a rteries that outl i n e the feta l bladder, which conta i ns no urine.
880 Obstetrica l Com pl ications

twins from the Eurofetus trial through 6 years of age did not
demonstrate an additional survival benefit beyond 6 months
or improved neurological outcomes in those treated with laser
(Salomon, 20 1 0) . At this time, laser ablation of anastomoses is
preferred for severe TTTS (stages II-IV) . Optimal therapy for
stage I disease is controversial.
After laser therapy, close ongoing surveillance is necessary.
Robyr and colleagues (2006) reported that a fourth of 1 0 1
pregnancies treated with laser required additional invasive ther­
apy because of either recurrent TTTS, or middle cerebral artery
(MCA) Doppler evidence of anemia or polycythemia. Recently,
in a comparison of selective laser ablation of individual anas­
tomoses versus ablation of the entire surface of the chorionic
plate along the vascular equator, Baschat and coworkers (20 1 3)
found that equatorial photocoagulation reduced the likelihood
of recurrence.
Selective fetal reduction has generally been considered if
severe amnionic luid and growth disturbances develop before
20 weeks. In such cases, both fetuses typically will die without
intervention. Any substance injected into one twin may afect
the other twin because of shared circulations. hus, for the fetus F I G U R E 45-22 Twi n reversed-a rteria l-pe rfusion seq uence. In the
chosen for reduction, feticidal techniques include methods that TRAP seq uence, there is u s u a l ly a norm a l ly formed donor twi n that
occlude the umbilical vein or umbilical cord of using radiofre­ has featu res of heart fa i l u re, a n d a reci pient twi n that lac ks a heart.
quency ablation, fetoscopic ligation, or coagulation with laser, It has been hypothesized that the TRAP seq uence is caused by a
monopolar, or bipolar energy (Challis, 1 999; Chang, 2009; l a rg e a rtery-to-artery placenta l s h u nt, often a l so accompanied by
a vei n-to-vei n s h u nt. With i n the si ng le, sha red placenta, perfusion
Parra-Cordero, 20 1 6) . Even after these procedures, however, the
pressure of the donor twi n overpowers that i n the reci pient twi n ,
risks to the remaining fetus are still appreciable (Rossi, 2009) . w h o thus receives reverse blood fl ow from i t s twi n s i b l i ng. The
This topic is further discussed on page 89 1 . "used" a rterial b lood that reaches the recipient twi n preferenti a l ly
goes to its i l iac vessels a n d thus perfuses o n ly the lower body. This
Twi n A n e m ia-Po lycythe m i a Seq u e n ce disrupts g rowth a nd development of the u pper body.
This form of chronic fetofetal transfusion, referred to as TAPS,
is characterized by significant hemoglobin diferences between (Fig. 4 5-22) . Within the single, shared placenta, arterial perfu­
donor and recipient twins. However, TAPS lacks the discrep­ sion pressure of the donor twin exceeds that in the recipient
ancies in amnionic luid volumes typical of TTTS (Slaghekke, twin, who thus receives reverse blood low containing deoxy­
20 1 0) . It is diagnosed ante natally by M CA peak systolic veloc­ genated arterial blood from its cotwin (Lewi, 20 1 3) . his "used"
ity (PSV) > 1 . 5 multiples of the median (MoM) in the donor arterial blood reaches the recipient twin through its umbilical
and < 1 .0 MoM in the recipient twin (Society for Maternal­ arteries and preferentially goes to its iliac vessels. Thus, only
Fetal Medicine, 20 1 3) . The spontaneous form of TAPS report­ the lower body is perfused, and therefore disrupted growth and
edly complicates 3 to 5 percent of monochorionic pregnancies, development of the upper body results. In these cases, failed
and it occurs in up to 1 3 percent of pregnancies after laser head growth is called acardius acephalus; a partially developed
photocoagulation of the placenta. Spontaneous TAPS usually head with identifiable limbs is called acardius myelacephalus;
occurs after 26 weeks' gestation, and iatrogenic TAPS develops and failure of any recognizable structure to form is acardius
within 5 weeks of a procedure (Lewi, 20 1 3) . Although a staging amorphous, which is shown in Figure 45-23 (Faye-Petersen,
system has been proposed by Slaghekke and colleagues (20 1 0) , 2006) . Because of this vascular connection, the normal donor
further studies are necessary t o better elucidate the natural his­ twin must not only support its own circulation but also pump
tory of TAPS and its management. In brief, evidence of fetal blood through the underdeveloped acardiac recipient. This may
compromise or greater diferences in MCA PSV between twins lead to cardiomegaly and high-output heart failure in the nor­
raise the stage. mal twin (Fox, 2007) .
In the past, the mortality rate among the pump twins
Twi n Reversed -A rterial- Perfu s i on Seq u e n ce exceeded 50 percent. This stemmed largely from complications
lso known as an acardiac twin, this is a rare but serious com­ of prematurity or from a prolonged high-output state leading
plication of monochorionic multifetal gestation. n estimated to cardiac failure (Dashe, 200 1 ) . Risk appears to be directly
incidence is 1 case in 35,000 births. In the classic twin reversed­ related to size of the acardiac twin. One sonographic method to
arterial-perfusion (TRAP) sequence, there is a normally formed estimate acardiac twin size uses the volume of an ellipse: length
donor twin that shows features of heart failure and a recipient X width X height x \/6. When the acardiac twin volume is
twin that lacks a heart (acardius) and other structures. In one < 50 percent of that of the pump twin, expectant management
theory, the TRAP sequence is caused by a large artery-to-artery may be reasonable given the inherent risks of fetal interven­
placental shunt, often also accompanied by a vein-to-vein shunt tion (Chap. 1 5, p. 326) (Jelin, 20 1 0) . When the volume of the
 M u ltifeta l Preg n a n cy 88 1

Diagnosis is usually made in the first half of pregnancy.

Sonographically, a normal-appearing twin is accompanied by
its cotwin, which is a large placenta containing multiple small
anechoic cysts (Fig. 20-4, p. 3 9 1 ) . Often, these pregnancies
are terminated, but pregnancy continuation is increasingly
adopted. First, the pregnancy prognosis is not as poor as pre­
viously thought, and live birth rates range between 20 and
40 percent (Dolapcioglu, 2009; McNamara, 20 1 6) . Second,
the risk of persistent trophoblastic disease is similar whether
the pregnancy is terminated or not (Massardier, 2009; Sebire,
2002) . That said, given the limited number of cases, robust
data for irm recommendations are lacking. Importantly, com­
plications of expectant management include vaginal bleeding,
hyperemesis gravidarum, thyrotoxicosis, and early-onset pre­
eclampsia (McNamara, 20 1 6) . Many of these complications
result in preterm birth with its attendant adverse perinatal
sequelae as well as perinatal loss. Logically, close surveillance is
needed for those continuing the pregnancy.

FIGURE 45-23 Photog ra p h of an a ca rdiac twi n weig h i n g 475 DISCORDANT GROWTH OF TWI N F ETUSES
g ra ms. The u nderd eveloped h ead i s i n d i cated by the black a rrow,
and its d eta i l s a re shown in the i n set. A yel l ow c l a m p is seen on its Fetal size inequality develops in approximately 1 5 percent of
u m b i l ica l cord. Its via ble donor cotwin wa s delivered vag i n a l ly at twin gestations and may relect pathological growth restric­
36 weeks a nd weighed 2325 g ra m s. (Used with perm ission from tion in one fetus (Lewi, 20 1 3; Miller, 20 1 2) . Generally, as the
Dr. M ichael D. H nat.)
weight diference within a twin pair rises, the perinatal mortality
rate increases proportionately. If it develops, restricted growth
acardiac twin is large, however, treatment has generally been of one twin fetus, often termed selective etal-growth restriction,
ofered. Radiofrequency ablation (RFA) is the preferred modal­ usually develops late in the second and early third trimester.
ity of therapy, and contemporary reports now suggest improved Earlier discordancy indicates higher risk for fetal demise in the
perinatal outcomes. he North American Fetal Therapy Net­ smaller twin. Speciically, when discordant growth is identified
work reviewed their experiences with 98 cases from 1 998 to before 20 weeks, fetal death occurs in approximately 20 percent
2008 in which RFA of the umbilical cord was performed (Lee, of the growth-restricted fetuses (Lewi, 20 1 3) .
20 1 3) . Median gestational age at delivery was 37 weeks, and
80 percent of neonates survived (Lee, 20 l 3) . he average ges­
• Etiopathogenesis
tational age at the time of the RFA was 20 weeks, and the
estimated acardius-to-pump twin volume on average was 90 he cause of birthweight inequality in twin fetuses is often
percent. Major complications were prematurely ruptured mem­ unclear, but the etiology in monochorionic twins likely difers
branes and preterm birth. from that in dichorionic twins. Because the single placenta is
Interestingly, TRAP sequences can also occur within mono­ not always equally shared in monochorionic twins, these twins
amnionic pregnancies. he perinatal outcomes of such pregnan­ have greater rates of discordant growth outside of TTTS than
cies appear to be worse than that of monochorionic diamnionic dichorionic twins. Discordancy in monochorionic twins is
cases. Sugibayashi and associates (20 1 6) in a review of 40 cases usually attributed to placental vascular anastomoses that cause
recently reported that pump twin survival following RFA was hemodynamic imbalance between the twins. Reduced pressure
88 percent in monochorionic diamnionic pregnancies but only and perfusion of the donor twin can cause diminished placental
67 percent in monoamnionic pregnancies. and fetal growth. Even so, unequal placental sharing is prob­
ably the most important determinant of discordant growth in
monochorionic twins (Lewi, 20 1 3) . Occasionally, monochori­
• Hydatidiform Mole with Coexisting onic twins are discordant in size because they are discordant for
Normal Fetus structural anomalies.
his unique gestation contains one normal fetus, and its Discordancy in dichorionic twins may result from various
cotwin is a complete molar pregnancy. Reported prevalence factors. Dizygotic fetuses may have diferent genetic growth
rates range from 1 in 22,000 to 1 in 1 00,000 pregnancies potential, especially if they are of opposite genders. Second,
(Dolapcioglu, 2009) . It must be diferentiated from a partial because the placentas are separate and require more implanta­
molar pregnancy, in which an anomalous singleton fetus­ tion space, one placenta might have a suboptimal implantation
usually triploid-is accompanied by molar tissue (Fig. site. Bagchi and associates (2006) observed that the incidence
20-4, p. 39 1 ) . At times, a twin pregnancy may occur with a of severe discordancy is twice as great in triplets as it is in twins.
normal twin in one sac and a partial mole in the other sac This fi n ding lends credence to the view that in utero crowding
(McN amara, 20 1 6) . is a factor in multifetal growth restriction. Placental pathology
882 O bstetrica l Com pl ications

may play a role as well. In one study of 668 twin placentas, a examination to search for TTTS is completed at each interven­
strong relationship between histological placental abnormalities ing 2-week mark between these sonograms.
and birthweight discordancy was observed in dichorionic, but For dichorionic pregnancies, a recent report suggests that
not monochorionic, twin pregnancies (Kent, 20 1 2) . sonographic evaluation every 2 weeks would identiY more
abnormalities prompting delivery (Corcoran, 20 1 5) . It has yet
to be determined if this practice would improve perinatal out­
• Diagnosis
comes. At our institution, dichorionic twins are sonographi­
Size discordancy between twins can be determined sonographi­ cally evaluated every 6 weeks.
cally. hat said, diferences in crown-rump length are not
reliable predictors for birthweight discordance (Miller, 20 1 2) . Feta l S u rve i l l a n ce
hus, most begin surveillance for discordancy ater the first Depending on the degree of discordancy and the gestational
trimester. One common method uses sonographic fetal biom­ age, fetal surveillance may be indicated, especially if one or both
etry to compute an estimated weight for each twin (Chap. 1 0, fetuses exhibit restricted growth. Nonstress testing, biophysical
p. 1 84) . The weight of the smaller twin is then compared with profi l e, and umbilical artery Doppler assessment have all been
that of the larger twin. hus, percent discordancy is calculated recommended in the management of twins. However, none has
as the weight of the larger twin minus the weight of the smaller been assessed in appropriately sized prospective trials (Miller,
twin, then divided by the weight of the larger twin. Alterna­ 20 1 2) .
tively, given that abdominal circumference (AC) relects fetal If discordancy i s identiied i n a monochorionic twin preg­
nutrition, some use the sonographic AC value of each twin. nancy, umbilical artery Doppler studies in the smaller fetus
With these methods, some diagnose selective fetal-growth may help guide management (Gratac6s, 2007) . Namely, inves­
restriction if the AC measurements difer more than 20 mm or tigators have correlated umbilical artery Doppler results with
if the estimated fetal weight diference is 20 percent or more. placental indings and with the degree of selective fetal-growth
That said, several diferent weight disparities between twins restriction to predict fetal outcome (Gratac6s, 20 1 2) . hese
have been used to deine discordancy. Accumulated data sug­ correlations have yielded categories of selective fetal-growth
gest that weight discordancy greater than 25 to 30 percent most restriction. Type I is characterized by positive end-diastolic
accurately predicts an adverse perinatal outcome. At Parkland, low, a smaller degree of weight discordance, and a relatively
Hollier and coworkers ( 1 999) retrospectively evaluated 1 370 benign clinical course. Type II displays persistently absent
delivered twin pairs and stratiied twin weight discordancy end-diastolic fl o w in the smaller twin and carries a high risk
in 5-percent increments within a range of 1 5 to 40 percent. of deterioration and demise. Type III is intermittently absent
They found that the incidence of respiratory distress syndrome, or reversed end-diastolic fl o w. Because of large artery-to-artery
intraventricular hemorrhage, seizures, periventricular leukoma­ anastomoses associated with the placentas in this category,
lacia, sepsis, and necrotizing enterocolitis rose directly with the type III is associated with a lower risk of deterioration than
degree of weight discordancy. Rates of these conditions grew type II. In all evaluated cases, unequally shared placenta was
substantially if discordancy exceeded 25 percent. The relative noted to some degree.
risk of fetal death increased significantly to 5.6 if discordancy With uncomplicated dichorionic multifetal gestations, use
was more than 30 percent and rose to 1 8.9 if it was greater of antepartum surveillance has not improved perinatal out­
than 40 percent. comes. In sum, the American College of Obstetricians and
Gynecologists (20 1 6) recommends that antepartum testing be
• Management performed in multi fetal gestations for indications similar to
those for singleton fetuses (Chap. 1 7, p. 33 1 ) .
Seria l Sonogra phy At Parkland, all women with twin discordancy : 2 5 percent
Sonographic monitoring of twin growth has become a mainstay undergo daily monitoring as an inpatient. Data are limited to
in management. Monochorionic twins are generally monitored establish the optimal timing of delivery of twins for size discor­
more frequently. his is because their risk of death is higher-3.6 dancy alone. For those at advanced gestational ages, delivery
percent versus 1 . 1 percent-and the risk of neurological dam­ can be pursued.
age in the surviving twin is substantial compared with those
risks in dichorionic twins (Hillman, 20 1 1 ; Lee, 2008) . Thorson
and colleagues (20 1 1 ) retrospectively analyzed 1 08 monochori­ F ETAL DEMISE
onic twin pregnancies and found that a sonographic evaluation
interval > 2 weeks was associated with a higher Quintero stage • Death of One Fetus
at the time of TTTS diagnosis. hese indings have led some At any time during multifetal pregnancy, one or more fetuses
to recommend serial sonographic examination every 2 weeks in may die, either simultaneously or sequentially. Causes and inci­
monochorionic twins (Simpson, 20 1 3; Society for Maternal­ dence of fetal death are related to zygosity, chorionicity, and
Fetal Medicine, 20 1 3) . However, there have been no random­ growth concordance.
ized trials of the optimal frequency of sonographic surveillance In some pregnancies, one fetus dies remote from term,
in monochorionic twin pregnancies. At Parkland Hospital, but pregnancy continues with one or more live fetuses. When
monochorionic twins undergo sonographic evaluation to assess this occurs early in pregnancy, it may manifest as a vanish­
interval growth every 4 weeks. In addition, a specific ultrasound ing twin, discussed on page 87 1 . In a slightly more advanced
 M u ltifeta l Preg n a n cy 883

greater than 22 weeks had a death of one or both twins. This

compared with 1 .2 percent of dichorionic twins. In this same
review, women with monochorionic diamnionic twins who lost
one twin were 16 times more likely to experience death of the
cotwin than women with dichorionic twins who lost one twin.
Other investigations have found similar trends (Danon, 20 1 3;
Hillman, 20 1 1 ; Mahony, 20 1 1 ) .
Other factors that afect the prognosis for the surviving twin
include gestational age at the time of the demise and duration
between the demise and delivery of the surviving twin. With a
vanishing twin, the risk of death after the irst trimester is not
increased for the survivor. However, when a fetus dies in the
second trimester or later, the efect of gestational age at the time
of death and the mortality risk to the cotwin are less clear. In an
analysis by Hillman and colleagues (20 1 1 ) , cotwin demise rates
were unafected regardless of whether the irst death occurred
at 1 3 to 27 weeks' gestation or at 28 to 34 weeks. In cases with
the death of one twin after the irst trimester, however, the odds
of spontaneous and iatrogenic preterm delivery of the remain­
FIGURE 45-24 This fetus pa pyraceus is a ta n ovoid mass com­ ing living twin were increased (Hillman, 20 1 1 ) . Preterm birth
pressed agai nst the feta l membranes. Anatomical pa rts can be was ive times more likely in monochorionic twin gestations
identified a s m a rked. Demise of this twi n had been noted d u ri n g complicated by demise of one twin between 28 and 33 weeks'
so nogra phic exa m i n ation performed at 1 7 weeks' g estation. Its gestation. If the fetus died after 34 weeks, preterm delivery rates
via b l e cotwin del ivered at 40 weeks. (U sed with perm ission from
were similar.
Dr. Michael V. Za retsky.)
The neurological prognosis for a surviving cotwin depends
almost exclusively on chorionicity. In their comprehensive
gestation, fetal death may go undetected until delivery. In this review, Ong and coworkers (2006) found an 1 8-percent rate of
case, delivery of a normal newborn is followed by expulsion of neurological abnormality in twins with monochorionic placen­
a dead fetus that is barely identiiable. It may be compressed tation compared with only 1 percent in those with dichorionic
appreciably-'tus compressus, or it may be lattened remarkably placentation. In another review, in twin pregnancies compli­
through desiccation-'tus papyraceus (Fig. 45-24) . cated by a single fetal demise before 34 weeks, a ivefold higher
As shown i n Figure 4 5-2 5 , the risk o f stillbirth i s related to risk of neurodevelopmental morbidity was identiied in mono­
gestational age in all twins but is much higher for monochori­ chorionic twins compared with dichorionic twins. If the one
onic twin pregnancies before 32 weeks' gestation. In a review fetus died after 34 weeks, the likelihood of neurological deicits
of 9822 twin pregnancies, Morikawa and associates (20 1 2) was essentially the same between monochorionic and dichori­
reported that 2 . 5 percent of monochorionic diamnionic twins onic twin pregnancies (Hillman, 20 1 1 ) .
Later i n gestation, the death o f one o f multiple fetuses could
theoretically trigger coagulation defects in the mother. Only a
30 few cases of maternal coagulopathy after a single fetal death in
• Monochorionic diamnionic a twin pregnancy have been reported. This is probably because
§ 25 Dichorionic diamnionic
•
the surviving twin is usually delivered within a few weeks of the
9 - demise (Eddib, 2006) . That said, we have observed transient,
= c spontaneously corrected consumptive coagulopathy in multi­
� � 20
o 0 fetal gestations in which one fetus died and was retained in
� :
.�
.. 0 utero along with its surviving twin. he plasma ibrinogen con­
D0
15
o centration initially decreased b ut then increased spontaneously,
6 "" and the level of serum ibrinogen-ibrin degradation products
g ll 1 0
) - increased initially but then returned to normal levels. At deliv­
. .

o ery, the portions of the placenta that supplied the living fetus
t 5
appeared normal. In contrast, the part that had once provided
for the dead fetus was the site of massive ibrin deposition .
o 22 24 26 28 30 32 34 36 38
M a n a gement
Gestational week
Decisions should be based on gestational age, the cause of
FIGURE 45-25 P rospective risk of sti l l bi rth among women who
death, and the risk to the surviving fetus. First-trimester losses
reached a g iven gestational week (per 1 000 women). (Reproduced
with permission from Morikawa M, Yamada 1, Ya mada T, et a l : P ro­ require no additional surveillance for this speciic indication. If
spective risk of sti l l b i rth: monochorionic d i a m n iotic twi n s vs d icho­ the loss occurs after the irst trimester, the risk of death or dam­
rion ic twi ns, J Peri nat Med. 2 0 1 2 J a n 1 0;40(3):245-249.) age to the survivor is largely limited to monochorionic twin
884 Obstetrical Com pl ications

gestations. Morbidity in the monochorionic twin survivor is immature neonates. At Parkland Hospital, women with multi­
almost always due to vascular anastomoses, which often cause fetal gestations are seen every 2 weeks beginning at 22 weeks'
the demise of one twin followed by sudden hypotension in the gestation. A digital cervical examination is performed at each
other (p. 878) . For this reason, if one fetus of a monochorionic visit to screen for cervical shortening or dilation. Identification
twin gestation dies ater the first trimester but before viability, of other unique complications discussed earlier may also lead to
pregnancy termination can be considered (Blickstein, 20 1 3) . interventions including admission or early delivery.
Occasionally, death o f one but not all fetuses results from a
maternal complication such as diabetic ketoacidosis or severe
• Diet
preeclampsia with abruption. Pregnancy management is based
on the diagnosis and the status of both the mother and sur­ long with more frequent prenatal VISItS, the maternal diet
viving fetus. If the death of one dichorionic twin is due to a should provide additional requirements for calories, protein,
discordant congenital anomaly in the irst trimester, it should minerals, vitamins, and essential fatty acids. he Institute of
not afect the surviving twin. Medicine (2009) recommends a 37- to 54-lb weight gain for
S ingle fetal death during the late second and early third women with twins and a normal BMI. In their review, Good­
trimesters presents the greatest risk to the surviving twin. night and Newman (2009) endorse supplementation of micro­
Although the risks of subsequent death or neurological dam­ nutrients such as calcium, magnesium, zinc, and vitamins C,
age to the survivor are comparatively higher for monochori­ D, and E. his is based on upper intake levels from the Food
onic twins at this gestational age, the risk of preterm birth is and Nutrition Board of the Institute of Medicine. he daily
equally increased in mono- and dichorionic twins (Ong, 2006) . recommended augmented caloric intake for women with twins
Delivery generally occurs within 3 weeks of diagnosis of fetal is 40 to 45 kcal/kg/d. Diets contain 20 percent protein, 40 per­
demise, thus antenatal corticosteroids for survivor lung matu­ cent carbohydrate, and 40 percent fat divided into three meals
rity should be considered (Blickstein, 20 1 3) . Regardless, unless and three snacks daily.
the intrauterine environment is hostile, the goal is to prolong
the preterm pregnancy. • Sonography
Timing of elective delivery after conservative management
As noted earlier (p. 882), serial sonographic examinations are
of a late second- or early third-trimester single fetal death is
usually performed throughout the third trimester to search for
debatable. Dichorionic twins can probably be safely delivered
abnormal fetal growth and assess amnionic fluid volume. Asso­
at term. Monochorionic twin gestations are more diicult to
ciated oligohydramnios may indicate utero placental pathology
manage and are often delivered between 34 and 37 weeks' ges­
and should prompt further evaluation of fetal well-being. That
tation (Blickstein, 20 1 3) . In cases of single fetal death at term,
said, quantiYing amnionic luid volume in multifetal gesta­
especially when the etiology is unclear, most opt for delivery
tion is sometimes diicult. Some measure the deepest vertical
instead of expectant management. The American College of
pocket in each sac or assess the luid subjectively. Magann and
Obstetricians and Gynecologists (20 1 6) also endorse an indi­
coworkers (2000) compared subjective assessment and several
vidualized approach to such cases.
objective methods of assessing amnionic fluid volume in 23 sets
of twins. They found all methods to be equally poor in predict­
• I m pending Death of One Fetus ing abnormal volumes in diamnionic wins. At Parkland Hos­
During antepartum surveillance tests of well-being, abnormal pital, the single deepest vertical pocket is measured in each sac.
results in one twin, but not the other, pose a particular dilemma. A measurement < 2 em is considered oligohydramnios, and a
Delivery may be the best option for the compromised fetus yet measurement > 8 cm is considered hydramnios (Duryea, 20 1 7;
may result in death from immaturity of the cotwin. If fetal lung Hernandez, 20 1 2) .
maturity is conirmed, salvage of both the healthy fetus and
its jeopardized sibling is possible. Unfortunately, ideal manage­ • Antepartum Fetal Surveillance
ment if twins are immature is problematic but should be based Of surveillance methods, the nons tress test or biophysical pro­
on the chances of intact survival for both fetuses. Often the file is often selected for twin or higher-order multifetal gesta­
compromised fetus is severely growth restricted or anomalous. tions. Because of the complex complications associated with
Thus, performing amniocentesis for fetal chromosomal analysis these gestations and the potential technical diiculties in dif­
in women of advanced maternal age carrying twin pregnancies ferentiating fetuses during antepartum testing, the usefulness
is advantageous, even for those who would continue their preg­ of these methods appears limited. According to DeVoe (2008) ,
nancies regardless of the diagnosis. Chromosomal abnormality the few exclusive studies of nonstress testing in twins suggest
identification in one fetus allows rational decisions regarding that the method performs the same as in singleton pregnancies.
interventions. Elliott and Finberg ( 1 995) used the biophysical profile as
the primary method for monitoring higher-order multifetal
PRENATAL CARE gestations. They reported that four of 24 monitored pregnan­
cies had a poor outcome despite reassuring biophysical proile
With prenatal management of multifetal pregnancy, primary scores. Although biophysical testing is commonly performed in
goals aim to prevent or interdict complications as they develop. multifetal gestations, there are insuicient data to determine its
A major imperative is to prevent preterm delivery of markedly eicacy (DeVoe, 2008) .
 M u ltifeta l P reg n a n cy 885

Similar indings have been reported with the addition of • Prevention of Preterm Birth
umbilical artery Doppler velocimetry in twins with concordant Several schemes have been evaluated to prevent preterm labor
growth. For example, when umbilical artery Doppler velocime­ and delivery. In recent years, some have been shown to decrease
try was added to management compared with fetal testing based the risk of preterm delivery, but only in subgroups of singleton
on fetal-growth parameters alone in the absence of growth dis­ pregnancies. In general, most have been disappointingly inef­
cordance, perinatal outcomes were not improved (Giles, 2003) . fective for both singleton and multifetal pregnancies (American
Likewise, Hack and associates (2008) investigated the utility College of Obstetricians and Gynecologists, 20 1 6) .
of umbilical artery Doppler velocimetry in 67 uncomplicated
monochorionic twin gestations and did not ind diferences in Bed Rest
mortality rates using pulsatility indices of the umbilical artery. The bulk of evidence suggests that routine hospitalization
All testing schemes have high false-positive rates in single­ does not prolong multifetal pregnancy. In one metaanaly­
tons, and data suggest that testing in multifetal gestations per­ sis, the practice did not reduce the risk of preterm birth or
forms no better. In cases of abnormal testing in one twin and perinatal mortality (Crowther, 2 0 1 0) . At Parkland Hospital,
normal results in another, iatrogenic preterm delivery remains elective hospitalization was compared with outpatient manage­
a major concern. Options are similar to those described in the ment, and no advantages were found (Andrews, 1 99 1 ) . I mpor­
management of impending fetal death (p. 884) . tantly, however, almost half of women managed as outpatients
required admission for specifi c indications such as hypertension
PRETERM BIRTH or threatened preterm delivery.
Limited physical activity, early work leave, more frequent
Preterm labor is common in multifetal pregnancies and may health-care visits and sonographic examinations, and structured
complicate up to 50 percent of twin, 75 percent of triplet, and maternal education regarding preterm delivery risks have been
90 percent of quadruplet pregnancies (Elliott, 2007) . Similar advocated to reduce pre term birth rates in women with mul­
to singleton preterm labor, intraamnionic infection is docu­ tiple fetuses. However, little evidence suggests that these mea­
mented in approximately one third of twin pregnancy cases sures substantially change outcome.
(Oh, 20 1 7) .
I n twins, the proportion o f preterm births varies widely from Pro p hylactiC Toco lys i s
40 to 70 percent (Giufre, 20 1 2) . For example, black women his has not been studied extensively in multifetl pregnancies.
have disparately higher risks for preterm delivery (Grant, 20 1 7) . In one review of prophylactic oral beta-mimetic therapy that
included 374 twin pregnancies, treatment did not reduce the
rate of twins delivering before 37 or before 34 weeks' gestation
• Prediction of Preterm Birth
(Ymasmit, 20 1 5) . In light of the Food and Drug Administration
A major goal of multi fetal prenatal care is accurate prediction warning against the use of oral terbutaline because of maternal
of women likely to experience preterm delivery. Within the side efects, the prophylactic use of beta-mimetic drugs in multi­
past decade, cervical length has been shown to be a potent pre­ fetal gestations seems unwarranted.
dictor of preterm labor and delivery. To and associates (2006)
so no graphically measured cervical length in 1 1 63 twin preg­ I ntra m uscu l a r Prog este ro n e Thera py
nancies at 22 to 24 weeks' gestation. Rates of preterm delivery lthough somewhat efective in reducing recurrent preterm birth
before 32 weeks were 66 percent in those with cervical lengths in women with a singleton pregnancy, weekly injections of 1 7
of 1 0 mm; 24 percent for lengths of 20 mm; and only 1 percent alpha-hydroxyprogesterone caproate ( 1 7-OHP-C) are not efec­
for 40 mm. In one review, Conde-Agudelo and coworkers tive for multifetal gestations (Caritis, 2009; Rouse, 2007) . hese
(20 1 0) concluded that a cervical length < 20 mm was most results were corroborated in a randomized trial of 240 twin preg­
accurate for predicting birth before 34 weeks, with a speciicity nancies (Combs, 20 1 1 ) . Moreover, women carrying twins and
of 97 percent and positive likelihood ratio of 9.0. Kindinger having a cervical length < 36 mm (25th percentile) did not ben­
and colleagues (20 1 6) noted that prediction depended on eit despite their greater risk for preterm birth (Durnwald, 2 0 1 0) .
both cervical length and gestational age at ascertainment. One Senat and colleagues (20 1 3) assigned 1 65 asymptomatic women
study compared serial cervical length measurements with a with twins and a cervical length <25 mm to 1 7-0HP-C and
single midgestation measurement. hese authors found that also found no reduction in delivery rate before 37 weeks. Last, in
multiple assessments were more accurate to determine the risk an evaluation of plasma drug concentrations, higher concentra­
of pre term twin birth in asymptomatic women (Melamed, tions of 1 7-OHP-C were associated with earlier gestational age at
20 1 6a) . In another study, a change in cervical length :0.2 cm delivery (Caritis, 20 1 2) . he authors concluded that 1 7-0HP-C
identified pregnancies at risk for delivery before 35 weeks may adversely lower the gestational age at delivery in women
(Moroz, 20 1 7) . Interestingly, a closed internal os by digital with twin gestations. In sum, administration of intramuscular
examination was found to be as predictive of postponed deliv­ 1 7-OHP-C to women with twin pregnancies, even to those with
ery as was the combination of a normal sonographically mea­ a shortened cervix, does not lower the preterm birth risk.
sured cervical length and negative fetal fibronectin test result
(McMahon, 2002) . Unfortunately, cervical length assessment Vag i n a l Progeste rone Thera py
in twin pregnancies has not been associated with improved Micronized progesterone administered vaginally to women with
outcomes (Gordon, 20 1 6) . twins to prevent preterm birth has provided conlicting results .
886 Obstetrica l C o m p l i cations

Cetingoz and coworkers (20 1 1 ) gave 1 00 mg of micronized Birth (ProTWIN) trial, 8 1 3 un selected women with twins
progesterone intravaginally daily from 24 to 34 weeks' gesta­ received either the Arabin pessary between 1 2 and 20 weeks
tion. his practice reduced rates of delivery before 37 weeks or no treatment (Liem, 20 1 3) . The pessary failed to reduce
from 79 to 5 1 percent in 67 women with twins. In contrast, preterm birth overall but did decrease delivery rates before
several studies have failed to demonstrate any preterm birth rate 32 weeks-29 versus 1 4 percent-in a subset of women with
reduction in women receiving various formulations of vaginal a cervical length <38 mm. Similar results were reported from
progesterone. In the Prevention of Preterm Delivery in Twin a randomized multicenter trial with a total of 1 1 80 twin preg­
Gestations (PREDICT) trial, 677 women with twins were ran­ nancies (Nicolaides, 20 1 6) . A smaller randomized study using
domly assigned to receive prophylactic, 200-mg progesterone a Bioteque cup pessay showed no diference in outcomes (Ber­
pessaries or placebo pessaries (Rode, 20 1 1 ) . Progesterone failed ghella, 20 1 7) . At this time, pessary use is not recommended
to reduce delivery rates before 34 weeks. In a subgroup analysis by the merican College of Obstetricians and Gynecologists
that included only women with a short cervix or a history of (20 1 6) . As noted above, results from the ongoing PROSPECT
prior preterm birth, also no benefit was found (Klein, 20 1 1 ) . trial are anticipated to provide more data.
Norman and colleagues (2009) also noted n o lower rates of
delivery before 34 weeks with progesterone gel treatment.
Romero and colleagues (20 1 7) performed a metaanalysis of • Treatment of Preterm Labor
individual patient data for 303 women with twin gestation and a Although many advocate their use, therapy with tocolytic
short cervix randomized to receive either vaginal progesterone or agents to forestall preterm labor in multifetal pregnancy does
no treatment. They reported a significantly reduced risk of pre­ not result in measurably improved neonatal outcomes (Chau­
term birth before 30 weeks' gestation and improved composite han, 20 1 0; Gyetvai, 1 999) . Another caveat is that tocolytic
perinatal outcomes in the treated women. Currently at Parkland therapy in women with a multifetal pregnancy entails higher
Hospital, management of women with multifetal gestations does risks than in singleton pregnancy. This stems in part from aug­
not typically include progestetone in any formulation. mented pregnancy-induced hypervolemia, which raises cardiac
The Eunice Kennedy Shriver National Institute of Child demands and increases the susceptibility to iatrogenic pulmo­
Health and Human Development (NICHD) is currently enroll­ nary edema (Chap. 47, p. 9 1 7) . Gabriel and colleagues ( 1 994)
ing patients into a randomized, placebo-controlled trial to fur­ compared outcomes of 26 twin and six triplet pregnancies with
ther evaluate the use of micronized vaginal progesterone or the those of 5 1 singletons-all treated with a beta-mimetic drug
Arabin pessary, describe subsequently (PROSPECT, 20 1 5) . The for preterm labor. Women with a multifetal gestation had
primary outcome is delivery prior to 35 weeks or fetal loss. significantly more cardiovascular complications-43 versus 4
percent-including three gravidas with pulmonary edema. In
Cerv i ca l Cerc l a g e a retrospective analysis, Derbent and coworkers (20 1 1 ) evalu­
Prophylactic cerclage does not improve perinatal outcome ated nifedipine tocolysis in 58 singleton and 32 twin pregnan­
in women with multifetal pregnancies. Studies have included cies. hese authors reported higher incidences of side efects
women who were not specially selected but also those who such as maternal tachycardia in women with twins-1 9 versus
were selected because of a shortened cervix that was identified 9 percent.
sonographically (Houlihan, 20 1 6; Newman, 2002; Rebarber,
2005) . Indeed, in the latter group, cerclage may actually worsen G l u cocorticoids for Lung M at u ration
outcomes (Berghella, 2005; Roman, 20 1 3) . Administration of corticosteroids to stimulate fetal lung matura­
Rescue cerclage i n women with a second-trimester twin tion has not been well studied in multifetal gestation. However,
gestation and a dilated cervix may be benefi c ial. Roman and these drugs logically should be as beneicial for multiples as they
coworkers (20 1 6) reported a retrospective cohort study in are for singletons (Roberts, 2006) . In a large retrospective study
which women undergoing rescue cerclage had significantly bet­ evaluating betamethasone therapy eicacy in preterm twin ver­
ter neonatal outcomes than those without cerclage. sus preterm singleton pregnancies, no diferences in neonatal
morbidity between the two groups were identiied (Melamed,
Pessary 20 1 6b) . Gyamfi and associates (20 1 0) evaluated betamethasone
A vaginal pessary that encircles and theoretically compresses the concentrations in women receiving weekly antenatal cortico­
cervix, alters the inclination of the cervical canal, and relieves steroids and found no diferences in levels between twins and
direct pressure on the internal cervical os has been proposed singletons. Conversely, another study found lower cord/mater­
as an alternative to cerclage. One of the most popular is the nal ratios of dexamethasone in twin versus singleton pregnan­
silicone Arabin pessary. In a study of its use in women with a cies (Kim, 20 1 7) . hese treatments are discussed in Chapter
short cervix between 1 8 and 22 weeks' gestation, a subgroup 42 (p. 823) . At this time, guidelines for the use of these agents
analysis of 23 women with twins showed a signiicant reduction do not difer from those for singleton gestations (American
in the delivery rate before 32 weeks compared with the rate in College of Obstetricians and Gynecologists, 20 1 6) .
23 control pregnancies (Arabin, 2003) . In another randomized
trial, women treated with a cervical pessary had signiicantly
fewer births before 34 weeks (Goya, 20 1 6) . • Preterm Premature Membrane Rupture
Other studies have been less favorable. In the randomized The frequency of preterm premature rupture of membranes
Pessaries in Multiple Pregnancy as a Prevention of Preterm (PPROM) rises with increasing plurality. In a population-
 M u lt ifeta l P re g n a ncy 887

based study of more than 290,000 live births, the proportion thus certain precautions and special arrangements are prudent.
of preterm birth complicated by premature rupture was 1 3.2 These should include the following.
percent in singletons (Pakrashi, 20 1 3) . This rate compared with
1 . An appropriately trained obstetrical attendant should re­
rates of 1 7, 20, 20, and 1 00 percent in twins, triplets, quadru­
main with the mother throughout labor. Continuous elec­
plets, and even higher-order multiples, respectively. Multife­
tronic monitoring is preferable. If membranes are ruptured
tal gestations with PPROM are managed expectantly similar
and the cervix dilated, the presenting fetus is monitored
to singleton pregnancies (Chap. 42, p. 820) . Ehsanipoor and
internally.
colleagues (20 1 2) compared outcomes of 4 1 twin and 82 sin­
2. An intravenous infusion system capable of delivering fluid
gleton pregnancies, both with ruptuted membranes between
rapidly is established. In the absence of hemorrhage, lactated
24 and 32 weeks. They found the median number of days to
Ringer or an aqueous dextrose solution is infused at a rate of
subsequent delivery was overall shorter for twins-3.6 days
60 to 1 25 mLlhr.
compared with 6.2 days for singletons. This latency diference
3. Blood for transfusion is readily available if needed.
was significant in pregnancies after 30 weeks- l .7 days and
4. n obstetrician skilled in intrauterine identification of fetal
6.9 days. Importantly, latency beyond 7 days approximated
parts and in intrauterine manipulation of a fetus should be
40 percent in both groups.
present.
5. A sonography machine is readily available to evaluate the
• Delayed Delivery of Second Twi n presentation and position of the fetuses during labor and to
image the remaining fetus(es) after delivery of the irst.
Infrequently, after preterm birth o f the presenting fetus, i t may
6. An anesthesia team is immediately available in the event that
be advantageous for undelivered fetus(es) to remain in utero.
emergent cesarean delivery is necessary or that intrauterine
Trivedi and Gillett ( 1 998) reviewed 45 case reports of asyn­
manipulation is required for vaginal delivery.
chronous birth in multifetal gestations. Although reported out­
7. For each fetus, at least one attendant who is skilled in resus­
comes may relect bias, pregnancies with a surviving retained
citation and care of newborns and who has been appropri­
twin or triplet continued for an average of 49 days. No advan­
ately informed of the case should be immediately available.
tage was gained by management with tocolytics, prophylactic
8. he delivery area should provide adequate space for the
antimicrobials, or cerclage. In their 1 0-year experience, Roman
nursing, obstetrical, anesthesia, and pediatric team members
and associates (20 1 0) reported a median latency of 1 6 days in
to work efectively. Equipment must be on site to provide
1 3 twin and ive triplet pregnancies with delivery of the irst
emergent anesthesia, operative intervention, and maternal
fetus between 20 and 25 weeks' gestation. Survival of the
and neonatal resuscitation.
irstborn neonate was 1 6 percent. Although 54 percent of the
retained fetuses survived, only 37 percent of survivors did so
without major morbidity. Livingston and coworkers (2004) • Timing of Delivery
described 14 pregnancies in which an active attempt was made Several factors afect this timing and include gestational age, fetal
to delay delivery of 1 9 fetuses after delivery of the irst neo­ growth, lung maturity, and presence of maternal complications.
nate. Only one fetus survived without major sequelae, and one As measured by determination of the lecithin-sphingomyelin
mother developed sepsis syndrome with shock. Arabin and van ratio, pulmonary maturation is usually synchronous in twins
Eyck (2009) reported better outcomes in a few of the 93 twin (Leveno, 1 984) . Moreover, although this ratio usually does not
and 34 triplet pregnancies that qualiied for delayed delivery in exceed 2.0 until 36 weeks in singleton pregnancies, it oten
their center during a 1 7 -year period. exceeds this value by approximately 32 weeks in multifetal preg­
If asynchronous birth is attempted, there must be careful nancies. Similar increased values of surfactant have been noted
evaluation for infection, abruption, and congenital anomalies. in twins after 3 1 weeks' gestation (McElrath, 2000) . In a com­
The mother must be thoroughly counseled, particularly regard­ parison of respiratory morbidity in 1 00 twins and 24 1 singleton
ing the potential for serious, life-threatening infection. The newborns delivered by cesarean before labor, Ghi and associates
range of gestational age in which the beneits outweigh the risks (20 1 3) found less neonatal respiratory morbidity in twins, espe­
for delayed delivery is likely narrow. Avoidance of delivery from cially those delivered < 37 weeks' gestation. In some cases, how­
23 to 26 weeks would seem most beneficial. In our experience, ever, pulmonary function may be markedly diferent, and the
good candidates for delayed delivery are rare. smallest, most stressed twin fetus is typically more mature.
At the other end of the spectrum, Bennett and Dunn ( 1 969)
suggested that a twin pregnancy of 40 weeks or more should
LABOR AN D DELIVERY be considered postterm. Twin stillborn neonates delivered at
40 weeks or beyond commonly had features similar to those of
• Preparations postmature singletons (Chap. 43, p. 836) . From an analysis of
A litany of complications may be encountered during labor and almost 300,000 twin births, at and beyond 39 weeks, the risk
delivery of multiple fetuses. In addition to preterm birth, rates of subsequent stillbirth was greater than the risk of neonatal
of uterine contractile dysfunction, abnormal fetal presentation, mortality (Kahn, 2003) .
umbilical cord prolapse, placenta previa, placental abruption, From their guidelines, the American College of Obstetricians
emergent operative delivery, and postpartum hemorrhage from and Gynecologists (20 1 6) recommends delivery at 38 weeks
uterine atony are higher. All of these must be anticipated, and for uncomplicated dichorionic twin pregnancies. Women with
888 Obstetrica l Co m pl ications

uncomplicated monochorionic diamnionic twin pregnancies maternal morbidity was increased with labor induction. In an
can undergo delivery between 34 and 376/ weeks. And, for analysis of twin births in the United States, induction rates of
women with monoamnionic twin pregnancies, delivery is rec­ twin pregnancies have decreased from a maximum of 1 3. 8 per­
ommended at 32 to 34 weeks. At Parkland Hospital, we gener­ cent in 1 999 to 9.9 percent in 2008 (Lee, 20 1 1 ) . Generally,
ally follow these recommendations but do not routinely deliver at Parkland Hospital we do not induce or augment labor in
monochorionic diamnionic twin pregnancies before 37 weeks women with a multifetal gestation. In suitable candidates with
unless another obstetrical indication develops. a strong desire for vaginal birth, amniotomy induction has been
one option.
• Eva luation of Fetal Presentation
In addition to the standard preparations for the conduct oflabor • Analgesia and Anesthesia
and delivery discussed in Chapter 22, there are special con­ During labor and delivery of multiple fetuses, decisions regard­
siderations for women with a multifetal pregnancy. First, the ing analgesia and anesthesia may be complicated by problems
positions and presentations of fetuses are best confirmed sono­ imposed by preterm labor, preeclampsia, desultory labor, need
graphically. Although any possible combination of positions may for intrauterine manipulation, and postpartum uterine atony
be encountered, those most common at admission for delivery and hemorrhage.
are cephalic-cephalic, cephalic-breech, and cephalic-transverse. Labor epidural analgesia is ideal because it provides excel­
At Parkland Hospital between 2008 and 20 1 3, 7 1 percent of lent pain relief and can be rapidly extended cephalad if internal
twin pregnancies had a cephalic presentation of the irst fetus at podalic version or cesarean delivery is required. If general anes­
the time of admission to labor and delivery. Importantly, with thesia becomes necessary for intrauterine manipulation, uterine
perhaps the exception of cephalic-cephalic presentations, these relxation can be accomplished rapidly with one of the halo­
are all unstable before and during labor and delivery. Accord­ genated inhalation agents discussed in Chapter 25 (p. 499) .
ingly, compound, face, brow, and footling breech presentations Some clinicians use intravenous or sublingual nitroglycerin or
are relatively common, and even more so if fetuses are small, intravenous terbutaline to achieve uterine relaxation yet avoid
amnionic luid is excessive, or maternal parity is high. Cord pro­ the risks associated with general anesthetics. hese agents are
lapse is also frequent in these circumstances. usually best administered by the anesthesia team.
After this initial evaluation, if active labor is conirmed, then
a decision is made to attempt vaginal delivery or to proceed with • Delivery Route
cesarean delivery. The latter is usually chosen because of fetal
Regardless of fetal presentation during labor, obstetricians must
presentations. In general, cephalic presentation of the irst fetus
be ready to deal with any change of fetal position during deliv­
in a laboring woman with twins may be considered for vaginal
ery. This is especially true following delivery of the first twin.
delivery (American College of Obstetricians and Gynecologists,
Importantly, related to delivery method, second twins at term
20 1 6) . The proportion of women undergoing an attempted
have worse composite neonatal outcomes compared with out­
vaginal delivery varies greatly depending on the skills of the
comes of their cotwin regardless of delivery method (Muleba,
delivering physician (de Castro, 20 1 6; Easter, 20 1 7; Schmitz,
200 5 ; Smith, 2007; Thorngren-Jerneck, 200 1 ) .
20 1 7) . Still, the cesarean delivery rate is high. For example, of
the 547 women with the irst twin presenting cephalic who Ce p h a l i c-Ce p h a l ic P resentati on
were admitted to Parkland Hospital during 5 years, only 32
If the first twin presents cephalic, delivery can usually be accom­
percent were delivered spontaneously. And, the overall cesar­
plished spontaneously or with forceps. According to D'Alton
ean delivery rate in twin pregnancies during those years was 77
(20 1 0) , there is general consensus that a trial of labor is reason­
percent. Notably, 5 percent of cesareans performed were for
able in women with cephalic-cephalic twins. From their review,
emergent delivery of the second twin following vaginal delivery
Hogle and associates (2003) found that planned cesarean deliv­
of the first twin. The desire to avoid this obstetrical dilemma
ery does not improve neonatal outcome when both twins are
has contributed to the rising cesarean delivery rate in twin preg­
cephalic. The randomized trial by Barrett and coworkers (20 1 3)
nancies across the United States (Antsalis, 20 1 3) .
airms this conclusion.

• Labor I nd uction o r Stimulation Cep h a l ic- N o n ce p ha l i c Presentation

After a comparison of 89 1 twins with more than 1 00,000 sin­ The optimal delivery route for cephalic-noncephalic twin pairs
gleton pregnancies included in the Consortium of Safe Labor, remains controversial. Patient selection is crucial, and options
Leftwich and colleagues (20 1 3) concluded that active labor include cesarean delivery of both twins, or less commonly, vagi­
progressed more slowly in both nulliparas and multiparas with nal delivery with intrapartum external cephalic version of the
twins. Provided women with twins meet all criteria for oxy­ second twin. Longer intertwin delivery time has been shown
tocin administration, it may be used as described in Chapter in some studies to be associated with poorer second twin out­
26 (p. 509) . Wolfe and associates (20 1 3) evaluated the suc­ come (Edris, 2006; Stein, 2008) . Thus, breech extraction may
cess of labor induction and concluded that oxytocin alone or be preferable to version. Least desirable, vaginal delivery of the
in combination with cervical ripening can safely be used in first but cesarean delivery of the second twin may be required
twin gestations. Taylor and coworkers (20 1 2) reported similar due to intrapartum complications such as umbilical cord pro­
results. Conversely, Razavi and colleagues (20 1 7) found that lapse, placental abruption, contracting cervix, or fetal distress.
 M u ltifeta l Preg n a ncy 889

·Most but not all studies report the worst composite fetal out­
TABLE 45-3. Materna l and Peri nata l O utcomes
comes for this scenario (Alexander, 2008; Rossi, 2 0 1 1 ; Wen,
of Women with a Twi n P reg na ncy
2004) .
Random ized to P la n ned Cesa rea n ve rs u s
Several reports attest to the safety of vaginal delivery of
Vag i n a l Del i very
second noncephalic twins whose birthweight is > 1 500g. A
French multicenter study of 5 9 1 5 twin pregnancies illustrates Planned Plan ned
this (Schmitz, 20 1 7) . Of these, 25 percent had a planned cesar­ Cesa rea n Vaginal
ean delivery. The other 75 percent with a first twin cephalic Outcome Delivery Delivery p val u e

and gestational age > 32 weeks had a planned trial of vaginal Maternal ( No.) 1 3 93 1 39 3
delivery, which was successful in 80 percent. Interestingly, peri­ Cesa re a n d e l ivery 89.9% 3 9.6%
natal mortality and morbidity rates were significantly higher in Before l a bor 5 3 .8% 1 4. 1 %
the planned cesarean delivery group delivered < 37 weeks-5 .2 Serious m o rbid ity 7.3% 8.5% 0.29
versus 3.0 percent, respectively. Fox and colleagues (20 1 4) Death (No.) 1 1
reported outcomes in 287 diamnionic twin pregnancies, of H e m orrhage 6.0% 7.8%
which 1 30 underwent a planned vaginal delivery. Only 1 5 per­ B l ood tra nsfu sion 4.7% 5 .4%
cent of the planned vaginal delivery group underwent a cesar­ Th ro m boe m bolism 0.4% 0. 1 %
ean delivery. Perinatal outcomes were similar in both groups. Peri nata l (No.) 2783 2 782
hese two studies included only those fetuses with estimated P r i m a ry com posite 2.2% 1 .9% 0.49
weights > 1 500 g. Notably, comparable or even better fetal out­ o utcom e
comes with vaginal delivery have been reported with neonates Peri n ata l morta l ity 9 per 1 000 6 per 1 000
weighing < 1 500 g compared with those weighing > 1 500 g Seri o u s m o rbid ity 1 .3% 1 .3%
(Caukwell, 2002; Davidson, 1 992). Poss i b l e 0.5% 0 .4%
Other investigators advocate cesarean delivery for both members e ncephal opathya
of a cephalic-noncephalic twin pair (Armson, 2006; Hofmann, I ntu bation 1 .0% 0 .6%
20 1 2) . Yang and coworkers (2005a,b) studied 1 5, 1 85 cephalic­
noncephalic twin pairs. he risks of asphyxia-related neonatal al ncl udes coma; stu por; hype ra l ert, d rowsy or letharg ic; or
deaths and morbidity were higher in the group in which both twins ::2 seizu res.
were delivered vaginally compared with the group in which both Data from Ba rrett, 20 l 3 .
twins underwent cesarean delivery.
To add insight into the clinical complexities just discussed, macrocephaly from hydrocephaly. Last, umbilical cord prolapse
a randomized trial was designed by the Twin Birth Study Col­ is an ever-present risk.
laborative Group from Canada. he study results described by If these problems are anticipated or identiied, cesarean deliv­
Barrett and associates (20 1 3) included 2804 women carrying a ery is often preferred with a viable-sized fetus. But even without
presumed diamnionic twin pregnancy with the irst fetus pre­ these problems, many obstetricians perform cesarean delivery if
senting cephalic. Women were randomly assigned between 32 the irst twin presents as breech. This is despite data that support
and 38 weeks' gestation to planned cesarean or vaginal deliv­ the safety of vaginal delivery. Specifically, Blickstein and asso­
ery. The time from randomization to delivery-1 2.4 versus ciates (2000) reported experiences from 1 3 European centers
1 3.3 days, the mean gestational age at delivery-36.7 versus with 6 1 3 twin pairs and the first twin presenting breech. Vaginal
36.8 weeks, and use of regional analgesia-92 versus 87 per­ delivery was attempted in 373 of these cases and was successful
cent, were similar in both groups. Salient maternal and perinatal in 64 percent. Cesarean delivery of the second twin was done
outcomes are shown in Table 4 5-3 . No significant diferences in 2.4 percent. here was no diference in the rate of 5-minute
in outcomes were noted between the two groups of women. Apgar scores <7 or of mortality in breech-presenting first twins
Although risks to mother or fetuses with planned vaginal deliv­ who weighed at least 1 500 g. Details of techniques for delivery
ery in these circumstances were not increased, Greene (20 1 3) of a breech presentation are described in Chapter 28 (p. 544) .
posited that this trial would have only modest efects on the Twin fetuses may become locked together during delivery if
cesarean delivery rate of women with twins. the irst presents breech and the second cephalic. As the breech
of the irst twin descends through the birth canal, the chin locks
B reech Presentation of F i rst Twi n
between the neck and chin of the second cephalic-presenting
Problems with the first twin presenting as a breech are simi­ cotwin. This phenomenon is rare, and Cohen and coworkers
lar to those encountered with a singleton breech fetus. hus, ( 1 965) described it only once in 8 1 7 twin gestations. Cesarean
major diiculties may develop in the following settings. First, delivery should be considered when the potential for locking
the fetus may be large, and the aftercoming head is larger is identiied.
than the birth canal. Second, the fetal body can be small, and
delivery of the extremities and trunk through an inadequately
efaced and dilated cervix causes the relatively larger head to • Vaginal Delivery of the Second Twin
become trapped above the cervix. his is more likely when Following delivery of the first twin, the presenting part of the
there is significant disproportion between the head and body. second twin, its size, and its relationship to the birth canal should
Examples are preterm or growth-restricted fetuses or those with be quickly and careully ascertained by combined abdominal,
890 Obstetrical Compl i cations

vaginal, and at times, intrauterine examination. Sonography is a

valuable aid. If the fetal head or the breech is fixed in the birth
canal, moderate undal pressure is applied and membranes are
ruptured. Immediately aterward, digital examination of the cervix
is repeated to exclude cord prolapse. Labor is allowed to resume.
If contractions do not begin within approximately 1 0 minutes,
dilute oxytocin may be used to stimulate contractions.
In the past, the safest interval between delivery of the irst
and second twins was frequently cited as < 30 minutes. Ray­
burn and colleagues ( 1 984) and others have shown that if
continuous fetal monitoring is used, a good outcome is usu­
ally achieved even if this interval is longer. A direct correla­
tion between worsening umbilical cord blood gas values and
increasing time between delivery of irst and second twins has
been shown (Leung, 2002; Stein, 2008). From review of 239
twin gestations, Gourheux and associates (2007) determined
that mean umbilical arterial pH was signiicantly lower after F I G U RE 45-26 Internal pod a l i c version. U pward pressure on the
the delivery interval exceeded 1 5 minutes. In a study of more head by a n a bd o m i n a l hand i s a pp l ied a s downwa rd traction is
than 1 75 ,000 twin pairs, Cheng and colleagues (20 1 7) reached exerted o n the feet.
similar conclusions for maternal and perinatal morbidity.
If the occiput or breech presents immediately over the pelvic this procedure are found in Cunningham and Gilstrap 5 Opera­
inlet, but is not ixed in the birth canal, the presenting part can tive Obstetrics, 3rd edition (Yeomans, 20 1 7) .
often be guided into the pelvis by one hand in the vagina, while
a second hand on the uterine fundus exerts moderate pressure • Vaginal Birth after Cesarean Delivery
caudally. A presenting shoulder may be gently converted into a
Any attempt to deliver twins vaginally in a woman who has
cephalic presentation. Alternatively, with abdominal manipula­
previously undergone one or more cesarean deliveries should
tion, an assistant can guide the presenting part into the pelvis.
be carefully considered. Some studies support the safety of
Sonography can aid guidance and allow heart rate monitoring.
attempting a vaginal birth after cesarean delivery (VBAC) for
Intrapartum external version of a noncephalic second twin has
selected women with twins (Cahill, 2005; Ford, 2006; Varner,
also been described.
2005). According to the American College of Obstetricians
If the occiput or breech is not over the pelvic inlet and can­
and Gynecologists (20 1 7c) , no evidence currently suggests an
not be so positioned by gentle pressure or if appreciable uterine
increased risk of uterine rupture, and women with twins and
bleeding develops, delivery of the second twin can be problem­
one previous cesarean delivery with a low transverse incision
atic. To obtain a favorable outcome, an obstetrician skilled in
may be considered candidates for trial of labor. At Parkland
intrauterine fetal manipulation and anesthesia personnel skilled
Hospital, we recommend repeat cesarean delivery.
in providing anesthesia to efectively relax the uterus for vaginal
delivery of a noncephalic second twin are essential (American
College of Obstetricians and Gynecologists, 20 1 6) . To take • Cesarean Delivery for Multifetal Gestation
maximum advantage of the dilated cervix before the uterus Several unusual intraoperative problems can arise during cesar­
contracts and the cervix retracts, delay should be avoided. ean delivery of twins or higher-order multiples. Supine hypo­
Prompt cesarean delivery of the second fetus is preferred if no tension is common, and thus gravidas are positioned in a left
one present is skilled in the performance of internal podalic ver­ lateral tilt to delect uterine weight of the aorta (Chap. 4,
sion or if anesthesia that will provide efective uterine relaxation p. 63) . A low transverse hysterotomy is preferable if the inci­
is not immediately available. sion can be made large enough to allow atraumatic delivery of
With internal podalic version, a fetus is turned to a breech both fetuses. Piper forceps can be used if the second twin is
presentation using the hand placed into the uterus (Fig. 45-26) . presenting breech (Fig. 28- 1 1 , p. 547) . In some cases, a vertical
h e obstetrician grasps the fetal feet t o then efect delivery by hysterotomy beginning as low as possible in the lower uterine
breech extraction (Chap. 28, p. 548) . As mentioned earlier, segment may be advantageous. For example, if a fetus is trans­
Fox and associates (20 1 0) described a strict protocol for man­ verse with its back down and the arms are inadvertently deliv­
agement of the delivery of the second twin, which included ered irst, it is much easier and safer to extend a vertical uterine
internal podalic version. hey reported that none of the 1 1 0 incision upward than to extend a transverse incision laterally or
women who delivered the irst twin vaginally underwent a to make a "T" incision vertically.
cesarean delivery for the second twin. Chauhan and coworkers
( 1 995) compared outcomes of 23 second twins delivered by
internal podalic version and breech extraction with those of • Triplet or Higher-Order Gestation
2 1 who underwent external cephalic version. Breech extraction Fetal heart rate monitoring during labor with triplet pregnan­
was considered superior to external version because less fetal cies is challenging. A scalp electrode can be attached to the
distress developed. Additional information and illustrations of presenting fetus, but it is diicult to ensure that the other two
 M u ltifeta l P reg n a n cy 891

fetuses are each being monitored separately. With vaginal deliv­ low. The smallest fetuses and any anomalous fetuses are cho­
ery, the first neonate is usually born with little or no manipula­ sen for reduction. Potassium chloride is then injected under
tion. Subsequent fetuses, however, are delivered according to sonographic guidance into the heart or thorax of each selected
the presenting part. his often requires complicated obstetri­ fetus. Care is used to avoid entry or traverse the sacs of fetuses
cal maneuvers such as total breech extraction with or without selected for retention.
internal podalic version or even cesarean delivery. Associated Evans and associates (2005) analyzed more than 1 000
with malposition of fetuses is an increased incidence of cord pregnancies from 1 995 to 1 998. he pregnancy loss rate var­
prolapse. Moreover, reduced placental perfusion and hemor­ ied from a low of 4.5 percent for triplets that were reduced to
rhage from separating placentas are more likely during delivery. twins. The loss rate rose with each addition to the starting num­
For all these reasons, many clinicians believe that preg­ ber of fetuses and peaked at 1 5 percent for six or more fetuses.
nancies complicated by three or more fetuses should undergo Operator skill and experience are believed responsible for the
cesarean delivery (American College of Obstetricians and low and declining rates of pregnancy loss.
Gynecologists, 20 1 6) . Vaginal delivery is reserved for those cir­
cumstances in which survival is not expected because fetuses are
markedly immature or maternal complications make cesarean • Selective Termination
delivery hazardous to the mother. Others believe that vaginal With the identification of multiple fetuses discordant for struc­
delivery is safe under certain circumstances. Grobman and asso­ tural or genetic abnormalities, three options are available: abor­
ciates ( 1 998) and Alran and coworkers (2004) reported vaginal tion of all fetuses, selective termination of the abnormal fetus,
delivery completion rates of 88 and 84 percent, respectively, in or pregnancy continuation. Because anomalies are typically not
women carrying triplets who underwent a trial of labor. Neo­ discovered until the second trimester, selective termination is
natal outcomes did not difer from those of a matched group of performed later in gestation than selective reduction and entails
triplet pregnancies undergoing elective cesarean delivery. Con­ greater risk. This procedure is therefore usually not performed
versely, in one review of more than 7000 triplet pregnancies, unless the anomaly is severe but not lethal. In some cases, ter­
vaginal delivery was associated with a higher perinatal mortality mination is considered because the abnormal fetus may jeopar­
rate (Vintzeleos, 2005) . Lappen and coworkers (20 1 6) reported dize the normal one.
similar results from the database of the Consortium on Safe Prerequisites to selective termination include a precise diag­
Labor. They recommended prelabor cesarean delivery for trip­ nosis for the anomalous fetus and absolute certainty of fetal
lets. Importantly, the overall cesarean delivery rate among trip­ location. Unless a special procedure such as umbilical cord
lets was 95 percent. interruption is used, selective termination should be performed
only in multichorionic multifetal gestations to avoid damag­
ing the surviving fetuses (Lewi, 2006) . Roman and coworkers
SELECTIVE REDUCTIO N OR TERM I NATION
(20 1 0) compared 40 cases of bipolar umbilical cord coagula­
In some cases of higher-order multi fetal gestation, reduction tion with 20 cases of radiofrequency ablation for treatment of
of the fetal number to two or three improves survival of the complicated monochorionic multifetal gestations at midpreg­
remaining fetuses. Selective reduction implies early pregnancy nancy. hey found similar survival rates of 87 and 88 percent,
intervention, whereas selective termination is performed later. and a median gestational age > 36 weeks at delivery in both.
he procedure should be performed by an operator skilled and Prefumo and colleagues (20 1 3) reported their preliminary
experienced in sonographically guided procedures. experience with microwave ablation of the umbilical cord for
selective termination in two monochorionic twin pregnancies.
One pregnancy aborted within 7 days, and the other resulted in
• Selective Reduction a term singleton delivered at 39 weeks' gestation.
Reduction of a selected fetus or fetuses in a multichorionic Evans and coworkers ( 1 999) have provided the most com­
multifetal gestation may be chosen as a therapeutic intervention prehensive results to date on second-trimester selective termina­
to enhance survival of the remaining fetuses (American College tion for fetal abnormalities. A total of 402 cases were analyzed
of Obstetricians and Gynecologists, 20 1 7b) . One metaanalysis from eight centers worldwide. Included were 345 twin, 39 trip­
of nonrandomized prospective studies indicates that pregnancy let, and 1 8 quadruplet pregnancies. Selective termination using
reduction to twins compared with expectant management is potassium chloride resulted in delivery of a viable neonate or
associated with lower rates of maternal complications, preterm neonates in more than 90 percent of cases, with a mean age
birth, and neonatal death (Dodd, 2004, 20 1 2) . of 3 5 . 7 weeks at delivery. The entire pregnancy was lost in 7
Pregnancy reduction can b e performed transcervically, percent of pregnancies reduced to singletons and in 1 3 percent
transvaginally, or transabdominally, but the transabdominal of those reduced to twins. The gestational age at the time of
route is usually easiest. Transabdominal fetal reductions are the procedure did not appear to afect the pregnancy loss rate.
typically performed between 1 0 and 1 3 weeks' gestation. This Before selective termination or reduction, a discussion should
gestational age is chosen because most spontaneous abortions include the morbidity and mortality rates expected if the preg­
have already occurred, the remaining fetuses are large enough nancy is continued; the morbidity and mortality rates expected
to be evaluated sonographically, the amount of devitalized fetal with surviving twins or triplets; and the risks of the procedure
tissue remaining after the procedure is small, and the risk of itself (American College of Obstetricians and Gynecologists,
aborting the entire pregnancy as a result of the procedure is 20 1 7b) . Speciic risks of selective termination or reduction are:
 OBSTETRICS II
3D
 MULTIFETAL PREGNANCY
OBII-12 Dr. Charisse Hu rtado | October 15, 2019
ETIOLOGY OF MULTIFETAL FETUSES
FRATERNAL TWIN
o Fertilization of 2 separate ova by 2 separate sperms
o “Double ova,” or dizygotic
o More common
o Always dichorionic, diamnionic
Causes:
- Environmental factors
- Heredity
- Increasing maternal age (>37yo)
- Increasing Parity
- Nutritional factors
- Pituitary Gonadotropin
- Infertility Therapy
- Assisted reproductive therapy

IDENTICAL TWIN
o Arises from single fertilized ovum and the formed
zygote divides into 2
o Frequency is relatively constant worldwide
o “Single ovum,” or monozygotic
o Have an increased incidence of discordant
malformation
Causes:
- Largely independent of race, heredity, age and
parity *Perinatal mortality and neurological injury rates are greater in
- Increased in assisted reproductive therapy monochorionic diamnionic twins.

SUPERFETATION AND SUPERFECUNDATION

Superfetation
 an interval as long as or longer than a menstrual
cycle intervenes between fertilizations
 requires ovulation and fertilization during the
course of an established pregnancy
 result from markedly unequal growth and
development of twin fetuses with the same
gestational age
Superfecundation
 refers to fertilization of two ova within the same
menstrual cycle but not at the same coitus, nor
necessarily by sperm from the same male
 may occur with ART, women should be advised
GENESIS OF MONOZYGOTIC TWINNING
to consider avoiding intercourse after embryo
*Once a structure has already differentiated, it will no
transfer
longer divide.

Tissue Time of Differentiation

DETERMINATION OF ZYGOSITY AND
Post fertilization
CHORIONICITY
Chorion Day 4 Infant Sex and Blood Type:
Amnion Day 8
 Twins of the opposite sex are almost always dizygotic
Embryonic Disk Day 12
 Infants of different blood types are dizygotic

1 CAYETANO
 OBII-12 MULTIFETAL PREGNANCY
Ultrasound:
 Number of placenta (chorionicity) can give clue on
zygosity
 Accuracy is greatest in the first trimester (10-13weeks)
 DICHORIONIC: presence of two separate placentas
and a thick (2mm or greater) dividing membrane,
termed “Twin-peak” sign or Lambda/ Delta sign

Case 1
38yo, G3P2 (2002)
14weeks AOG, with history of Asthma
UTZ: Twin Live Intrauterine pregnancy
Cephalic – Breech
14 weeks by UTZ
(+) Twin-peak sign
What is the complete diagnosis?
 MONOCHORIONIC: dividing membrane, called
“T” sign, is <2mm in thickness and reveals only 2  G3P2 Twin Pregnancy 14weeks, Cephalic-Breech,
layers Dichorionic, Diamnionic

When trying to establish chorionicity of the pregnancy

shown in the image below, which of the following
statements is true?

Placental Examination:
 Visual examination of placenta and membranes a. There are 2 placentas
 Placenta should be carefully delivered to preserve the b. The twins must be monozygotic (*only 1 gestational sac)
attachment of the amnion and chorion to the placenta c. The twins share the same amnion
d. The twins must have risen from two ova

DIAGNOSIS OF MULTIPLE FETUS

Fundal Height: PREGNANCY COMPLICATIONS
 5cm greater than expected of singleton pregnancies  Spontaneous abortion
Ultrasonography:  Congenital fetal malformations
 Separate gestational sacs can be identified early in twin  Low birthweight
pregnancy  Hypertension (blood volume expansion up to 50-60%)
 Two fetal heads or two abdomens should be seen in  Preterm birth
the same plane, to avoid scanning the same fetus twice  Long term infant development
and interpreting it as twins

2 CAYETANO
 OBII-12 MULTIFETAL PREGNANCY
COMPONENTS OF ANTEPARTUM  Growth discordancy alone is not an indication of
MANAGEMENT OF TWIN PREGNANCY immediate delivery
Prenatal Care (POGS CPG)  Increased surveillance is warranted in cases of
 Every month until 24weeks (*Normal – until significant growth discordancy
28weeks)
 Every 2weeks until 32weeks (*Normal - until Fetal Wellbeing Studies
36weeks)  Biometry every 2weeks
 Weekly thereafter  NST/BPS twice weekly
Diet  Weekly Doppler ultrasound (to diagnose IUGR)
 Caloric requirement is increased (40-  Steroid at 24-34 weeks
45kcal/kg/day)
 Iron supplement is doubled (*Normal - 27mg) Case 2
 Folic acid is increased to 1mg/day CAS at 20weeks – Normal
 ASA 80mg OD (to prevent preeclampsia) Biometry every 4weeks
 Weight gain (37-54kgs) 32weeks: Cephalic-Breech
Prevention of Preterm Delivery Twin A: 1,850grams
 Bed rest Twin B: 1,375grams
 Tocolytic therapy Is there growth discordancy?
 Corticosteroids for lung maturation = 1850-1375 x 100%
 Cerclage – not been shown to improve perinatal outcome 1850
 Twin gestation with preterm ruptured membranes = 25.7% (+) growth discordancy
are managed expectantly much like singleton
pregnancies Case 3
Antepartum Surveillance 32weeks: Doppler of the umbilical artery revealed normal
 Ultrasound at 10-13weeks (ideal time to determine indices
chorionicity) BPS 8/8 (normal)
 Congenital Anomaly Scan (CAS) at 18-22weeks 36weeks: Cephalic-Breech
 Biometry every 4weeks Twin A: 2,850grams
 Biophysical Profile Scoring (BPS)/ Non Stress Twin B: 2,050grams
Test (NST) (starting at 28weeks) Dichorionic – Diamnionic
 Doppler studies in case of IUGR Is there growth discordancy?
= 2850-2050 x 100%
DISCORDANT TWINS 2850
o Size inequality of twin fetuses = 28% (+) growth discordancy
 20mm difference in abdominal circumference
 % discordancy:
Weight of bigger – Weight of smaller x 100% INTRAPARTUM MANAGEMENT
Weight of bigger twin o Timely attendance by a physician competent to
 >20% is considered discordant twins manage a twin birth
o As the weight difference within a twin pair increases, o Assessment of lie and presentation
perinatal mortality increases proportionately o Blood readily available for use (for possible uterine atony)
Pathology: o Epidural anesthesia is advantageous
1. Monochorionic Twins o Continuous EFM for both twins
 Placental vascular anastomoses that cause o Active management of the third stage
hemodynamic imbalance between the twins 1. Oxytocin
2. Controlled Cord Traction
 Unequal placental sharing 3. Cord Clamping
2. Dizygotic fetuses may have different genetic growth
potential
DELIVERY
 One placenta may have suboptimal placental site A. Cephalic – Cephalic Vaginal (if dichorionic)
CS (if monochorionic, monoamnionic)
Principles In The Management Of Growth
Discordancy B. Cephalic – Noncephalic Vaginal (if<1500kg)
 IUGR is more predictive of poor perinatal outcome EFW: 1500-4000grams CS
than growth discordancy alone
C. Twin A Non vertex Planned CS
3 CAYETANO
 OBII-12 MULTIFETAL PREGNANCY
Which of the following scenarios presents the best 2. Hydramnios (largest vertical pocket >8cm) in
opportunity for a vaginal trial of labor? one sac and oligohydramnios (largest vertical
a. Nonvertex – Vertex presentation pocket <2cm) in the other twin sac
b. Vertex – Nonvertex presentation *Stuck twin or polyhydramnios-oligohydramnios
c. Nonvertex 2nd twin with EFW <1,500grams syndrome “polyoli” - virtual absence of amnionic fluid in
d. Vertex Twin B with EFW >20% larger than the the donor sac preventing fetal motion; associated with growth
presenting vertex twin restriction, contractures, and pulmonary hypoplasia in the donor
twin, and premature rupture of the membranes and heart failure
Case 4 in the recipient
After 8hours of labor, Twin A delivered vaginally with  Other ultrasonographic criteria:
good outcome. 1. Gender concordance
How should the 2nd twin be delivered? 2. Growth discordancy >20%
 External Cephalic Version (ECV) 3. Umbilical cord size discrepancy
 May be attempted but operator skill dependent 4. Cardiac dysfunction in the recipient twin
 More associated with fetal distress 5. Abnormal Doppler studies
o TTTS Quintero Staging System
 Total Breech Extraction
Stage I: discordant amnionic fluid volumes
 Possible
(polyhydramnios/oligohydramnios) but urine is still
 Associated with lower rates of CS
visible sonographically within the bladder of the
donor twin, Doppler studies are normal
Stage II: criteria for stage I but urine is not visible
UNIQUE COMPLICATIONS within the donor bladder
Monoamnionic Twins Stage III: criteria for stage II and abnormal Doppler
 Associated with high risk fetal death rate: studies of the umbilical artery, ductus venosus or
– Cord entanglement umbilical vein; Donor – absent/ reversed EDF while
– Congenital Anomaly Recipient – reversed wave or pulsatile umbilical vein
– Pre-term Birth Stage IV: ascites or frank hydrops in either twin
– Twin-to-twin Transfusion syndrome Stage V: demise of either twin
 Management: o Management:
– 1hour daily fetal heart rate monitoring beginning  Amnioreduction
at 26-28weeks  Laser ablation of vascular placental anastomoses
– Corticosteroid therapy at this time to promote  Selective feticide
fetal lung maturity  Septostomy
– CS at 34weeks o Prognosis:
- Related to Quintero Stage and gestational age at
TWIN-TO-TWIN TRANSFUSION SYNDROME presentation
 From a monochorionic placenta - Stage I: >3/4 remain stable or regress without
 Blood is transfused from a donor twin to its recipient intervention
sibling - Stage III and higher: perinatal loss rate is 70-100%
DONOR TWIN RECIPIENT TWIN without intervention
Anemic Plethoric
Growth restricted Hydropic (due to circulatory If one twin of an affected pregnancy dies, cerebral
overload heart failure ) pathology in the survivor results from acute
hypotension due to an emboli of thromboplastic
Polycythemic
material originating from the dead fetus
This morbidity was related to the gestational age at the
o Chronic TTTS results from the unidirectional flow
death of the cotwin. If the death occurred:
through deep arteriovenous anastomoses
 between 28 and 33 weeks’ gestation,
o Deoxygenated blood from a donor placental artery is
monochorionic twins – 8fold risk of
pumped into a cotyledon shared by the recipient
neurodevelopmental morbidity
o One oxygen exchange is completed in the chorionic
 after 34 weeks, the likelihood decreased – odds
villus, the oxygenated blood leaves the cotyledon via a
ratio 1.48
placental vein of the recipient twin
o Diagnosis: Immediate delivery is not considered beneficial in the absence of
another indication.
 Based on 2 sonographic criteria
1. Monochorionic diamnionic pregnancy is
identified
4 CAYETANO
 OBII-12 MULTIFETAL PREGNANCY
TWIN REVERSED ARTERIAL PERFUSION Which of the following is the most important predictor of
(TRAP) SEQUENCE neurologic outcome of the survivor after death of a co-
 “Acardiac Twin” twin?
 From a monochorionic placenta a. Chorionicity
 Rare but serious complication of monochorionic b. Gestational age at the time of demise
gestation (1 in 35,000 births) c. Malformations present in the deceased twin
 There is normally formed donor that shows features d. Length of time between demise and delivery of
of heart failure and a recipient twin that lacks a heart survivor
(acardius) and other structures
 Arterial-arterial and venous-venous anastomoses Case 5
A 40yo G5 sought consult at the outpatient department.
Early ultrasound revealed a twin gestation which could
have divided between days 8-12 post fertilization.
Regarding manner of delivery, which of the following
statements is correct?
a. Vaginal delivery if the presentation is cephalic-cephalic
b. Elective CS if one of the twins is non-cephalic
c. Regardless of presentation, elective CS at 39weeks
d. Elective CS at 34weeks

STUDY GUIDE QUESTIONS 24TH EDITION

45–1. Compared with singleton pregnancies, multifetal
gestations have a higher risk of all EXCEPT which of the
following complications?
a. Preeclampsia b. Hysterectomy
c. Maternal death d. Postterm pregnancy
45–2. Compared with singleton pregnancies, multifetal
gestations have an infant mortality rate that is how many
times greater?
a. Twofold b. Threefold
c. Fivefold d. Tenfold
45–3. Which of the following mechanisms may prevent
monozygotic twins from being truly “identical”?
a. Postzygotic mutation
b. Unequal division of the protoplasmic material
c. Variable expression of the same genetic disease
d. All of the above
45–4. A patient delivers a twin gestation in which one
infant has blood type A and one has type O. The patient
DEATH OF ONE FETUS and her husband are both type O. A particular
 “vanishing twin” phenomenon is proposed as the etiology of the discordant
 the prognosis for the surviving twin depends on the blood types. How would you explain this to the mother?
gestational age and chorionicity a. The proposed phenomenon does not spontaneously
occur in humans.
Dichorionic Monochorionic c. It involves fertilization of two ova within the same
Pregnancies Pregnancies menstrual cycle, but not at the same coitus.
Risk of Small Increased d. It involves fertilization of two ova separated in time
Complication by an interval as long as or longer than a menstrual cycle.
With neurologic 45–6. Which of the following factors increases the risk for
abnormality monozygotic twinning?
Delivery At 37weeks If remote from term: a. Increased parity
Expectant b. Increased maternal age
Neonatal Likely with c. The father is an identical twin.
Survival immediate delivery d. None of the above

5 CAYETANO
 OBII-12 MULTIFETAL PREGNANCY
45–7. The first-trimester sonographic image here shows 45–14. A patient presents for prenatal care at 12 weeks’
two fetal heads arising from a shared body. How many gestation and wants to know about specific risks to her
days after fertilization must the division of this zygote have pregnancy. She has spontaneously conceived a
occurred to lead to the abnormality shown? monochorionic twin gestation. Which statement is false
a. 0–3 days b. 4–7 days regarding these twins?
c. 8–12 days d. More than 13 days a. They have a higher risk of pregnancy loss than
45–8. A patient with twins is referred for prenatal care. At fraternal twins.
the referring clinic, she had several sonographic b. Those born at term have a higher risk of cognitive
examinations that establish these to be monochorionic delay than term singletons.
twins. Today, you see only one fetus sonographically. c. They have twice the risk of malformations compared
Which of the following statements is false regarding the with singleton pregnancies.
risk of a vanishing twin? d. They have a lower risk of pregnancy loss than
a. The risk exceeds 10% in multifetal gestations. identical twins conceived with assisted reproductive
b. The risk is higher in monochorionic than in technologies.
dichorionic pregnancies. 45–15. The differential diagnosis of clinically suspected
c. This risk is increased if she used assisted reproductive twins includes all EXCEPT which of the following?
technologies to conceive. a. Obesity b. Hydramnios
d. A vanishing twin does not affect first-trimester c. Leiomyomas d. Blighted ovum
biomarker testing if it occurs after 10 weeks’ gestation. 45–16. Regarding maternal adaptations to multifetal
45–9. What is the approximate risk of triplet or higher pregnancy, which of the following is lower in twin
order multifetal gestation if ovarian stimulation and pregnancy compared with that in a singleton pregnancy?
intrauterine insemination is used to achieve pregnancy? a. Blood volume expansion
a. 10% b. 20% b. Blood pressure at term
c. 30% d. 40% c. Blood loss at delivery
45–10. What can be confirmed about the placenta being d. Systemic vascular resistance
examined in the image here? 45–17. A fetus that is part of a dichorionic twin pair is
a. Dizygosity estimated to weigh 2000 g at 33 weeks’ gestation. What can
b. Monozygosity be said about its growth?
c. One chorion, two amnions a. The fetus already shows growth restriction.
d. Two chorions, two amnions b. The fetus will be growth restricted at term.
45–11. Which of the following is true regarding the rate of c. The fetal growth is adequate for gestational age.
monozygotic twinning? d. Growth differences will not be apparent until delivery.
a. It approximates 1 in 250 worldwide. 45–18. Among complications that may be seen in twin
b. It is increased with maternal age and parity. pregnancies, which of the following may be seen in
c. It is lower for Hispanic women than for white women. dichorionic pregnancies?
d. It can be modified by FSH (follicle-stimulating a. Acardiac twin
hormone) treatment. b. Fetus-in-fetu
45–12. Which of the following statements is true regarding c. Twin-twin transfusion syndrome
chorionicity in multifetal pregnancy? d. Complete mole with coexisting normal twin
a. Dichorionic pregnancies are always dizygotic. 45–19. What is the major cause of increased neonatal
b. Monochorionic membranes should have four layers. morbidity rates in twins?
c. Monochorionic pregnancies are always monozygotic. a. Preterm birth
d. Chorionicity is accurately determined by measuring b. Congenital malformations
the thickness of the dividing membranes during c. Abnormal growth patterns
sonographic examination in the first trimester. d. Twin-twin transfusion syndrome
45–13. Among the following choices, which is the 45–20. When diagnosed at 20 weeks’ gestation, which of
strongest risk factor for multifetal pregnancy? the following statements is true regarding the twin vascular
a. Advanced maternal age complication seen in the image here?
b. Use of clomiphene citrate a. It precludes vaginal delivery.
c. African American ethnicity b. It implies the twins are conjoined.
d. Maternal history of being a twin herself c. It has a 50% associated fetal mortality rate.
d. It can be monitored effectively with daily sonography.

6 CAYETANO
 OBII-12 MULTIFETAL PREGNANCY
45–21. Which are the most common vascular anastomoses 45–29. With growing discordance, rates of which of the
seen in monochorionic twin placentas? following neonatal complications are increased?
a. Deep vein-vein a. Neonatal sepsis
b. Deep artery-vein b. Necrotizing enterocolitis
c. Superficial artery-vein c. Intraventricular hemorrhage
d. Superficial artery-artery d. All of the above
45–22. Which of the following statements is true in twin 45–31. Which of the following methods of antepartum
reversed-arterial-perfusion (TRAP) sequence? fetal surveillance has been shown to improve outcomes in
a. It is caused by a large arteriovenous placental shunt. twin pregnancies?
b. The donor is at risk of cardiomegaly and high output a. Nonstress test
heart failure. b. Biophysical profile
c. The most effective treatment is injection of KCl into c. Doppler velocimetry of the umbilical artery
the recipient twin. d. None of the above
d. Placental arterial perfusion pressure in the recipient 45–32. Which of the following interventions has been
exceeds that of the donor. shown to decrease the rate of preterm birth in twins?
45–23. A pair of monochorionic twins presents at 20 a. Cerclage
weeks’ gestation with sonographic findings that suggest b. Betamimetics
twin-twin transfusion syndrome. There is significant c. 17-Hydroxyprogesterone caproate
growth discordance, no bladder is visualized in the smaller d. None of the above
twin, neither twin has ascites or hydrops, and umbilical 45–33. Which of the following findings can predict a lower
Doppler studies are normal. What would be the assigned risk of preterm birth in twins?
Quintero stage? a. Closed cervix on digital examination
a. Stage I b. Stage II b. Negative fetal fibronectin assessment
c. Stage III d. Stage IV c. Normal cervical length measured by transvaginal
45–24. The recipient cotwin in a monochorionic twin sonography
gestation affected by twin-twin transfusion syndrome may d. All of the above
experience all EXCEPT which of the following neonatal 45–34. Which is the most common presentation of twins
complications? in labor?
a. Thrombosis b. Hypovolemia a. Vertex/vertex b. Vertex/breech
c. Kernicterus d. Heart failure c. Breech/vertex d. Vertex/transverse
45–25. What percentage of Quintero stage I cases remain 45–35. For twins in labor, risk factors for an unstable fetal
stable without intervention? lie include all EXCEPT which of the following?
a. 25% b. 50% a. Small fetuses
c. 75% d. 90% b. Polyhydramnios
45–26. Which of the following therapies for severe twin- c. Increased maternal parity
twin transfusion syndrome has been shown in a d. Vertex/vertex presentation
randomized trial to improve survival rates of at least one
twin to age 6 months?
a. Septostomy
b. Amnioreduction
c. Selective feticide
d. Laser ablation of vascular anastomoses
45–27. What is the calculated fetal growth discordance of a
twin pair where the estimated fetal weight of twin A is 800
g and that of twin B is 600 g?
a. 10% b. 15%
c. 25% d. 33%
45–28. A second sonographic evaluation of the twin pair
described in Question 45–27 shows 27% discordance. One
fetus is male and one is female. Which mechanism is not
the likely cause of their discordance?
a. Unequal placental sharing
b. Different growth potential
c. Histological placental abnormality
d. Suboptimal implantation of one placental site

7 CAYETANO
MULTIFETAL PREGNANCY OB II | MIDTERMS (1st Sem)
Dr. Daisy Dulnuan

OUTLINE II. MULTIPLE ECTOPIC PREGNANCY

I. I. TYPES OF MULTIFETAL PREGNANCY  Combined intrauterine and extrauterine pregnancy; or
II. II. MULTIPLE ECTOPIC PREGNANCY
III. III.MECHANISM OF MULTIFETAL GESTATION
 Both embryos or fetuses can be extrauterine
A. Superfetation and Superfecundation
B. Determining Chorionicity and Zygosity III. MECHANISM OF MULTIFETAL GESTATION
C. Diagnosis of Multifetal Gestation
IV. IV. PREGNANCY COMPLICATIONS Genesis of Monozygotic Twin
V. V. COMPONENTS OF ANTEPARTUM MANAGEMENT  Increased two- to fivefold in pregnancies conceived
VI. VI. TWIN-TWIN TRANSFUSION SYNDROME
A. Diagnosis of TTTS
using assisted reproductive technology
B. Management of TTTS  Outcome of the monozygotic twinning process
VII. VII. DISCORDANT GROWTH OF TWIN FETUSES depends on when division occur:
A. Diagnosis of Discordant Fetuses
B. Principles of Management of Discordant Fetuses 72 hours Diamnionic
VIII. VIII. PREVENTION OF PRETERM DELIVERY Dichorionic
IX. IX. LABOR AND DELIVERY
X. X. TRIPLET OR HIGHER ORDER GESTATION 4th- 8th day Diamnionic
XI. XI. REDUCTION AND TERMINATION Monochorionic
XII. XII. DEATH OF A FETUS
* Those highlighted in red are the concepts discussed by Dr. Dulnuan during her 8th day Monoamionic
online discussion last 10-27-2020
Monochorionic

I. TYPES OF MULTIFETAL PREGNANCY

A. FRATERNAL, DIZYGOTIC, DOUBLE-OVUM TWINS A. Superfetation and Superfecundation
 Arises from the fertilization of two separate ova during Superfetation
a single ovulatory cycle  An interval as long as or longer than a menstrual
cycle intervenes between fertilizations
 Influenced by race, heredity parity and age
 Requires ovulation and fertilization during the course
 More common
of an established pregnancy
 Result from markedly unequal growth and
B. IDENTICAL, MONOZYGOTIC, OR SINGLE OVUM TWINS development of twin fetuses with the same gestational
 Arises from the fertilization of a single ovum which age
early in its stage of development splits into two
separate identical halves, each with the potential of Superfecundation
developing into complete identical  Refers to fertilization of two ova within the same
 Frequency is more or less the same menstrual cycle but not at the same coitus, nor
necessarily by sperm from the same male
A. Classification  May occur with art, women should be advised to
consider avoiding intercourse after embryo transfer

Factors affecting twinning

 Race (common among Blacks)
 Heredity
 Fertility treatment
 Parity
 Maternal age -important risk factor
o Frequency rises almost fourfold between the
ages of 15 and 37 years
o Paradox of declining fertility but increasing
twinning rates with advancing maternal age
 Maternal Size and Nutrition (obese)
 There may also be instances that one of the twins may be
 Induction of Ovulation
blighted and never develops significantly enough to be
ever recognized.
B. Determining Zygosity and Chorionicity
 Fetal death up the end of the first trimester can lead to
 Twins of the opposite sex are almost always dizygotic
complete resorption of the involved product, and leave no
traces at delivery
Sonographic determination
 Integral tool to assist in multifetal pregnancy
FETUS PAPYRACEOUS OR COMPRESSUS
management
 Fetal death at the end of first
 Recognized indication for first-trimester sonography
trimester can be retained up to the
end of pregnancy becoming
Four features assessed after 10th-14th wk AOG:
markedly shrunken and
1. number of placental masses
compressed between the uterine
2. thickness of the membrane dividing the sacs
wall and membraned of the loving
3. presence of an intervening membrane
twin
4. fetal gender

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 Midterms (1st Sem) Multifetal Pregnancy
Dr. Daisy Dulnuan
OB II· October 27, 2020

IDENTIFICATION OF THICK DIVIDING MEMBRANE  Two fetal heart tones with a rate difference of at least 10
1. Dichorionic beats per minute
 Generally >2mm- supports presumed diagnosis of  Ultrasound
dichorionicity
 Composed of a total of four layers: Fundal Height:
 Two amnion  5cm greater than expected of singleton pregnancies
 Two chorion
Twin peak sign Ultrasonography:
 Also called lambda or delta sign; the point  Most accurate method
of origin of the dividing membrane on the  Separate gestational sacs can be identified early in
placental surface twin pregnancy
 Peak appears as a triangular projection of  Two fetal heads or two abdomens should be seen in
placental the same plane, to avoid scanning the same fetus
 Tissue extending a short distance between twice and interpreting it as twins
the layers of the dividing membrane

Figure 3. Sonograms of first trimester twins. A. Dichorionic diamnionic twin. B.

Monochorionic diamnionic twin.

Figure 1.Sonographic image of the “twin-peak” sign also termed as “lambda IV. PREGNANCY COMPLICATIONS
sign” in 24-wk gestation.  Spontaneous abortion
 Congenital fetal malformations
2. Monochorionic  Low birthweight
 Pregnancies have a dividing membrane that is so thin
 Hypertension (blood volume expansion up to 50 -60%)
 Generally <2 mm that it may not be seen until the
 Preterm birth
second trimester
 Long term infant development
T sign
A. Maternal Risks/Complications
 Relationship between the membranes and placenta
 Increased symptoms of early pregnancy (more
without apparent extension of placenta between the
pronounced nausea, vomiting)
dividing membranes
 Increased risk of miscarriage (greater likelihood of genetic
abnormality)
 Vanishing twin syndrome
 Minor disorders of pregnancy
 Hypertension
 Preterm labor and delivery
 Anemia
 Antepartum Hemorrhage
 Hydramnios
 Possible need for prenatal hospitalization
Figure 2..Sonographic image of the “T” sign in a monochorionic diamnionic  Single fetal death in twins
gestation at 30 weeks.  Increased risk of an operative vaginal birth
 Increased likelihood of cesarean birth (most likely due to
Placental Examination: malpresentation)
 Visual examination of placenta and membranes  Postpartum hemorrhage
 Placenta should be carefully delivered to preserve the  Postnatal problems
attachment of the amnion and chorion to the placenta  Maternal mortality
 Malpresentation
C. Diagnosis of Multifetal Gestation
 Family history B. Fetal Risks
 Assisted reproduction  Stillbirth or neonatal death
 A gravid uterus larger than the age of gestation  Single fetal death in twins
 Multiplicity of small parts as noted on palpation  Preterm labor and delivery
 Palpation of two heads and two buttocks  Intrauterine growth restriction

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 Midterms (1st Sem) Multifetal Pregnancy
Dr. Daisy Dulnuan
OB II· October 27, 2020

 Congenital anomalies LABOR AND DELIVERY

 Congenital anomaly in one twin Hospital Delivery III B
 Twin reverses arterial perfusion sequence Experienced Obstetrician and other health III B
professionals
 Conjoined twins Await spontaneous labor if no complication Ia A
 Cord accident occur
 Zygosity Pediatrician neonatal nurse, and anesthetist III GPP
 Monoamniotic twins available at the time of delivery, with one
pediatrician at infant present if preterm delivery
 Hydramnios or operative delivery or fetal problems are
 Twin-twin transfusion syndrome anticipated
 Risks of asphyxia Continuous monitoring of all fetuses during labor III B
 Operative vaginal birth, especially for the second of twin IV access III GPP
Epidural analgesia recommended III B
 Twin entrapment
Aim for vaginal delivery unless the leading twin III B
 Cerebral palsy has a nonlongitudinal lie
Some advocate elective cesarean delivery if the III B
C. Management Options first of twin is not cephalic
PREPREGNANCY Quality of Strength of Vaginal delivery of the first of twin, if appropriate III B
Evidence Recommendation Synthetic oxytocin infusion for uterine inertia, - GPP
Counsel women about the risk III B especially after the first twin is delivered
of multiple pregnancy If the second twin has a longitudinal lie, III B
No data available to guide on Ia A amniotomy and delivery
“ideal” number of If an infant has a nonlongitudinal lie, convert to a III B
embryos/oocytes longitudinal lie by external version or internal
Pre-conceptional & peri- Ia A podalic version
conceptual folate Prophylactic oxytocin infusion after delivery to Ia A
supplementation reduce risk of postpartum hemorrhage
Some advocate elective cesarean delivery for IIB B
triplets and higher-order births
PRE-NATAL
Specialized clinics may lessen adverse III B
outcomes POSTNATAL
Documentation of zygosity or chorionicity at 10- III B Extra support while in the hospital to assist with GPP
14 weeks infant care
No prospective data on whether this IIb B Offer longer in-patient stay GPP
documentation improves outcome Arrange support at home GPP
Increased surveillance if twins are at increased IIb B Provide adequate contraceptive advice GPP
risk for adverse outcome
Iron and Folate supplementation from second IIb B V.COMPONENTS OF ANTEPARTUM MANAGEMENT OF
trimester TWIN GESTATION
Screening for hypertension IIa B
Prenatal care
Conflicting evidence of the value of screening IIa B
for gestational diabetes  Primary goals aim to prevent or interdict complications
Nuchal translucency measurement of each fetus III B as they develop
identifies fetuses at risk for trisomy21,  Visits every 2wks beginning at 22wks AOG
cardiothoracic abnormalities, & Twin-Twin Diet
Transfusion Syndrome
 Caloric requirement is increased (40-45kcal/kg/day)
Routine Anomaly Ultrasound scan at 18-20 wks III B
 Iron supplement is doubled (*Normal - 27mg)
CONJOINED TWINS III B  Folic acid is increased to 1mg/day
 Careful ultrasonographic evaluation of  ASA 80mg OD (to prevent preeclampsia)
anatomy  Weight gain (37-54kgs)
 Interdisciplinary discussion of therapeutic
options VI. TWIN-TWIN TRANSFUSION SYNDROME
Vigilance for early symptoms of preterm labor; Ib A
 From a monochorionic placenta
Prompt self-referral if it is suspected
Possible ultrasound assessment of cervical IIa B  Blood is transfused from a donor twin to its recipient
changes and fetal fibronectin as part of preterm sibling
delivery screening  Presents in midpregnancy when the donor fetus becomes
Prenatal corticosteroids preterm birth before 34 Ia A oliguric from decreased renal perfusion
weeks is possible
o This fetus develops oligohydramnios, and the
No evidence that hospitalization to prevent Ia A
preterm labor and delivery is effective recipient fetus develops severe hydramnios
No evidence that prophylactic cervical cerclage Ia A
is effective to prevent preterm labor and delivery Chronic TTTS results from the unidirectional flow through
Regular fetal ultrasound assessment of growth Ib A deep arteriovenous anastomoses
and umbilical artery doppler
 Deoxygenated blood from a donor placental artery is
Hospitalization at the woman’s request or if Ia A
complications are detected pumped into a cotyledon shared by the recipient
Consider therapeutic amniocentesis for extreme IIb B  One oxygen exchange is completed in the chorionic
hydramnios and maternal distress villus, the oxygenated blood leaves the cotyledon via a
Prenatal education about possible modes of IV C placental vein of the recipient twin
delivery, analgesia, and care in labor

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 Midterms (1st Sem) Multifetal Pregnancy
Dr. Daisy Dulnuan
OB II· October 27, 2020

Prognosis:
o Related to Quintero Stage and gestational age at
presentation
o Stage I: >3/4 remain stable or regress without
Figure 3..Anastomoses between twins intervention
maybe artery-to-vein, artery-to-artery or vein- o Stage III and higher: perinatal loss rate is 70-100%
to-vein without intervention

 If one twin of an affected pregnancy dies, cerebral

pathology in the survivor results from acute hypotension
Fetal brain damage:
due to an emboli of thromboplastic material originating
 Cerebral palsy, microcephaly, porencephaly and from the dead fetus
multicystic encephalomalacia are serious  This morbidity was related to the gestational age at the
complications associated with placental vascular death of the cotwin.
anastomoses
 If the death occurred: between 28 and 33 weeks’
o Donor twin- ischemia results from
gestation,
hypotension, anemia, or both
o Monochorionic twins – 8fold risk of
o Recipient twin- ischemia develops from
neurodevelopmental morbidity
blood pressure instability and episodes of
o After 34 weeks, the likelihood decreased –
profound hypotension
odds ratio 1.48
 Immediate delivery is not considered beneficial in the
A. Diagnosis of TTTS
absence of another indication
Based on 2 sonographic criteria
1. Monochorionic diamnionic pregnancy is Identified
VII. DISCORDANT GROWTH OF TWIN FETUSES
2. Hydramnios (largest vertical pocket >8cm) in one sac and
 Size inequality of twin fetuses
oligohydramnios (largest vertical pocket <2cm) in the
other twin sac  May reflect pathological growth restriction in one fetus

Stuck twin or polyhydramnios-oligohydramnios syndrome Causes:

“polyoli” o Monochorionic twins
 Virtual absence of amnionic fluid in the donor sac  Attributed to placental vascular anastomoses
preventing fetal motion that cause hemodynamic imbalance between
o Associated with growth restriction, the twins
o Dizygotic twins
contractures, and pulmonary hypoplasia in
the donor twin, and premature rupture of the  Have different genetic growth potential
membranes and heart failure in the recipient especially if they are of opposite genders
 One placenta might have a suboptimal
Other ultrasonographic criteria: implantation site
1. Gender concordance
2. Growth discordancy >20% A. Diagnosis of discordant fetuses
3. Umbilical cord size discrepancy % discordancy:
4. Cardiac dysfunction in the recipient twin
5. Abnormal Doppler studies
 >20% is considered discordant twins
TTTS Quintero Staging System  As the weight difference within a twin pair increases,
Stage I Discordant amnionic fluid volumes but urine is perinatal mortality increases proportionately
still visible sonographically within the bladder of
the donor twin B. Principles of management of discordant fetuses
Stage II Criteria of stage I, but urine is not visible within  IUGR is more predictive of poor perinatal outcome than
the donor bladder growth discordancy alone
Stage III Criteria of stage II and abnormal Doppler studies  Growth discordancy alone is not an indication of
of the umbilical artery, ductus venosus, or immediate delivery
umbilical vein  Increased surveillance is warranted in cases of significant
Stage IV Ascites or frank hydrops in either twin
growth discordancy
Stage V Demise of either fetus.
Fetal Wellbeing Studies
B. Management of TTTS
1. Biometry every 2weeks
 Amnioreduction
2. NST/BPS twice weekly
o Laser ablation of vascular placental anastomoses
3. Weekly Doppler ultrasound (to diagnose IUGR)
 Selective feticide 4. Steroid at 24-34 weeks
 Septostomy

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 Midterms (1st Sem) Multifetal Pregnancy
Dr. Daisy Dulnuan
OB II· October 27, 2020

Antepartum Surveillance XI. REDUCTION AND TERMINATION

1. Ultrasound at 10-13weeks (ideal time to determine Reduction
2. chorionicity) o May be chosen as a therapeutic intervention to
3. Congenital Anomaly Scan (CAS) at 18-22weeks enhance survival of the remaining fetuses
Biometry every 4weeks o Can be performed transcervically, transvaginally, or
4. Biophysical Profile Scoring (BPS)/ Non Stress transabdominally (easiest)
5. Test (NST) (starting at 28weeks) o Transabdominal fetal - typically performed between 1
6. Doppler studies in case of IUGR 0 and 1 3 weeks' gestation

VIII. PREVENTION OF PRETERM DELIVERY Termination

 Bed rest o Performed later in gestation than selective reduction
 Tocolytic therapy and entails greater risk
 Corticosteroids for lung maturation o Prerequisites to selective termination include:
 Cerclage – not been shown to improve perinatal outcome 1. Precise diagnosis for the anomalous fetus
 Twin gestation with preterm ruptured membranes 2. Absolute certainty of fetal location
 are managed expectantly much like singleton
 pregnancies Specific risks of selective termination or reduction:
1. Abortion of the remaining fetuses
IX. LABOR AND DELIVERY 2. Abortion or retention of the wrong fetus(es)
1. Timing of delivery: 3. Damage without death to a fetus
 Gestational age 4. Preterm labor
 Fetal growth 5. Discordant or growth-restricted fetuses
 Lung maturity 6. Maternal complications
 Presence of maternal complications
XII. DEATH OF A FETUS
2. Evaluation of fetal presentation
3. Labor induction or stimulation  “Vanishing twin”
4. Analgesia and anesthesia  The prognosis for the surviving twin depends on the
5. Delivery route: gestational age and chorionicity
o Cephalic-cephalic presentation
 If the first twin presents cephalic, delivery can Dichorionic Monochorionic
usually be accomplished spontaneously or with Pregnancies Pregnancies
forceps. Risk of Small Increased
o Cephalic-noncephalic presentation Complication
With neurologic
 Options include cesarean delivery of both twins
abnormality
 Less commonly, vaginal delivery with
intrapartum external cephalic version of the Delivery At 37 weeks If remote from
second twin term:
 Least desirable, vaginal delivery of the first but Expectant
cesarean delivery of the second twin may be Neonatal survival Likely with
required due to intrapartum complications such immediate delivery
as umbilical cord prolapse, placental abruption,
contracting cervix, or fetal distress
o Breech presentation of first twin References
 Cesarean delivery is often preferred with a th
William’s Obstetrics 25 Edition
viable-sized fetus Old ppt (2019)
Dr. Dulnuan’s lecture & powerpoint presentation
X. TRIPLET OR HIGHER ORDER GESTATION
 Pregnancies complicated by three or more fetuses should
undergo cesarean delivery
 Vaginal delivery
o Reserved for those circumstances in which survival is
not expected because fetuses are markedly immature
or maternal complications make cesarean delivery
hazardous to the mother

MAPALO | PAGUIRIGAN | QUINTO | TAMANI 5 of 7

 Midterms (1st Sem) Multifetal Pregnancy
Dr. Daisy Dulnuan
OB II· October 27, 2020

STUDY GUIDE QUESTIONS 45–9. What is the approximate risk of triplet or higher order
multifetal gestation if ovarian stimulation and intrauterine
45–1. Compared with singleton pregnancies, multifetal gestations insemination is used to achieve pregnancy?
have a higher risk of all EXCEPT which of the following a. 10% b. 20%
complications? c. 30% d. 40%
a. Preeclampsia b. Hysterectomy 45–10. What can be confirmed about the placenta being examined
c. Maternal death d. Postterm pregnancy in the image here?
45–2. Compared with singleton pregnancies, multifetal gestations
have an infant mortality rate that is how many times greater? a. Dizygosity
a. Twofold b. Threefold b. Monozygosity
c. Fivefold d. Tenfold c. One chorion, two amnions
45–3. Which of the following mechanisms may prevent d. Two chorions, two amnions
monozygotic twins from being truly “identical”?
a. Postzygotic mutation
b. Unequal division of the protoplasmic material
c. Variable expression of the same genetic disease
d. All of the above 45–11. Which of the following is true regarding the rate of
45–4. A patient delivers a twin gestation in which one infant has monozygotic twinning?
blood type A and one has type O. The patient and her husband a. It approximates 1 in 250 worldwide.
are both type O. A particular phenomenon is proposed as the b. It is increased with maternal age and parity.
etiology of the discordant blood types. How would you explain c. It is lower for Hispanic women than for white women.
this to the mother? d. It can be modified by FSH (follicle-stimulating hormone) treatment.
a. The proposed phenomenon does not spontaneously occur in 45–12. Which of the following statements is true regarding
humans. chorionicity in multifetal pregnancy?
c. It involves fertilization of two ova within the same menstrual cycle, a. Dichorionic pregnancies are always dizygotic.
but not at the same coitus. b. Monochorionic membranes should have four layers.
d. It involves fertilization of two ova separated in time by an interval as c. Monochorionic pregnancies are always monozygotic.
long as or longer than a menstrual cycle. d. Chorionicity is accurately determined by measuring the thickness of
45-5. When trying to establish chorionicity of the the dividing membranes during sonographic examination in the first
pregnancy shown in the image here, which of the trimester.
following statements is true? 45–13. Among the following choices, which is the strongest risk
factor for multifetal pregnancy?
a. There are two placentas. a. Advanced maternal age
b. The twins must be monozygotic. b. Use of clomiphene citrate
c. The twins share the same c. African American ethnicity
amnion. d. Maternal history of being a twin herself
d. The twins must have arisen from 45–14. A patient presents for prenatal care at 12 weeks’ gestation
two separate and wants to know about specific risks to her pregnancy. She has
ova. spontaneously conceived a monochorionic twin gestation. Which
statement is false regarding these twins?
a. They have a higher risk of pregnancy loss than fraternal twins.
b. Those born at term have a higher risk of cognitive delay than term
singletons.
45–6. Which of the following factors increases the risk for c. They have twice the risk of malformations compared with singleton
monozygotic twinning? pregnancies.
a. Increased parity d. They have a lower risk of pregnancy loss than identical twins
b. Increased maternal age conceived with assisted reproductive technologies.
c. The father is an identical twin. 45–15. The differential diagnosis of clinically suspected twins
d. None of the above includes all EXCEPT which of the following?
45–7. The first-trimester sonographic image here shows two fetal a. Obesity b. Hydramnios
heads arising from a shared body. How many days after c. Leiomyomas d. Blighted ovum
fertilization must the division of this zygote have occurred to lead 45–16. Regarding maternal adaptations to multifetal pregnancy,
to the abnormality shown? which of the following is lower in twin pregnancy compared with
that in a singleton pregnancy?
a. Blood volume expansion
b. Blood pressure at term
a. 0–3 days c. Blood loss at delivery
b. 4–7 days d. Systemic vascular resistance
c. 8–12 days 45–17. A fetus that is part of a dichorionic twin pair is estimated to
d. More than 13 days weigh 2000 g at 33 weeks’ gestation. What can be said about its
growth?
a. The fetus already shows growth
restriction.
b. The fetus will be growth restricted
45–8. A patient with twins is referred for prenatal care. At the at term.
referring clinic, she had several sonographic examinations that c. The fetal growth is adequate for
establish these to be monochorionic twins. Today, you see only gestational age.
one fetus sonographically. Which of the following statements is d. Growth differences will not be
false regarding the risk of a vanishing twin? apparent until delivery.
a. The risk exceeds 10% in multifetal gestations. 45–18. Among complications that
b. The risk is higher in monochorionic than in dichorionic pregnancies. may be seen in twin pregnancies, which of the following may be
c. This risk is increased if she used assisted reproductive technologies seen in dichorionic pregnancies?
to conceive. a. Acardiac twin
d. A vanishing twin does not affect first-trimester biomarker testing if it b. Fetus-in-fetu
occurs after 10 weeks’ gestation. c. Twin-twin transfusion syndrome
d. Complete mole with coexisting normal twin

MAPALO | PAGUIRIGAN | QUINTO | TAMANI 6 of 7

 Midterms (1st Sem) Multifetal Pregnancy
Dr. Daisy Dulnuan
OB II· October 27, 2020

45–19. What is the major cause of increased neonatal morbidity

rates in twins?
a. Preterm birth 45–29. With growing discordance, rates of which of the following
b. Congenital malformations neonatal complications are increased?
c. Abnormal growth patterns a. Neonatal sepsis
d. Twin-twin transfusion syndrome b. Necrotizing enterocolitis
45–20. When diagnosed at 20 weeks’ gestation, which of the c. Intraventricular hemorrhage
following statements is true regarding the twin vascular d. All of the above
complication seen in the image here? 45–30. Which of the following is the most important
predictor of neurological outcome of the survivor
after death of a cotwin?
a. It precludes vaginal delivery. a. Chorionicity
b. It implies the twins are b. Gestational age at time of demise
conjoined. c. Malformations present in the deceased twin
c. It has a 50% associated fetal d. Length of time between demise and delivery of
mortality rate. survivor
d. It can be monitored effectively 45–31. Which of the following methods of antepartum fetal
with daily sonography. surveillance has been shown to improve outcomes in twin
pregnancies?
45–21. Which are the most common vascular anastomoses seen a. Nonstress test
in monochorionic twin placentas? b. Biophysical profile
a. Deep vein-vein c. Doppler velocimetry of the umbilical artery
b. Deep artery-vein d. None of the above
c. Superficial artery-vein 45–32. Which of the following interventions has been shown to
d. Superficial artery-artery decrease the rate of preterm birth in twins?
45–22. Which of the following statements is true in twin reversed- a. Cerclage
arterial-perfusion (TRAP) sequence? b. Betamimetics
a. It is caused by a large arteriovenous placental shunt. c. 17-Hydroxyprogesterone caproate
b. The donor is at risk of cardiomegaly and high output heart failure. d. None of the above
c. The most effective treatment is injection of KCl into the recipient 45–33. Which of the following findings can predict a lower risk of
twin. preterm birth in twins?
d. Placental arterial perfusion pressure in the recipient exceeds that of a. Closed cervix on digital examination
the donor. b. Negative fetal fibronectin assessment
45–23. A pair of monochorionic twins presents at 20 weeks’ c. Normal cervical length measured by transvaginal sonography
gestation with sonographic findings that suggest twin-twin d. All of the above
transfusion syndrome. There is significant growth discordance, 45–34. Which is the most common presentation of twins in labor?
no bladder is visualized in the smaller twin, neither twin has a. Vertex/vertex b. Vertex/breech
ascites or hydrops, and umbilical Doppler studies are normal. c. Breech/vertex d. Vertex/transverse
What would be the assigned Quintero stage? 45–35. For twins in labor, risk factors for an unstable fetal lie
a. Stage I b. Stage II include all EXCEPT which of the following?
c. Stage III d. Stage IV a. Small fetuses
45–24. The recipient cotwin in a monochorionic twin gestation b. Polyhydramnios
affected by twin-twin transfusion syndrome may experience all c. Increased maternal parity
EXCEPT which of the following neonatal complications? d. Vertex/vertex presentation
a. Thrombosis b. Hypovolemia 45–36. Which of the following scenarios presents the best
c. Kernicterus d. Heart failure opportunity for a vaginal trial of labor?
45–25. What percentage of Quintero stage I cases remain stable a. Nonvertex/vertex presentation
without intervention? b. Vertex/nonvertex presentation
a. 25% b. 50% c. Nonvertex second twin whose estimated fetal
c. 75% d. 90% weight is < 1500 g
45–26. Which of the following therapies for severe twin-twin d. Vertex second twin whose estimated fetal weight
transfusion syndrome has been shown in a randomized trial to is > 20% larger than the presenting vertex twin
improve survival rates of at least one twin to age 6 months?
a. Septostomy
b. Amnioreduction
c. Selective feticide
d. Laser ablation of vascular anastomoses
45–27. What is the calculated fetal growth discordance of a twin
pair where the estimated fetal weight of twin A is 800 g and that of
twin B is 600 g?
a. 10% b. 15%
c. 25% d. 33%
45–28. A second sonographic evaluation of the twin pair
described in Question 45–27 shows 27% discordance. One fetus
is male and one is female. Which mechanism is not the likely
cause of their discordance?
a. Unequal placental sharing
b. Different growth potential
c. Histological placental abnormality
d. Suboptimal implantation of one placental site

MAPALO | PAGUIRIGAN | QUINTO | TAMANI 7 of 7