ANTENATAL CARE OF

TWIN PREGNANCY

Prof. Gomathy Narayanan

Relevance1. Increasing Incidence:

• Following Induction of ovulation – 5-10%

• Following ART – 32%

• Advanced maternal age at pregnancy

2. Increased Morbidity & Mortality:

• Maternal – 4-fold

• Fetal – 20-fold

3. Technological advances

Complications

I Trimester:

• Hyperemesis

• Threatened abortion

• Miscarriage

• Congenital anomalies

• Vanishing twin

Complications

II Trimester:

• Extreme Preterm labor – 44% / Delivery

• PPROM

• Growth discordance – 15-29%

• IUGR

• Fetal anomaly – 4.9%

• Single fetal demise – 2-5%

Complicationsunique to

Monochorionic Twins

• TTTS – 15-30%

(Twin to Twin Transfusion Syndrome)

• TAP – 3-5%

(Twin Anemia Polycythemia Sequence)

• TRAP – 1%

(Twin Reversal Arterial Perfusion)

• Selective IUGR

Complicationsunique to

Monoamniotic Twins

• Conjoint twins – 1:50,000 Births

• Cord entanglement

• Fetal death

Maternal complications

• Anemia (Iron / Folic acid)

• Polyhydramnios

• PET / HELLP syndrome

• GDM

• APH

• Acute fatty liver

• Choliestasis

• Pressure effects DVT

• Pulmonary edema (Tocolysis)

• Chorioamnionitis (PPROM)

Antenatal Care

Increased:

•AN visits

•Hospitalization

• Intervention

Where to care antenatally?

• PHC not recommended

• Uncomplicated Twins:

District hospital / Similarly equipped Nursing Home

• Complicated Twins:

Tertiary center / Fetal Medicine units

Uncomplicated Twins

• No bed rest or hospitalization

• Restricted physical activity

• Diet:

• 300 Kcal more than singleton pregnancy

• Elemental iron: 60 mg/day

• Folic acid: 1 mg/day

• Calcium: 2500 mg/day

Preterm Prophylaxis

Indicated only when Short cervix or Preterm labour:

• Tocolysis

• Cervical cerclage

• Progesterone

• Steroids

• Home uterine activity monitoring

USG is the Conerstoneof

Managementin

Twin Pregnancy

USG in First Trimester

• Confirmation of number of foetuses

• R/O hetertropic pregnancy

• Viability

• Retroplacental hemorrhage

• Cervical status

• Chorionicity & Amnionicity

• NT Scan

• Down Screening

• Fetal anomalies

• CVS & Karyotyping

• Fetal reduction

Screening for Downs

• Combination of NT & Maternal age acceptable

• Serum Screening increases rate of pick up

• Vanishing twin can confuse alfa fetoproteins

• Increased NT may be early manifestation of TTTS

USG in II & III Trimester

• Growth assessment (Every 2-4 weeks in Monochorionic & 4-6 weeks in Dichorionic Twins)

• Growth discrepancy

• Selective IUGR

• Biophysical profile

• Fetal demise

• Vascular aberrations

• Fetal Doppler, Echo & MRI

Special Situations

Preterm Labour

• Hospitalization

• Tocolysis

• Progesterone

• Surveillance

• Induction

• Termination

PPROM

• Hospitalization

• Tocolysis

• Antibiotics

• Steroids

• Termination

• Monochorionic II Twin is more at risk of infection than Dichorionic II Twin

Twin to Twin Transfusion Syndrome (TTTS)

• Incidence: 15% in Monochorionic Twins

• Manifests at midpregnancy

• Single placenta

• Polyhydramnios in the Recipient and Oligoamnios in donor

• Growth discordancy

• Hemodynamic & Cardiac compromise in Recipient twin

Outcome in TTTS

Survival depends on Gestational age & severity

• No intervention: 0 to 30%

• Amnioreduction: 64%

• Laser coagulation: 73%

• Amniotic septostomy: 83%

Twin Anemia Polycythemia Sequence (TAP)

Diagnosis:

• MCA PSV tracing

• Absence of polyhydramnios

Treatment:• Intra uterine transfusion

• Partial exchange transfusion

• Laser coagulation

• Expectant & post delivery treatment

Incidence:• Spontaneous: 3-5%• Post laser: 2-13%

Twin Reversal Arterial Perfusion (TRAP)

• Normal pump twin (Stuck twin)

• Acardiac recipient

Treatment:

• Laser coagulation

• Cord occlusion

Single fetal demise

Surveillance of surviving twin

• Serial USG

• Serial BPP

• Serial Doppler

• MRI

• Maternal coagulation profile

• Anti D if mother is Rh Negative

Conjoint twin

• Termination in I & II trimester

• If diagnosed later, CS

• Plan separation after delivery

• Prognosis poor

Avoid Iatrogenic Twinning

•Mono follicular induction of ovulation

•Mono embryo transfer

Thank you!