ANTENATAL CARE OF TWIN PREGNANCY Prof. Gomathy Narayanan

Relevance 1. 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%

Complications unique 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

Complications unique 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 Tocolysis Cervical cerclage Progesterone Steroids Indicated only when Short cervix or Preterm labour: Tocolysis Cervical cerclage Progesterone Steroids Home uterine activity monitoring

USG is the Conerstone of Management in 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) Treatment: Incidence: Spontaneous: 3-5% Post laser: 2-13% Intra uterine transfusion Partial exchange transfusion Laser coagulation Expectant & post delivery treatment Diagnosis: MCA PSV tracing Absence of polyhydramnios

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!