1. ANTENATAL CARE OF TWIN PREGNANCY
Prof. Gomathy Narayanan

2. 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

4. Complications I Trimester: Hyperemesis Threatened abortion Miscarriage
Congenital anomalies
Vanishing twin

5. Complications II Trimester: Extreme Preterm labor – 44% / Delivery
PPROM
Growth discordance – 15-29%
IUGR
Fetal anomaly – 4.9%
Single fetal demise – 2-5%

6. 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

7. Complications unique to Monoamniotic Twins
Conjoint twins – 1:50,000 Births
Cord entanglement
Fetal death

8. Maternal complications
Anemia (Iron / Folic acid)
Polyhydramnios
PET / HELLP syndrome
GDM
APH
Acute fatty liver
Choliestasis
Pressure effects DVT
Pulmonary edema (Tocolysis)
Chorioamnionitis (PPROM)

9. Antenatal Care
Increased:
AN visits
Hospitalization
Intervention

10. Where to care antenatally?
PHC not recommended
Uncomplicated Twins:
District hospital / Similarly equipped Nursing Home
Complicated Twins:
Tertiary center / Fetal Medicine units

11. 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

12. Preterm Prophylaxis Tocolysis Cervical cerclage Progesterone Steroids
Indicated only when Short cervix or Preterm labour:
Tocolysis
Cervical cerclage
Progesterone
Steroids
Home uterine activity monitoring

13. USG is the Conerstone of Management in Twin Pregnancy

14. 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

15. 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

16. 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

17. Special Situations

18. Preterm Labour Hospitalization Tocolysis Progesterone Surveillance
Induction
Termination

19. PPROM Hospitalization Tocolysis Antibiotics Steroids Termination
Monochorionic II Twin is more at risk of infection than Dichorionic II Twin

20. 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

21. Outcome in TTTS Survival depends on Gestational age & severity
No intervention: 0 to 30%
Amnioreduction: 64%
Laser coagulation: 73%
Amniotic septostomy: 83%

22. 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

23. Twin Reversal Arterial Perfusion (TRAP)
Normal pump twin (Stuck twin)
Acardiac recipient
Treatment:
Laser coagulation
Cord occlusion

24. Single fetal demise Surveillance of surviving twin Serial USG
Serial BPP
Serial Doppler
MRI
Maternal coagulation profile
Anti D if mother is Rh Negative

25. Conjoint twin Termination in I & II trimester If diagnosed later, CS
Plan separation after delivery
Prognosis poor

26. Avoid Iatrogenic Twinning
Mono follicular induction of ovulation
Mono embryo transfer

27. Thank you!