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TWIN PREGNANCY
K.VINEELA,2K8
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DEFINITION: SIMULTANEOUS DEVELOPMENT OF TWO FETUSES IN THE UTERUS
TYPES: MONOZYGOTIC DIZYGOTIC
INCIDENCE:HELLIN’S RULE:MATHEMATICAL FREQUENCY OF MULTIPLE BIRTH IS TWINS
1 IN 80 PREGNENCIES,TRIPLETS 1 IN 80,QUADRUPLETS 1 IN 80
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GENESIS OF TWINS• DIZYGOTIC TWINS: FERTILIZATION OF TWO OVA MOST LIKELY
RUPTURED FROM TWO DISTINCT GRAAFIAN FOLLICLES BY TWO SPERMS IN A SINGLE OVTARIAN CYLCE.
• MONOZYGOTIC TWINS: TWINNING MAY OCCUR AT DIFFERENT PERIODS
AFTER FERTILIZATION
DIAMNIOTIC DICHORIONIC DIAMNIOTIC MONOCHORIONIC MONOAMNIOTIC MONOCHORIONIC
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DETERMINATION OF ZYGOSITYPLACENTA COMMUNIC
ATING VESSELS
INTERVENING MEMBRANES
SEX GENETIC FEATURES (DOMINANT BLOOD GROUP)DNA FINGERPRINTING
SKIN GRAFTING(RECIPROCAL)
FOLLOW UP
MONOZYGOTIC
ONE PRESENT TWO(AMNIONS)
ALWAYS IDENTICAL
SAME ACCEPTANCE
USUALLY IDENTICAL
DIZYGOTIC
TWO(MOST OFTEN FUSED)
ABSENT FOUR(TWO AMNIONS TWO CHORIONS)
MAY DIFFER DIFFER REJECTION NOT IDENTICAL
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ETIOLOGY:
MONOZYGOTIC: MATERNAL ENVIRONMENTAL FACTORS
DIZYGOTIC: RACE HERIDITY ADVANCING AGE OF MOTHER INFLUENCE OF PARITY IATROGENIC
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SUPER FECUNDATIONSUPERFETAIONFETUS PAPYRACEOUS OR
COMPRESSUSFETUS ACARDIACUSHYDATIDIFORM MOLEVANISHING TWIN
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MATERNAL PHYSIOLOGICAL CHANGES IN TWIN PREGNANCY:
o THERE IS INCREASE IN WEIGHT GAIN AND CARDIAC OUTPUT
o PLASMA VOLUME IS INCREASED BY 500ML,BUT THERE IS NO CORRESPONDING INCREASE IN RED CELL VOLUME RESULTING IN EXAGGERATED HEMODILUTION AND ANEMIA
o THERE IS INCREASE IN AFP LEVELS,TIDAL VOLUME AND GFR
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LIE AND PRESENTATION:COMMENEST IS LONGITUDINAL
COMBINATION OF PRESENTATION OF FETUSES ARE:
BOTH VERTEX---60%FIRST VERTEX AND SECOND BREECH—20%FIRST BREECH AND SECOND VERTEX---10%BOTH BREECH---10%FIRST VERTEX AND SECOND TRANSVERSEBOTH BEING TRANSVERSE--POSSIBILITY OF CONJOINT TWINS SHUD BE RULED OUT
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DIAGNOSISHISTORY:o HISTORY OF OVULATION INDUCING DRUGS LIKE
GONADOTROPHINS,FOR INFERTILITY OR USE OF ARTo FAMILY HISTORY OF TWINNING,MORE OFTEN IN THE
MATERNAL SIDE
SYMPTOMS: INCREASED NAUSEA AND VOMITING IN THE EARLY
MONTHS CARDIORESPIRATORY EMBARASSMENT IN THE LATER
MONTHS LIKE PALPITATIONS,BREATHLESSNESS TENDENCY OF SWELLING OF THE LEGS,VARICOSE
VEINS AND HEMORRHOIDS IS GREATER UNUSUAL RATE OF ABDOMINAL ENLARGEMENT AND
EXCESSIVE FETAL MOVEMENTS
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GENERAL EXAMINATION: PREVELENCE OF ANAEMIA IS MORE
UNUSUAL WEIGHT GAIN NOT EXPLAINED BY PREECLAMSIA OR OBESITY
EVIDENCE OF PREECLAMSIA IS COMMON
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ABDOMINAL EXAMINATION:INSPECTION: BARREL SHAPED AND UNDULY ENLARGED ABDOMEN
PALPATION: HEIGHT OF UTERUS IS MORE THAN THE PERIOD OF
AMENORRHOEA GIRTH OF THE ABDOMEN AT THE LEVEL OF UMBILICUS
IS MORE THAN NORMAL FETAL BULK SEEMS DISPROPORTIONATELY LARGER IN
RELATION TO THE SIZE OF THE FETAL HEAD FINDING OF TWO FETAL HEADS OR THREE FETAL
POLES
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AUSCULTATION: SIMULTANEOUS HEARING OF TWO DISTINCT FETAL
HEART SOUNDS LOCATED AT SEPARATE SPOTS WITH A SILENT AREA IN BETWEEN BY TWO OBSERVERS WITH A DIFFERNCE IN HEART RATE ATLEAST 10BPM
INTERNAL EXAMINATION: IN SOME CASES ONE HEAD IS FELT DEEP IN THE
PELVIS,WHILE THE OTHER IS LOCATED BY ABDOMINAL EXAMINATION
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INVESTIGATIONSSONOGRAPHY:
CONFIRMATION OF DIAGNOSIS AS EARLY AS 10TH WEEK OF PREGNANCY
VIABIALITY OF FETUSES,VANISHING TWIN IN THE 2ND TRIMISTER,
CHORIONICITY (LAMBDA OR TWIN PEAK SIGN) PREGNANCY DATING FETAL ANOMALIES FETAL GROWTH MONITORING FOR IUGR PRESENTATION AND LIE OF THE FETUSES TWIN TRANFUSION (DOPPLER STUDIES) PLACENTAL LOCALISATION AMNIOTIC FLUID VOLUME
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CHORIONICITY OF PLACENTA:
IT IS BEST DIAGNOSED BY USG AT 6 TO 9 WKS OF GESTATION.
IN DICHORIONIC TWINS THERE IS A THICK SEPTUM BETWEEN THE CHORIONIC SACS,WHICH IS BEST IDENTIFIED AT THE BASE OF THE MEMBRANE,WHERE A TRIANGULAR PROJECTION IS SEEN.THIS IS KNOWN AS “LAMBDA OR TWIN PEAK SIGN”. IT INDICATES DICHORIONIC PLACENTA.
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Dichorionic Diamniotic twins at 13 weeks gestation. Axial transabdominal US image of the uterus shows the twin peak sign (arrow). P = single placental mass due to contiguous
or fused placentas.
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RADIOGRAPHYBIOCHEMICAL TESTS
DIFFERNTIAL DIAGNOSIS:
HYDRAMNIOS BIG BABY FIBROID OR OVARIAN TUMOUR WITH PREGNANCY ASCITES WITH PREGNANCY
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