Multiple pregnancy

Multiple pregnancy refers to pregnancy with two or more fetuses. Twin pregnancies can be differentiated into monozygotic and dizygotic pregnancies. Monozygotic twin pregnancies result from the division of the fertilized oocyte into two embryonic layers, whereas dizygotic twin pregnancies arise from the fertilization of two oocytes with two spermatozoa. Multiple pregnancies are classified based on how the amniotic sac and placenta are divided among the fetuses, which is determined via ultrasound. In monozygotic twin pregnancies with a shared placenta (monochorionic), twin-to-twin transfusion syndrome is a possible complication. In these cases, blood vessels are shared between the twins, with one twin transferring blood (donor) to the other twin (recipient). Twin-to-twin transfusion syndrome is associated with various risks, including anemia and growth retardation in the donor twin, and polycythemia in the recipient twin. Pregnancies with more than one fetus are generally considered high-risk pregnancies, increasing the likelihood of almost all potential complications of pregnancy, including preterm labor, pregnancy-induced hypertension, and preeclampsia.

• The frequency of multiple births is calculated in accordance with Hellin's law. ^[1]
  • Twins: ∼ 1:89
  • Triplets: ∼ 1:89² (1:7,921)
  • Quadruplets: ∼ 1:89³ (1:704,969)
• The incidence of multiple pregnancies (particularly dizygotic) has increased since the 1980s as assisted reproductive technology has become readily available

Epidemiological data refers to the US, unless otherwise specified.

Predisposing factors ^[2]

• Advanced maternal age (≥ 35 years)
• Previous multiple pregnancy
• Use of assisted reproductive technology
• Maternal family history of dizygotic twins

Monozygotic vs. dizygotic twins

Special features in the development of monozygotic twins

• Dizygotic pregnancy results in a dichorionic-diamniotic pregnancy.
• In monozygotic pregnancies, there are various ways in which the amniotic sac and placenta are shared.

A four-wheeler has SPACe for twins.” 1^st four days (0–3): Separate placenta and amniotic sac; 2^nd four days (4–7): shared Placenta; 3^rd four days (8–11): shared Amniotic sac; day 12 and beyond: Conjoined twins.

Physical examination ^[2]

• Fundal height and abdominal girth are unusually large for the gestational age.
• Two or more fetal heart rates can be heard on auscultation.

Ultrasound ^[2]

• Evidence of more than one fetus
• Differentiation between monochorionic and dichorionic twins during early pregnancy
  • Dichorionic twins: lambda sign
    • Both chorionic cavities are separated from one another.
    • Separation of the chorionic and amniotic sacs resembles the Greek symbol λ (lambda) on ultrasound.
  • Monochorionic twins: T-sign
    • One chorionic cavity is present and each twin has an individual amniotic sac.
    • Separation of the amniotic sacs resembles the letter T on ultrasound.

Almost all complications associated with normal pregnancies are more likely in multifetal pregnancies.

Maternal illnesses ^[2]

• Preterm labor and birth (most common complication)
• Hyperemesis gravidarum
• Gestational diabetes
• Preeclampsia, eclampsia, pregnancy-induced hypertension
• Cervical incompetence, premature rupture of membranes
• Placental insufficiency, hypotrophy, and intrauterine malnutrition of at least one fetus
• Uterine atony
• Miscarriage or loss of one fetus during the first trimester
• Placenta previa
• Birth complications: prolonged first stage of labor , premature placental abruption after birth of the first fetus, prolapsed cord
• Increased risk of maternal morbidity

Fetal illnesses

• Spontaneous reduction or vanishing twin syndrome: can occur during the first trimester
• Twin-to-twin transfusion syndrome ^[3]
  • Affects 10–15% of monochorionic twin pregnancies (twins that share the placenta)
  • Blood is continuously shunted from one twin to the other through vascular anastomoses on the shared placenta, posing a risk to both fetuses.
  • Recipient twin
    • Polycythemia
    • Hypervolemia
    • Polyhydramnios in diamniotic pregnancies
  • Donor twin
    • Anemia
    • Growth retardation
    • Hypovolemia, dehydration (stuck twin or cocooned appearance)
    • Oligohydramnios in diamniotic pregnancies
• Cord entanglement: can occur only in monoamniotic twin pregnancies
• Increased risk of neonatal morbidity (growth restrictions, prematurity, cerebral palsy, congenital abnormalities) and mortality

We list the most important complications. The selection is not exhaustive.

Prenatal care ^[2]

• Multifetal pregnancies are high-risk pregnancies and require more frequent prenatal care visits.
• Frequent early evaluations of monochorionic pregnancies are indicated to assess for twin-to-twin transfusion syndrome.
• From the 32^nd week of gestation: weekly prenatal care visits, including ultrasound, to monitor fetal growth

Childbirth

• Indications for Cesarean delivery:
  • Monochorionic-monoamniotic twin pregnancies between 32–34 weeks' gestation
  • Breech presentation
  • Significant difference in fetal weight
• Indication for vaginal delivery: diamniotic twins ≥ 32 0/7 weeks with one fetus in vertex presentation
• Indication for induction of labor: dichorionic-diamniotic twin pregnancy at 38 weeks' gestation