M-1 Coop 2009

Class: Human Development

Date: 12/1/05 11:00-12:00 am
Lecturer: Dr. Randall Kulhmann

Twins and Other Multiples “Double Trouble, Triple Trouble”

A. Dizygotic Twins (Dz): Fraternal – (Two fertilized eggs), “Womb mates” – (Same
womb, but genetically dissimilar, usually dichorionic/diamniotic)
• Incidence 1/80-1/100 pregnancies (INCREASING in frequency in recent yrs.)
• Hereditary tendency, tendency in advanced maternal age, reproductive
technology advances
• Hellin’s Hypothesis (less used due to increasing trends, 1/40-1/80)
o 1/80-1/90 for twins
o 1/902 for triplets
o 1/903 for quadruplets

B. Monozygotic (Mz): Identical – (Egg splits after fertilization), genetically identical,

phenotypically similar
• Incidence 1/250-1/300 pregnancies (CONSTANT for decades)
• The earlier the “SPLIT” the better for mom and babies
• Chorion gives rise to the placenta, can fuse,
• Imbalance in placenta size or sharing can lead to intrauterine growth
restriction to one of the twins
• Biggest risk is congenitial anastomoses (chorioangiopagus)
o TTTS (Twin-Twin Transfusion Syndrome)
• Dichorionic/diamniotic – 30% of Mz pregnancies, egg separation before day 3
• Monochorionic/diamniotic – 70% of Mz pregnancies, blastomere separation
in 1st week
• Monochorionic/monoamniotic – Rare, ICM seperation in 2nd week
o Biggest risk is congenitial anastomoses (chorioangiopagus)
 TTTS (Twin-Twin Transfusion Syndrome)
• Often results in polycythemic/anemic twin pairs
• Recipient – polycythemic (too much blood),
polyhydramnios, larger
• Donor – anemic, oligohydramnios, smaller
• Different variations
o A-A Artery to Artery (MOST COMMON)
o A-V Artery to Venous
o V-V Venous to Venous
• FLOC-Fetoscopic Laser Oblation of Chorioangiopagus
o Method to stop anastomosis
o 60% have umbilical cord entanglement (in same amniotic sac), 4% of
these actually tie knots
 o Mothers advised to be admitted at 24 weeks and put on monitor and
babies will be delivered no later than 32 weeks (40% survival rate for
fetus at 24 weeks, put in NICU)
• Conjoined Twins – Very Rare, incomplete separation of ICM in 3rd week
o No increase in chromosomal abnormalities
o Organ involvement determines potential for separation
o Classified according to conjoined anatomy
 Thoracopagus – at thorax, chest
 Pyopagus – at sacrum (posteriorly)
 Ischiopagus – at pelvis (anteriorly)
 Sirenomelic – at extremities
 Craniopagus – at head

C. Problems with Multiple Pregnancies & Births

• Increase in Premature births
o Polyhydramnios “mass effect”
o Preeclampsia – hypertension, proteinuria, edema
o Abrubtion
o Preterm labor
• Complications
o Discordancy of growth – 20-25% difference in fetus size
o Congenital abnormalities – 2 major ones are heart and neural tube defects
o Chromosomal abnormalities (Trisomy 21)
I. Problems affecting the mother
1. Pregnancy induced or aggravated hypertension
2. Maternal anemia – iron or folate deficiency, hemorrhaging (“ob is a
bloody business”)
3. Maternal hemorrhage – uterine atony (over distended uterus won’t
contract back down after birth, sometimes need transfusions)
4. Complicated labor – preterm, preeclampsia, fetal position
5. Hydramnios – mass effect (distended uterus, stimulus of contractions)
II. Problems affecting the fetus
1. Increased incidence of spontaneous abortion
2. Perinatal mortality
3. Low birth weight – prematurity, intrauterine growth restriction
4. Malformations – fetus-in-fetu (parasitic twin), acardia (pump twin, not
fully formed and takes blood from normal twin)
5. Fetal to fetal hemorrhage
6. Placental disorders – abruption (premature separation of placenta, 1% of
normal population, 5-10% in twin pregnancies), Placenta Previa (placenta
covers cervix)
D. Misc. Info. (He said he was required to say)
• Superfecundation (cats and dogs) – fertilization of 2+ oocytes in same cycle
• Superfetation – ovulation during established pregnancy resulting in delayed twin