INTRODUCTION

 INSIDENCY INCREASE
 PROBLEMS OF MULTIPLE PREGNANCIES:
FETAL COMPLICATION
-Prematurity
-Deceased survival (fetal death rate 4x greater,
the likelihood not surviving the first year 7xgreater)
-IUGR (14-25%) and 25% require NICU admission
-Risk of Cerebral palsy 4x greater for twins, 17x
greater for triplet
MATERNAL COMPLICATION
-Preeclampsia and diabetes are 2-3 times more
common.
Factors That Influence Twinning
 Race
 Maternal Age
 Parity
 Nutritional Factors
 Herediter
 Pituitary Gonadotropin
MONOZYGOTIK (IDENTICAL)
 1/3 of MULTIPLE PREGNANCIES
 One egg
 Based on classic report by BERNIRSHKE AND KIM,
there are 3 types of placentation:
1. DICHORIONIC-DIAMNIOTIC(1/3,on day 0-3)
2. MONOCHORIONIC-DIAMNIOTIC(2/3,on day 4-8)
3. MONOCHORIONIC-MONOAMNIOTIC(<1%,
occuring on day 9-12)
4. CONJOINED TWINS
DIZYGOTIK/POLIZYGOTIK
 2/3 of MULTIPEL PREGNANCY
 FERTILISAZION 2 OR MORE OOSIT BY 2 SPERM IN
THE SAME CYCLE
 THE MOST DRAMATIC INCREASES: ART
 THE TYPE OF PLACENTATION IS THE MOST
IMPORTANT PREDICTOR
 1/90 PREGNANCIES
 ANOTHER TYPE: SUPERFETACY
.
DIAGNOSIS OF TWINS
 Ultrasound is crucial for the diagnosis of twins.
 US scanning should begin with a complete imaging sweep of
the uterus.
 Always start in the suprapubic area and scan cephalad in a
transverse axial plane until reach the top of the uterine
fundus.
 Important sonographic details to note in the first trimester
include:
 The number of gestational sacs
 The location of the placenta or placentas,
Cont.
 The presence and characteristics of the dividing membrane or
membranes,
 Amniotic fluid status
 The number of yolk sacs and
 The fetal hearts.
 This informations helps to determine chorionicity
DICHORIONIC
 EASY TO DIAGNOSE IN FIRST TRIMESTER
 THICK MEMBRANETWIN PEAK SIGN
 > 16-20 MG TWIN PEAK DIFFICULT TO FIND
 IF IT IS FOUND DICHORIONIC
 IF IT IS NOT FOUND  STILL NOT EXCLUDED
DICHORIONICITY
 CAROLL et al performed study at 10-14 weeks: Sensitivity
97%, specificity 100%
TWIN PEAK SIGN
TRIPLET
MONOCHORIONIC
 MONOZIGOTIK TWINS
1. MONOCHORIONIC MONOAMNIOTIC
2. MONOCHORIONIC DIAMNIOTIC
 λ --- LAMBDA SIGN
 T APPEARANCE
 >9 MINGGU : LAMBDA SIGN
MONOKORIONIK
MONOAMNIOTIK

 CLEAVAGE ON DAY 7-13

 ONE AMNIOTIC SAC
 ONE PLACENTATTTS
 SAME SEX
 CORD COULD BE ENTANGLED
 NORMAL AMNIOTIC FLUID
 MEMBRANE NOT FOUND
 ONE YOLK SAC
COMPLICATION
 CORD ENTANGLED
 A VELAMENTOUS INSERTION OF THE UMBILICAL
CORDS
 TWIN TO TWIN TRANSFUSION SYNDROME
CONJOINED TWINS
 RARE PHENOMENON ON MO-MO TWINS
 EMBRYO DIVIDES ON DAY 13-15
 THE MOST COMMON: OMPHALOPAGUS AND
THORACOPAGUS.
 NO MEMBRANE
 US FEATURES:
 Visualizing the twins on the same relative positions in all views.
 Direct opposition of the twin from each outher
 Extreme extension of the spinal spine
 Inseparable skin contours must be persisten and in the same
anatomic level to avoid false diagnosis.
CONJOINED TWINS
 DUPLICATA COMPLETA
MEMPUNYAI BAGIAN YANG SAMA
THORACOPAGUS,CRANIOPAGUS,DLL.

 DUPLICATA INCOMPLETA
DICEPHALUS
TYPES OF CONJOINED TWIN
DISCORDANT TWINS
 STRUCTURAL CARDIAC ABNORMALITIES IN
MONOZYGOTIC TWINS WITHOUT TTTS ARE 4 X
 ESTIMATED FETAL WEIGHT < 20%
 AC > 20%
 BPD > 6MM
 HEAD PERIMETER DIFFERENT >5%
 S/D RASIO >15%
DISCORDANT TWIN
FETUS PROBLEM
 CONGENITAL ANOMALY (15-20%)
 SINGLETON 1,2%, MULTIPEL 2,1%
 CHROMOSOM ABNORMALITY
SPONTAN REDUCTION OF THE
FETUS
 7 WEEKS : 71 % > 20 WEEKS
 7-9 WWKS > 84%
 VANISHING TWIN
TTTS (TWIN TO TWIN TRANSFUSION
SYNDROME)

 PATOLOGIS
 ABNORMAL ANASTOMOSIS OF PLACENTA
VASCULAR
 DONOR: ANEMIC, HIPOVOLEMIC , IUGR, URINE
PRODUCTION DECREASED
 RESIPIEN: HIPERVOLEMIC, HIPERSYSTEMIC,
HIDROPS
DIAGNOSIS
 MONOCHORIONIC
 SAME SEX
 SECOND TRIMESTER, UNBALANCED AMNIOTIC
FLUID
 DISCORDANT GROWTH,RESIPIEN >DONOR
 DONOR BLADDER FOUND, RESIPIEN BLADDER
DILATED
 HIDROPS
ACARDIAC TWIN/TWIN REVERSE ARTERIAL
PERFUSION (TRAP)

 1% OF MONOCHORIONIC TWIN
 ANASTOMOSIS ARTERI-ARTERI, VENA-VENA.
 DELAYED HEART FUNCTION
 CHROMOSOM ABNORMALITY
 DOPPLER: REVERSE ARTERIAL PERFUSION
ACARDIAC TWIN
FETUS IN FETU
 0,02:10.000, 5% FROM CONJOINED TWIN
 DEFFECT PRIMORDIAL GROWTH
 ABNORMAL GERM CELL GROWTH.
 STRUCTURAL ABNORMALITY FOUND.