Multiple Pregnancy

Section I: Background

1. Epidemiology/Incidence of Multiple Pregnancy

Tiran Dias and Amarnath Bhide

1.1 Introduction

1.2 Ethnic Variation

1.3 Familial Tendency

1.4 Geographical Variation

1.5 Genetics of Twins

1.6 Reproductive Age

1.7 Assisted Reproductive Techniques

2. Classification of Multiple Pregnancy

Tiran Dias and Amarnath Bhide

2.1 Introduction

2.2 Classification of Multiple Pregnancy

3. Mechanism of Multiple Pregnancy/Aetiology

Tiran Dias

3.1 Introduction

3.2 Zygosity

3.3 Chorionicity and Amnionicity

4. Placentation in Multiple Pregnancy

AAH Priyani

4.1 Introduction

4.2 Zygosity

4.3 Placentation in Multiple Pregnancy

4.4 Placental Growth During Pregnancy

4.5 Twin Growth Discordance and Related Placental Characteristics

4.6 Vascular Anastomoses and Related Complications

4.7 Monoamniotic Twinning

Section II: Antenatal Management of Multiple Pregnancy: Early Pregnancy

5. Confirmation of Viability and Assessing Number of Fetuses

Tiran Dias and Amarnath Bhide

5.1 Introduction

5.2 Confirmation of Viability and Assessing the Number of Fetuses

5.3 Vanishing Twin

6. Assessment of Gestational Age

Tiran Dias and Amarnath Bhide

6.1 Introduction

6.2 Crown–Rump Length or Last Menstrual Period to Date the Pregnancy?

6.3 Can Singleton Charts be Used Reliably to Date Twin Pregnancies?

6.4 Should Pregnancy be Dated by Measurements of the Larger Twin,

Smaller Twin or Their Average?

6.5 Gestational Age Assessment After the First Trimester

6.6 Gestational Age Assessment in IVF Multiple Pregnancy

7. Assessment of Chorionicity

Tiran Dias and Amarnath Bhide

7.1 Introduction

7.2 Ultrasound Determination of Chorionicity

8. Antenatal Labelling

Tiran Dias and Amarnath Bhide

8.1 Introduction

8.2 Antenatal Labelling

Section III: Aneuploidy Risk Assessment in Multiple Pregnancy

9. Principles of Aneuploidy Screening in Multiple Pregnancy

Tiran Dias

9.1 Introduction

9.2 Assessment of the Aneuploidy Risk with Regard to Zygosity, Chorionicity and Maternal Age

10. Aneuploidy Risk in Multiple Pregnancy and Assessment: Ultrasound and Serum Biochemistry

Tiran Dias

10.1 Introduction

10.2 First-Trimester Risk Assessment Using Nuchal Translucency in Twin Pregnancy

10.3 First-Trimester Combined Screening

10.4 Second-Trimester Maternal Serum Screening

10.5 Integrated Screening for Chromosomal Aneuploidy in Twins

10.6 Second-Trimester Ultrasound Screening for Aneuploidy in Twin Pregnancies

11. Non-invasive Methods of Risk Assessment in Twins

Tiran Dias

11.1 Introduction

11.2 Fetal Gender Determination in Twin Pregnancy

11.3 Twin Zygosity Determination Using Maternal Plasma DNA Analysis

11.4 Fetal Chromosomal Aneuploidy Detection Using Sequencing of Maternal Plasma DNA

11.5 Prenatal Diagnosis of Pregnancy Complications

11.6 Noninvasive Prenatal Diagnosis of Twins Using Circulating MicroRNAs in Maternal Plasma

12. Invasive Methods of Screening in Multiple Pregnancy

Tiran Dias

12.1 Introduction

12.2 Counselling in Invasive Testing

12.3 Principles of Invasive Diagnostic Procedures

12.4 Amniocentesis

12.5 Chorionic Villus Sampling

13. Managing Twins Divergent for Karyotypic Abnormalities

Tiran Dias

13.1 Introduction

13.2 Preliminary Counselling

13.3 Selective Reduction of Multifetal Pregnancies

Section IV: Antenatal Care in Multiple Pregnancy: Late Pregnancy

14. Antenatal Fetal Monitoring

Tiran Dias

14.1 Introduction

14.2 Uncomplicated MCDA Twins

14.3 Uncomplicated DCDA Twins

14.4 Uncomplicated MCTA or DCTA Triplets

14.5 Uncomplicated TCTA Triplets

14.6 Assessments at Each Ultrasound Scan

14.7 Nutritional Supplements

14.8 Separate Growth Reference Ranges

15. Perinatal Morbidity and Mortality in Twins

Tiran Dias

15.1 Introduction

15.2 Potential Contributors for Morbidity

15.3 Cerebral Palsy

15.4 Cognitive Impairment

15.5 Any Major Disability

15.6 Early Pregnancy Loss in Twins

Section V: Planning of Delivery in Multiple Pregnancy

16. Planning of Delivery in Multiple Pregnancy

Tiran Dias

16.1 Introduction

16.2 Timing of Delivery

17. Mode of Delivery

Tiran Dias

17.1 Introduction

17.2 Intrapartum Management of Multiple Pregnancies

17.3 Route of Delivery

17.4 Time Gap Between Delivery of Twins

17.5 Anaesthesia (Pain Relief in Multiple Pregnancies)

17.6 Caesarean Section

17.7 Vaginal Birth After Caesarean Section in Twin Pregnancy

Section VI: Maternal Implications in Multiple Pregnancy

18. Physiological Changes in Pregnancy

Carmeline Motha

18.1 Introduction

18.2 Cardiovascular System

18.3 Renal System

18.4 Respiratory System

18.5 Haematological System

18.6 Endocrine System

18.7 Glucose Metabolism

18.8 Lipid Metabolism

18.9 Protein Metabolism

19. Implications of Multiple Pregnancy on Physiological Adaptations

Carmeline Motha

19.1 Introduction

19.2 Physiological Adaptations

Section VII: Problem-Based Management of Twin Pregnancy Complications in First Trimester

20. Chromosomal Defects and Twinning

Tiran Dias and Amarnath Bhide

20.1 Introduction

20.2 Chromosomal Defects and Twinning

21. Complications Unique to Egg Splitting

Tiran Dias and Amarnath Bhide

21.1 Introduction

21.2 First-Trimester Detection of Fetal Structural Anomalies

21.3 Monoamniotic Twins

21.4 Twin Reversed Arterial Perfusion

21.5 Conjoined Twins (Siamese Twins)

21.6 Fetus in Fetu

22. Vanishing Twin Sequence

Tiran Dias and Amarnath Bhide

22.1 Introduction

22.2 Vanishing Twin Sequence

Section VIII: Problem-Based Management of Twin Pregnancy Complications in Second Trimester

23. Twin-to-Twin Transfusion Syndrome (TTTS)

Tiran Dias

23.1 Introduction

23.2 Twin-to-Twin Transfusion Syndrome

24. Selective Fetal Growth Restriction (sFGR) 236

Tiran Dias and Amarnath Bhide

24.1 Introduction

24.2 Classifi cation of sFGR

24.3 Type I sFGR

24.4 Type II sFGR

24.5 Type III sFGR

24.6 Late-onset sFGR

25. Twin Anaemia-Polycythaemia Sequence (TAPS)

Tiran Dias and Amarnath Bhide

25.1 Introduction

25.2 Diagnosis and Classification of TAPS

25.3 Treatment

25.4 Outcome

26. Discordant Amniotic Fluid Index 258

Tiran Dias

26.1 Introduction

26.2 Amniotic Fluid Index

26.3 Physiology of Amniotic Fluid Production

26.4 Discordant Amniotic Fluid Index

27. Congenital Malformations in Twins

Tiran Dias

27.1 Introduction

27.2 Congenital Malformations in Twins

28. Co-twin Demise

Tiran Dias

28.1 Introduction

28.2 Definition

28.3 Factors Causing the Risks to the Remaining Co-Twin

28.4 Pathophysiology

28.5 Management

Section IX: Problem-Based Management of Twin Pregnancy Complications in Third

Trimester

29. Discordant Fetal Size and Fetal Growth Restriction

Thilina Palihawadana

29.1 Introduction

29.2 Growth Discordance

29.3 Fetal Growth Restriction

29.4 High Perinatal Mortality

30. Preterm Delivery

Thilina Palihawadana

30.1 Introduction

30.2 Delivery in Monoamniotic Twins

Section X: Medical Complications of Multiple Pregnancy

31. Medical Complications of Twin Pregnancy

Carmeline Motha

31.1 Introduction

31.2 Gestational Diabetes Mellitus

31.3 Hypertensive Disorders in Pregnancy

31.4 Hyperemesis Gravidarum

31.5 Peripartum Cardiomyopathy

Section XI: Management of Delivery Complications in Multiple Pregnancy

32. Malpresentations in Twin Vaginal Delivery

Thilina Palihawadana

32.1 Introduction

32.2 Proportion and Risks of Malpresentation and Malpositions

32.3 Twin Delivery in the Presence of Malpresentations and Malpositions

32.4 Malpresentations in the Twins at Vaginal Delivery and Perinatal Outcome

32.5 Delivery of Second Twin in a Nonvertex Presentation

33. Intertwin Delivery Interval at Vaginal Delivery of Twin Pregnancies

Thilina Palihawadana

33.1 Introduction

33.2 Mechanisms of Prolonged Intertwin Delivery at Twin Vaginal Delivery

33.3 Intertwin Delivery Interval and the Perinatal Outcome

33.4 Optimal Time for Intervention in Prolonged Intertwin Delivery

Section XII: Obstetric Emergencies in Twin Pregnancy

34. Epidemiology of Antepartum Haemorrhage (APH)/Postpartum Haemorrhage (PPH) and Other Obstetric Emergencies in Twins

Tiran Dias

34.1 Introduction

34.2 Antepartum Haemorrhage

34.3 Morbidly Adherent Placenta

34.4 Placental Abruption

34.5 Velamentous Cord Insertion and Vasa Praevia

34.6 Postpartum Haemorrhage

Index