I. Epidemiology

  1. 1 in 80 white pregnancies

II. Definitions

  1. Dizygotic Twins (66% U.S. twins)
    1. Fertilization of 2 ova (egg) by 2 sperm
    2. Dichorionic: Separate chorion (placenta)
    3. Diamniotic: Separate amnion (amniotic sac)
  2. Monozygotic Twins (33% U.S twins, identical)
    1. Division of 1 ova (eggs) fertilized by same sperm
    2. Ova division <72 hours: Dichorionic, diamniotic
    3. Ova division 4-8 days: monochorionic, diamniotic
    4. Ova division 8-13 days: monochorionic, monoamniotic
    5. Ova division >13 days: Conjoined twins
  3. Fetus Papyraceous
    1. One twin does not develop
    2. Amorphous, shriveled, and flattened twin

III. Risk factors for Dizygotic twins

  1. Older mother
  2. Multiparous mother
  3. Family History of dizygotic Twin Gestation

IV. Differential Diagnosis Multiple Gestation (early)

  1. Misdated pregnancy
  2. Polyhydramnios
  3. Uterine Fibroid tumors
  4. Cyst
  5. Hydatiform mole

V. Intrapartum Associated Complications

  1. Large Placenta
    1. Placenta Previa
    2. Postpartum Hemorrhage
  2. Large Fetal Demand
    1. Iron Deficiency Anemia
    2. Megaloblastic Anemia
  3. Large bulk or polyhydramnios
    1. Preterm Labor or premature infant
    2. Pyelonephritis
  4. Placental Insufficiency
    1. Growth retardation
  5. Miscellaneous associated conditions
    1. Pregnancy Induced Hypertension
    2. Conjoined twins
    3. Hyperemesis Gravidarum
    4. Congenital defect risk doubles in twins

VI. Peripartum Complications

  1. Umbilical Cord Prolapse
  2. Fetal Malpresentation
  3. Placental Abruption
  4. Postpartum Hemorrhage
  5. Locked twins
    1. Description: Twins lock heads
      1. First twin Breech
      2. Second twin vertex
    2. Management
      1. Push second twin's head from Pelvis
      2. Frees first fetus
  6. Transfusion Syndrome
    1. Placental AV shunt in monozygotic twins
    2. Arterial twin
      1. Pumps blood to other twin
      2. Starves self
    3. Other twin
      1. Bulky and plethoric
      2. Polycythemic

VII. Presentation

  1. First twin presents vertex: 75%
  2. Both twins vertex: 45%
  3. One twin vertex, one twin Breech: 37%
  4. Both twins Breech: 10%

VIII. Management: Pregnancy

  1. General Measures
    1. Good diet
    2. Supplement iron and Folic Acid
    3. Reduce activity and increase rest
  2. Clinic visits at least every 2 weeks after 24 weeks
    1. Cervical checks each visit after 24 weeks
    2. Preterm Labor Education
    3. Fetal Movement Counts daily after 32 weeks
  3. Obstetric Ultrasound every 4-6 weeks after diagnosis
    1. Assess for Placenta Previa
    2. Assess Fetal Growth
    3. Follow Fetal Presentation
  4. Weekly Nonstress Tests after 32 weeks
    1. Assess fetal well-being
    2. Predict cord compression
  5. Perinatology Consultation as needed

IX. Management: Cesarean Delivery Indications

  1. Twin A (first twin) not vertex presentation
  2. Twin B (second twin) not vertex
    1. External Cephalic Version of second twin fails
    2. Second twin experiences Fetal Distress
    3. Breech Delivery not an option
      1. Mother not willing to undergo Breech Delivery
      2. Physician discretion
      3. Fetus <2 kg
      4. Twin B larger than Twin A

X. Management: Vaginal Delivery if First Twin Vertex

  1. Monitor first twin by Internal scalp electrode
  2. Monitor second twin by External fetal monitor
  3. Deliver first twin vaginally (vertex)
  4. Second Twin Delivery (Do not delay)
    1. Consider external version of second twin if Breech
    2. Consider vaginal Breech Delivery for infant >2 kg
    3. Consider cesarean delivery of second twin

Images: Related links to external sites (from Google)

Ontology: Multiple Pregnancy (C0032989)

Definition (MSH) The condition of carrying two or more FETUSES simultaneously.
Definition (NCI) A gestation with more than one fertilized egg implanted as a viable fetus in the uterus.
Definition (NCI) A pregnancy involving twins or higher-order multiple fetuses (e.g., triplets, quadruplets).
Concepts Pathologic Function (T046)
MSH D011272
ICD9 651.90, 651.9, 651
ICD10 O30 , O30.9, O30.90
SnomedCT 16356006, 156150006, 199341006, 156154002, 199338002, 199337007
English Multiple Pregnancies, Pregnancies, Multiple, Pregnancy, Multiple, Unspecified multiple gestation, Multiple gestation, MULTIPLE PREGNANCY, PREGNANCY MULTIPLE, Pregnancy, multiple, Multiple gestation, NOS, Multiple pregnancy, NOS, Multiple pregnancy NOS, Multiple gestation, unspecified, Multiple pregnancy NOS unspec., Multiple pregnancy NOS, unspecified, MULTIPLE PREGN, PREGN MULTIPLE, multiple pregnancy (diagnosis), multiple pregnancy, Multiple pregnancy NOS (disorder), Pregnancy multiple, GESTATION MULTIPLE, Multi gestat NOS-unspec, Multiple pregnancy NOS, unspecified (disorder), Multiple Gestation, Multiple gestation, unspecified, unspecified trimester, Multiple Pregnancy, multiples pregnancy, pregnancy multiple, Pregnancy;multiple, multiple pregnancies, gestations multiple, multiple gestation, gestation multiple, Multiple pregnancies, Multiple pregnancy, Multiple pregnancy (disorder), gestation; multiple, multiple; gestation, multiple; pregnancy, pregnancy; multiple gestation, pregnancy; multiple, Unspecified multiple gestation, unspecified as to episode of care
Portuguese GRAVIDEZ MULTIPLA, Gestação múltipla NE, episódio de cuidados NE, Gestação múltipla, Gestação múltipla NE, Gravidez múltipla, Gravidezes múltiplas, Gravidez Múltipla
Spanish EMBARAZO MULTIPLE, Gestación múltiple no especificada, Gestación múltiple, Gestación múltiple no especificada, sin especificación del episodio de asistencia, Embarazo Múltiple, Embarazo Multiple, Multiple pregnancy, Multiple pregnancy NOS, embarazo gemelar, SAI (trastorno), embarazo gemelar, SAI, no especificado (trastorno), embarazo gemelar, SAI, no especificado, embarazo gemelar, SAI, embarazo múltiple (trastorno), embarazo múltiple, SAI, no especificado, embarazo múltiple, SAI, embarazo múltiple, gestación múltiple, Embarazo múltiple, Embarazos múltiples
Italian Gravidanze multiple, Gravidanza multipla non specificata, Gravidanza multipla non specificata, episodio di cura non specificato, Gravidanza multipla
Dutch zwangerschap meerling, meerlingzwangerschap niet-gespecificeerd, meerlingzwangerschap niet-gespecificeerd, niet-gespecificeerd naar behandelperiode, meerlingzwangerschap, niet-gespecificeerd, gestatie; multipel, multipel; gestatie, multipel; zwangerschap, zwangerschap; meerlingzwangerschap, zwangerschap; multipel, Meerlingzwangerschap, niet gespecificeerd, meerdere zwangerschappen, meerlingzwangerschap, Meerlingzwangerschap, Zwangerschap, meerling-
French Gestation multiple, non précisée, Gestation multiple non précisée, épisode de soins non précisé, Gestation multiple, Gestation multiple non précisée, GROSSESSES MULTIPLES, Grossesses multiples, Grossesse multiple
German Mehrlingsschwangerschaft, unspezifisch, unspezifische multiple Schwangerschaft, ohne Angabe der Behandlungsepisode, unspezifische multiple Schwangerschaft, Schwangerschaft multiple, MEHRLINGSSCHWANGERSCHAFT, Mehrlingsschwangerschaft, nicht naeher bezeichnet, Multiple Schwangerschaften, Mehrlingsschwangerschaft, Schwangerschaft, Mehrlings-
Japanese 詳細不明の多胎妊娠, 多胎妊娠、詳細不明, ショウサイフメイノタタイニンシン, タタイニンシン, タタイニンシンショウサイフメイ, 多胎妊娠, 妊娠-多胎
Swedish Flerbördsgraviditet
Czech těhotenství mnohočetné, Blíže neurčené vícečetné těhotenství, bez určení vztahu k péči, Vícečetné těhotenství, blíže neurčené, Blíže neurčené vícečetné těhotenství, Vícečetné těhotenství, Vícečetná těhotenství
Finnish Moniraskaus
Russian BEREMENNOST' MNOGOPLODNAIA, БЕРЕМЕННОСТЬ МНОГОПЛОДНАЯ
Korean 다태 임신, 상세불명의 다태 임신
Croatian TRUDNOĆA, MULTIPLA
Polish Ciąża mnoga
Hungarian Többes terhesség, Többszörös terhesség, nem meghatározott, Nem meghatározott többszörös terhesség, a terhesgondozás időszaka szerint nem meghatározott, Nem meghatározott többszörös terhesség, Többszörös terhességek, Többszörös terhesség

Ontology: Pregnancy, Twin (C0152150)

Definition (MSH) The condition of carrying TWINS simultaneously.
Concepts Finding (T033)
MSH D059285
ICD9 651.0
ICD10 O30.0 , O30.00, O30.009
SnomedCT 156151005, 199319006, 199316004, 65147003
English Twin pregnancy NOS, Twin pregnancy unspecified, twin pregnancy, twin pregnancy (diagnosis), Twin pregnancy NOS (disorder), Twin pregnancy unspecified (disorder), pregnancy twins, Pregnancy;twins, twins pregnancy, pregnancies twin, pregnancy twin, Twin pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, Twin pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, unspecified trimester, Twin Pregnancies, Pregnancy, Twin, Twin Pregnancy, Pregnancies, Twin, Twin pregnancy, Twin pregnancy (disorder), pregnancy; twin, twin; pregnancy, pregnancy with twins
Spanish embarazo gemelar, sin especificación, Twin pregnancy, embarazo de mellizos, embarazo gemelar (trastorno), embarazo gemelar doble no especificado, embarazo gemelar doble, SAI (trastorno), embarazo gemelar doble, SAI, embarazo gemelar no especificado, embarazo gemelar, sin especificación (trastorno), embarazo gemelar, Embarazo gemelar
Italian Gravidanza gemellare
Japanese 双胎妊娠, ソウタイニンシン
Czech Dvojčetné těhotenství
Korean 쌍둥이 임신
Hungarian Ikerterhesség
Dutch tweeling; zwangerschap, zwangerschap; tweeling, Tweelingzwangerschap, tweelingzwangerschap
Portuguese Gravidez bigemelar
French Grossesse gémellaire
German Zwillingsschwangerschaft

Ontology: Pregnancy, Triplet (C0152151)

Definition (MSH) The condition of carrying TRIPLETS simultaneously.
Concepts Pathologic Function (T046)
MSH D059286
ICD9 651.1
ICD10 O30.1
SnomedCT 156152003, 199320000, 199323003, 64254006
English Triplet pregnancy NOS, Triplet pregnancy unspecified, triplet pregnancy (diagnosis), triplet pregnancy, Triplet pregnancy unspecified (disorder), Triplet pregnancy NOS (disorder), pregnancy triplet, pregnancy triplets, Pregnancy, Triplet, Triplet Pregnancies, Triplet Pregnancy, Pregnancies, Triplet, Triplet pregnancy, Triplet pregnancy (disorder), pregnancy; triplet, triplet; pregnancy
Dutch drieling zwangerschap, drieling; zwangerschap, zwangerschap; drieling, Drielingzwangerschap
French Grossesse de triplés
German Drillingsschwangerschaft
Italian Gravidanza trigemina
Portuguese Gravidez tripla
Spanish Embarazo con trillizos, Triplet pregnancy, embarazo de trillizos (trastorno), embarazo de trillizos, embarazo gemelar triple no especificado (trastorno), embarazo gemelar triple no especificado, embarazo gemelar triple, SAI (trastorno), embarazo gemelar triple, SAI
Japanese 三胎妊娠, サンタイニンシン
Czech Trojčetné těhotenství
Korean 세쌍둥이 임신
Hungarian Hármasiker terhesség