Twins and higher order pregnancies have increased in occurrence over the years and are fairly common today. This shift is attributed to two main factors: increase in average maternal age and the advent of various assisted reproductive therapies, such as in vitro fertilisation (IVF). The odds of conceiving twins are higher for women over the age of 35, as well as for women ingesting ovulation-inducing drugs or undergoing fertility treatments such as IVF. Twin pregnancies present increased chances of fetal and maternal complications. Thus, such pregnancies are considered high-risk, worthy of special attention and care. On Cloudnine, The Twin Clinic is a specialised facility singularly devoted to higher order pregnancies.
There are two types of twins: identical and fraternal.
Identical twins, also known as monozygotic twins, are the products of the split of a single fertilised egg, producing two babies with identical genetic information. Identical twins are always of the same gender and often share the same placenta. Monozygotic twins are also known as monochorionic twins and unfortunately, they run a higher risk of complications.
Fraternal twins or dizygotic twins, on the other hand, originate from the union of two separate sets of eggs and sperm. As a result, fraternal twins are genetically unique and may or may not be of the same gender.
The detection of twins and multiples (triplets/quadruplets) is possible via an early ultrasound scan. It is vital to determine whether twins are monochorionic or dichorionic by the 11-13 week mark.
Triplet pregnancy3D image of twin pregnancy
Triplet pregnancy3D image of twin pregnancy
A multiple order pregnancy usually entails exaggerated pregnancy symptoms, including an increase in nausea, morning sickness, heartburn, breast tenderness, urination and constipation. It can also lead to excessive hunger and perpetual exhaustion. The second trimester sometimes gives rise to difficulties in breathing, increased heartburn or acidity, swelling (edema) of the hands and legs and abdominal enlargement. Fetal movements also become more pronounced.
Anaemia (decreased haemoglobin) is common with twin and multiple pregnancies, and is a condition that can lead to excessive fatigue. Other problems such as increased blood pressure (pre-eclampsia) and gestational diabetes could also develop during the second trimester. Premature labour and delivery are major risk factors for higher order births. About 10% of twins are delivered before 32 weeks of gestation and between 50% and 70% are delivered before 37 weeks. Hence, a specialised neonatal intensive care unit (NICU) is essential to support a twin pregnancy.
Fetal Anomalies: Both dichorionic and monochorionic twins are susceptible to birth defects and chromosomal abnormalities. Hence, screening for potential conditions via superior ultrasound techniques in the first and second trimesters is imperative. The interpretation of results and the creation of a subsequent management roadmap can be challenging in some cases, especially when one twin presents normal scan parameters while the other does not. Hence, expert fetal medicine advice is essential, a platform that is available at The Twin Clinic on Cloudnine.
Fetal Growth Restriction: Both dichorionic and monochorionic twins can suffer poor growth inside the womb and can be born at low birth weights. Some twins develop selective intrauterine growth restriction (sIUGR), which warrants specialised management.
Prematurity: Preterm babies run a higher risk of respiratory distress, infection, intestinal problems and poor weight gain. They often also require phototherapy and a longer hospital stay. Cloudnine Hospitals offer Level III neonatal intensive care units that provide such babies with a holistic ecosystem to thrive in.
Complex Problems in Monochorionic Twins: Monochorionic twins, or identical twins, are likely to share a placenta. The division of a placenta can lead to specific problems like twin to twin transfusion Syndrome (TTTS), acardiac twinning, twin reverse arterial perfusion (TRAP) and selective intrauterine growth restriction (sIUGR), all conditions that can fatally deprive one twin of essential nutrients or resources. If one of the twins in a monochorionic pair dies in utero, it can cause neurological problems in the surviving twin, resulting in mental abnormalities.
As evident from the points mentioned above, twin pregnancies carry a high risk of maternal and fetal complications. On Cloudnine, The Twin Clinic is a specialised facility that extends expert care and intensive monitoring to higher order pregnancies. With our bouquet of technologies, we ensure both maternal and fetal wellbeing and excellent outcomes, even in the most complex of situations.
The Twin Clinic is composed of maternal and fetal medicine experts and obstetricians experienced in managing high-risk pregnancies. Our Level III neonatal intensive care units are armed with seasoned neonatologists who have a wealth of expertise in managing preterm and growth-restricted babies.
First Trimester Screening (11-13 weeks): All twin pregnancies that are detected early are scheduled for a scan at 11-13 weeks. At this stage, the embryo count, viability, chorionicity and chromosomal integrity are determined.
Fetal Anomaly Scan (18-20 weeks): This is a detailed scan performed to look for malformations and birth defects. If one twin is found to have anomalies while the other is normal (discordant twins), expert counselling and management decisions are required.
Cervical Assessment: The cervical length is checked through a transvaginal scan and subsequent steps are planned depending on the result. This assessment can serve as a risk measure for preterm delivery.
Fetal Echocardiography: All twins, especially monochorionic twins need to undergo a special fetal heart scan to rule out abnormalities. On Cloudnine, the echocardiography is performed by fetal medicine experts, with support from a paediatric cardiologist.
Dichorionic Twins: Dichorionic twins are scanned at 4-week intervals, typically at the 24, 28, 32 and 36-week marks. These scans are performed to check if all fetal parameters are progressing normally. Any deviation from the normal would necessitate a new plan.
Monochorionic Twins: Monochorionic twins need closer monitoring due to the problems associated with placental sharing. They are scanned at 2-week intervals, usually at 16, 18, 20, 22, 24, 26, 28, 30, 32, 34 and 36 weeks.
Maternal Monitoring: Weight, blood pressure and urine checks are effective yardsticks for maternal health. Aside from these, additional investigations may also be recommended based on your condition. On Cloudnine, prenatal development is overarched by a multidisciplinary panel of experts, including a maternal-fetal medicine specialist, an obstetrician, a physiotherapist, a nutritionist, a lactation expert, an anaesthesiologist, an endocrinologist and a neonatologist.
Embryo Reduction/Selective Feticide: This procedure is generally performed in dichorionic twins to achieve selective feticide. It is usually adopted if abnormalities are detected in one twin or if the pregnancy involves triplets or quadruplets. Higher order pregnancies pose a significant risk of prematurity and hence, selective feticide enhances maternal and fetal health.
Amniocentesis/CVS Procedure: Sometimes, diagnostic test results point to chromosomal abnormalities and infections in higher order pregnancies. In such cases, selective feticide is a preferred option. On Cloudnine, feticide is conducted only by experienced fetal medicine experts.
Fetoscopic Laser Coagulation for Twin to Twin Transfusion Syndrome: Twin to twin transfusion syndrome (TTTS) is a serious condition that can complicate 1 in 5 monochorionic twin cases. Left untreated, 9 in 10 fetuses die in utero. Laser ablation of connecting placental vessels can stop this condition from regressing. The procedure presents a positive outcome in 70-75% of cases. Laser photocoagulation is performed in an operation theatre under anaesthesia. A 2-3 millimetre fetoscope is inserted into the amniotic cavity and the linked vessels are coagulated via laser. The excess amniotic fluid is then drained and the mother-to-be is observed for 24-48 hours.
Radiofrequency Ablation / Interstitial Laser: Radiofrequency ablation is used for selective feticide in monochorionic twins if one twin exhibits anomalies or if there is evidence of severe intrauterine growth restriction (sIUGR) or twin reverse arterial perfusion (TRAP).
Bipolar Cord Coagulation: Bipolar cord coagulation is another method of selective feticide used for monochorionic twins. This technique is employed in sIUGR or in cases where one twin needs to be salvaged while the other has an abnormality. The procedure minimises the risk of handicap in the surviving twin.