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
