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Of all the types of multiple births, twins normally face the fewest medical problems and complications. Each additional baby a woman carries during her pregnancy increases the possibility of developing pregnancy complications.

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What are the most common complications associated with multiples?

• Low birth weight
• Fetal Demise/Loss

Preterm Labor/Delivery

Preterm labor/delivery is defined as delivery before 37 completed weeks of pregnancy. The length of gestation typically decreases with each additional baby. On average most single pregnancies last 39 weeks, twin pregnancies 36 weeks, triplets 32 weeks, quadruplets 30 weeks, and quintuplets 29 weeks.

Almost 60% of twins are delivered preterm, while 90% of triplets are preterm.

Higher order pregnancies are almost always preterm. Many times premature labor is a result of preterm premature rupture of the membranes (PPROM). PPROM is a rupture of the membranes prior to the onset of labor in a patient who is less than 37 weeks of gestation.

Low Birth Weight

Low birth weight is almost always related to preterm delivery. Low birth weight is less than 5.5 pounds (2,500 grams). Babies born before 32 weeks and weighing less than 3.3 pounds (1,500 grams) have an increased risk of developing complications as newborns.

They are at increased risk of having long-term problems such as mental retardation, cerebral palsy, vision loss, and hearing loss.

Intrauterine Growth Restriction (IUGR)

Multiple pregnancies grow at approximately the same rate as single pregnancies up to a certain point. The growth rate of twin pregnancies begins to slow at 30 to 32 weeks.

Triplet pregnancies begin slowing at 27 to 28 weeks, and quadruplet pregnancies begin slowing at 25 to 26 weeks.

IUGR seems to occur because the placenta cannot handle any more growth and because the babies are competing for nutrients. Your doctor will monitor the growth of your babies by ultrasound and by measuring your abdomen.

Preeclampsia

Preeclampsia, Pregnancy Induced Hypertension (PIH), Toxemia, and high blood pressure are all synonymous terms. Twin pregnancies are twice as likely to develop preeclampsia as single pregnancies. Half of the triplet pregnancies develop preeclampsia.

Frequent prenatal care increases the chance of detecting and treating preeclampsia. Adequate prenatal care also decreases the risk of developing a serious problem from preeclampsia for both the babies and the mother.

Gestational Diabetes

The increased risk for gestational diabetes in a multiples pregnancy appears to be a result of the two placentas increasing the resistance to insulin, increased placental size, and an elevation in placental hormones.

The risk of occurrence of gestational diabetes in a multiples pregnancy is still being researched at this time. In one study, an increased risk of gestational diabetes did seem to be apparent, but the doctors involved recommended that further testing be conducted.

Placental Abruption

Placental abruption is three times more likely to occur in a multiples pregnancy. This may be linked to the fact that there is an increased risk of developing preeclampsia. It most often occurs in the third trimester, but the risk significantly increases once the first baby has been delivered vaginally.

Fetal Demise or Loss

Intrauterine fetal demise is extremely uncommon. Your healthcare provider will determine whether it is best to expose the other baby or babies to the fetus that has died or to proceed with delivery.

If the pregnancy is dichorionic (two chorions present), then intervention may not be necessary. (The chorion is a membrane that forms the fetal portion of the placenta. Fraternal twins always have two chorions while identical twins can have one or two chorions.)

If the pregnancy has a single chorion, fetal maturity will be assessed to see if immediate delivery is recommended. In this situation, it would be necessary to weigh the risks between having a premature baby and the risks of remaining in utero.

Cesarean

If you are pregnant with multiples it does not necessarily mean that you will have a cesarean birth. The typical recommendation for the delivery of triplets and higher-order multiples is a cesarean, but twins are often delivered vaginally.

The vaginal delivery of twins depends on the presentation of the babies.

Twins can be delivered vaginally when:

• The gestation is greater than 32 weeks
• Twin A (the baby closest to the cervix) is the largest
• Twin A is head down
• Twin B is head down, Breech, or sideways
• Twin B is smaller than twin A
• There is no evidence of fetal distress
• There is no cephalopelvic disproportion (CPD)

Last updated: October 15, 2019 at 20:35 pm

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A dichorionic diamniotic (DCDA) twin pregnancy is a type of twin pregnancy where each twin has its own chorionic and amniotic sacs. This type occurs most commonly with dizygotic twins, but may also occur with monozygotic twin pregnancies. This type of pregnancy may have characteristic findings on ultrasound.

Epidemiology

DCDA pregnancies account for the majority (~76%) of all twin pregnancies. They account for all dizygotic pregnancies and ~20% of monozygotic pregnancies.

Pathology

With a dizygotic pregnancy, two ova are independently fertilised by two sperm leading to two zygotes.

With a monozygotic twin pregnancy, a DCDA pregnancy results from the separation of the zygotes at ~1-4 days post fertilisation (morula) stage.

Radiographic features

Ultrasound

Sonographic assessment of chorionicity is most accurate in the first trimester.

First trimester

Features supporting a DCDA pregnancy:

• presence of two gestational sacs with a thick echogenic chorion surrounding each embryo
• a thick inter-twin membrane (often taken as > 2 mm)
• two yolk sacs may be seen (this, however, does not differentiate a DCDA pregnancy from a monochorionic diamniotic (MCDA) pregnancy)

Second trimester

• when there is no placental fusion, two separate placental sites may be seen ⁴
• a finding of two different genders for each twin is a definitive feature for a dizygotic pregnancy which in turn will invariably mean a DCDA pregnancy

If the twins are of the same gender then it is extremely difficult if not impossible to determine if they are monozygotic or dizygotic on ultrasound.

Complications

While the complication rate is still much higher with twins than with a singleton pregnancy, a DCDA pregnancy carries the lowest rate of complications amongst twin pregnancies. Such recognized complications include:

• increased risk of intrauterine growth restriction (IUGR)
• placenta-related problems
  • increased risk of velamentous cord insertion
  • increased risk of marginal cord insertion
  • increased incidence of placenta previa spectrum

• 1. Trop I. The twin peak sign. Radiology. 2001;220 (1): 68-9. Radiology (full text) - Pubmed citation
• 2. Merz E, Bahlmann F. Ultrasound in obstetrics and gynecology. Thieme Medical Publishers. (2005) ISBN:1588901475. Read it at Google Books - Find it at Amazon
• 3. Kurtz AB, Wapner RJ, Mata J et-al. Twin pregnancies: accuracy of first-trimester abdominal US in predicting chorionicity and amnionicity. Radiology. 1992;185 (3): 759-62. Radiology (abstract) - Pubmed citation
• 4. Hertzberg BS, Kurtz AB, Choi HY et-al. Significance of membrane thickness in the sonographic evaluation of twin gestations. AJR Am J Roentgenol. 1987;148 (1): 151-3. AJR Am J Roentgenol (abstract) - Pubmed citation

Related Radiopaedia articles

Ultrasound - obstetric

• obstetric ultrasound
  • first trimester and early pregnancy
    • gestational sac
    • embryo/fetus
      • fetal heart rate
  • ectopic pregnancy
  • multiple gestations
    • signs
  • second trimester​
    • fetal biometry
      • basic biometry
      • amniotic fluid volume
        • oligohydramnios (mnemonic)
    • fetal morphology assessment
      • fetal echocardiography views
      • soft markers
        • absent nasal bone
        • shortened fetal long bones
        • aberrant right subclavian artery
        • fetal pyelectasis / fetal renal pelvic dilatation
    • Doppler ultrasound
      • umbilical artery Doppler assessment
      • fetal middle cerebral arterial Doppler assessment
      • fetal ductus venosus flow assessment
  • chorionic villus sampling (CVS) and amniocentesis
  • placenta
  • other

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