MULTIPLE PREGNANCY

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Multiple Gestation — Surveillance & Delivery Planning

Every multiple pregnancy carries higher maternal and fetal risk than a singleton — but the single most important determinant of how risky is chorionicity: whether the fetuses share one placenta or have separate placentas. This is easiest to determine accurately on early ultrasound (10–14 weeks) and shapes almost every decision that follows — surveillance frequency, complications to screen for, and timing of delivery.

👯 AT A GLANCE — RISK BY CHORIONICITY

Determine Early, Determine Once

Best assessed at 10–14 weeks — the "lambda/twin-peak sign" indicates dichorionic; the "T-sign" indicates monochorionic

Becomes progressively harder to determine accurately as pregnancy advances — don't miss this window

Additional risk drivers: higher-order multiples (triplets+), significant growth discordance, conception via assisted reproduction

GREEN — DCDA twins (dichorionic-diamniotic): separate placentas — lower risk, but still higher than a singleton pregnancy

AMBER — MCDA twins (monochorionic-diamniotic): shared placenta — needs closer surveillance for TTTS

RED — MCMA twins (monochorionic-monoamniotic) or higher-order multiples: highest risk — manage at a tertiary fetal medicine centre

🧪 ANTENATAL SURVEILLANCE

10–14 weeks: dating scan + definitive chorionicity/amnionicity determination

DCDA twins: growth scans every 4 weeks from around 24 weeks

MCDA twins: growth scan + Doppler every 2 weeks from 16 weeks — for early TTTS detection

Screen for anaemia and consider aspirin prophylaxis for pre-eclampsia risk, per local protocol

Additional nutritional needs — extra calories, iron, and folate compared to a singleton pregnancy

⚠️ COMPLICATIONS TO WATCH FOR

1

Preterm labour and birth — the most common complication overall

2

Twin-to-twin transfusion syndrome (TTTS) — monochorionic twins only

3

Twin anaemia-polycythaemia sequence (TAPS)

4

Selective fetal growth restriction / growth discordance

5

Pre-eclampsia and gestational diabetes — both more common than in singletons

6

Malpresentation — common, and central to delivery planning

🚨 SUSPECT TTTS OR ACUTE COMPROMISE — ESCALATE

Discordant liquor volumes — oligohydramnios in one sac, polyhydramnios in the other

Significant growth discordance between twins

Abnormal umbilical artery Doppler in either fetus

Symptoms of preterm labour, or reduced fetal movements

Any of the above → refer promptly to a fetal medicine unit

🔄 TWIN-TO-TWIN TRANSFUSION SYNDROME (TTTS)

Occurs only in monochorionic twins, via unbalanced blood flow through shared placental vascular connections

Diagnostic pattern: donor twin — oligohydramnios (maximum vertical pocket < 2 cm); recipient twin — polyhydramnios (MVP > 8 cm)

Staged using the Quintero classification at the referral centre

Management: fetoscopic laser photocoagulation of shared vessels is the definitive treatment at experienced fetal centres; serial amnioreduction is used where laser is unavailable or not feasible.

🗓️ DELIVERY PLANNING

Typical Timing (Uncomplicated Course)

DCDA twins: around 37–38 weeks

MCDA twins: around 36–37 weeks

MCMA twins: around 32–34 weeks — earlier, given cord entanglement risk

Triplets and higher: often around 35 weeks, individualized

Mode of delivery depends heavily on the presentation of the leading (first) twin — vertex/vertex pairs often deliver vaginally; a non-vertex leading twin usually means caesarean

MCMA twins: caesarean delivery is generally recommended because of cord entanglement risk

Deliver at a centre with immediate access to emergency caesarean and neonatal care for more than one baby at once.

DCDA Twins

Two placentas, two amniotic sacs

Lowest-risk pattern, still above singleton baseline

MCDA Twins

One shared placenta, two sacs

Needs 2-weekly surveillance for TTTS/TAPS

MCMA Twins

One placenta, one shared sac — cords can entangle

Highest-risk pattern; tertiary centre, early planned caesarean

Higher-Order (Triplets+)

Risk compounds with each additional fetus

Individualized, tertiary multidisciplinary planning essential

Anticipate It

Postpartum Haemorrhage Risk

~36

WEEKS
TYPICAL TWIN DELIVERY

An overdistended uterus after multiple birth is more prone to atony — the leading cause of postpartum haemorrhage in these pregnancies. Plan for it before delivery, not after.

Active management of the third stage is essential — give a prophylactic uterotonic promptly after the last baby is delivered

Secure two large-bore IV lines and have blood grouped and cross-matched before delivery

Keep additional uterotonics ready and know the escalation pathway for atony

Monitor closely through the early postpartum hours — do not relax vigilance once the babies are safely delivered

Reminder: the mother's risk doesn't end at delivery — the highest-risk moments for haemorrhage are in the minutes and hours right after.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary for structured teaching and triage; delivery timing, surveillance intervals, and thresholds should follow local and tertiary fetal medicine protocols.