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6 - Pathology of twinning and higher multiple pregnancy

Published online by Cambridge University Press:  05 September 2014

By
Phil Cox
Edited by
Marta C. Cohen  and
Irene Scheimberg
Phil Cox
Affiliation:
Birmingham Women’s Hospital
Marta C. Cohen
Affiliation:
Sheffield Children’s Hospital
Irene Scheimberg
Affiliation:
Barts and the London NHS Trust, London
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Summary

Introduction

Incidence of twins and higher multiples

Multiple pregnancy is not the normal situation in humans. Naturally conceived twins account for only 1% of pregnancies, while only 0.1% are triplets and higher multiples. Since the advent of assisted conception and in vitro fertilization (IVF) the rate of multiple pregnancies has increased substantially. In the UK the multiple pregnancy rate has increased from 9.6 per 1000 in 1976 to 15.7 per 1000 in 2010 [1]. In the United States the situation is similar, with an increase from 18.9 per 1000 in 1980 to 32 per 1000 in 2005 [2].

Types of multiple pregnancy (MZ/DZ) plus etiology

Multiple pregnancies may be derived from the same or separate fertilized ova. Approximately 28% of twins in Western countries are from a single ovum (monozygous) and result in identical twins, while 72% are from separate ova (dizygous), resulting in non-identical or fraternal twins. The rate of monozygotic twinning appears to be constant worldwide, whereas dizygous twinning is more common in Black Africans (1 in 24 pregnancies) and least common in those of Far Eastern origin (1 in 140 pregnancies) [3].

Monozygous twins are thought to arise as the result of a random event in the conceptus, leading to splitting of the early embryo into two halves. Occasionally it is thought that an abnormal clone arising in the early conceptus leads to splitting into twins. However, in general, monozygous twins appear to be genetically and physically identical.

Dizygous twinning shows a familial tendency, which is maternally inherited. Sisters of dizygous twins have a 2.5-fold increased rate of having dizygous twins [4]. Dizygous twins are also more common in older mothers [4].

Exogenous hormones given to enhance fertility are associated with multiple ovulations and thus multiple fertilized ova and dizygous twins. The vast majority of twins resulting from assisted conception (AC) and IVF are the result of implantation of more than one fertilized egg into the mother’s uterus. However, 0.8–5% of pregnancies following AC and IVF turn out to be monozygous, compared to the expected rate of 0.45% [5].

Type
Chapter
Information
The Pediatric and Perinatal Autopsy Manual , pp. 93 - 104
Publisher: Cambridge University Press
Print publication year: 2000

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References

Office for National Statistics. Live births in England and Wales by Characteristics of birth, 2010, Cardiff, ONS, 2010.
Martin, J. A., Hamilton, B. E., Sutton, P. D., et al. Births: final data for 2007. National Vital Statistics Reports: From the Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System 2010; 58: 1–85.Google ScholarPubMed
Derom, R., Orlebeke, J., Eriksson, A., and Thiery, M.The epidemiology of multiple births in Europe. In: Keith, L. G., Papiernik, E., Keith, D. M., and Luke, B., eds., Multiple Pregnancy. 1st edition. London, The Parthenon Publishing Group, 1995, 145–62.Google Scholar
Bulmer, M. G.The Biology of Twinning in Man. Oxford, Oxford Clarendon Press, 1970.Google Scholar
Aston, K. I., Peterson, C. M., and Carrell, D. T.. Monozygotic twinning associated with assisted reproductive technologies: a review. Reproduction 2008; 136: 377–86.CrossRefGoogle ScholarPubMed
Sepulveda, W., Sebire, N. J., Hughes, K., et al. Evolution of the lambda or twin-chorionic peak sign in dichorionic twin pregnancies. Obstet Gynecol 1997; 89: 439–41.CrossRefGoogle ScholarPubMed
Denbow, M. L., Cox, P., Taylor, M., Hammal, D. M., and Fisk, N. M.. Placental angioarchitecture in monochorionic twin pregnancies: relationship to fetal growth, fetofetal transfusion syndrome, and pregnancy outcome. Am J Obstet Gynecol 2000; 182: 417–26.CrossRefGoogle ScholarPubMed
Office for National Statistics. Infant and Perinatal Mortality by Health Areas in England and Wales, 2009. Cardiff, ONS, 2011.Google Scholar
Glinianaia, S. V., Obeysekera, M. A., Sturgiss, S., and Bell, R.. Stillbirth and neonatal mortality in monochorionic and dichorionic twins: a population-based study. Hum Reprod 2011; 26: 2549–57.CrossRefGoogle ScholarPubMed
Martin, J. A., Hamilton, B. E., Ventura, S. J., et al. Births: final data for 2010. In: National Vital Statistics Reports. Hyattsville, MD, National Center for Health Statistics, 2012.Google Scholar
Victoria, A., Mora, G., and Arias, F.. Perinatal outcome, placental pathology, and severity of discordance in monochorionic and dichorionic twins. Obstet Gynecol 2001; 97: 310–15.Google ScholarPubMed
Branum, A. M. and Schoendorf, K. C.. The effect of birth weight discordance on twin neonatal mortality. Obstet Gynecol 2003; 101: 570–4.Google ScholarPubMed
Lopriore, E., Pasman, S. A., Klumper, F. J., et al. Placental characteristics in growth-discordant monochorionic twins: a matched case-control study. Placenta 2012; 33: 171–4.CrossRefGoogle ScholarPubMed
Gupta, N., Sebire, N. J., Miskry, T., and Rees, H. C.. Massive perivillous fibrin deposition associated with discordant fetal growth in a dichorionic twin pregnancy. J Obstet Gynaecol 2004; 24: 579–80.CrossRefGoogle Scholar
Sebire, N. J., Foskett, M., Paradinas, F. J., et al. Outcome of twin pregnancies with complete hydatidiform mole and healthy co-twin. Lancet 2002; 359: 2165–6.CrossRefGoogle ScholarPubMed
Ville, Y., Hyett, J. A., Vandenbussche, F. P., and Nicolaides, K. H.. Endoscopic laser coagulation of umbilical cord vessels in twin reversed arterial perfusion sequence. Ultrasound Obstet Gynecol 1994; 4: 396–8.CrossRefGoogle ScholarPubMed
Pasquini, L., Wimalasundera, R. C., Fisk, N. M.. Management of other complications specific to monochorionic twin pregnancies. Best Pract Res Clin Obstet Gynaecol 2004; 18: 577–99.CrossRefGoogle ScholarPubMed
Bryan, E., Little, J., and Burn, J.Congenital anomalies in twins. Bailliere Clin Obstet Gynaecol 1987; 1: 697–721.CrossRefGoogle ScholarPubMed
Machin, G. A.. Some causes of genotypic and phenotypic discordance in monozygotic twin pairs. Am J Medi Genet 1996; 61: 216–28.3.0.CO;2-S>CrossRefGoogle ScholarPubMed
Nieuwint, A., Van Zalen-Sprock, R., Hummel, P., et al. “Identical” twins with discordant karyotypes. Prenat Diag 1999; 19: 72–6.3.0.CO;2-V>CrossRefGoogle ScholarPubMed
Denbow, M. L. and Fisk, N. M.. The consequences of monochorionic placentation. Bailliere Clin Obstet Gynaecol. 1998; 12: 37–51.CrossRefGoogle ScholarPubMed
Denbow, M. L., Battin, M. R., Cowan, F., et al. Neonatal cranial ultrasonographic findings in preterm twins complicated by severe fetofetal transfusion syndrome. Am J Obstet Gynecol 1998; 178: 479–83.CrossRefGoogle ScholarPubMed
Umur, A., van Gemert, M. J., Nikkels, P. G., and Ross, M. G.. Monochorionic twins and twin–twin transfusion syndrome: the protective role of arterio-arterial anastomoses. Placenta 2002; 23: 201–9.CrossRefGoogle ScholarPubMed
Galea, P., Jain, V., and Fisk, N. M.. Insights into the pathophysiology of twin–twin transfusion syndrome. Prenat Diag. 2005; 25: 777–85.CrossRefGoogle ScholarPubMed
Bajoria, R.. Vascular anatomy of monochorionic placenta in relation to discordant growth and amniotic fluid volume. Hum Reprod 1998; 13: 2933–40.CrossRefGoogle ScholarPubMed
Fieni, S. and Gramellini, D.. Very-early-onset discordant growth in monochorionic twin pregnancy. Obstet Gynecol 2004; 103(5 Pt 2): 1115–17.CrossRefGoogle ScholarPubMed
Roberts, D., Neilson, J. P., Kilby, M., and Gates, S.Interventions for the treatment of twin–twin transfusion syndrome. Cochrane Database Syst Rev 2008; 1: CD002073.Google Scholar
Muratore, C. S., Carr, S. R., Lewi, L., et al. Survival after laser surgery for twin-to-twin transfusion syndrome: when are they out of the woods?J Pediatr Surg. 2009; 44: 66–9; discussion, 70.CrossRefGoogle ScholarPubMed
Lewi, L., Jani, J., Cannie, M., et al. Intertwin anastomoses in monochorionic placentas after fetoscopic laser coagulation for twin-to-twin transfusion syndrome: is there more than meets the eye?Am J Obstet Gynecol 2006; 194: 790–5.CrossRefGoogle ScholarPubMed
Habli, M., Bombrys, A., Lewis, D., et al. Incidence of complications in twin–twin transfusion syndrome after selective fetoscopic laser photocoagulation: a single-center experience. Am J Obstet Gynecol 2009; 201: e1–7.CrossRefGoogle ScholarPubMed
Fusi, L., McParland, P., Fisk, N., Nicolini, U., and Wigglesworth, J.. Acute twin–twin transfusion: a possible mechanism for brain-damaged survivors after intrauterine death of a monochorionic twin. Obstet Gynecol 1991; 78(3 Pt 2): 517–20.Google ScholarPubMed
Fusi, L. and Gordon, H.Twin pregnancy complicated by single intrauterine death: problems and outcome with conservative management. Br J Obstet Gynaecol 1990; 97: 511–16.CrossRefGoogle ScholarPubMed
Margono, F., Feinkind, L., and Minkoff, H. L.. Foot necrosis in a surviving fetus associated with twin–twin transfusion syndrome and monochorionic placenta. Obstet Gynecol 1992; 79(5 (Pt 2)): 867–9.Google Scholar
Lo, A. A., Faye-Petersen, O. M., and Ernst, L. M.. Intrauterine fetal death of a monochorionic twin with peripheral pulmonary infarcts: potential thromboembolic events following death of co-twin. Pediatr Dev Pathol 2012; 15: 142–5.CrossRefGoogle ScholarPubMed
Umur, A., van Gemert, M. J., and Nikkels, P. G.. Monoamniotic-versus diamniotic-monochorionic twin placentas: anastomoses and twin–twin transfusion syndrome. Am J Obstet Gynecol 2003; 189: 1325–9.CrossRefGoogle ScholarPubMed
Pasquini, L., Wimalasundera, R. C., Fichera, A., et al. High perinatal survival in monoamniotic twins managed by prophylactic sulindac, intensive ultrasound surveillance, and Cesarean delivery at 32 weeks’ gestation. Ultrasound Obstet Gynecol 2006; 28: 681–7.CrossRefGoogle Scholar

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