The ultrasound today revealed a dichorionic/diamniotic (monochorionic diamniotic) twin gestation. I spent *** minutes of direct face to face physician time of which greater than 50% involved counseling reviewing the concerns and management of a twin gestation. During this encounter, we reviewed the overall concerns along with management for dichorionic diamniotic twin gestation

  1. Per recommendations of the USPSTF, all patients with a multiple gestation should be taking a daily low dose aspirin (baby aspirin, 81 mg) for preeclampsia prevention
  2. Serial transvaginal cervical surveillance every 2-4 weeks starting at 18 weeks, depending on past obstetrical history and initial cervical length. If the patient has no history of a prior preterm birth, a cervical length 3.0 has a sensitivity of 41% and specificity of 87% for preterm delivery prior to 34 weeks. Using a cut off of > 3.5 cm has a sensitivity of 78% and specificity of 66%. Therefore, if the cervix is > 3.0 cm, ultrasounds for cervical length could be performed every 4 weeks but more frequent if < 3.0 cm.
  3. If the cervical length is 2.0 cm, discuss intravaginal progesterone, 200 mg nightly and a vaginal pessary though the data on this intervention is controversial
  4. Serial ultrasounds for growth/fluid every 4 weeks due to the risk of growth restriction/discordant growth
  5. Fetal echocardiogram at 22-24 weeks if the pregnancy is the result of IVF
  6. Deliver at 37 weeks due to the increased risk of perinatal mortality after this gestational age
  7. If there are no other co-morbidities and there is normal/concordant growth, then there is no proven benefit from fetal testing in the 3rd trimester

If monochorionic diamniotic twin gestation, then substitute this

Monochorionic diamniotic placentation is a more complicated situation due to the 15-20% risk of twin twin transfusion syndrome (TTTS), twin anemia polycythemia syndrome (TAPS), congenital anomalies, and antenatal fetal compromise. Therefore, the level of fetal surveillance needs to be increased in this subset of twins.

  1. Per recommendations of the USPSTF, all patients with a multiple gestation should be taking a daily low dose aspirin (baby aspirin, 81 mg) for preeclampsia prevention
  2. Serial transvaginal cervical lengths every 2 weeks starting at 16 weeks until 24 weeks if remains asymptomatic for preterm labor. If the patient has no history of a prior preterm birth, a cervical length 3.0 has a sensitivity of 41% and specificity of 87% for preterm delivery prior to 34 weeks. Using a cut off of > 3.5 cm has a sensitivity of 78% and specificity of 66%.
  3. If the cervical length is 2.0 cm, discuss intravaginal progesterone, 200 mg nightly and a vaginal pessary though the data on this intervention is controversial
  4. Twin twin transfusion syndrome surveillance every 2 weeks starting at 16 weeks and continuing throughout the pregnancy. This should involve assessment of amniotic fluid volume, presence of fetal bladders, and dopplers of the umbilical cord and middle cerebral artery. Fetal growth should be performed every 4 weeks as a routine
  5. Routine fetal echocardiogram at 22-24 weeks
  6. Twice weekly fetal surveillance at 32 weeks, sooner if there is evidence of TTTS
  7. Delivery in the 36th week due to the increased risk of perinatal mortality/morbidity
  8. If the patient has not received corticosteroids for lung maturity prior to anticipated delivery at this gestational age, consider its administration so as to decrease respiratory morbidity