Multiple Pregnancy
Presented by
Varsha Sharma
MSc. Nursing 2nd year
Incidence
Hellins Law Twin = 1:80
Triplets = 1:80
Quadruplets =
1:80
Monozygotic = 3-5/1000 births
Dizygotic = varies depending
on maternal age, race and
geographical distribution
Aetiology
Assisted reproduction techniques
Increase parity
Increase maternal age
Family history
Previous multiple pregnancy
African race
Type of multiple
pregnancy
1. Dizygotic / binovular / fraternal
2. Monozygotic / Uniovular / identical
Monozygotic / Uniovular /
Identical
Dizygotic / binovular /
fraternal
1.1/3 twins
1.2/3 twins
2. 1 sperm and 1 ovum
2. 2 sperms and 2 ova
3.Identical
3. Dichorionic
Diamniotic twins
4. Type of placenta
depends on the time of
splitting of embryo
5.Incidence is
independent of race,
age, parity
4. 2 separate placenta
present
5. Incidence is
dependent of race, age,
parity, and ovulation
inducing drugs
Types of Monozygotic
twins
1.Dichorionic Diamniotic :
i. Division occurs with in 72 hrs of fertilization
ii.May have 2 diff placentas/ single fused
placenta
iii.Difficult to differentiate form dizygotic twins
iv.Both babies have same sex
2.Monochorionic Diamniotic:
I. Division occurs with in 4 8 days of
fertilization
3. Monochorionic Monoamniotic:
I. Division occurs 9-12 days of fertilization
4. Conjoined twins:
I. Division occurs after 13 th day
II. Incomplete division of embryonic disc
III. Types:
-thoracopagus
- omphalophagus
-craniopagus
-pyopagus
-ischiopagus
Clinical presentation
Symptoms :
nausea, vomiting
pressure symptoms:
constipation, pedal edema, varicosity of veins,
palpitations, precordial pain
Fatigue, indigestion, backache, sleeplessness
H/O overdistension
H/O premature labor
Excessive fetal movements
Fundal height , H/O ovulation inducing drugs
SIGNS :
Anemia
Edema
Abnormal Weight Gain
Uterine Height > POG
It may be normal size in case of binovular twins/ when
1 of the babies die in utero
Palpation:
Feel 2 separate heads/ > 2 poles
Auscultation :
2 FHS with difference of at least 10 beats heard on 2
sides of uterus by 2 people, at least 6 inches away
Role of ultrasound
Confirmation of chorionicity
Twin peak sign / Lambda sign = dichorionic
placenta
Identify the number and site of placenta, fuse
or separate
Lie and presentation of twin
Amniotic fluid assessment
Intrapartum complications
PROM & cord
prolapse
Abruption in the
2nd twin
Interlocking of
twins
Twin to Twin Trasfusion Syndrome
TWIN- TWIN TRANSFUSION
SYNDROME
Arterio venous anastomoses
with net flow in one direction..
Donor(arterial
recipient
Severe IUGR
poor renal
side)
perfusion
Anuria
severe
oligohydramnios
Hypervolemia
Polyuria with
polyhydramnios
CCFdeath
Vanishing twin
Cessation of cardiac
activity in a previously
viable foetus
Fetus
papyraceous
Cord entanglement
Single fetal demise
monochorionic
Shift of blood
Death of one
twin
Normal
twin
25% risk of co-twin death /25% risk of
neurological damage in surviving twin
Congenital anomalies
Structural
malformations
Conjoint twins
Acardiac fetus
Anencephaly
Talipes
Dislocation of hip
etc..
Chromosomal
anomalies
Downs syndrome
Conjoint twins
Always monozygotic
classification
Thoracopagus
Craniopagus
omphalopagus
Pygopagus
ischiopagus
Prenatal diagnosis-to counsel the parents for
mtp / to plan site & mode of delivery
Acardiac foetus
A-A
anastamoses
in placenta
De
oxygenated
blood
Umb. A
Um
b.A
Normal fetus/pump
twin
Umb.V V-V
anastomoses
in placenta
Minimal oxy. extracted by
lower part of
fetus
Acardiac
Fully de oxygenated
Upper part of fetus ,no grow
Umb.V
Acardiac twins
Anencephaly
Management of multiple pregnancy
Antenatal care :
Extra attention & diet: at least 300 kcal more
than in normal pregnancy
Routine iron and folic acid
Detailed anomaly scan followed by serial
growth scan at 28, 32 and 36 week
Hospitalization if suspected pretem
Mode of delivery
Depend on presentation of 1st twin
Both vertex / 1st twin vertex
vaginal delivery
Indication for Elective LSCS
-More than 2 fetuses
-1st twin malpresentation, CPD
-Scarred uterus
-Conjoint twin
-IUGR in dichorionic twin
-TTTS
Emergency LSCS :
-Fetal distress
-cord prolapse in 1st baby
-Non progress of labor
-2nd twin is transverse, version failed after
delivery of 1st twin
Management during labour 1st stage
1.
2.
3.
4.
5.
6.
Determine the presentation of 1st twin
Maintain partogram
Establish IV line
Blood grouping and cross matched
Continous intrapartum twin CTG monitoring
Analgesic
Management during labour 2nd stage
1. Delivery of 1st twin
2. Clamp and cut the cord
3. Note lie of the 2nd twin (delivered within 20 min)
4. Longitudinal lie (abdominally & vaginally) :
Start 2 units of pitocin IV drip
Cephalic Fix the head into pelvisARM &
deliver the fetus
Breech Assisted breech delivery, Breech
extraction
If 2nd twin has transverse lie :
Assistant performs ECV.
Fix the head in lower pole of the uterus and
accoucher performs controlled ROM (rupture
of membrane)
If this fails: do IPV (internal podalic version)
followed by breech extraction
Or proceed with emergency LSCS
