Multiple Pregnancy
dr. A. Farid Abdullah, [Link], [Link]
Multiple Pregnancy/
Multifetalpregnancy
The presence of more than one fetus in the
gravid uterus is called multiple pregnancy
Two fetuses (twins)
Three fetuses (triplets)
Four fetuses (quadruplets)
Five fetuses (quintuplets)
Six fetuses (sextuplets)
INCIDENCE
Hellin’s Law:
Twins: 1:89
Triplets: 1:892
Quadruplets: 1:893
Quintuplets: 1:894
Conjoined twins: 1 : 60,000
Worldwide incidence of monozygotic - 1 in 250
Incidence of dizygotic varies & increasing
Demography
• Race: most common in Negroes
• Age: Increased maternal age
• Parity: more common in multipara
• Heredity - family history of multifetal gestation
• Nutritional status – well nourished women
• ART - ovulation induction with clomiphene citrate,
gonadotrophins and IVF
• Conception after stopping OCP
Twins
Varieties:
1. Dizygotic twins: commonest (Two-third)
2. Monozygotic twins (one-third)
Genesis of Twins:
Dizygotic twins (syn: Fraternal, binovular) -
- fertilization of two ova by two sperms.
Monozygotic twins (syn: Identical,
uniovular):
• Upto 3 days - diamniotic-dichorionic
• Between 4th & 7th day - diamniotic
monochorionic - most common type
• Between 8th & 12th day- monoamniotic-
monochorionic
• After 13th day - conjoined / Siamese twins.
Conjoined twins
Ventral:
1) Omphalopagus
2) Thoracopagus
3) Cephalopagus
4) Caudal/ ischiopagus
Lateral:
1) Parapagus
Dorsal:
1)Craniopagus,
2)Pyopagus
Superfecundation
Fertilization of two different ova
released in the same cycle
Superfetation
Fertilization of two ova released in
different cycles
Differences in zygocity
Monozygotic Dizygotic
1 ova + 1 sperm 2 ova + 2 sperm
Same sex Same or opposite sex
Identical features Fraternal resemblance
Single or double placenta Double or s/t fused
Same genetic features Different genetic features
DNA microprobe -same DNA microprobe - different
Differences in chorionicity with single
placenta
D / D ( fused placenta ) M/D
Monozygotic or dizygotic Monozygotic
Thick dividing membrane Thin dividing membrane
> 2mm 2mm or less
Twin peak / lambda sign T sign
Diagnosis
• HISTORY:
I. History of ovulation inducing drugs specially
gonadotrophins
II. Family history of twinning (maternal side).
• SYMPTOMS:
i. Hyperemesis gravidorum
ii. Cardio-respiratory embarrassment - palpitation or
shortness of breath
iii. Tendency of swelling of the legs,
iv. Varicose veins
v. Hemorrhoids
vi. Excessive abdominal enlargement
vii. Excessive fetal movements.
GENERAL EXAMINATION:
I. Prevalence of anaemia is more than in singleton
pregnancy
II. Unusual weight gain, not explained by pre-
eclampsia or obesity
III. Evidence of preeclampsia(25%)is a common
association.
ABDOMINALEXAMINATION:
Inspection:
• The elongated shape of a normal pregnant uterus is
changed to a more "barrel shape” and the abdomen
is unduly enlarged.
• Palpation:
Fundal height more than the period of amenorrhoea
girth more than normal
Palpation of too many fetal parts
Palpation of two fetal heads
Palpation of three fetal poles
• Auscultation:
Two distinct fetal heart sounds with
Zone of silence
10 beat difference
D/D of increased fundal height
Full bladder
Wrong dates
Hydramnios
Macrosomia
Fibroid with preg
Ovarian tumor with preg
Adenexal mass with preg
Ascitis with preg
Molar pregnancy
INVESTIGATIONS
Sonography: In multi fetal pregnancy it is done to
obtain the following information:
i. Suspecting twins – 2 sacs with fetal poles and cardiac
activity
ii. Confirmation of diagnosis
iii. Viability of fetuses, vanishing twin
iv. Chorionicity – 6 to 9 wks ( single or double placenta,
twin peak sign in d /d gestation or Tsign in m/d )
v. Pregnancy dating,
Sonography ( ctd )
i. Fetal anomalies
ii. Fetal growth monitoring (at every 3-4 weeks
interval) for IUGR
iii. Presentation and lie of the fetuses
iv. Twin transfusion (Doppler studies)
v. Placental localization
vi. Amniotic fluid volume
Radiography
Biochemical tests: raised but not diagnostic
Maternal serum chorionic gonadotrophin,
Alpha fetoprotein
Unconjugated oestriol
Lie and Presentation
Longitudinal lie (90%)
1. both vertex (40%)
2. Vertex + breech (28%)
3. breech + vertex ( 9%)
4. both breech ( 6%)
Others
vertex + transverse
breech + transeverse
both transeverse
Complications
Maternal
Pregnancy
Labour
Puerperium
Fetal
MATERNAL: During pregnancy:
- miscarriages
Hyperemesis gravidorum
Anaemia
Pre-eclampsia (25%)
Hydramnios ( 10 % )
GDM ( 2 – 3 times)
Antepartum hemorrhage – placenta previa and
placental abruption
Cholestasis of pregnancy
Malpresentations
Preterm labour (50%) twins – 37 weeks, triplets –
34 weeks, quadruplets – 30 weeks
Mechanical distress such as palpitation, dyspnoea,
varicosities and haemorrhoids
Obstructive uropathy
During Labour:
Prelabour rupture of the membranes
Cord prolapse
Incoordinate uterine contractions
Increased operative interference
Placental abruption after delivery of 1st baby
Postpartum haemorrhage
During puerperium:
Subinvolution
Infection
Lactation failure
FETAL – more with monochorionic
Spontaneous abortion
Single fetal demise
Vanishing twin – before 10 weeks
Fetus papyraceous/compressus – 2nd trim
Complications in 2nd twin (depend on
chorionicity)
– neurological, renal lesions
- anaemia, DIC
- hypotension and death
FETAL – more with monochorionic
Low birth weight ( 90%)
Prematurity – spontaneous or iatrogenic
Fetal growth restriction - in 3rd trimester,
asymmetrical, in both fetus
Discordant growth - Difference of >25% in weight ,
>5% in HC, >20mm in AC, abnormal doppler
waveforms -
Causes – unequal placental mass, lower segment
implantation, genetic difference, TTTS, congenital
anomaly in one
FETAL COMPLICATIONS (ctd)
Congenital anomalies – conjoined twins, neural tube
defects – anencephaly, hydrocephaly, microcephaly,
cardiac anomalies, Downs syndrome, talipes,
dislocation of hip
TTTS -Twin to twin transfusion syndrome
- cause – AV communication in placenta – blood from
one twin goes to other – donor to recipient
- donor – IUGR, oligohydramnios
- recipient – overload, hydramnios, CHF, IUD
FETAL COMPLICATIONS (ctd)
TRAP -Twin reversed arterial perfusion syndrome or
Acardiac twin - absent heart in one fetus with arterio-
arterial communication in placenta, donor twin also
dies
Cord entanglement and compression – more in
monoamniotic twins
Locked twins
Asphyxia – cord complication, abruption
Still birth – antepartum or intrapartum cause
Monoamniotic twins
high perinatal morbidity, mortality.
Causes : cord entanglement
congenital anomaly
preterm birth
twin to twin transfusion syndrome
Antenatal Management
Diet: additional 300 K cal per day, increased
proteins, 60 to 100 mg of iron and 1 mg of folic acid
extra
Increased rest
• Frequent and regular antenatal visit
• Fetal surveillance by USG – every 4 weeks
• Hospitalisation not as routine
• Corticosteroids -only in threatened preterm labour
, same dose
• Birth preparedness
Management During Labour
Place of delivery: tertiary level hospital
FIRST STAGE:
blood to be cross matched and ready
confined to bed, oral fluids or npo
intrapartum fetal monitoring
ensure preparedness
SECOND STAGE – first baby
-- second baby
Management During Labour
SECOND STAGE –delivery of first baby
as in singleton pregnancy
start an IV line
no oxytocic after delivery of first baby
secure cord clamping at 2 places before cutting
ensure labeling of 1st baby
Delivery of second twin
FHS of second baby
lie and presentation of second twin
wait for uterine contractions
conduct delivery
Management During Labour
Delivery of second twin – problems & interventions
-inadequate contraction- augmentation – ARM, oxytocin
-transverse lie – ECV, IPV
-fetal distress, abruption, cord prolapse- expedite delivery –
forceps, ventouse, breech extraction
THIRD STAGE – AMTSL
- continue oxytocin drip
- carboprost 250µgm IM
- monitor for 2 hours
Indications of caesarean
Non cephalic presentation of first twin
Monoamniotic twins
Conjoined twins
Locked twins
Other obstetric conditions
Second twin – incorrectible lie, closure of
cervix
TERIMA KASIH
