MULTIPLE PREGNANCY

INTRODUCTION
• Multiple pregnancy presents a series of special
problems in obstetric practice.
• It also has significant implications for the
children after birth and during development.
• The great majority of multiple pregnancies are
associated with twins.
 INTRODUCTION: Continuation.
.The increasing use of in-vitro fertilization has now changed
the incidence of higher multiple pregnancies
.Spontaneous twinning highest among blacks and East Indians
. Account for 2.5% of births
. Rate of monozygotic twin 3.5 /1000 live birth(constant)
. Rate of dizygotic twin is variable
. Influenced by several factors like ethnicity , maternal age,
genetic tendency
 EMBRYOLOGY:
• • Zygote: sperm + oocyte
• • Embryo: prenatal period between 14 days to 9 week
• • Implantation occurs in form of blastocyst on 6 to 8 day
• • Fetus: prenatal period between 9 week to birth Primitive
uteroplacental circulation: begins at the end of 2 nd week • Placenta:
chorion frondosum(fetal)+decidua basalis(maternal) • Placental
borders :chorionic plate (fetal side) and desidual plate(maternal side)
• Amnion: innermost avascular layer facing fetus
 EMBRYOLOGY: Continuation:

• Placenta: chorion frondosum(fetal)+decidua

basalis(maternal)
• Placental borders :chorionic plate (fetal side)
and desidual plate(maternal side)
• Amnion: innermost avascular layer facing
fetus
• Chorion begins to form at 3rd day after
fertilization • Amnion begins to form between
day 6 to 8
 TYPES OF TWINNING:
Twins may be monozygotic, derived from one
fertilized egg, or dizygotic, derived from two
different eggs. With very rare exceptions, all
pairs discordant for sex are dizygotic. About
one-third of all twin pairs are of unlike sex.
Monochorionic twins are never completely
identical but are frequently indistinguishable to
the casual observer.
TYPES OF TWINNING: Continuation

Difference in hair and eye colour indicate

zygosity. It is possible to assign zygosity with
reasonable accuracy in most twin pairs by sex,
placentation and physical appearance.
TYPES OF TWINNING: Continuation
The determination of blood group may also help assign
zygosity. Discrepant blood groups indicate zygosity.
Monochorionic placentae can be determined by direct
examination at the time of delivery or by submitting a
sample of the dividing membranes for histological
examination. In monochorionic placentae, positive
transfer will occur through the placental circulation,
whereas in dichorionic placentae, transfer does not occur.
 ETIOLOGY:

• Increasing maternal age

• Maternal parity
• Nutritional factor
• Family history
• Infertility therapy •
 ETIOLOGY: continuation

• Assisted reproductive therapy

• High pituitary gonadotropins; act on the
granulosa cells of the ovaries to stimulate synthesis
and production of both steroid hormones, such as
progesterone, and peptide hormones, such as
inhibin.
 PREDISPOSING FACTORS

• Dizygotic twin pregnancies are slightly more

likely when the following factors are present in
the woman:
•She is between the age of 30 and 40 years
•She is greater than average height and weight
 PREDISPOSING FACTORS : Conti

•She has had several previous pregnancies.

•Women undergoing certain fertility treatments
may have a greater chance of dizygotic multiple
births.
 PREDISPOSING FACTORS : Conti
•The risk of twin birth can vary depending on
what types of fertility treatments are used.
With in vitro fertilization (IVF), this is
primarily due to the insertion of multiple
embryos into the uterus.
•Ovarian hyperstimulation without IVF has a
very high risk of multiple birth.
 PREDISPOSING FACTORS : Conti

•Reversal of anovulation with clomifene has a

relatively less but yet significant risk of multiple
pregnancy.
 CLINICAL DIAGNOSIS:

• Uterine size more than expected age

• Weight gain more than expected
• Two fetal heart sound
• Hyperemesis gravidarum
 MATERNAL PHYSIOLOGICAL
CHANGES:
1. There is increase in weight gain and cardiac
output.

2. Plasma volume is increased by an addition of

500ml.
 MATERNAL PHYSIOLOGICAL
CHANGES: Conti
3. There is no corresponding increase in red cell
volume resulting in exaggerated haemodilution
and anaemia.
4. There is increased alpha fetoprotein level,
tidal volume and glomerular filtration rate
 DIAGNOSIS:

• By USG as early as 5weeks by multiple

gestational sac
• At 6th week by cardiac activity
• From 10th to 14th weeks by placentation
 DIAGNOSIS:Conti

• Lambda sign: internal dividing membrane or

ridge at placental surface in dichorionic
• Increased maternal AFP,hcg
 MATERNAL COMPLICATION:

• Preterm labour(57% in twin,76-90% in higher

order multiple)
• Operative delivery(66% in twins and 91%)
 MATERNAL COMPLICATION:
Continuation.

• PROM: Premature rupture of membranes (PROM)

is a rupture (breaking open) of the membranes
(amniotic sac) before labor begins. If PROM occurs
before 37 weeks of pregnancy, it is called preterm
premature rupture of membranes (PPROM). PROM
occurs in about 8 to 10 percent of all pregnancies
 Continuation.

• HELLP syndrome; named for 3 features of the

disease (hemolysis, elevated liver enzyme levels,
and low platelet levels), is a life-threatening
condition that can potentially complicate
pregnancy
 Continuation.

• Anaemia
• Acute fatty liver; is an obstetric emergency characterized
by maternal liver dysfunction and/or failure that can lead
to maternal and faetal complications, including death.
Prompt delivery and supportive maternal care are
important for achieving a full recovery for the mother.
 Continuation.
• Hypertensive diseases during pregnancy are
classified into 4 categories; chronic
hypertension, preeclampsia-eclampsia,
preeclampsia superimposed on chronic
hypertension, and gestational hypertension
(transient hypertension of pregnancy or chronic
hypertension identified in the latter half of
pregnancy) 
 Continuation.

• Postpartum endometritis;  refers to infection

of the decidua (ie, pregnancy endometrium). It
is a common cause of postpartum fever and
uterine tenderness and is 10- to 30-fold more
common after cesarean than vaginal delivery.
 Continuation.

• Gestation diabetes mellitus

• Spontaneous abortion(vanishing
twin)8%to36%
• Incompetent cervix(up to 14%)
 Continuation.

• PIH (2.5 times) defined as sustained elevated blood

pressures of ≥ 160 mm Hg systolic and ≥ 110 mm Hg
diastolic.
• Complication associated with tocolytic treatment;  drugs
that are used to delay your delivery for a short time (up to
48 hours) if you begin labor too early in your pregnancy.
 FETAL COMPLICATION:

• IUGR; Intrauterine growth restriction, is

when a baby in the womb (a fetus) does not
grow as expected. The baby is not as big as
would be expected for the stage of the mother's
pregnancy. This timing is known as an unborn
baby's "gestational age."
 FETAL COMPLICATION:
Continuation.
• Prematurity
• Low birth weight
• Fetal growth discordance is a term used in obstetric
imaging to describe a significant size or weight
difference between the two fetuses of a twin
pregnancy.
 FETAL COMPLICATION:
Continuation.
.Congenital malformations can be defined
as structural or functional anomalies that occur
during intrauterine life. Also called birth defects,
congenital disorders, or congenital malformations,
these conditions develop prenatally and may be
identified before or at birth, or later in life.
 FETAL COMPLICATION:
Continuation

• Intra uterine fetal demise(IUFD) is the medical

term for a child who dies in utero after the 20th
week of pregnancy in the second trimester.
Although there is no agreed-upon time, most
doctors deem the death to be an IUFD if it occurred
after 20 weeks of gestation.
 FETAL COMPLICATION:
Continuation

• Chromosomal anomalies; a change to a child's

genetic material or DNA, which alters the baby's
development before birth. This can include extra,
missing or irregular chromosomes.
 FETAL COMPLICATION:
Continuation
.Twin-to-twin transfusion syndrome (TTTS) is a
rare pregnancy condition affecting identical
twins or other multiples. It occurs in pregnancies
where twins share one placenta (afterbirth) and a
network of blood vessels that supply oxygen and
nutrients essential for development in the womb.
 FETAL COMPLICATION:
Continuation
.Velamentous cord insertion and vasa previa;  Vasa previa is
defined when unprotected umbilical vessels run through the
amniotic membranes, and pass over the cervix. Two types: Type
I: Velamentous cord insertion and fetal vessels that run freely
within the amniotic membranes overlying the cervix or in close
proximity of it (2cm from os).
•
 FETAL COMPLICATION:
Continuation.
• • Perinatalmortality refers to the death of a fetus
or neonate and is the basis to calculate the
perinatal mortality rate. Variations in the precise
definition of the perinatal mortality exist,
specifically concerning the issue of inclusion or
exclusion of early fetal and late neonatal fatalities.
 FETAL COMPLICATION:
Continuation.
• Thromboembolic arterial occlusion is defined
as obstruction usually followed by infarction of
arterial beds by embolic material derived from
a thrombus from a distant site and in the
presence of intact endothelial surface (to be
distinguished from arterial thrombosis).
 FETAL COMPLICATION:
Continuation
• • Necrotic limb; Necrosis is caused by a lack of
blood and oxygen to the tissue. It may be triggered
by chemicals, cold, trauma, radiation or chronic
conditions that impair blood flow. 1 There are many
types of necrosis, as it can affect many areas of the
body, including bone, skin, organs and other tissues.
 FETAL COMPLICATION:
Continuation
• Small bowel atresia, also known as intestinal
atresia, is a birth defect that affects a part of the
small intestine, the tube that connects the stomach
to the large intestine and helps digest food.
Depending on the extent of the blockage, the defect
is classified as either atresia or stenosis.
 FETAL COMPLICATION:
Continuation
• Horse shoe kidney is when the 2 kidneys join (fuse)
together at the bottom. They form a U shape like a
horseshoe. It is also known as renal fusion. The
condition occurs when a baby is growing in the womb,
as the baby's kidneys move into place. Horseshoe
kidney can occur alone or with other disorders .
 FETAL GROWTH DISCORDANCE

• Intrapair difference in birth weight >20% of larger

twin`s weight Classification: Mild 30%
Risk factors :TTTS, placental dysfunction, fetal
infection, fetal structural and chromosomal
abnomalities, antepartum bleeding, velamentous
cord insertion
 MANAGEMENT (ANTENATAL)
• Early diagnosis
• Nutritional intervention
• Prophylactic tocolytic; drugs that are used to delay your delivery
for a short time (up to 48 hours) if you begin labor too early in
your pregnancy.

•
 MANAGEMENT (ANTENATAL)
Continuation.
• Steroid stimulation of fetal lung maturity
• Therapeutic amniocentesis
• Multifetal reduction
• Bed rest beginning before 28 weeks
 MANAGEMENT IN LABOR AND
DELIVERY:
• • Best method of delivery depend on
• 1. No of fetus 2. Presentation of first fetus 3.
Gestational age Twin presentation Vertex-
vertex:42.5% Vertex-nonvertex:38.4%
Nonvertex:19.1%
 MODE OF DELIVERY:

• • Vertex-vertex=vaginal and interval should not be >20

min • Vertex –breech=vaginal by senior obstetrician
• • Breech-vertex=prefer CS to avoid interlocking(a
rare complication 1/1000)
• • Breech-breech=CS
 TWIN TO TWIN TRANSFUSION:

• Only in monochorionic gestation

• Complicates 10-20% of such pregnancy
• Pathophysiology : 1. placental vascular
anastomoses 2. Unequal placental sharing 3.
Abnormal umbilical cord insertion
 TWIN TO TWIN TRANSFUSION:
Continuation.
• AV anastomoses with unidirectional flow leads
to shunting of blood from one twin to other
• AA connections are thought to be protective
 DIAGNOSIS:

• Usually made between 17 and 26 weeks

gestation
• May occur as early as 13 weeks
 DIAGNOSIS: Continuation.
• Criteria: 1. Monochorionicity 2. Cord size
discrepancy 3. Significant growth
discordance(>20%wt difference and Hb
difference>5g/dl) 4. Polyhydroamnios in recipient
sac and oligohydramnios in donor sac 5. Cardiac
dysfunction in polyhydroamniotic twin ,abnormal
umbilical artery and/or ductus venosus doppler
velocimetry
 TREATMENT MODES OF TWIN-TO-TWIN TRANSFUSION
SYNDROME :

Conservative management and monitoring:

• USG • Biophysical profile • Doppler blood flow
velocimetry • Fetal echocardiography
• Cardiotocography • Digoxin • Serial
aminoreduction • Fetoscopic laser occlusion of
placental vessels
 CONJOINED (SIAMESE TWIN):

• Result of late incomplete embryonic division

• Only in monochorionic –monoamniotic twins
• Incidence -1 in 50,000 to 100,000 births
• Mostly female sex • Most common –
thoracopagus
 CONJOINED (SIAMESE TWIN):
Continuation.
• Serial USG required for fetal anatomy and
management
• Ex utero intrapartum
treatment(EXIT):procedure for delivery of co-
twin when one twin is not likely to survive
OMPHALOPAGUS
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