Multiple Pregnancy

Dr. I.S.H. Hansingo

1
Definitions
 Multiple Pregnancy refers to pregnancy with
two or more fetuses
- May be twins; triplets; quadruplets;
quintuplets; sextuplets; septuplets; etc
- Twin is the commonest
 Zygosity refers to whether fetuses came
from same ovum or from different ova
 Chorionicity refers to the number of
placentae
2
Types of twinning
1. Dizygotic twinning
- (non-identical; fraternal; bi-ovular)
 Two ova are fertilized & implant separately
- Each fetus has its own placenta &
membranes
- Dichorionic & diamniotic

3
Types of twinning
2. Monozygotic twinning
- (identical; uniovular)
 Derived from splitting of single embryo
 Exact configuration of placenta depends on
age of embryo when the split occurs
 At or before 3 days post-fertilization →
dichorionic & diamniotic
 4 -7 days post-fertilization →monochorionic,
diamniotic
4
Types of twinning
 7 -14 days post-fertilization → monochorionic
& monoamniotic
 Beyond 14 days post-fertilization → conjoined
twins

5
Chorionicity Determination
 Essential to allow risk stratification
 Most easily determined in 1st or early 2nd
trimester by ultrasound
- Widely separated 1st trimester sacs &
separate placentae → dichorionic
- Lambda sign → dichorionic
- Dividing membrane thicker than 2mm → often
dichorionic
- Different sex fetuses → always dichorionic
6
7
Predisposing/ Risk Factors
 Incidence of monozygotic twins is constant
throughout the world

8
Predisposing/ Risk Factors
 Incidence of dizygotic twins is related to:
 Race: Highest in Nigeria, & lowest in Japan
 Hereditary: More likely to transmitted through
female relatives
 Maternal age: Maximal at 30 -35 years
 High parity: More after 5th pregnancy
 Previous history
 Reproductive technologies such as
ovulation induction & IVF
9
Complications During Pregnancy
Maternal complications
Anaemia: Greater iron & folate requirements
Pre-eclampsia
Polyhydramnios: More common in
monozygotic twins
Pressure symptoms: Heartburn, dyspnoea,
varicosities
Antepartum haemorrhage: Placenta praevia
due to bigger placenta encroaching on lower
segment
10
Complications During Pregnancy
Fetal complications
Structural defects: Greater in monozygotic
twins
- Neural tube defects; GI atresia; cardiac
anomalies
Miscarriages: Greater in high order
pregnancies
IUGR: One fetus may be severely affected

11
Complications During Pregnancy
Fetal complications cont’d
 Fetal demise: Vanishing twin; fetus
papyraceus
 No consequences in 1st trimester death
 Late 2nd trimester & 3rd trimester
- precipitates labour within 3wks;
- risk of death & cerebral damage in co-twin;
risk of DIC;
- psychological sequelae
12
Complications During Pregnancy
Fetal complications cont’d
 Twin-to-twin transfusion syndrome
 Blood vessels connect within placenta
 Divert blood from one fetus to the other
- Donor twin becomes anaemic, hypovolaemic,
oligohydromniotic, growth-restricted, & may
develop hydrops
- Recipient becomes polycythaemic, hyper-
volaemic, & polyuric with polyhydramnios
 More common in monozygotic twins 13
Complications During Pregnancy
Fetal complications cont’d
 Twin reversed arterial perfusion sequence
(acardia)
 One twin pumps blood into the other’s
umbilical artery
 The pump twin becomes acardiac and upper
part of the body fails to develop

14
Complications of labour
 Preterm labour:
- Mean duration of pregnancy reduces as
number of fetuses increases
 Cord accidents:
- Cord prolapse following PROM
- Cord entanglement & knotting in MZ
 Malpresentations:
- C/C 40%; C/B 40%; B/B 10%; C/T 5%;
B/T 4%; T/T 1%
15
Complications of labour
 Operative delivery:
- Either as elective or emergency procedure
before or after delivery of 1st twin
 Twin entrapment:
- Typically with MZ twins
 Postpartum haemorrhage:
- Uterine atony due to overdistension
- Large placental area

16
Postpartum Complications
 Postnatal depression

 Demanding breastfeeding
- Both physically & psychologically

 Financial difficulties

17
Diagnosis
1. History
 Family history of multiple pregnancy
 Exaggerated minor ailments of normal
pregnancy
 Increased nausea and vomiting in early
pregnancy
 Excessive abdominal enlargement and
excessive fetal movements

18
Diagnosis
- History of ovulation inducing drugs
- Unusual weight gain
- Pre-eclampsia developing before 20wks

19
Diagnosis
2. Abdominal examination
- Large-for-dates HOF
- Abdominal girth > 100cm
- Multiple fetal parts
- Two heads
- Three fetal poles
- Fetal head smaller than expected for size of
uterus
- Two FHRs with difference of at least 10bpm
20
Diagnosis
3. Investigations
- Ultrasounds confirms diagnosis
- Abdominal X-ray: Only where U/S is not
available, & not before 16 wks gestation

21
Antenatal Care
 More frequent visits than in singletons
 Determine chorionicity in 1st trimester
 Iron & folate supplementation
 Detailed anomaly scan at 22 -24 wks
 Avoid physical and mental strain, especially
after 32 wks
 Induction of labour beyond 40 wks

22
Labour/ Delivery
 Place of delivery is in unit equipped for
operative delivery and neonatal care
 Intravenous access
 Group & save serum
 Continuous monitoring of FHR (2 monitors to
be used)
 Pain relief when contractions start
 Immediate VE if SROM occurs

23
Labour/ Delivery
 Staff to be available for delivery include 2
midwives, senior obstetrcian, anaesthetist,
paediatrician, & neonatal nurse
 Aim for vaginal delivery if 1st twin’s
presentation is vertex

24
Labour/ Delivery
 Indications for CS include:
- Non-vertex presentation of 1st twin
- Previous CS
- Higher-order deliveries
- Conjoined twins
- Poor progress or fetal distress during labour
- Accompanying obstetrical complication

25
Labour/ Delivery
 Second stage management:
- 1st baby delivered as in singleton
- Cord is clamped immediately after delivery, &
remains clamped until 2nd baby has been
delivered
- Immediately after delivery of 1st baby,
ascertain lie & presentation, & auscultate FH
of 2nd baby

26
Labour/ Delivery
- If 2nd baby is in longitudinal lie, wait for
engagement, then ARM & deliver as in
singleton
- If 2nd twin is in transverse lie →ECV or (if ECV
fails) IPV + breech extraction
- If fetal distress &/or cord prolapse →CS

27
Labour/ Delivery
 For the 3rd stage:
- Deliver placenta(s) as usual
- Rub up the uterus
- Give oxytocic drug
- Administer oxytocin 20 -40iu/L over 8 -12hrs

28
THANK YOU

29