M U LT I P L E

PR E G N A N C Y
DE R S UPER VIS IO N OF
UN
F. D R / HOW IDA AWAD
ASSIST. PRO
DR / ROQAYA FATHY
‫ب‬‫ع‬ ‫ن‬‫م‬‫ي‬ ‫ا‬ ‫ه‬‫م‬‫س‬‫ب‬ / ‫م‬‫س‬ ‫ال‬‫ا‬
‫د المنعم علي‬
 ‫‪Prepared‬‬
‫‪by :‬‬
‫(‪Group (A1‬‬

‫‪2025‬‬

‫َو َز َكِر َّيا ِإْذ َناَدٰى َر َّبُه َر ِّب اَل َتَذْر ِني َف ْر ًدا َو َأنَت "‬
‫َخ ْيُر اْلَو اِر ِثيَن " سوره األنبياء اآلية (‪)٨٩‬‬
 OUT LINE
🔻TRODUCTION

🔻DEFINITION

🔻INCIDENC

🔻TYPES

🔻 DIAGNOSES
🔻COMPLICATIONS

🔻MANAGEMENT
Introduction
The term multiple pregnancy is used to describe
the development of more than one fetus in utero at
the same time. When more than one fetus
simultaneously develops in the uterus, it is called
multiple pregnancy. Simultaneous development of
two fetus (twins) is the commonest; although rare
development of three fetus (triplets), four fetuses
(Quadruples), five fetuses (Quintuplets) or six
fetuses (Sextuplets) may also occur.
Definition
A multiple pregnancy occurs when a woman
has two or more than one fetus or embryo in
her uterus at the same time. The fetus can
come from the same egg (identical) or
different eggs (fraternal).
Incidence

The incidence of multiple pregnancies has

increased worldwide due to the use of assisted
reproductive technologies, such as in vitro
fertilization. In the USA, the rate of twin births has
increased by nearly 80% since 1980, while the rate
of triplet and higher-order births has increased by
more than 400%. The overall rate of multiple births
is around 4% of all pregnancies.
Hellin rule can be applied to spontaneously
occurring multiple pregnancy. According to this rule
the incidence of twins is one in 80 pregnancies,
triplets one in 80×80, quadruplets one in 80×80×80
and so on.
 Types
🔹 Uniovular "monozygotic, identical" Twins
20%(
result from division of a single fertilized ovum.
According to the stage of developmentat which
division of the embryo occur.
🔹Binovular "Bizygotic, Freternal" Twins %80
Result from fertilization of two separate ova.
Uniovular twins may be :
1. Dichorionic diamniotic
2. Monochorionic diamniotic
3. Monochorionic monoamniotic
4. Conjoined twins
 . 1 DICHORIONIC DIAMNIOTIC

2 placenta,2Chorion and 2
amniotic sacs.
The 2 placenta may fused
together giving rise to a
single placenta "division
occurs at morula stage
within 3 days after
fertilization %23"
. 2 MONOCHORIONIC _DIAMNIOTIC

One placenta, one

chorions and 2
amniotic sacs
"division occurs at
the blastocyst 7_4
days after fertilization
%75
. 3 MONOCHORIONIC _MONOAMNIOTIC

One placenta, one chorions

and one amniotic sac
"division occurs 13_8 days
after fertilization %1
4- Conjoined twins:
Due to incomplete division of the fertilized ovum
(occurring after 13 days of fertilization). There is one
placenta, one chorion and one amniotic sac.
Twins with one amniotic sac have a high fetal mortality
(up to 50%) due to entanglement of the cord leading to
obstruction of the umbilical vessels.
The uniovular twins are identical. They are of the same
sex, blood group and appearance but with different
fingerprints, iris pattern, and voice.
Types of Conjoined twins

1. Thoracopagus "%28"
2. Omphalopagus "%10"
3. Craniopagus "%6"
4. Ischiopagus
5. Pygopagus
. 1Thoracopagus (28%):

Twins joined at the

chest, often sharing a
heart and possibly other
organs like the liver.
. 2Omphalopagus
(10%):

Twins connected at the

abdomen, typically
sharing organs such as
the liver and parts of
the digestive system,
but usually having
separate hearts.
. 3Craniopagus (6%):

Twins fused at the

skull, with separate
bodies.
. 4Ischiopagus:

Twins joined at the

pelvis, potentially sharing
lower gastrointestinal
tracts and genitourinary
systems.
. 5Pygopagus:

Twins connected at the

sacral region (lower back),
often sharing the lower
gastrointestinal tract and
sometimes the genitourinary
System.
(Binovular (BIZYGOTIC, FRATERNAL) Twins – 80%):-
Result from fertilization of two separate ova.
Multiple ovulation is influenced by:
🔹Race and familial tendency.
🔹Increased maternal age, parity, height, weight
(obesity).
🔹Ovulation-stimulating drugs (e.g., clomiphene,
gonadotrophins).
*Twins are not identical.
Placental and sac arrangements:
2 placentas, 2 chorions, and 2 amniotic sacs
(Dichorionic Diamniotic).
* However if implantation occurs close
together: Single placenta, 2 chorions, and 2
amniotic sacs.
Comparison between Uniovular and Binovular :
Binovular Twins Uniovula Twins

Result from fertilization of Result from division of

2 separate ova fertilized ova
No identical Identical

2 placenta _2 cord 1 placenta _2 cord_2

2 amniotic sac amniotic sacs
Presentation in twin pregnancy:
🔹Cephalic-Cephalic (most common 45%):
both present by the head.
🔹Cephalic-Transverse (5%): The first twin
is head-first, and the second is lying
sideways (transverse).
🔹Transverse-Transverse (least common
0.5%): Both are lying sideways
 🔹Cephalic_breech presentation :where the
first twin is head-down and the second twin
is in a breech position (40_30%)

Note : Cephalic-Cephalic presentation is ideal

for vaginal delivery.
Non_chephalic & Transverse presentation
require C_Section
Diagnosis :

1. History "Personal, Family & Medical history"

2. Physical examination
_General examination
_abdominal examination "inspection, Palpation,
auscultation"
_Vaginal examination
. 3 Investigatios " sonography"
🔹History
_personal "Biographic data" name _age_marital
status _social factors (
_Family history "They may be a past or a family
history of twins (in the family of the wife, husband,
or both(
_Medical history" history of drugs which induce
ovulation as clomid.
🔹Physical examination
_General examination) Manifestations of pre-
eclampsia are usually present (25- 50%)
_Abdominal examination :
_Inspection: The abdomen is abnormally huge and
over distended, due to presence of two fetuses, and
polyhydramnios which is frequently present.
_Palpation: The fundal level is higher than the
period of amenorrhea.
palpation shows multiple small parts, the palpation
of 3 large poles is a sure sign of twin
pregnancy. Sometimes one head is deeply
engaged, and so it’s felt by the second pelvic grip
during abdominal examination.
_Auscultation: The auscultation of two fetal heart
sounds at two points far away from each other and
head simultaneously by two observers with a
difference of at least 10 beats per minute is
diagnostic. ARNOUX sign is suggestive and not
diagnostic and means over lapping of two fetal heart
sounds giving a galloping rhythm.
_Vaginal examination: The condition is
suspected during labor if the presenting part is
Small in relation to the size of uterus.
On PV you will find:
_Two bags of forewater
_Small presenting part with oversized abdomen
_Cephalic presentation vaginally, while Abdominal
suggest breech
🔹 Investigations

Sonography: This confirms the diagnosis and

shows the position and presentation, by sonar the
pregnancy sacs appear as white rings as early as
4 weeks by transvaginal ultrasound.
At 12th weak, the 2 heads can be detected by
sonar.
 Complications of
multiple pregnancies

Maternal Fetal
complications complications
 Maternal complication

During pregnancy During labor During puerperium

A_During pregnancy:

🔹Hyperemesis gravidarum
🔹Abortion sometimes only fetus is aborted
early pregnancy. (Vanishing or failed twin) the
condition is diagnosed by ultrasound.
🔹Preterm labor. Labor occurs in about 60%
of twins and 90% of triplets before 37 weeks.

🔹Premature rupture of membranes (25%)

🔹Pre- eclampsia (25-50%)
🔹Placenta previa due to large placental site
🔹Increased incidence of pyelonephritis due to
marked pressure of ureters
🔹Malpresentation
🔹Non engagement of the presenting part
🔹 Polyhydramnios (10%).
🔹Nutritional deficiency & anemia (Iron
deficiency and megaloblastic)
🔹Pressure symptoms as dyspnea,
palpitation, and edema of the lower limbs.

🔹Disseminated intravascular
coagulation if a dead twin is retained. It’s
due release of thromboplastin from the
dead fetus.
B_During labor:
🔹Premature rupture of membranes
🔹Prolapse of arm- cord or both
🔹Obstructed labor. The causes are, first twin is
transverse, conjoined or locked twins, and double
headed monster
🔹Placental abruption due to premature separation
of the placenta, due to drop of intrauterine
pressure of delivery of the first twin.
🔹Uterine atony due to over distension of
uterus.
🔹Postpartum hemorrhage due to a tony and
large placental site.
🔹Splanchnic shock. The marked pressure of
the uterus on the splanchnic vessels drops after
delivery leading to pooling of blood in the
splanchnic area and chock.
🔹Locking of twins: A very rare condition
Locking twins:
Is a rare complication of
multiple pregnancy where two
fetuses become interlocked
during presentation before
birth. Occurs when the first
baby is breech and the second
is cephalic
Treatment:

Disimpaction: Tried under

general anesthesia by
grasping the second head,
rotating, and pushing it up.
Scarification of the first fetus:
The first twin usually dead ➞
Decapacitation ➞ so the second
twin can be delivered.
C_During puerperium:

The uterus may take a longer time to

involute.
Puerperal sepsis due to premature rupture
of membranes and manipulations.
 Fetal complications

🔹Prematurity and its complications as respiratory

distress syndrome, and infection.
🔹Intrauterine growth restriction due to placental
insufficiency or twin- to- twin transfusion syndrome
(TTS) it may affect one or both fetuses- sometimes one
fetus dies and becomes compressed against the
uterine wall (fetus compresses or papyraceous).
N.B Papyraceous:
relating to, or being the
flattened remains of one of
twin fetuses which has
died in the uterus and
been compressed by the
growth of the other )
The Twin-to- Twin Transfusion Syndrome
(TTS):-
The Syndrome occurs in about 15% of
uniovular twins (the monochorionic type).
Frequently, there is anastomosis between
the 2 fetal circulations in the single
placenta.
This may be artery to artery, artery to vein
or vein to vein.
 Compare between the donor and recipient in Twin to Twin syndrome

Donor Recipient
Polycythemia Anemia
Hypertension Hypotension
Hypervolemia Hypovolemia
Polyuria Oligurea
Oligohydramnios
polyhydramnios
Over grown Under grown
Die from congestive heart failure Die from heart failure due to anemia
due to overperfusion
Larger and has double or triple size Fetus compressor or papyraceous
Treatment:
Laser fetoscopy (selective LASER
ablation): fetoscopy used to interrupt
vascular communication that allows
exchange of blood between the two
fetuses.
_The plethoric fetus bleeds from the
umbilical cord at a rate of 10 ml/hour, while
the anemic fetus given packed RBCs.
Lesar fetoscopy
Management:
During pregnancy:
Rest: both mental and physical
2) Diet:
🔹Restrict salt to avoid pre-eclampsia.
🔹Liberal amounts of protein, vitamins and
minerals.
🔹Folic acid and iron: to guard against preterm
labor.
. 3Tocolytics: to guard against preterm labor.
. 4Corticosteroid: at the 34th week to enhance
fetal pulmonary maturation.
. 5Hospitalization: routine admission for rest
and observation is not essential.
During labor:
🔹Delivery must be in hospital.
🔹If labor starts before 37 weeks, the mother is
given 2g ampicillin IV/6 hours until delivery, to
prevent group B strepptococal infection in the
newborn.
First stage
If the first fetus is vertex, vaginal delivery is
allowed, and the first stage is managed as in
normal labor.
Second stage:
Delivery of the first twin (Twin A).
Delivery with minimal intervention:
_No labor augmentation.
_No artificial rupture of membranes
_Generous episiotomy and low forceps if needed
(No ventouse delivery).
After delivery of the first twin:
_Umbilical cord immediately clamped to avoid
bleeding from the second twin.
_No ergometrine is given.
Delivery of the second twin (Twin B):
Twin (B) assessed for presentation, position and
excludes monoamniotic twins and cord prolapse.
Oxytocin: if there is inertia.
High presenting part ➞ do moderate fundal
pressure.
Assess the second amniotic sac:
_🔹No sac ➞ immediate delivery.
_🔹Sac present ➞ examine for fetal lie.
 Delivery: Depends upon the fetal presentation:
Cephalic presentation:
Head engaged: ➞ Fundal pressure and vaginal
delivery.
Head not engaged: ➞Internal podalic version and
breech extraction.
Breech presentation: ➞ Bring down a leg and breech
extraction.
Transverse lie: ➞ Bring down a leg and breech
extraction.
Third stage
Declared placental delivery: ➞ manual removal
under general anesthesia.
The placenta: Examined for zygosity and missed
fragments.
Uterine massage and I.V ecbolic: To guard against
postpartum hemorrhage.
Antibiotics: To guard against puerperal infection.