Multiple Pregnancy

(twins in pregnancy)

Supervised by:-
Dr:hanaa abd-elhadi
Dr:-naglaa fathi
Prepared by :-
1.Mohamed mahrous
2.Mohamed Nasser
3.Mostafa Mahmoud Gaber
4.AbdElrhim Amer
5.Mohamed Salem
6.Mohamed Kassban
7.Yasser Ahmed
8.AbdElrhman Ashraf
 Contents
• introduction
• Definition
• Twins pregnancy types
• Incidence
• Factors influencing twinning
• Diagnosis
– History and clinical examination
– Symptoms
– Abdominal examination
– Investigations
• Complications
• Management
• References
 Introduction:-
Multiple births are much more common today than they
were in the past. According to the US Department of Health
and Human Services,thetwin birth rate has increased by
over 75% since 1980, and triplet, quadruplet, and high-order
multiple births have increased at an even higher rate. There
are more multiple births today in part because more women
are receiving infertility treatment, which carries a risk of
multiple pregnancy. However, since the first publication in
1998 of the American Society for Reproductive Medicine’s
(ASRM’s) Guidelines on Number of Embryos Transferred, the
number of treatment-related pregnancies with triplets or
more has decreased dramatically. Also, more women are
waiting until later in life to attempt pregnancy, and older
women are more likely than younger women to get
pregnant with multiples, especially with fertility treatment.
Multiple pregnancy
• When more than one fetus simultaneously develops
in the uterus then it is called multiple pregnancy.
• Simultaneous development of two fetuses (twins) is
the commonest; although rare, development of three
fetuses (triplets), four fetuses (quadruplets), five
fetuses (quintuplets or six fetuses (sextuplets) may
also occur.
• Presence in Utero or birth of more than one
fetuses.

Twins pregnancy
Varieties:
• Dizygotic twins: is the commonest (two-third) and results
from the fertilization of two ova.
• Monozygotic twins (one-third) results from the
fertilization of single ovum.

Genesis of twins:-
• Imonozygotic twins (syn. identical, uniovulvar)
• Dizygotic twins (syn: fraternal, binovular
Twin pregnancy Types:-
Monozygotic ("identical twins")
• Fertilization of a single ovum,
• Have the same sex & BG
• Identical in every way including the HLA genes
• Not genetically determined
• Constant in all races; its prevalence: 1/250.
• Their fingerprints differ
Dizygotic ("fraternal twins")
• Fertilization of 2 separate ova
• Its etiology and prevalence varies, with racial /
hereditary difference,
• Its actual prevalence is increasing due to:
– Early diagnosis by U/S.
– Induction of ovulation
– Change of the ages of women experiencing their first
pregnancy and delivery ( > 35 years age).
***Slightly more than 30% of twins are monozygotic; nearly
70% are dizygotic.
• Approximately 75% of dizygotic twins are the same sex.
– Both twins are males in approximately 45% of cases
(a lesser preponderance of males in twins than in
singletons) and both females in approximately 30%.
• Dizygotic multiple pregnancy tends to be recurrent.
• Women who have borne dizygotic twins have a 10-fold
increased chance of subsequent multiple pregnancy.
• Dizygotic twinning probably is inherited via the female
descendants of mothers of twins; the father's genetic
contribution plays little or no part.
• White women who are dizygotic twins or who are siblings
of dizygotic twin mothers have a higher twinning rate
among their offspring than do women in the general
population.
• Parity does not influence the incidence of dizygotic
twinning but aging does.
Incidence:-
• Varies widely. Highest in Nigeria being 1 in 20 and lowest
in Far Eastern countries being 1 in 200 pregnancies.
Monozygotic twins 1 in 250 in the world.
• According to Hellin’s rules, the mathematical frequency of
multiple birth is twins 1 in 80 pregnancies, triplets 1 in
802, quadruplets 1 in 803 and so on.

Factors that Influence Twinning:-

• The causes of twin pregnancy is not known.
• Race: Highest amongst Negroes (once in every 20 births),
lowest amongst Mongols and intermediate among
Caucasians
• Heredity: Family history in mother.
• Maternal Age and Parity: Twinning peaks at age 37 years
• Increasing parity: 5th gravid onwards.
• Nutritional Factors: Taller, heavier women—twinning rate
25 to 30 % greater.
• Pituitary Gonadotropin
• Infertility Therapy
• Assisted Reproductive Technology
Diagnosis:-
 History and Clinical Examination
• Recent administration of either clomiphene citrate or
gonadotropins or pregnancy accomplished by ART are
much stronger associates.
• Clinical examination with accurate measurement of
fundal height.
 Symptoms
• Minor symptoms of normal pregnancy are often
exaggerated.
• Increased nausea and vomiting in early months
• Cardio-respiratory embarrassment
• Tendency of swelling in the legs, varicose veins and
hemorrhoids is greater
• Unusual rate of uterine enlargement and excessive fetal
movements
 Abdominal examination
Inspection: Barrel shaped and the abdomen is unduly enlarged
Palpation:-
– Height of uterus > period of amenorrhoea
– Girth of abdomen> normal average at term (100 cm)
 – Fetal bulk disproportionately larger in relation to the
size of the fetal head.
– Palpation of too many fetal parts
– Finding of two fetal heads or three fetal poles
Auscultation:-
• Two distinct FHS at separate spots, difference in heart
rates is at least 10 beats/minute.
 Investigations
• Sonography
• Biochemical Tests:
– Levels of hCG in plasma and in urine are higher
• Radiological examination

Complications:-
 Maternal (During pregnancy)
• Nausea and vomiting
• Anemia
• Pre-eclapmsia (25%)
• Hydramnios (10%)
• Antepartum hemorrhage
• Malpresentation
• Preterm labour (50%)
• Mechanical distress
 During labour
• Early rupture of membranes and cord prolapse
• Prolonged labour
• Increased operative interference
• Bleeding
• Postpartum hemorrhage

 During puerperium

• Subinvolution
• Infection
• Lactation failure

 Fetal
• Miscarriage
• Prematurity (80%)
• Growth problem (25%)
• Intrauterine death
• Asphyxia and still birth
• Fetal anomalies
 Ante partum Management of Twin Pregnancy:-
To reduce perinatal mortality and morbidity rates in
pregnancies complicated by twins, it is imperative that:
• Delivery of markedly preterm neonates be prevented
• Fetal-growth restriction be identified and afflicted fetuses
be delivered before they become moribund
• Fetal trauma during labor and delivery be avoided, and
• Expert neonatal care be available.
• Diet: increased requirement of calories, protein, minerals,
vitamins, and essential fatty acids. Caloric should be
increased by another 300 kcal/day. Supplementation with
60 to 100 mg/day of iron and1 mg/day of folic acid.
• Bed Rest
• Antepartum Surveillance: sonographic examinations
• Tests of Fetal Well-Being
• Prevention of Preterm Delivery
• Hospitalization
• Use of corticosteroids to accelerate fetal lung maturation.
First stage:
• A skilled obstetrician, presence of ultrasound machine
and experienced anesthetist
• Bed rest to prevent early rupture of membrane.
• Limit use of analgesic drugs
• Careful monitoring
• Internal examination soon after the rupture of
membranes
• An intravenous line with ringer’s solution
• Availability of one unit of compatible and cross matched
blood
• Neonatologist: Present at the time of delivery.
Management of third stage
• Routine administration of 0.2mg methergin IV with
delivery of anterior shoulder.
• Deliver placenta by CCT
• Continue oxytocin drip for at least one hour, following
delivery of second baby.
• The patient is to be carefully watched for about 2 hours
after delivery.
Postnatal period:-
Care of the babies
• Immediate care
• Maintenance of body temperature,
• Use of overhead heaters,

• Parents given the opportunity to check the identity tag

and cuddle them.

Breastfeeding
• Provide knowledge to mother regarding different
positions for breastfeeding, along with advantages,
attachment, positioning timing.
Nutrition
• Expressed breast milk is best (for small babies), they may
need to be fed intravenously or by nasogastric tube or
cup-fed, depending on their size and general condition.
• Careful monitoring of weight gain, regular capillary blood
glucose estimations
• Reassure her that lactation responds to the demands
made by babies sucking at the breast.
• At feeding times, mother must be provided support and
advised on positioning and fixing babies.
 Care of the mother
• Slow involution of uterus, increased ‘After pains’ so
analgesia should be offered.
• High calorie diet.
• Teach extra support to handle twin babies.

References
• Fraser DM, Cooper MA.Myles Textbook for Midwives.15th edition.
Philadelphia:Churchill livingstone elsevier;2009

• Dutta DC.Textbook of obstetrics. 6th edition.Calcutta:New central book

agency;2004

• Pillitteri A. Maternal and child health nursing. Care of the childbearing

and childrearing family. Sixth edition. Philadelphia; Lippincott Williams &
Wilkins: 2010.

• Cunningham, Leveno, Bloom. William’s obstetrics. 23rd edition. United

states of America; Mcgraw Hill companies: 2010.

• Nettina S.M, Mills E.J. Lippincott Manual of Nursing Practice. 8th Edition.
Philadelphia: Lippincott Williams and Wilkins; 2006

• Multiple Pregnancy and Birth: Twins, Triplets, and High-order Multiples:

A Guide for Patients. Patient information series. American Society for
Reproductive Medicine. 2012