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Multifetal Pregnancy: Radha Venkatakrishnan
Multifetal Pregnancy: Radha Venkatakrishnan
Pregnancy
Radha Venkatakrishnan
Clinical Lecturer
Warwick Medical School
Incidence :
Monozygotic twins - 4/1000 births
Dizygotic twins 2/3rds, race, age,
assisted conception
Triplets 1 in 7000 to 10,000 births
Quadruplets 1 in 600,000 births
Almost every maternal and obstetric
problem occurs
more frequently in multiple Pregnancy
Perinatal mortality rate in twins is 5 times
higher and
Zygosity
and Chorionicity
Mechanism of dizygotic
twinning
Fertilization of a
single ovum
Similar sex
Genetically
identical
Fertilization of 2
separate ova
Monochorionic twins
Within 72 hours
(18-32%)
Monochorionic twins
8-12 days later (1-2%)
Multiple pregnancy
Maternal responses
Cardiac output, GFR and renal blood
flow
Plasma volume by 1/3 > singletons
Red cell mass 300 ml > singletons
Hematocrit and hemoglobin
Iron stores in 40% of women with
twins
Diagnosis
Patient profile:
Etiological factors:
positive past history and family history
specially maternal, race, age
Assisted reproductive technology
Early pregnancy:
Hyperemesis, excessive weight gain
minor complications of pregnancy such as
backache, edema, varicose veins,
hemorrhoids, striae, etc
Physical signs
General:
Pallor, weight gain, excessive pedal edema/
varicose veins
Pregnancy Induced Hypertension(PIH) and Preeclampsia (5-10times more)
Abdominal:
Size > Date especially in midpregnancy
Multiple fetal parts
Auscultation of FHS:
2 different recordings by 2 observers and a
difference > 10 bpm
Differential diagnosis
Elevation of the uterus by a distended
bladder
Hydramnios
Hydatidiform mole
Uterine fibroids
Ultrasonography
Detect multifetal gestation 99%
before 26 weeks
Maternal complications
Symptoms hyperemesis, aches and
pains of pregnancy worsen
Hypertensive disease of pregnancy
Preterm delivery
Premature rupture of membranes
Polyhydramnios
Placenta praevia
Malpresentation
Delivery complications (operative delivery,
placental abruption, cord accidents)
Postpartum hemorrhage, depression
Fetal complications
Antenatal care
Intrapartum management
Presence of skilled obstetrician,
anesthetist and neonatologist available at
delivery
Reliable intravenous access
Cardiotocograph with dual monitoring
capability
Portable ultrasound scanner
Delivery bed with lithotomy stirrups
Obstetric forceps or vacuum apparatus
active management of third stage:
Uterotonics
Immediate availability of blood
Monochorionic Monoamniotic
twins
3 - 12 x perinatal mortality
10 x cerebral necrotic lesions
1% of monozygotic twins are
monoamnionic
Perinatal mortality rate of 30-50%,
largely relates
to a risk of
intrauterine death before 32 weeks
Large volume
amnioreduction
Amniotic
Septostomy
Fetoscopic Laser
Ablation
Treatment options
No optimal management
Prompt delivery -Iatrogenic prematurity
risks
Conservative treatment -Subsequent
handicaps
Intrauterine interventions