Multiple

Multiple Pregnancy
Pregnancy

Dr. Urmila Karki,

MBBS,DGO,MD

Kathmandu Medical College

Teaching Hospital
Introduction
• Problem of multiple pregnancy pose
unique challenge in the practice of
obstetrics.
• Successful outcome-coordination of
clinician with experienced group including
anaesthetist and neonatologists.
• Despite difficulties, with modern
treatment modalities the maternal and
perinatal outcomes are good.
 Definition
• More than one fetus simultaneously
develops in the uterus- multiple
pregnancy.
• Simultaneous development of two fetuses
– termed twins is the most common.
• Rarely, the development of three fetuses
– triplets
• Four fetuses – quadruplets
• Five fetuses – quintuplets
• Six fetuses – sixtuplets may occur.
Incidence
• Overall – 2% of LB
• Monozygotic – 3.5/1000 (constant)
• Dizygotic – China 3/1000
• (↑Blacks ↓Orientals) –
Scotland – 12/1000
Nigeria – 57/1000
 Incidence
Hellins law
• Twins 1:80
• Triplets 1:802
• Quadruplets 1:803
• Qunituplets 1:804
• Study of Twins is a part of the new
branch of science named gemellology
 Incidence
Incidence of twin gestation
– increases with maternal age up to 35 to 39
years, and parity.
– doubles if conception occurs within 1 month
after discontinuation of a long-term use of
oral contraceptives.
– Use of ovulation induction in infertile
couples (6.8 and 17 percent).
– Use of gonadotropins, the risk of multifetal
Gestation varies between 18 and 53 percent.
Heriditary
 Genesis of Twins
1. Monozygotic twins – originate by
fertilization of a single ovum by a single
sperm.
– In uniovular (identical or monozygotic) the
twinning may occur at different periods
after fertilization.
– Markedly influences the process of
implantation and the formation of the fetal
membranes.
– Most commonly separation occurs after the
formation of inner cell mass(4th – 8th day)
Genesis of Twins

– Two embryos develop and are

enclosed by a single chorion.

– There is a single placenta and two

separate amniotic sacs, resulting
in diamniotic monochorionic twins
Genesis of Twins
– Rarely following possibilities may occur
• Diamniotic-dichorionic: division takes place within
72 hours after fertilization and the resulting
embryos will have two separate placenta.
• Monoamniotic-monochorionic: division occurs
after the 8the day of fertilization, when the
amniotic cavity has already formed; embryos will
share one placenta and one amniotic sac.
• Conjoined twins: very rarely, the division occurs
after the development of embryonic disc
resulting in conjoined twins.
Genesis of Twins
2. Dizygotic or Binovular twins
– result from fertilization of two ova which have most
probably ruptured from two distinct graafian
follicles, usually of the same or one from each ovary
by two sperms.
– Babies bear only fraternal resemblance to each
other – Fraternal Twin.
– Rarely results from matings with two different
fathers within the same menstrual cycle-
Superfecundation
– The fertilisation and implantation of ova from
different menstrual cycle – Superfetation- does not
occur in Human being.
Differentiating features between monozygotic
and Dizygotic twins
Features Monozygotic Dizygotic
Ovum Single Two
Sperm Single Two
Sex Same Opposite or
same
Similarity Identical Fraternal
resemblance
Placenta Single(43%)/Do Double sometimes
uble fused at margins
Differentiating features between monozygotic
and Dizygotic twins
Features Monozygotic Dizygotic
Communicating Present Absent
vessels
Intervening Absent in MCMA Present
membrane twins
Thickness of <2mm(82-89%) >2mm (95%)
intervening
membrane
Twin pig sign Absent (44%) Present(97%)

Same Different
Genetic feature
Diagnosis
• History – Family history, H/o taking Ovulation inducing
drugs.
• Symptoms –Excessive nausea vomiting, Leg swelling,
Varicose veins, Haemorrhoids getting worse, cardio
respiratory embarrassment due to excessive
enlargement of the uterus
• Signs –
Anaemia, edema, raised BP, Abnormal weight gain.
Height of fundus and abdominal girth- more than
corresponding period of gestation Two
or more foetal head Three
or more foetal poles Two distinct
FHS heard by two observers with at least a
difference of 10 beats per minute
• Investigation- USG/x-Ray
Complications
Maternal
• Morbidity – 3-7 times increased in multiple Pregnancy
• Miscarriage
• Increased symptoms of early pregancy
• PIH - 14 – 20% (M)
- 6 – 8% (S)
• Anemia – 9% (M) vs 4% (S)-Iron, folic acid, Vit B 12,
• Preterm labour - 22 – 50% (M)
- 10% (S)
• PROM – 3 times
• Polyhydramnios- more common in uniovular twins and usually involves
the second sac.
• PPH – 20%
• Incidence of Placenta praevia/ Abruptio Placentae is more.
• Increased incidence of malpresentation
• Overall AN complications - 80% (M)
- 30% (S)
• Increased risk of operative delivery
• Postnatal problems
Complications
Fetal & Neonatal
• Mortality – 10%- Single fetal death
• PTL, PROM
• IUGR (12 – 30%), twin-twin
transfusion synd.
• Twin reversed arterial perfusion
• Stuck twin (sonographic appearance
of an extreme form of T-T
transfusion syndrome)
• Asphyxia
• Neonatal death
Complications
• Congenital anomalies – 17%
Common – cleft lip, palate,
CNS, cardiac defects
Unique – conjoined T, fetal
acardia
• Abruptio
• Cork problems – 1 – 5%
Complications
• Malpresentations:
Vx – Vx – 40%
Vx – Breech – 28%
Vx-transverse-7.5%
Breech-vx-9%
Br – Br – 6.7%
Breech – transverse-2.6%
other combinations-6.7%%

• Intrapartum complications
Birth trauma : 5 – 10%
Discordant growth (15 – 30%)
• Weight discrepancy> 20%
• After 24 weeks
• 5%- head circumference,20mm
in abdominal girth and 15-20% in
EFW
• Unequal placental mass
• Genetic syndromes
• TTS
Twin – Twin transfusion syndrome
(5-17% - monochorionic.)
• Abnormal Vascular communications (A – V)
Circulatory imbalance

Anemia Polycythemia
• Discrepancy in Hct & BW > 20%
• Donor twin- markedly smaller/less liquor/appears stuck to the
uterine wall/IUGR, Hydrops, high output failure
• Recipient –large/polyhydramnios/ cardiomegaly – CCF, IUD,
RDS
• Overall mortality-60-70%
• Single placenta
• Fetal hydrops in one/both
• U. cords differ in size
• –Mx – Bedrest
- Glucocort & PTD
- Nd-YAG laser occlusion of vascular anastomosis
Amniocentesis – polyhydramniotic sac
 Single foetal demise
• Occurs in monochorionic twins
• <14 weeks-does not increase the risk of
survivor twin
• >14 weeks- risk of neurological damage of the
survivor resulting from transfer of
thromboplastin from the dead twin producing
thrombotic arterial oclussions
• Occlusion of anterior and middle cerebral
arteries cause multicystic encephalomalacia.
• Mother is at a risk of developingconsumptive
coagulopathy usually after 3 weeks
 Conjoined twins
(1/200 MZ; 1/900 TB; 1/50,000LB)
1. Thoracopagus (40%)
2. Omphalo pagus (35%)
3. Pyopagus (18%)
4. Ischiopagus (6%)
5. Craniopagus (2%)
6. Surgical separation:
» Absence of malformations
» Lack of bone unions
» Separate hearts
Antepartum Mx: Frequent ANc
• Prevention of PTD – cerclage
- bedrest
- glucocorticoids
- tocolysis
- infection control
• Monitoring fetal growth
• Deciding optimal mode of delivery
• Dietetic advice-Adequate calorie intake to meet
increased demand- Supplementary iron, Vitamin,
Calcium and folic acid
• Elective Hospitalisation –Provides physical rest,
improves uteroplacental circulation, may have a
quiescent effect on uterine contractility
• More frequent visit- every 2 weeks to detect
anaemia or PIH at earliest
Management during labour
• Should be confined to tertiary
health centre(anaesthesia/NICU)
• NPO/IV fluids
• X-match the blood
• Continuous IP Foetal monitoring
• Pain releif- epidural anaesthesia
• Two neonatologists should be
present at the time of delivery.
 Intrapartum management of twns

Criteria for VDelivery fulfilled

Deliver the first twin

Clamp and cut the cord

Note lie of 2nd twin

Transverse lie Longitudinal lie

ECV/IPV/Deliver ARM/Oxytocin

Unsuccessful Vertex Breech

LSCS Vaginal or Assisted V D Breech/A br delivery

Management of third stage of labour

• Active management of third stage of

labour- Do not forget to palpate for the
second twin before giving oxytocic
• Start amtsl only after delivery of
second twin
• Inj Methyl ergometrine can also be
used-0.25 mg
Indications of LSCS (Elective)
• 1st baby noncephalic- shoulder
• Conjoined twins
• Congenital anomalies precluding vaginal
delivery
• IUGR in dichorionic twin
• T-T Transfusion syndrome
• Monoamniotic twin
• Placenta Praevia
• Contracted Pelvis
• Previous LSCS
• Severe preeclampsia
Indications of LSCS (Emergency)
• Foetal distress
• Cord prolapse in first baby
• Nonprogress of labour
• Collison of both twins
• 2nd twin transversely presenting
and version failed
conclusion
• Incidence are on increase mainly due to ART
• Both antenatal and intranatal management
requires expertise
• Need to be seen at tertiary level or at district
level with senior obstetrician and
neonatalogist in attendance.
• Preterm delivery and IUGR are common
sequalae
• To reduce perinatal mortality and morbidity- a
good neonatal unit is a must