Multiple pregnancy

SAS Dr Thawda Win Naing

OB/GY

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 Introduction

• Multiple pregnancies consist of two or more fetuses.

• 3% of livebirths in UK
• 99% of multiple pregnancies twins
• 1:80 at term multi-fetal

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Risk factors
• ART – Ovulation induction , IVF ( 1 in 5)
• High parity ( 1 in 10 over 45 years in UK)
• Black race
• Maternal family history

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Classification of multiple pregnancy
It is based on:
• Number of fetuses :Twins,Triplets,Quadruplets,etc.,
• Number of fertilized eggs: Zygosity
• Number of placentas: Chorionicity
• Number of amniotic cavity: Amnionicity

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• Monozygotic twins arise from from a single fertilized ovum that splits
into two identical structures.
• Dizygotic twins arise from fertilization of two separate eggs.

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Incidence of monozygotic and dizygotic twin
pregnancies

Not all dichorionic pregnancies

All monochorionic
are dizygotic
twins are monozygotic.

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Diagnosis and determination of chorionicity
• Dizygous twins are always DC/DA.
• The chorionicity of monozygotic twins depends on the timing of
embryo splitting after fertilisation. They may be:
• DC/DA, if <3 days;
• MC/DA, 4–7 days;
• MC/MA, 8+ days.

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 Monozygotic Dizygotic
Development Single ovum Two separate ova
Sex Same sex Same or different

Blood group same Same or different

Genetic materials same different
Placenta and Same or separate separate
membranes

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Complications Monozygotic Dizygotic
1. Acute hydramnios more less
2. TTTS more less
3. Preterm delivery more less
4. Malformations more less

5. Conjoint twin & more No

locked twin

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Fetal presentation in twin pregnancy

10%
10%
cephalic/cephalic
cephalic/breech
breech/cephalic
20% 60% breech/breech

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Diagnosis of twins pregnancy.
History
• Family history of twins may be present,
• More troublesome minor ailments of pregnancy like nausea, vomitting
heartburn;Constipation, piles, breathlessness, joint pains.
• Pre existing health problems  Morbidity
• Unusual degree of abdominal enlargement.
• Excessive fetal movement

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On physical Examination

• Anaemia
• Edema legs & vulva
• Varicose veins of the legs

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Obstetric examination
• Uterus larger than dates.
• Polyhydramnios may be associated.
• Multiple fetal parts
• More than two fetal poles e.g. two heads and one breech
• Fetal head smaller than expected.
• FHR difference at least 10 bpm when auscultated simultaneously

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Investigation
Diagnosis is confirmed by ultrasound.
Differential diagnosis
1. Pregnancy with fibroids
2. Polyhydramnios
3. Pregnancy with ovarian mass

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Ultrasound abdomen and pelvis
• Dating scan
• Screening in multiple pregnancy
To accurately estimate gestational age
To determine chorionicity
To screen for Down syndrome

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Ultrasound abdomen and pelvis
• Number of fetuses
• Fetal anomalies
• Lie
• Presentation Late scans
• Placenta
• Liquor
• Fetal growth and well being

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Complications during pregnancy and labour
During pregnancy
• Preterm labour
• Miscarriage
• IUGR
• Congenital malformation
• APH due to placenta praevia or abruptio placenta
• Anaemia

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During pregnancy
• Pre-eclampsia
• Polyhydramnios .
• Twin to twin transfusion syndrome.
• Death of one twin
• Complications unique to monoamniotic twins-cord accidents, cord
entanglement
• Twin to twin transfusion syndrome, TAPS in monochorionic twin

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During labour
• Malpresentation and abnormal lie.
• Cord prolapse especially with second twin
• Locked twins
• Retained second twin
• PPH

The perinatal mortality rate for twins is around six times higher than for
singleton pregnancy.

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Puerperium
• Anaemia
• PPH
• Subinvoluted uterus
• Infection
• Postnatal depression
• Breastfeeding problems

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 Management of twins pregnancy

Antenatal management
• More frequent AN visits
• Advised on diet, adequate rest, loose clothing, exercise and personal
hygiene
• Early detection and treatment of complications like PE,
polyhydramnios, APH, anaemia.
• Iron and folic acid supplement

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• First trimester scan for confirmation of diagnosis, dating and
chorionicity
• 20 weeks scan for detection of fetal anomalies (Monozygotic twins are
two to three times more likely to have structural defects than dizygotic
twins or singleton fetuses).
• Monitor the fetal growth by serial ultrasound (A growth discrepancy
of 25% or greater should be considered clinically significant).

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 Ultrasound appearance of dichorionic twin

Ultrasound appearance of monochorionic

twin

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• Detection & effective treatment of complications eg. IUGR, Twin to
twin transfusion syndrome.
• Contact with multiple pregnancy support group
• Twin pregnancies are associated with financial, personal and social
cost for family.

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• Admission for AN rest should be advisable if the home conditions are
poor.
Management of threatened preterm labour
• Bed rest
• Antenatal corticosteroids
• Tocolytics

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Plan for delivery

Timing of delivery
DCDA  37 - 38 wks
MCDA  36 – 37 wks

( earlier for P.E, hydramnios )

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Type of delivery
• Vaginal delivery is allowed when
first twin presents with vertex,
no fetopelvic disproportion,
no maternal complications &
no contraindications to vaginal delivery.

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Caesarean section is indicated in:
Twin pregnancy with severe PIH
Elderly primigravida or BOH
First twin present with breech
First twin lying transversely
Conjoined twins
Higher multiple pregnancies
Second twin larger than the first
IUGR in one or both twin

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MCMA
Placenta previa
Preterm labour before 34 wk if the leading twin presents by breech
Prolonged delay in the first stage which did not respond to a careful
trial of oxytocin.

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Intrapartum management
 All cases of twin labour should be delivered in hospital
 Antenatal education and a preagreed birth plan
Requirements for twin delivery
1. Large delivery room
2. Senior OG, anaesthetist, paediatrician, at least two midwives, twin
resuscitaires
3. Analgesia, ideally in the form of an early epidural
4. Operating theatre and staffs ready
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5. IV access and Blood for G & M and reserved
6. pre mixed Oxytocin infusion
7. portable ultrasound
8. forceps and vacuum

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1. First stage
• Put up partogram for maternal and fetal monitoring
• Set up IV line , blood for G&M and reserved
• Maternal monitoring-PR, BP, Pain Note
• Adequate pain relief with preferably epidural analgesia
• Augmentation of labour if necessary
• Continuous monitoring of FHR by twin CTG

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2. Second stage
• Delivery should be attended by paediatrician
• After first twin delivery, clamp cord in 2 places and cut in between
• Majority of 2nd twin will be delivered within 15 -30 minutes.
• Check lie of second twin

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• If the lie is longitudinal and the presenting part is head, wait until the
head is descending and the perform amniotomy .
• If there is no efficient uterine contraction , oxytocin infusion should be
started.
• Fetal distress or cord prolapse - immediate delivery
Head presentation - forceps extraction
If head is high - vacuum extraction

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• Vaginal delivery of non-vertex second twin
• If the second twin is breech, membrane can be ruptured once the
breech is fixed in the birth canal and breech extraction may be
performed in cases of fetal distress.
• If the fetus is transverse, ECV can be performed. (70% success)
• If ECV fails, internal podalic version will be performed.

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 Internal podalic version

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3. Third stage
• Active management of third stage by giving I.V syntocinon 10 unit
with the birth of anterior shoulder of second twin
• Early detection of complications of third stage and treat promptly eg.
PPH
• Check placenta for completeness and chorionicity.

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4. Fourth stage
• Vigilance of PPH
• Care of new born babies

5. Post natal care

• Brestfeeding
• Uterine involution
• Care of the babies
• Family planning

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 THANK YOU
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