Multiplepregnancy 131213091755 Phpapp02

Multiple Pregnancy
Powerpoint Templates
Page 1
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.
Page 2
Twins pregnancy
Varieties:
• Dizygotic twins: is the (two-third) and
commonest results from the fertilization
of two ova.
• Monozygotic twins (one-third) results from
the fertilization of single ovum.
Page 3
Genesis of twins
• monozygotic twins (syn. identical, uniovulvar)
• Dizygotic twins (syn: fraternal, binovular
Page 4
On rare occasion, the following
possibilities may occur
• If the division takes place within 72 hours after
fertilization the resulting embryos will have two separate
placenta, chorions and amnions (D/D)
• If the division takes place between the 4th and 8th day
after the formation of inner cell mass when chorion has
already developed diamniotic monochorionic twins
develop (D/M)
• If the division after 8th day of fertilization, when the

amniotic cavity has already formed, a monoamniotic
monochorionic twins develop (M/M)
Page 5
Diamniotic Diamniotic Diamniotic
Dichorionic Monoamniotic
DiChorionic Monochorionic single
Separate placenta Monochorionic
fused placenta placenta
Frequency: 35% single placenta
Frequency 27% Frequency 36%
Mortality: 13% Frequency
Mortality 11% Mortality 32%
2%
Mortality 44%
Page 8
Multiple pregnancy contd…
• On extreme rare occasions, division occurs after 2 weeks

of the development of embryonic disc resulting in the
formation of conjoined twins called-Siamese twins.
• Four types of fusion may occur

– Thoracopagus (commonest)
– Pyopagus (Posterior fusion)
– Craniopagus (cephalic)
– Ischiopagus (caudal)
Page 9
Examination of placenta and
membranes
Dizygotic Twin Monozygotic twin
Two placenta, either completely Placenta is single.
separated or more commonly fused at
the margin appearing to be one.
No anastomosis between the two fetal Varying degrees of anastomosis
vessels. between the two fetal vessels.
Each fetus is surrounded by a amnion Each fetus is surrounded by a separate

and chorion amniotic sac with the chorionic layer
common to both.
Intervening membranes consist of 4 Intervening membrane consists of two

layers-amnion, chorion, chorion and layers of amnion only.
amnion.
Page 10
Anastomosis between placenta
Page 11
• Sex: while twins having opposite sex are almost always
binovular and twins of the same sex are not always uniovular
but the uniovular twins are always of the same sex.
• If the fetuses are of the same sex and have the same genetic
features (dominant blood groups), monozygosity is likely.
• A test skin graft: Acceptance of reciprocal skin graft—proof of

monozygosity.
• DNA microprobe technique is more definitive.
• Follow-up study between 2-4 years—showing almost similar

physical and behavioral features suggestive of monozygosity.
Page 12
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 Page 13
Terms
• Superfecundation
• Superfetation
• Fetus papyraceous or compressus
• Fetus acardius
• Hydatidiform mole
• Vanishing twin
Page 14
Superfecundation is the
fertilization of two or more ova from
the same cycle by sperm from
separate acts of sexual intercourse,
which can lead to twin babies ...
Superfetation is different from
superfecundation. This similar-sounding term
describes twins conceived with sperm from
two different sources. In superfecundation,
conception of each fetus occurs on the same
day or within a few days; the eggs are from
the same menstrual cycle.31
Fetus papyraceus is a rare condition which describes a
mummified fetus in a multiple gestation pregnancy in
which one fetus dies and becomes flattened between
the membranes of the other fetus and uterine wall
Vanishing twin syndrome
If the egg fails to fully separate, the result is conjoined

twins.
Sometimes, one of the fetuses is partially absorbed by the
other in early pregnancy.
The partially absorbed fetus stops developing and
becomes parasitic. The other twin continues to develop
normally and becomes dominant.
Fetus acardicus :
A deformed fetus having developed no heart,
connected as a parasite to another fetus.
Twin reversed arterial perfusion, also known as
acardia, is defined by the absence of a normally
functioning heart in one fetus of a multiple
pregnancy.
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.
Page 20
Diagnosis contd…
• In women with a uterus that appears large for gestational
age, the following possibilities are considered:
– Multiple fetuses
– Elevation of the uterus by a distended bladder
– Inaccurate menstrual history
– Hydramnios
– Hydatidiform mole
– Uterine leiomyomas
– A closely attached adnexal mass
– Fetal macrosomia (late in pregnancy)
Page 21
Diagnosis contd…
Symptoms
• Minor of normal pregnancy are
symptoms 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
Page 22
Diagnosis contd…
General examination
• Prevalence of anemia is more
• Unusual weight gain, explained by

not preeclampsia or obesity
• Evidence of is a common
preeclampsia association.
Page 23
Diagnosis contd…
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
• AuscultationTwo distinct FHS at separate spots,
difference in heart rates
is at least 10 beats/minute
Page 24
• .
Diagnosis contd…
Investigations
Sonography
• separate gestational sacs identified early
• Confirmation of diagnosis as early as10th week
of pregnancy
• Variability of fetuses, vanishing twin in second trimester
• Chorionicity (twin peak sign)
• Pregnancy dating, Fetal anomalies
• Fetal growth monitoring, Presentation and lie of fetuses
• Twin transfusion localization, Amniotic fluid volume
Page 25
Twin peak sign
Page 26
Diagnosis contd…
Biochemical Tests:
• Levels of hCG in plasma and in urine are higher
• Maternal serum alpha-fetoprotein level: Elevated
• Unconjugated oestriol: approximately double
Radiological examination
Page 27
Complications
Maternal
During pregnancy
Nausea and vomiting
Anemia
Pre-eclapmsia (25%)
Hydramnios (10%)
Antepartum hemorrhage
Malpresentation
Preterm labour (50%)
Mechanical distress
Page 28
Complications contd…
• During labour
Early rupture of membranes and

cord prolapse
Prolonged labour
Increased operative interference
Bleeding
Postpartum hemorrhage
Page 29
Complications contd…
• During puerperium
Subinvolution
Infection
Lactation failure
• Fetal
Miscarriage
Prematurity (80%)
Growth problem (25%)
Intrauterine death
Asphyxia and still birth
Fetal anomalies
Page 27
Page 31
Complications of monochorionic twins
Twin twin transfusion syndrome (TTS)

• one twin appears to bleed into other through placental
vascular anastomosis.
• Receptor twin becomes larger with hydramnios,
polycythemic, hypertensive and hypervolemic
• Donor twin which become smaller with oligohydramnios,

anemic, hypotensive and hypovolemic.
• Donor may appear stuck due to severe oligohydramnios.
• Difference of hemoglobin concentration between the twin

usually exceeds 5 gm% and estimated fetal weight
discrepancy is 25% or more.
Page 32
contd…
TTTS contd..
Management
• Antenatal diagnosis: ultrasound with doppler flow
study
in the placental vascular bed.
• Repeated amniocentesis to control polyhydramnios
in recipient twin.
– prevent preterm labour and placental abruption.
• Selective reduction of one twin is done when survival of
both the fetuses is at risk.
• Smaller twin generally have got better outcome.
• Plethoric twin: risk of CCF and hydrops.
• Perinatal mortality: Powerpoint
70%. Templates
Page 33
Page 34
contd…
Dead fetus syndrome
• Death of one twin (2-7%) is with poor
associated
outcome of the Co-twin (25%) specially in monochorionic
placenta.
• The surviving twin runs the risk of cerebral palsy,
microcephaly, renal cortical necrosis and DIC.
• This is due to thromboplastin liberated from the dead
twin that crosses via placental anastomosis to the living
twin.
Page 35
contd…
Twin reversed arterial perfusion (TRAP):

• Characterized by an acardiac perfused twin having blood
supply from a normal co-twin via large arterio-arterial
anastomosis.
Conjoint twin:
• Rare.
• Perinatal survival depends upon the type of joint.
• Major cardiovascular anastomosis leads to
high mortality.
Page 36
Fetal acardius
contd…
Monoamniocity:
• Monochorionoc twins leads to high perinatal
mortality due to cord problems.
• Prostaglandin synthase inhibitor used to reduce fetal

urine output, creating borderline oligohydramnios and to
reduce the excessive movements.
Page 38
Antepartum 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.

Page 39
Management contd…
• 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.

Page 40
Management during labour
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.

Page 39
Management during labour contd..
Delivery of the first baby:
• Delivery: Same guidelines as in normal with
labour liberal episiotomy.
• Forceps delivery: if needed, should be done
preferably under pudendal block anaesthesia.
• Do not give intravenous ergometrine with delivery of the
anterior shoulder of the first baby.
• Clamp the cord at two places and cut it between.
• At least 8-10 cm of cord is left behind for administration

of any drug or transfusion, if required.
• The baby should be labeled one.
Page 42
Management during labour contd..
Conduction of labour after the delivery of the first baby:

Steps of management:
Step I:
• Ascertain lie, presentation, size and FHS of the second
baby.
• Vaginal examination: To confirm the abdominal findings
and to exclude cord prolapsed, if any to note the status
of membrane.
Page 43
Management during labour contd...
Lie longitudinal:
• Step I: Low rupture of membranes, syntocinon,
internal examination to exclude cord prolapse.
• Step II: If the uterine contraction is poor, 5 units
of oxytocin is added.
• Step III: Is there is still a delay, interference is to
be done.
Page 44
1. Vertex: Low down—forceps are applied.

• High up—CPD should be ruled out.
• The possibility of hydrocephalic head should also

be
kept in mind and excluded by ultrasonography.
• If these are excluded, internal version followed by breech
extraction is performed under general anesthesia.
• Ventouse: effective alternative.
2. Breech: Breech extraction.
3. Lie transverse: Correct by external version or internal

version to cephalicPowerpoint
or podalic.
Templates
Page 45
Indication of urgent delivery of second baby:

– Severe vaginal bleeding,
– Cord prolapse
– Inadvertent use of IV ergometrine with the delivery of

anterior shoulder of the first baby,
– First baby delivered under general anesthesia,
– Appearance of fetal distress.
Page 46
Delay in the birth of second twin

• Birth of second twin be completed within 45
should of the first twin being born but with close
minute
monitoring can be extended if there are no signs of fetal
compromise.
• The risk of delays:

– intrauterine hypoxia,
– birth asphyxia,
– sepsis
Page 47
Management of third stage

• Routine administration of methergin IV with
0.2mg 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.
Page 48
Indications of caesarean section
Obstetric causes:
– Placenta previa
– Severe preeclampsia
– Previous caesarean section
– Cord prolapse of the first baby
– Abnormal uterine contractions
– Contracted pelvis
• For twins: Both fetuses or even first fetus with non-

cephalic presentation,
• Twins with complications: IUGR, twins;

conjoint
Monoamniotic twins, monochorionic
Powerpoint Templates twins with TTS
Page 49
Management of difficult cases of
twins
Interlocking
• Commonest: Aftercoming head of first baby getting
locked with forecoming head of second baby.
• Vaginal manipulation to separate chins of the fetuses
• Decapitation of first baby (dead), pushing up decapitated

head, followed by delivery of second baby and lastly,
delivery of decapitated head.
• Occasionally, two heads of both vertex get locked at the
pelvic brim preventing engagement of either of the head.
• Disengagement of the higher head: Under
general
anesthesia, If fails, caesarean section is the alternative
Page 50
Management of difficult cases of
twins contd..
Conjoined twins
• Extremely rare.
• Often diagnosed during delivery
• Presence of a bridge of tissue between the fetuses on

vaginal examination confirms the diagnosis.
• Antenatal diagnosis is important.
• Benefits are: reduces maternal trauma and morbidity,

improves fetal survival, helps to plan method of delivery,
allows time to organize pediatric surgical team.
Page 51
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 regarding different
mother positions for with advantages,
breastfeeding,
attachment, positioning
along timing.
Page 52
Postnatal period contd..
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 of uterus, increased ‘After pains’ so analgesia
involution
should be offered.
• High calorie diet.
• Teach extra support to handle twin babies
Page 53
Management and Nursing
Interventions
• Nutrition counseling
• Fetal evaluation
• Evaluate woman for signs and symptoms of obstetrical

complications
– Encourage bed rest and hydration.
– Institute fetal monitoring and assist with tocolytic
therapy, if ordered.
• Explain to the woman that mode for delivery depends on

the presentation of the twins, maternal and fetal status,
and gestational age
Page 54
Management and nursing interventions contd…
Intrapartum management
• Establish I.V. access
– Provide for electronic fetal monitoring for each fetus.
– Double setup is recommended for delivery.
• Availability of two units of crossmatched whole blood.
• I.V. access with large bore catheter.
• Surgical suite immediately available.
• An obstetrician and assistant experienced in vaginal births of twins.
• Best choice of anesthesia: epidural.
• Anesthesia provider capable of administering general anesthesia.
• Neonatal team for each neonate present at birth
for neonatal resuscitation.
– Pitocin induction/augmentation may be required
secondary to
hypotonic labor.
– Postpartum hemorrhage may occur due to uterine atony.
• Emotional support. Powerpoint Templates
Page 53
Nursing diagnoses
• Anxiety
• Deficient Knowledge Regarding High-risk Situation/Preterm
Labor
• Risk for Imbalanced Nutrition: Less/More than Body
Requirements
• Risk for Fetal Injury
• Risk for Maternal Injury
• Risk for Deficient Fluid Volume
• Risk for Impaired Gas Exchange
• Risk for Activity Intolerance
• Risk for Ineffective/Compromised Family Coping
• Risk for Interrupted Family Process.
Page 56
Nursing diagnoses contd…
For Cesarean Delivery

• Deficient Knowledge Regarding Surgical Procedure, and
Postoperative Regimen
• Anxiety (Specify Level)
• Powerlessness
• Risk for Acute Pain
• Risk for Infection
• Risk for Impaired Fetal Gas Exchange
• Risk for Maternal Injury
• Risk for Decreased Cardiac Output
Page 57
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Multiple Pregnancy

• Simultaneous development of two fetuses (twins) is the

• monozygotic twins (syn. identical, uniovulvar)

• Dizygotic twins (syn: fraternal, binovular

• If the division after 8th day of fertilization, when the

• On extreme rare occasions, division occurs after 2 weeks

• Four types of fusion may occur

Each fetus is surrounded by a amnion Each fetus is surrounded by a separate

Intervening membranes consist of 4 Intervening membrane consists of two

• A test skin graft: Acceptance of reciprocal skin graft—proof of

• DNA microprobe technique is more definitive.

• Follow-up study between 2-4 years—showing almost similar

• The causes of twin pregnancy is not known.

• Fetus papyraceous or compressus

If the egg fails to fully separate, the result is conjoined

• Clinical examination with accurate measurement of

• Tendency of swelling in the legs, varicose veins

• Unusual rate of uterine enlargement and excessive fetal

• Unusual weight gain, explained by

Early rupture of membranes and

Increased operative interference

Twin twin transfusion syndrome (TTS)

• Donor twin which become smaller with oligohydramnios,

• Donor may appear stuck due to severe oligohydramnios.

• Difference of hemoglobin concentration between the twin

Twin reversed arterial perfusion (TRAP):

• Prostaglandin synthase inhibitor used to reduce fetal

• Delivery of markedly preterm neonates be

• Fetal-growth restriction be identified and afflicted fetuses

• Fetal trauma during labor and delivery be avoided, and

• Expert neonatal care be available.

• Antepartum Surveillance: sonographic examinations

• Tests of Fetal Well-Being

• Prevention of Preterm Delivery

• Use of corticosteroids to accelerate fetal lung maturation.

• Limit use of analgesic drugs

• 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.

• At least 8-10 cm of cord is left behind for administration

Conduction of labour after the delivery of the first baby:

1. Vertex: Low down—forceps are applied.

• The possibility of hydrocephalic head should also

2. Breech: Breech extraction.

3. Lie transverse: Correct by external version or internal

Indication of urgent delivery of second baby:

– Inadvertent use of IV ergometrine with the delivery of

– Appearance of fetal distress.

Delay in the birth of second twin

• The risk of delays:

Management of third stage

• Deliver placenta by CCT

• The patient is to be carefully watched for about 2 hours

• For twins: Both fetuses or even first fetus with non-

• Twins with complications: IUGR, twins;

• Decapitation of first baby (dead), pushing up decapitated

• Often diagnosed during delivery