Multiple pregnancy

MULTIPLE PREGNANCY

• When more than are fetus

simultaneously develops in the
uterus, it is called multiple
pregnancy Two fetus growth and
development in uterus (twins) is
common although three
(triplets), four (Quadruplets),
five (Quimluplets) or Sexuplets)
can also occurs.
 Classification of Twin Pregnancy
• Dizygotic (binovular) twins: Results from the fertilizing of two oval nest
likely rupture from two distinct Graafian follicles usually of the same or
one from each ovary by two sperms during a single ovarian cycle. The body
bears only fraternal resemblance to one another that of brothers and sisters,
hence called fraternal/dizygotic twins.

• Monozygotic (uniovular twin): Results from fertilization of a single ovum.

In this twinning may occur at different periods after fertilization and this
influences the process of implantation andformation of fetal membranes.
 Determination of Zygosity
• Determining the zygosity of
fetuses

Zygosity Placenta Communica Intervening Sex Genetic Skin Follow- up

ting vessels membranes features grafting

Monozygotic One Present 2(amnions) Always Same Acceptance Usually

identical identical

Dizygotic Two Absent 4(2amnions May differ Differ Rejection Not identical
4cherians)
 Causes

• The exact cause is unicorn. It may be due

to national and environmental factors.
Several risk factor includes:
• Race: Highest among Negroes, lowest
among mangles and intermediate among
Caucasians
• Hereditary: More transmitted through the
female (maternal side)
• Advancing age of mother (maximum
between 30-35 years)
• Increased parity (mostly from 5th gravida
onward)
• latrogenic: Example drug (gonadotropin
therapy)
 • Undue enlargement of
uterus
• Increased nausea and
Sign and Symptoms vomiting ■
• Cardiorespiratory
embarrassment
• Swelling of legs
• Increased chances of
varicose veins/
hemorrhoids
• Excessive fetal
movements
 Diagnosis

 History taking
 History of ovulation induced drugs specially gonadotropins, for infertility or use of antiretroviraltherapy (ART).
 Family history of twinning
 General examination
• Increased prevalence of anemia
• Unusual weight gain
• More chances of preeclampsia
 Abdominal examination
• Inspection: It may reveal undulater till distention
• Palpation: Height of uterus and girth is more than period of amenorrhea. On palpation, fetal parts are felt sometime two fetal heads can be
palpated easily.
• Auscultation: Simultaneous hearing of two distinct fetal heart sounds located at separate spots with a silent area in between
 Internal examination: In some cases, one head is felt deep in the pelvis, while the other one is located by abdominal examination. On
occasions, the clinical methods fails to detect twins prior to the delivery of first baby
• Investigations:
• Sonography: It can detect two gestational sacs as early as 10th week.
Repeated sonography is helpful
• Biochemical tests like serum human chorionic gonadotropin (hCG) a-
fetoprotein.
 • Maternal complications
 During pregnancy
• Nausea/vomiting
• Anemia
• Hydramnios
• Antepartum hemorrhage

Complications • Malpresentation
• Preterm labor
• Mechanical distress (Ex: Palpitation, dyspnea etc
 During labor
• PROM
• Cord prolapse
• Prolonged labor
• Increased operative interference
• Bleeding (following delivery of first baby an
following separation of placenta)
• PPH
 During puerperium
• Subinvolution
• Increased operative interference
• More chances of infection
• Lactation failure
 Fetal complications
• Miscarriage.
• Premature birth
• Discordant twin growth
• Intrauterine death of one fetus
• Congenital malformations
• Asphyxia
Complication of Multiple
Pregnancy
• Twin to twin transfusion
syndrome
• Dead fetus syndrome
• Twin reversed Arterial
perfusion
• Monoamniotic
• Conjoined twin
Twin to twin transfusion syndrome
Twin reversed Arterial perfusion
 Management
• Antenatal Management
• Early diagnosis to detect chorionicity, amniocity, fetal growth pattern and
congenital malformation
• Careful antenatal supervision throughout pregnancy
• Diet: Increased day dietary supplement is needed for increased energy supply to
the extent of 300 Kcal/day.
• Increased rest: At home and early cessation of work from 24 weeks onward is
advised to providedpre term labor and other complications
• Supplement therapy e.g. Iron therapy, additional multivitamins are given
• Serial sonography at every 3-4 weeks interval or earlier if needed. Assessment of
fetal growth, AFI,non-stress test and Doppler velocimetry are correlated
• Hospitalize the patient at term if no complication aries, if emergency occurs,
admit the patient at earlier phases also.
During the First Stage of
Labor
 During the First Stage of Labor

• The woman should be kept in bed and the enema should be withheld to prevent early
rupture of membranes
• Skilled obstetrician should be present. An experienced anaesthetist should be made
available
• Use of analgesics is limited as the babies are small and rapid delivery may occur. Epidural
analgesia is preferred as it facilitates manipulation of second fetes if it would become
necessary
• Neonatologists should be present. Careful fetal monitoring of both babies should be done;
continues fetal monitoring using electronic fetal monitor is better.
• Vaginal examination should be done soon after the rupture of membranes to exclude cord
prolapse
• An line with ringer’s lactate should be setup for any urgent IV therapy, if
required One IV unit of cross matched blood should be made readily
available
• Presence of neonatologists at the time of delivery is mandatory and if
fetal distress occurs, delivery will need to be expedited, usually by
cesarean section
• In case of poor uterine contractions, start oxytocin drip once the
membranes have been ruptured
• Artificial rupture of membranes is helpful to induce uterine contraction
but may need to be usedin conjunction with IV syntocinon
• Midwife should provide physical and emotional support to the mother
throughout labor.
 During Second Stage (Management of Delivery)
• Delivery of first twin should be conducted in the same manner as in normal labor if it present by vertex
• Liberal episiotomy under local infiltration with 1% lignocaine is given to prevent intracranial damage
to the fore coming or after coming head of the premature baby
• Methergine should not be given after the delivery of first baby
• Clamp the cord at two places and cut in between, to prevent exsanguination of second baby through
communicating placental circulation in monozygotic twins
• At least 8-10 cm of cord is left behind for administration of any drug or transfusion, if required
• When the first twin is born, the time of delivery and the sex of fetus is noted
• The baby must be labeled as "twin one" immediately
• After delivery of first twin, abdominal palpation must be done to ascertain the lie, presentation and
position of the second twin and to auscultate the fetal heart
• A vaginal examination should be done to exclude cord prolapse, if any and to note the status of the
membranes
• if lie is not longitudinal, an attempt may be made to correct it by external cephalic version
• If presenting part is not engaged, it should be pushed into the pelvis by fundal pressure before the
second sac of membrane are ruptured
• If uterine contractions are not effective, oxytocin drip should be started to stimulate contractions
• When presenting part of second twin becomes visible, mother should be encouraged to push
withcontractions to deliver the second twin
• Delivery will proceed as normal if the presentation is vertex
• Delivery of second twin must be completed with 45 minute of the first twin as long as there are
tosigns of fetal distress
• If there is delay, to cut short the duration of second stage of labor, forceps/ventouse should be used
• If baby is in breech presentation, breech extraction it to be done
• Following the delivery of anterior shoulder of second twin, methergine 0.2 mg is given intravenously
• The baby is labeled as “twin two” and the time of delivery and sex of baby are noted.
 • The placenta is delivered by cord
controlled traction.

Management of Third • Oxytocin drip should be continued

for at least 1 hour following delivery
Stage of second baby
• Mother and baby should be carefully
watched for 2 hours following
delivery.
• If blood loss is more than average, it
should be replaced by blood
transfusion.
• Placental membranes and cord
should be examined carefully for
any abnormalities.
 Obstetric causes
• Contracted pelvis
• Placenta previa

Indications for Cesarean • Severe preeclampsia

• Previous h/o cesarean section
Section • Cord prolapse of first baby
• Abnormal uterine contractions
Fetal causes:
• Both babies or first baby in transverse lie
• Non vertex twins with estimated weight
2 kg or less
• Conjoined twins
• Collision of both heads at brim
preventing engagement of either head.
 Management of Postnatal Period
• Care of the babies
• After the delivery of both twins, make sure that airway should be cleared and temperature must be
maintained
• Identification of the infants should be clear and parents must be given the opportunity to check the
identity bracelets and cuddle their babies
• Until the mother condition stabilizes after delivery, admits the infants directly to the neonatalunit
from the labor room and later transferred to the postnatal ward to be with the mother
• Advise the mother for breast feeding either simultaneously or separately to both babies. Offer help
during initial days
• If babies are preterm, they may have to be fed with expressed breast milk.
• If infants are low birth weight, they are more susceptible to infection and hence the mother should
be encouraged to wash her hands before & after handling her babies and particularly after changing
their nappies.
• Care of the mother
• Involution of the uterus will be slower
because of increased bulk.
• After pains may be troublesome and
analgesics must be given when she needs.•
• If mother is breastfeeding, a high calorie
diet, high proteins are required. Instruct the
mother for postnatal exercises to improve
tone of the abdominal and pelvic floor
muscles.
• Provide reassurance to mother if babies are
in nursery.
• Provide appropriate support and assistance
because mother of multiple twins are more
susceptible to postpartum depression.