Multifetal

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

Zygosity refers to the type of

conception
Chorionicity denotes the type of
placentation
Chorionicity rather than zygosity
determines out
outcome

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%)

3-8 days later (60-70%)

Monochorionic twins
8-12 days later (1-2%)

12-13 days later (0.5%)

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

Inaccurate menstrual history

Hydramnios

Hydatidiform mole

Uterine fibroids

A closely attached adnexal mass

Fetal macrosomia (late in pregnancy)

Ultrasonography
Detect multifetal gestation 99%
before 26 weeks

Confirm fetal number [ 2 sacs or

2fetal heads
in 2 perpendicular planes]

Diagnose type and presentation and

position and relation to each other

Exclude congenital abnormalities/

conjoint twin

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

Spontaneous early pregnancy loss

Prematurity
Intra-uterine growth restriction
Cerebral palsy - related to
gestational age, 3 times in twins, >
10 times in triplets
Intrapartum trauma
Monochorionic twins specific
complications

Antenatal care

Routine booking investigations

Folic acid supplementation
anemia treat immediately
Support symptomatically

Serial growth scans :

Dichorionic :4 weekly from 24
weeks
Monochorionic : 2 weekly from 18
weeks

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

Twin-Twin Transfusion Syndrome

Incidence : 4 - 20% of MC twins
It is characterised by an imbalance of blood
flow
between the twins
15 - 20% of perinatal deaths
Untreated, perinatal loss rates in the midtrimester
(80 - 100%)

Large volume
amnioreduction

Amniotic
Septostomy

Fetoscopic Laser
Ablation

Delivery by Caesarean section

at 34 weeks

Conjoined twins or Siamese

twins
Anterior (thoracopagus)
Posterior (pygopagus)
Cephalic (craniopagus)
Caudal (ischiopagus)

Single intrauterine demise

2-6% of twins pregnancies
Up to 25% in MC twin pregnancy
Perinatal morbidity and mortality of the
surviving
co-twin
- 19% perinatal death
- 24% having serious long term sequelae

Treatment options
No optimal management
Prompt delivery -Iatrogenic prematurity
risks
Conservative treatment -Subsequent
handicaps
Intrauterine interventions

High order multiples

Perinatal risk increases exponentially with
increasing
number of fetuses
Multifetal pregnancy reduction (MFPR) at
10 to 12
weeks should be recommended for
quadruplets and
higher multiples
The situation with triplets is more
controversial