OBSTETRICS II EXIMIUS

Multifetal Pregnancy 2021

Dr. Marites Butaran October 2019
MULTIPLE PREGNANCY l DIAMNIOTIC MONOCHORIONIC TWINS
l When more than one fetus simultaneously develops in the n 66%
uterus, it is called multiple pregnancy. n division takes place between the 4th and 8th day after
l result from two or more fertilization events, from a single the formation of inner cell mass when chorion has
fertilization followed by splitting of the zygote, or from a already developed
combination of both.
l MONOAMNIOTIC-MONOCHORIONIC TWIN
VARIETIES n 3%
Dizygotic n division occurs after 8th day of fertilization, when the
l most common (80%) amniotic cavity has already formed
l results from the fertilization of two ova by two sperms during a
single ovarian cycle l CONJOINED TWIN
l babies bear only fraternal resemblance to each other n <1%
n division occurs after 2 weeks of the development of
Monozygotic twins
embryonic disc
l Identical Twin (20%)
l fertilization of a single ovum
l twinning may occur at different periods after fertilization

Two placenta separated or fused w/o vascular interaction. Intervening

membrane consist of 4 layers.

DETERMINATION OF ZYGOSITY
l Zygosity refers to the genetic makeup of twin pregnancy
l Chorionicity indicates the pregnancy’s membrane status.

Monozygotic Dizygotic
Placenta 1 2
Communicating Present absent
vessels
Intervening 2 amnions (4) 2 Amnions, 2
membranes chorions
Sex Identical May differ
Genetic Features same differ
Skin grafting acceptance rejection
Follow up identical Not identical No chorion
DNA microprobe technique- most definite one placenta with free internal vascular anastomosis; the intervening
membranes consist of 2 layers (D/M) ; or without any intervening
membranes (M/M)

MONOZYGOTIC TWINS INCIDENCE AND ETIOLOGY

l DIAMNIOTIC-DICHORIONIC OR D/D l Incidence :Increased
n 30% l early detection by ultrasound
n division takes place within 72 hours after fertilization l Induction ovulation
(prior to morula stage) l ART
n two separate placenta, chorions and amnions l Etiology :Unknown
l Frequency of monozygotic twins- constant
l Prevalence of dizygotic twin – varies

TRANSCRIBERS Gosiengfiao, Padua, Toribio, Udarbe

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 OBSTETRICS II EXIMIUS
Multifetal Pregnancy 2021
Dr. Marites Butaran October 2019
DIZYGOTIC TWINS l General Examination
PREVALENCE OF DIZYGOTIC TWINS n Anemia, weight gain, pre-eclampsia
l Race: high negroes, intermediate Caucasians l Abdominal Examination
l Heredity: likely transmitted in maternal side l Inspection
l Advaced Age of mother- 30-35yo n barrel shape and enlarged abdomen
l Parity – increased from 5th gravida onwards l Palpation
l Iatrogenic- use of drugs 20-40% GNRH therapy, n FH>, Abdominal Girth>, Many fetal parts, 2 fetal head
l 5-6% by clomiphene citrate l Auscultation
Superfecundation
2 distinct fetal hearts located at separate spot with silent
l
n
n fertilization of 2 different ova release in the same cycle,
area in between
by separate act of coitus within a short period of time.
l Internal Examination
l Superfetation
n one head felt in the pelvis, the other in the abdomen.
n fertilization of two ova released in different menstrual
l Clinical exam may fail to detect twins prior to delivery.
cycles. The nidation and development of one fetus over
another fetus is theoretically possible until the decidual
DIAGNOSTIC TEST
space is obliterated by 12 weeks of pregnancy.
l Biochemical Test: Maternal HCG, AFP, Estriole doubles
l Sonography
Fetus papyraceous or compressus
l occurs if one of the fetuses dies early. The dead fetus is 1. Confirmation of diagnosis as early as 10th week of
flattened, mummified and compressed between the pregnancy
membranes of the living fetus and the uterine wall. 2. Viability of fetuses, vanishing twin in the second trimester
3. Pregnancy dating
Fetus acardiacus 4. Fetal anomalies
l occurs only in monozygotic twins. Part of one fetus remains 5. Fetal growth monitoring (at 3–4 weeks interval) for IUGR
amorphous and becomes parasitic without a heart. 6. Presentation and lie of the fetuses
7. Twin transfusion (Doppler studies)
Hydatidiform mole (from one placenta) and a normal fetus and 8. Placental localization
placenta (from the other conceptus) have been observed 9. Amniotic fluid volume
ultrasonographically.
10. Chorionicity (lambda or twin peak sign) triangle with the
base at the chorionic surface and the apex in the
Vanishing twin
l imaging in multiple pregnancy since early gestation has intertwin membrane
revealed occasional death of one fetus and continuation of
pregnancy with the surviving one. The dead fetus (if within 14
weeks) simply ‘vanishes’ by resorption. The rate of
disappearance 40%.

MATERNAL PHYSIOLOGICAL CHANGES

l There is increase in weight gain and cardiac output.
l Plasma volume is increased by an addition of 500 mL. There is
no corresponding increase in red cell volume resulting in
exaggerated hemodilution and anemia.
l There is increased a fetoprotein level
l Increased tidal volume
l Increased glomerular filtration rate

LIE AND PRESENTATION DIFFERENTIAL DIAGNOSIS

l Lie: 90 % Longitudinal l Hydramnios
l Presentations: l Big baby
n Both vertex -50% l Fibroid or ovarian tumor with pregnancy
n Vertex, Breech- 30% l Ascites with pregnancy
n Breech , Vertex – 10%
n Both Breech- 10% COMPLICATIONS
n Vertex , transverse and both transverse: rare Maternal
During Pregnancy
DIAGNOSIS l Nausea and vomiting
l History l Anemia – Megaloblastic anemia
l Symptoms l Preeclampsia
n N/V, palpitation, shortness of breath, leg cramps, excess l Hydramnios
fetal movement l Antepartum Hemorrhage
l Preterm labor
l Mechanical Distress
TRANSCRIBERS Gosiengfiao, Padua, Toribio, Udarbe
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 OBSTETRICS II
Multifetal Pregnancy
Dr. Marites Butaran October 2019
During Labor
l EROM and cord prolapse
l Prolonged labor
l Increased Operative Interference
l Intrapartum Hemorrhage
l Postpartum hemorrhage
n Atony of the uterine muscle due to overdistension of
the uterus
n A longer time taken by the big placenta to separate
n Bigger surface area of the placenta exposing more uterine
sinuses
n Implantation of a part of the placenta in the lower
segment which is less retractile
Fetal
l Abortion: >mzt
l Preterm birth: 80%
l Discordant growth: 25% wt. difference
l Fetal Anomalies : >mzt
l Asphyxia and stillbirth: >mzt , 2nd twin
l IUFD of 1fetus: > mzt ,death due to compression, competion of
nourishment, congenital anomaly
l 1st trimester (vanishes)
l 2nd trimester ( Fetus papyraceous)
l 3rd fetal death of 2nd twin or DIC of mother
COMPLICATIONS OF MONOCHORIONIC TWINS
l Twin-twin transfusion syndrome (TTTS)
n Implantation of a part of the placenta in the lower
segment which is less retractile
n It is a clinicopathological state with MZT
n one twin appears to bleed into the other through
placental vascular anastomosis
n receptor twin becomes larger with hydramnios,
polycythemic, hypertensive and hypervolemic, donor
twin which becomes smaller with oligohydramnios,
anemic, hypotensive and hypovolemic
n donor twin may appear “stuck” due to severe
oligohydramnios
n Difference of hemoglobin concentration between the
two, exceeds 5 gm% and EFW discrepancy is 25% or
more.
l Dead fetus syndrome
n death of one twin (2–7%) is associated with poor
outcome of the cotwin (25%)
n surviving twin runs the risk of cerebral palsy,
microcephaly, renal cortical necrosis and DIC
n due to thromboplastin liberated from the dead twin
l Monoamniocity
n 2% of all twins
n high perinatal mortality due to cord problems
l Conjoined twin
n rare (1.3 per 100,000 births)
n Perinatal survival depends upon the type of joint
n Major cardiovascular connection leads to high mortality
TRANSCRIBERS Gosiengfiao, Padua, Toribio, Udarbe
EXIMIUS
2021
PROGNOSIS
l Maternal mortality
n increased
n death is due to hemorrhage, preeclampsia and anemia
l Perinatal mortality
n Increased
n prematurity, cord entanglement
l During delivery 2nd baby is at risk to placenta insufficiency,
operative interference and cord prolapse
l High Risk Pregnancy- hospital Delivery
MANAGEMENT
Antenatal Management
l Diet- increased dietary supplement
l Increased rest
l Supplementary therapy
l Increased Prenatal visit
l Fetal surveillance – 3 to 4 weeks, fetal growth, AFI, NST and
doppler
l Hospitalization
n Development of complicating factors necessitates urgent
admission irrespective of the period of gestation.
n Use of corticosteroids to accelerate fetal lung maturation
is given to women with preterm labor <34 weeks.
During labor
l Vaginal delivery – allowed when both twin or at least first of
twin is vertex
l First stage
n Labor after the delivery of the 1st baby: < 30 mins interval
n Head
l If low down, delivery by forceps
l If high up, delivery by internal version under
general anesthesia
n Breech should be delivered by breech extraction
n Transverse lie—internal version followed by breech
extraction under general anesthesia.
n If the patient bleeds heavily following the birth of the first
baby, low rupture of the membranes can control blood
loss.
n administration of 0.2 mg methergin IV or oxytocin 10 IU
IM with the delivery of the anterior shoulder of the
second baby to minimize postpartum hemorrhage.
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 OBSTETRICS II EXIMIUS
Multifetal Pregnancy 2021
Dr. Marites Butaran October 2019
l Selective termination of a fetus with structural or genetic
abnormality may be done in a dichorionic multiple pregnancy in
the second trimester.

Reference: Dr. Butarans’s lecture/ppt

Indication for cesarean section

Obstetric indication
l Placenta previa
l Severe preeclampsia
l Previous cesarean section
l Cord prolapse of the first baby
l Abnormal uterine contraction
l Contracted pelvis

For Twins
l Both the fetuses or even the first fetus with breech or
transverse.
l Twins with complications: IUGR, Conjoint
l Monoamniotic twins
l Monochorionic twins with TTS
l Collision of both the heads at brim

TRIPLETS, QUADRUPLETS, ETC

l Triplets may develop from fertilization of a single ovum or two
or even three ova.
l Female outnumber the male
l Selective reduction
n done to improve outcome of the cofetuses
n intracardiac injection of potassium chloride between 11
and 13weeks under ultrasonic guidance.
n Umbilical cord of the targeted twin is occluded by
fetoscopic
l ligation or by laser or by bipolar coagulation, to protect the co-
twin from adverse drug effect.

TRANSCRIBERS Gosiengfiao, Padua, Toribio, Udarbe

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