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Multiple

Pregnancy
Multiple Pregnancy

• 3% of all pregnancies

• Account for 1 in 8 of perinatal deaths

mostly as a result of prematurity.


Multiple Pregnancy

• Twins 1:100------65% increase


• Triplets 1:10,000 ----500% increase
• Quadriplets 1:750,000---- 500 % increase
Etiology of Multiple Fetuses
• Dizygotic: Fertilization of two separate ova,
(fraternal twins). Two thirds

• Monozygotic: Fertilization of a single ovum


(identical twins)

Triplets or more may have a mixture of both di &


monzygotic.
Genesis of Monozygotic Twins
Frequency of Twins
• Monozygotic:
– 1/250 births, relatively constant worldwide
– Independent of race, heredity, age, and parity
• Dizygotic:
– Doubled following ovulation induction
– Influenced remarkably by race, heredity, maternal
age, parity, and especially, fertility drugs
• Incidence underestimated because of abortions or
vanishing twin
Frequency of Twins

• Induction of ovulation
– Increases both mono & dizygotic twining
– Gonadotropins - risk 20-40%
– Clomiphine - risk 7% twins, 0.5% triplets,
0.3 quadruplets
Risk Facotrs
• Race
– Blacks > White
– Africans
• Heredity
– Maternal transmission is stronger than paternal.
• Maternal Age & Parity
• Maternal size
Determination of Zygosity

• Why important?

– Assessing obstetrical risks

– Guiding management

– Inter-twin organ transplantation later in life


Determination of Zygosity
• Ultrasound
– High resolution
ultrasound
especially in first
trimester
– Fetal sex, separate
placental sites, and
dividing membrane
relationships.
Determination of Zygosity
• Placental examination
– One common
amnionic sac or if
juxtaposed amnions
not separated by
chorion the infants
are monozygotic.
Determination of Zygosity
• Placental examination
– If adjacent amnions
are separated by
chorion, the fetuses
may be
monozygotic, but
more often are
dizygotic
Determination of Zygosity
• Sex
– Twins of opposite sex are almost always
dizygotic
• Blood group
• DNA

Zygosity may not determined in 35% of twin


sets
Diagnosis of Multiple Fetuses
• Suspected if
– Large for date uterus
– Recent administration of either clomiphene or
pituitary gonadotropin
– Familial history of twins- weak clue
Diagnosis of Multiple Fetuses
• Ultrasound
– Detection of two
separate fetal
echoes with fetal
heart activities
visualized
simultaneously
Other Diagnostic Aids
• Unreliable methods:
– Palpation of fetal Parts
– Fetal Heart Sounds
– Level of β hCG
– Level of α -fetoprotein
Maternal Adaptation
• Blood volume- mean increase amounts to about 50-60%
with twins compared to 40-50% in singleton gestations, i.e.
500 mL greater
• Cardiac output: Increased:

– Increased pulse rate and stroke volume

– Increased shortening fraction

– Increased contractility
Maternal Adaptation
• Uterus may reach a volume of 10 L or more and weigh in
excess of 9 K especially if polyhydramnios is present.

• Compression and displacement of abdominal viscera as


well as the lungs

• Obstructive uropathy which may lead to impairment of


renal function
Fetal Complications
• Abortions
• Malformations
• Prematurity
• Low birth weight
• Growth Discorcance
• Twin-twin transfusion syndrome
• Death of one/both fetuses
• Conjoined and acardiac twin
Morbidity and Mortality in Multiple Gestation

Characteristic Twins Triplets Quadruple


ts

Average birth weight g 2,347 g 1,687 g 1,309

Average gestational age at delivery wk 35.3 wk 32.2 wk 29.9

Percentage with growth restriction 25–14 60–50 60–50

Percentage requiring admission to 25 75 100


neonatal intensive care unit
Average length of stay in neonatal days 18 days 30 days 58
intensive care unit
Percentage with major handicap — 20 50

Risk of cerbral palsy 4 times more than 17 times more —


singletons than singletons

Risk of death by age 1 year 7 times higher times higher 20 —


than than singletons
singletons
Maternal Complications
• Anemia: Iron & folate deficiency
• Discomfort
• Hypertension
• Cesarean births
• Placental Abruption
• Postpartum hemorrhage
• Hospitalization
Congenital Malformations
• Major- 2% vs. 1% in singleton
• Minor- 4% vs. 2.5%
• Aneuploidy
• Polyhydramnios
– usually transient at midgestation
– if persistent may indicate risk of anomalies
Low Birth Weight
• Diminished nurture especially in 3rd trimester
• Preterm labor
• Placental insufficiency
• Vascular anastomoses
• Related to no. of fetuses
• More in monozygotes
• Gender influence
• Anomalies
ART pregnancies
• Preterm delivery
• Low birth weight
• Perinatal mortality
Prematurity
• The major reason for the increased risk of neonatal
death and morbidity in twins
• Mostly due to spontaneous preterm labour (PTL)
• Medically Indicated PTL: HBP, IUGR, abruptio
Unique Complications
• Discordant twins
• Vascular communications between fetuses
• Death of one fetus
• Monoamnionic twins
• Conjoined twins
• Acardiac twin
Discordant Twins
• Incidence 10%
• Significant if >25% weight difference, larger twin is the
index
• Perinatal mortality & morbidity increased
• Related to neurological disability later in life
• Discordancy in dichorionic twins is due to placental
insufficiency
• Discordancy in monochorionic twins is due to
hemodynamic imbalance of vascular anastomosis.
Vascular Communications
• Nearly 100% of monochorial placentas have
vascular anastomosis of variable number, size and
direction
– Artery-to-artery 75%
– Vein-to-vein 50%
– Artery-to-vein 50%
Vascular Communications
• Most shunt are heniodynamically balanced
• If unbalanced
– Twin-twin transfusion syndrome
– Acardiac twining
Twin Twin Transfusion Syndrome
(TTTS)
• Typically presents in midtrimester
• Donor
– Anemic
– Growth restricted
– Oligohydramnios
• Recipient
– Polycythemic
– Circulatory overload (hydrops)
– Polyhydramnios
Twin Twin Transfusion Sydnrome
(TTTS)
• Antenatal complications
– Polyhydramnios-olighydramnios
– Growth discordance & IUGR
– IUFD of one/both twins
– Preterm labor and delivery
Twin Twin Transfusion Sydnrome
(TTTS)
• Postnatal complications
– Circulatory overload
– Polycythemia
– Hyperbilirubinemia and kernicterus
– Heart failure
– Hypervolemia and hyperviscosity
– Occlusive thrombosis
– Death
Death of One Fetus
• Risk of maternal disseminated intravascular coagulation
(consumptive coagulopathy)

• Risk of consumptive coagulopathy to a surviving fetus


theoretically higher if anastomosis present
Monoamnionic Twins
• Rare variety of monozygotic twins (1%)

• Extremely high fetal death rate, mostly due to cord


interwining

• Prophylactic cesarean delivery at 32-33 weeks is


controversial
Conjoined Twins
• Siamese twins, after Chang and
Eng Bunker of Siam (Thailand)
• After the embryonic disc and
the rudimentary amnionic sac
have been formed

• Incidence unestablished
– 1/60,000 births

• Surgical separation may be


successful if vital organs not
shared
Antepartum Management
• Diet
– Energy sources increased by another 300 kcal/day.
– Iron supplementation of 60 to 100 mg/day
– Folic acid, 1 mg/day if inadequate protein intake
Antepartum Management
• Antepartum Surveillance
– serial sonography is usually employed throughout the
third trimester
– Nonstress test
– Biophysical profile
– Doppler study to assess feto-placental perfusion
Antepartum Management
• Prevention of Preterm Delivery
– Rest. Routine hospitalization is not recommended
– Tocolysis: No significant benefit
– Antenatal steroids: No proven benefit
– Cerclage: No proven benefit
• Pulmonary maturation at 32 weeks (34 in singletons):
tested by lecithin-sphingomyelin ratio in amniotic fluid
Labor Complications
• Preterm labor
• Uterine dysfunction
• Abnormal presentations
• Prolapse of the umbilical cord
• Premature separation of the placenta
• Postpartum hemorrhage
Intrapartum Management
• Appropriately trained obstetrical attendant
• Continuous external/internal electronic fetal monitoring
• Blood transfusion products should be readily available
• Intravenous fluid infusion
Intrapartum Management
• Skilled Obstetrician
• Anesthesiologist
• Two neonatal team, one skilled in resuscitation
• Adequate space in delivery area for maternal and infants
management
• Induction or stimulation of labor can be used with caution
Breech-Breech Others
5% 8%
Cephalic- Cephalic-cephalic
transverse 42%
18%

Cephalic-breech
27%
Intrapartum Management
• Mode of delivery
– Vaginal for cephalic-cephalic
– Controversial for cephalic-non cephalic especially if
prematurity is a concern
– Increased rate of CS for second twin
– Controversial for breech-cephalic because of rare risk
of Locked twins
Intrapartum Management
• Delivery of the second twin
– Interval can be prolonged more than 30 minutes if
continuous fetal monitoring is employed
– Cesarean delivery rate is increased if interval is > 15
minutes
– External cephalic version
– Internal podalic version
External Cephalic Version
Internal Podalic Version
Triplets or More
• Increased maternal physiological adaptation &
complications
• Survival improved for triplets (>95%)
• Higher risk of prematurity
• Risk of vaginal delivery
• Cesarean is recommended