Multiple Pregnancy

Kevin Andrew
Definition:
• Multiple pregnancy is the term used to describe pregnancy with more
than one fetus.
• The vast majority of such pregnancies are cases of twins (2 fetuses).
• The other forms of multiple pregnancy are triplets (3 fetuses),
quadruplets (4 fetuses), quantiplets (5 fetuses), and so on.
Superfetation:
• formation of a fetus while another fetus is already present in the
uterus.
• situation where a woman becomes pregnant when she is already
pregnant
• occurs when ovum from two separate menstrual cycles are released,
fertilized, and implant in the uterus
• Very rare
Superfecundation:
• The fertilization of two or more ovum from the same cycle by sperm
from separate acts of sexual intercourse, which lead to twin babies
from two separate biological father
• Therefore this phenomenon happens to be very rare.
Demography
• Race: most common in Negroes, least in Asia
• Age: Increased maternal age
• Parity: more common in multipara
• Heredity - family history of multifetal gestation
• Nutritional status – well nourished women
• ART - ovulation induction with clomiphene citrate,
gonadotrophins and IVF
• Conception after stopping OCP
INCIDENCE
Hellin’s Law:
Twins: 1:89
Triplets: 1:892
Quadruplets: 1:893
Quintuplets: 1:894
Conjoined twins: 1 : 60,000
Worldwide incidence of monozygotic - 1 in 250
Incidence of dizygotic varies & increasing
Twins
Varieties:
• 1. Dizygotic twins: commonest (Two-third)
• 2. Monozygotic twins (one-third)

Genesis of Twins:
• Dizygotic twins (syn: Fraternal, binovular) -
- fertilization of two ova by two sperms.
Monozygotic twins (Identical, uniovular):
• Upto 3 days - diamniotic-dichorionic
• Between 4th & 7th day - diamniotic
monochorionic - most common type
• Between 8th & 12th day- monoamniotic-
monochorionic
• After 13th day - conjoined / Siamese
twins.
Differences in zygocity:
Monozygotic
• 1 ova + 1 sperm
• Same sex
• Identical features
• Single or double placenta
• Same genetic features
• DNA microprobe -same
Dizygotic
• 2 ova + 2 sperm
• Same or opposite sex
• Fraternal resemblance
• Double or s/t fused
• Different genetic features
• DNA microprobe - different
Conjoined twins:
Ventral:
1) Omphalopagus
2) Thoracopagus
3) Cephalopagus
4) Caudal/ ischiopagus
Lateral:
1) Parapagus
Dorsal:
1)Craniopagus,
2)Pyopagus
Differences in chorionicity with single
placenta:
D / D ( fused placenta ) M/D
• Monozygotic or dizygotic • Monozygotic
• Thick dividing membrane > • Thin dividing membrane 2mm or
2mm less
• Twin peak / lambda sign • T sign
Maternal Physiological Adaptation:
• Increase blood volume and cardiac output
• Increase demand for iron and folic acid
• Maternal respiratory difficulty
• Excess fluid retention and edema
• Increase attacks of supine hypotension
Diagnosis of Multiple Pregnancy:
• Positive family history mainly on maternal side
• Positive history of ovulation induction
• Exaggerated symptoms of pregnancy
• Marked edema of lower limb
• Discrepancy between date and uterine size
• Palpation of many fetal parts
• Auscultation of two fetal heart beats at two different sites with a
difference of 10 beats
Other causes of apparent abnormal uterine
enlargement during early pregnancy
Excess fetal parts
• USS:

Two sacs by 5 weeks by transvaginal USS.

Two embryos by 7 weeks by transvaginal USS
Antenatal Care
Follow Up:

 Every two weeks.

 Diet: additional 300 K cal per day, increased proteins, 60 to 100 mg
of iron and 1 mg of folic acid extra
 Assess cervical length and competency.
• Fetal surveillance by USG – every 4 weeks
• Hospitalisation not as routine
• Corticosteroids -only in threatened preterm labour , same dose
Antenatal Care
Fetal Surveillance

 Monthly USS from 24 weeks to assess fetal growth and weight.

 A discordinate weight difference of >25% is abnormal (IUGR).
 Weekly CTG from 36 weeks.
Management During Labour
• FIRST STAGE:
blood to be cross matched and ready
confined to bed, oral fluids
intrapartum fetal monitoring
ensure preparedness
• SECOND STAGE – first baby
• - second baby
Management During Labour
• SECOND STAGE –delivery of first baby
as in singleton pregnancy
start an IV line
no oxytocin after delivery of first baby
secure cord clamping at 2 places before cutting
ensure labeling of 1st baby
• Delivery of second twin
FHS of second baby
lie and presentation of second twin
wait for uterine contractions
conduct delivery
Management During Labour
• THIRD STAGE
• - continue oxytocin drip
- monitor for 2 hours
Method Of Delivery
Vertex- Vertex (50%)
 Vaginal delivary, interval between twins not to exceed 20 minutes.

Vertex- Breech (20%)

Vaginal delivary by senior obstetrician
Method Of Delivery
Breech- Vertex( 20%)
 Safer to deliver by CS to avoid the rare interlocking twins( 1:1000
twins ).

Breech-Breech( 10%)
 Usually by CS.
Indications of caesarean
• Non cephalic presentation of first twin
• Monoamniotic twins
• Conjoined twins
• Locked twins
• Other obstetric conditions
• Second twin – incorrectible lie, closure of cervix
Clinical manifestation and complication
Complications of Multiple Gestation

Maternal Fetal
• Malpresentation
• Anemia
• Placenta previa
• Hydramnios
• Abruptio placentae
• Preeclampsia
• Premature rupture of the
• Preterm labour membranes
• Postpartum hemorrhage • Prematurity
• Cesarean delivery • Umbilical cord prolapse
• Intrauterine growth
restriction
• Congenital anomalies
Twin-to-twin transfusion syndrome
 Results from vascular anastemoses between twins vessels at the
placenta.
 Usually arterio (donor) venous (recipient).
 Occurs in 10% of monochorionic twins.
 Chronic shunt occurs ,the donor bleeds into the recipient so one is
pale with oligohydraminose while the other is polycythemic with
hydraminose.
 If not treated death occurs in 80-100% of cases.
 The donor twin can become hydropic because of anemia and high-
output heart failure.
 The recipient twin can become hydropic because of hypervolemia.
 The recipient twin can also develop hypertension, hypertrophic
cardiomegaly, disseminated intravascular coagulation, and
hyperbilirubinemia after birth.
Possible methods of treatment:

• Repeated amniocentesis from recipient.

• Indomethacin.
• Fetoscopy and laser ablation of communicating vessels.
Prognosis
• Risk of the mother with multiple pregnancy are higher than the
singleton pregnancy. Due to the high risk of having anemia, pre-
eclampsia, and post-partum hemorrhage,
• The prognosis for the mother is worse.
• The numbers of perinatal mortality is also high because of the
premature, umbilical cord prolapse, solutio placenta and other
obstetric intervention due to malposition of the fetus.
Conclusion:
• During multiple fetal pregnancy, it needs to be anticipated
abnormality that occurs to the mother and the baby, therefore more
intensive antenatal care should be applied.
Thank you