When one or more fetus

simultaneously develops in the

uterus, it is called multiple
pregnancy.
TWIN
S
 VARIETIES

• Dizygotic Twins (80%)

•Monozygotic Twins (20%)

 Placenta Commu Interv Sex Geneti Skin Resemb
ni e c Graftin la nce
cating ning Featur g
Vessels Memb e s
ranes
Monozygotic One Present 2 Alwa Same Acceptance Usually
amni ys Identica
o ns iden l
t
ical
Dizygotic Two Absent 4:2 May Differ Rejection Not
amni differ identical
o
ns,2
chori
o ns
Monozygotic Dizygotic
The Cause of twinning is not
known. Predisposing
factors
Dizygotic twin pregnancies are slightly more likely when the following
factors are present in the woman:

•She is between the age of 30 and 40 years

•She is greater than average height and weight
•She has had several previous pregnancies.
•Women undergoing certain fertility treatments may have a greater
chance of dizygotic multiple births.
•The risk of twin birth can vary depending on what types of fertility treatments
are used. With in vitro fertilisation (IVF), this is primarily due to the insertion
of multiple embryos into the uterus.

•Ovarian hyperstimulation without IVF has a very high risk of multiple birth.
•Reversal of anovulation with clomifene has a relatively less but yet significant
risk of
multiple pregnancy.
 Maternal Physiological Changes
1. There is increase in weight gain and

cardiac output.

2. Plasma volume is increased by an

addition of 500ml.

3. There is no corresponding increase in

red cell volume resulting in

exaggerated haemodilution and

anaemia.

4. There is increased alpha fetoprotein

LIE AND PRESENTATION
Both Both
Breec Verte
h x
(10%) (50%
)

Commonest lie is First

Longitudinal Vertex
Rarest and
one Both second
transvers breech
e (Rule First
(30%)
out breec
conjoined h and
twins) secon
d
vertex
(10%)
 Diagnosis
History of Abdomina
ovulation l
Minor
inducing drugs. examinatio
ailments of
n
normal
pregnancy
Family history are Internal
of exaggerated examination
Twinning
 Abdominal
Examination

Not easy
More “barrel shaped” inspection due to
presence
of
hydramnios

Abdominal girth more than

100cm.
Too many fetal parts on
palpation.

Two distinct fetal heart sounds

on Auscultation.
 Ultrasonogr
aphy
Confirmation of pregnancy
as
early as 10th week
of pregnancy
Viability of fetus

Chorionicity

Amniotic Fetal Anomalies

fluid
volume Twin transfusion
Presentation and Lie of
the fetus
Placental
Localization
Fetal growth monitoring
for IUGR
 Lambda or twin peak
sign

The sign describes the triangular appearance

to chorion insinuating between the layers of the
inter twin membrane and strongly suggests a
dichorionic twin pregnancy. It is best seen in the
first trimester (between 10-14 weeks).

In contrast the T sign refers to the appearance of

the intertwin membrane in a monochorionic twin
pregnancy. The sign should not be confused
with the lambda sign of sarcoidosis.
 A potential space
exists in the
intertwin
membrane, which is
filled by
proliferating
placental villi giving
rise to the twin peak
sign.
Differential
Diagnosis

Hydramnios

Big Baby

Fibroid or ovarian
tumour with
pregnancy.
Ascites with
pregnancy
 Complicati
ons
Maternal Fetal

Pregnanc
y

Labour

Puerperiu
m
 During
Pregnancy

Anaemia
Pre-eclampsia
(25%) Hydramnios
(10%)
Antepartum
Haemorrage
Malpresentation
Preterm Labour
(50%) Mechanical
Distress
 Durin
Increased operative
g interference
Labour
Early Rupture of
membranes and
cord prolapse

Bleeding

Prolonged labour Postpartum

Haemorrhage
 Increased
incidence of
During Subinvolution
Puerperiu Infection.
.
Lactation
m Failure.
 Increased risk of
miscarriage

Premature rate (80%)

Twin-twin
transfusion
syndrome
Placental insuffiency

IUGR

Structural anomalies

Intrauterine death of
one fetus

Asphyxia and stillbirth

 Management during Labour

What happens during a twin birth?

Most twins are born before 38 weeks. If labour didn’t started by then,
you may need to induce labour .

During labour, regular monitoring of the twins with electronic fetal

monitors (EFM) is standard practice. This is used to listen to the
babies' heartbeats and the intensity and frequency of the contractions.
The doctor may place a needle in a vein in the arm (a drip) in case it is
needed later.

Discuss pain relief preferences during pregnancy and write them in

birth plan. But keep in mind that labour and birth
are unpredictable. Your midwife may need to recommend a course of
action at any time which is not what you had originally hoped for, but
which will always be in the best interests of you and your baby.
Once the first baby is born, the midwife
or doctor will check the position of the
second twin by feeling the tummy and
doing a vaginal examination, or an
ultrasound scan.

If the second baby is in a good position

to be born, the waters surrounding him
will be broken. the second baby should
be born very soon after the first,
because the cervix is already fully
dilated. If the contractions stop after the
first twin is born, hormones are added to
the drip to restart them.

You'll usually be recommended to

have a managed third stage. This is
when the placenta is delivered with
the help of a hormone injection,
instead of a natural
delivery. This is because there is an
increased risk of bleeding when the
placenta is larger, and the uterus (womb)
 Triplets Quadruple
ts

Female usually outnumber the number of male one. Perinatal loss is

markedly
increased due to prematurity.
Average time for delivery in quadruplets is 30-31 weeks.

Selective reduction: If there are 4 or more fetuses, selective

reduction of the fetuses leaving behind only two is done to improve
the outcome. This can be done by intracardiac injection of potassium
chloride between 11-13 weeks.

Selective termination of a fetus with structural or genetic abnormalities

may be done in a chorionic multiple pregnancy in the second trimester.