MULTIFETAL

PREGNANCY
 DEFINITION

• Multiple pregnancy-occurs when more than one fetus simultaneously

develop in the uterus.
• Twin pregnancy- Is the simultaneous development of two fetuses.
• Although rare, Development of three fetus (triplets), four (quadruplet),
five(quintuplets), six (sextuplets) may also occur.
 TWIN PREGNANCY

• Twin pregnancy is the commonest variety of multiple pregnancy.

• It is of two types:
1. Dizygotic twins (80%), which results from fertilization of two ova leading to
fraternal twin.
2. Monozygotic twins (20% ), which results from fertilization of one ova
leading to identical twin.
 RISK FACTORS OF TWIN PREGNANCY

1. Increasing maternal age (30-35yrs)

2. Increasing parity (5 gravida onwards)
3. Nutritional factors
4. Pituitary gonadotropin
5. Infertility therapy
6. 6. Assisted reproductive therapy
7. 7. Genetic, hereditary
8. 8. Race, b>w
 GENESIS OF DIZYGOTIC TWINS

Results from Fertilization of two ova, mostly likely rupture from two
distinct graafian follicles usually of the same or one from each ovary, by
two sperms during single ovarian cycle.
• •There are two placentae either completely separated or more
commonly fused at the margin

• Each fetus is surrounded by a separate amnion and chorion.

• Sex of the fetus may differ. Genetic features(blood group, finger

prints)also differs.
 GENESIS OF MONOZYGOTIC

• The twinning may occur at different periods after fertilization.

• If the division takes place within 72 hours after fertilization (prior to
morula stage) resulting embryos will have two separate placenta,
chorion, amnions (diamniotic- dichorionic)
• • If the division takes place between 4th and 8th day after the
formation of inner cell mass when chorion has arleady developed -
diamniotic monochorionic twins develop.
• If division occurs takes place after 8th day of fertilization when
amniotic cavity has arleady formed (monoamniotic monochorionic
twins)
• Division after two weeks of davit of embryonic disc resulting in the
formation of conjoined twin.
 METHOD OF DELIVERY

VERTEX – VERTEX [50%] VERTEX – BREECH [20%]

• Vaginal delivery – interval between • Vaginal delivery by senior
twins not to exceed 20 minutes obstetrician
 METHOD OF DELIVERY

BREECH – VERTEX [20%] BREECH – BREECH [10%]

• Safer to deliver by CS to avoid rare • Usually by CS
interlocking twins (1:1000 twins)
 VAGINAL DELIVERY

• When the first twin is cephalic, delivery can usually be accomplished

spontaneously or with forceps.
• As in singletons, when the first fetus presents as a breech, major problems are
most likely to develop if:
- fetus is unusually large and the aftercoming head is larger than the capacity of
the birth canal.
- Fetus is sufficiently small so that the extremities and trunk are delivered through
a cervix inadequately effaced and dilated to allow the head to escape easily.
- umbilical cord prolapses.
 VAGINAL DELIVERY OF THE SECOND TWIN

• •As soon as the presenting twin has been delivered, the presenting part
of the second twin, its size, and its relationship to the birth canal
should be quickly and carefully ascertained by combined abdominal,
vaginal, and at times intrauterine examination
 VAGINAL DELIVERY OF THE SECOND TWIN

If the fetal head or the breech is fixed in the birth:

• moderate fundal pressure is applied and membranes are ruptured.
• digital examination of the cervix is repeated to exclude prolapse of the cord.

• Labor is allowed to resume, and the fetal heart rate is monitored.

• With reestablishment of labor there is no need to hasten delivery unless a non-
reassuring fetal heart rate or bleeding develops.
• If contractions do not resume within approximately 10 minutes, dilute oxytocin may
be used to stimulate contractions.
 VAGINAL DELIVERY OF THE SECOND TWIN

• • If the occiput or the breech presents immediately over the pelvic inlet but is not
fixed in the birth canal
• Presenting part can often be guided into the pelvis by one hand in the vagina while a
second hand on the uterine fundus exerts moderate pressure caudally.• Alternatively,
an assistant can maneuver the presenting part into the pelvis using ultrasonography
for guidance and to monitor heart rate.
• It is essential to have an obstetrician skilled in intrauterine fetal manipulation and an
anesthesiologist skilled in providing anesthesia to effectively relax the uterus for
vaginal delivery of a noncephalic second twin to obtain a favorable outcome.
 INTERVAL BETWEEN FIRST AND SECOND
TWINS

• •The American College of Obstetricians and Gynecologists (1998) has

determined that the interval between delivery of twins is not critical in
determining the outcome of the twin delivered second.
 CESAREAN DELIVERY

• The American College of Obstetricians and Gynecologists (1998) has concluded that, in
general, cesarean delivery is the method of choice when the first twin is noncephalic.
• It is important to place patients in a left lateral tilt so as to deflect the uterine weight off
the aorta to avoid hypotension.
• The uterine incision should be large enough to allow atraumatic delivery of both fetuses.
• It is important that the uterus remain well contracted during completion of the cesarean
delivery and thereafter.
• Remarkable blood loss may be concealed within the uterus and vagina and beneath the
drapes during the time taken to close the incisions.
 DELIVERY OF THE FIRST BABY

• Babies are small-pose less difficulties

• Forceps delivery-if necessary should be under pudendal block anaethesia, avoid
general Anaesthesia as the 2nd baby may be subjected effect of prolong
Anaesthesia.

DON'T GIVE ERGOMETRINE

• Leave 8-10cm of the cord for admn of any drugs or transfusion
 DELIVERY OF THE SECOND BABY

• •After delivery of the first baby,the lie, presentation and size of the
second baby is ascertained through abdominal examination
• Perform vaginal exam to exclude cord prolapse and ascertain
membrane status
• Delivery the second baby as required
 SPECIAL CASE
• Twins with previous scar
• Trial of scar if twins has a first vertex should not be an
absolute contraindication
• Judicious external or internal manipulations are not
contraindicated
• Prefer caesarean if tranverse / breech
• Success rate 30-75%
• Risk of uterine rupture is the same as in a singleton
pregnancy