Multiple Gestation

:Definition •
It is the presence of more than one fetus in •
.the uterus
:Incidence •
Twins-15:1000- •
triplets-1:5000- •
Quadruplets-1:360 000- •
Higher multiples than this are extremely rare,- •
.but do occur
-:Types •
:Dizygotic twins)1 •
result from two separate ova being fertilized- •
.by different sperm
.Diamniotic dichorioic- •
.Twins may be of different sexes- •
accounts for two thirds of multiple- •
.pregnancies
affected by predisposing factors ,such as age- •
.&ethnicity
-:Monozygotic twins)2 •
Due to fertilization of one ovum by one sperm- •
: then zygote divides
A)<3 days(inner cell mass is formed but before •
outer cell mass becomes the chorion)
.DCDA30%
B)4-8days(after differentiation of the chorion •
. but before amnion) MCDA70%
C)9-13 days(after differentiation the amnion) •
.MCMA <1%
D)>13 days(after formation of embryonic •
.disc)conjoined twins ,very rare
This type is random (not genetically- •
.determined ,with little racial variation)
.Babies are identical &same sex- •
% Has fixed incidence=1:250. 30- •

: Risk factors* •
Related mainly to dizygotic twins •
.previous multiple pregnancy- •
family history- •
Increasing parity- •
 Advanced maternal age- •
yr. 6:1000 20< •
35yrs 22:1000> •
45yrs 57:1000> •
Assisted reproduction- •
CC 10%* •
IUI 10-20%* •
% IVF with two embryo transfer 20-30* •
Race /geographic area :less in Asian , Higher- •
.in Africans
. Maternal weight &height :obese and tall-
.folic acid supplementation-
Diagnosis* •
Hyperemesis gravidarum- •
Uterus is larger than expected for date- •
.Three or more fetal pole may be palpable at >24wks- •
Two fetal hearts may be heard on auscultation- •
The vast majority are diagnosed on U/S- •
-: Chorionicity*
is best done by U/S in the 1st trimester or early In 2nd
trimester
DC -widely separated sacs or placenta
Membrane insertion showing the lambda ʎ-
Sign DC
Absence of lambda signs <14wks diagnostic of MC- •
Fetus of different sex DC- •
-:Complication*
:During pregnancy
A)Maternal complication
Maternal medical illness (anemia, preeclampsia –)1
.eclampsia, GDM ,Hyperemesis gravidarum,VTE)
Pressure symptoms(difficult)2
.breathing,UTI,,increase varicosity&lower limb edema
APH)3
Amniotic fluid disorders)4
-:B)Fetal complications •
Abortions: due to increase chromosomal)1 •
anomalies &uterine over distension
congenital malformation :in monozygotic)2 •
PPROM)3 •
Low birth weight)4 •
IUFD)5 •
Twin to twin transfusion syndrome)6 •
During labor •
Preterm labor 50%)1 •
Prolonged or obstracted labor due to abnormal)2 •
.uterine action, malpresentation &locked twins
Intrapartum hemorrhage(placental)3 •
separation)
PPH)4 •
Intrapartum fetal death (cord presentation,)5 •
prolapse, premature separation of placenta,
operative manipulation, Hypoxia)
Fetal birth trauma&cerebal palsy : from)6 •
.operative manipulation
:Puerperal complication &later sequlae •
Puerperal sepsis (ROM, internal manipulation- •
.Social and psychological problems- •
 Increase perinatal mortality- •
possible delayed subsequent- •
.development :may be due to preterm delivery

-:Management*
:Antenatal management
All multiple pregnancies are by definition high-
.risk &care should be consultant led
An early U/S should be considered to establish-
.chorionicity
Routine use of iron and folate supplements- •
A detailed anomaly scan should be undertaken- •
Advise aspirin 75 microgram if additional risk- •
factor for preeclampsia
Serial growth scan at 28,32 and 36 wks. for DC - •
More frequent AN checks because of increase - •
.risk of preeclampsia
establish presentation of leading twin by- •
.34wks
.Discuss mode , timing ,and place of delivery- •
Delivery •
Timing* •
a) Gestational age •
Dichorionic twins at 38-39wks- •
Monochorionic at 34-38wks- •
Monoamniotic twins :earlier delivery may be - •
indicated as complication as cord entanglement are
.common at 32 wks
b)Maternal condition :development of any •
complication indicating delivery as PE
C) Fetal condition: non-reassuring FHR, BPP,IUFD,or •
.malformation incompatible with life
D)The pt. is in labor •
-:Mode of termination* •
A)Cesarean delivery •
Non vertex presentation of the 1st twin- •
Retained living 2nd twin (failed ECF or IPV)- •
Triplet or more fetus (relative indication)- •
Monoamniotic twins (relative indication)- •
Conjoined twins- •

B)Vaginal delivery •
If the first is in a vertex presentation &in the •
absence of other obstetric factors
 Intra natal assessment* •
manage in well –equipped hospital- •
early admission once in labor or RM- •
Maternal &fetal monitoring ,using two CTG-
Assess progress of labor by partogram-
.Delivery of the first twin : vaginal delivery*
Delivery of the second twin*
.If vertex : rupture of membrane and delivery-
if breech: assisted breech delivery or breech-
.extraction
If transverse : internal podalic version with breech-
.extraction or external cephalic version and ROM
Placental delivery and examination of* •
-:zygosity

. If retained manual removal- •

.Examine placenta for zygosity- •
Exploration of genital tract for retained- •
.products and laceration
.Guard against PPH (massage and ecbolic)- •
: Monochorionic ,diamniotic twins •
The shared circulation of MC twins can lead to •
: several problems

Twin to twin transfusion syndrome (TTTS) )1 •

This is due to unbalanced vascular anastomoses- •
within a Monochorionic placenta
This affects about 5-25% of MC twin &left - •
.untreated has an 80% mortality rate
It occurs if there are artery to vein anastomoses.- •
The artery of one fetus feeds the vein of the
: other. Leading to
:Donor twin* •
Anemic and SGA- •
Oligohydramnios- •
Dehydrated and oliguria manifested by lack of - •
bladder filling
Dies from anemic heart failure- •
Recipient twin* •
Plethoric and LGA- •
Polyhydramnios- •
Odematous with hypertension ,ascites, enlarged - •
liver
Dies from congestive heart failure- •
MC twins require intensive- •
monitoring ,usually in the form of serial USS
every 2wk from 16-24wks and every 3 wks.
.until delivery
: The treatment options available include- •
.Laser ablation of the placental anastomoses*
Leads to survival of at least one in 80% and both
.in 50%
Selective feticide by cord occlusion is * •
.reserved for refractory disease
Single Fetal demise)2 •
Death of the one fetus during pregnancy- •
:A)In the 1st trimester •
There is minimal risk to the mother •
Pregnancy allowed to continue while the 2nd fetus •
is closely monitored
May cause vanishing twin syndrome •
: B) In the 2nd or 3rd trimester •
The dead fetus is compressed and displaced to •
one side by growing sac and fetus
Pregnancy continues but the risk of •
.hypofibrinogenaemia and DIC is higher
close monitoring of maternal bleeding- •
.&coagulation profiles
Follow up of the living fetus by close ANC- •
&repeated US
Delivery of the living twin should be attempted- •
once it can survive conditions outside the uterus
.or if maternal hazards as DIC are anticipated

-:The vanishing twin syndrome*)3 •

Early in the 1st trimester ,one embryo dies then •
disappear and while the 2nd continues to grow in
.a normal pattern
-:The discordant twins)4 •
One fetus shows abnormally increased- •
growth ,while the second shows SGA with a
differences in fetal weight >25%. The
: condition may be due to
.unequal placental masses- •
genetic syndromes- •
twin-to –twin transfusion syndrome- •