Multiple pregnancy

Complications
Roll no:122
Complication
Maternal
-pregnancy
-labor
-puerperium
Fetal
 Maternal – During pregnancy
●Hyperemesis
due to higher level of pregnancy hormones
● Anemia
Due to increased iron and folate requirement
result in both iron deficiency anemia and megaloblastic
anemia
●mechanical distress
palpitation, dyspnea, varicosities, hemorrhoids may be
increased compared to singleton pregnancy
●Pre eclampsia
Due to superabundance of chorionic villi
●Gestation diabetes mellitus
Due to increased hormones secreted by placental mass
● malpresentation

Malpresentation
is thus more common in the second baby.
●Polyhydramios
Mc in monochorionic twins involving second sac
Due to increased renal perfusion with consequent
renal output
● Antepartum hemorrhage
large placental mass can predispose to placenta previa
and increased incidence of pre eclampsia contributes to
abruptio placenta
●Preterm labor
due to overdistension of uterus, polyhydramnios,
preterm rupture of membranes
During labor
●Early rupture of the membrane and cord prolapse
Due to increased prevalence of malpresentation
●Prolonged labor
●Increased operative interference
Caesarean delivery
Forceps
●Bleeding – following birth of first baby may be alarming and is
due to separation of placenta following reduction of placental site
Postpartum hemorrhage is the real
danger in twins. It is due to:
(i) Atony of the uterine muscle due to
overdistension of the uterus
(ii) A longer time taken by the big
placenta to separate
(iii) Bigger surface area of the placenta
exposing more uterine sinuses
(iv) Implantation of a part of the placenta in
the lower segment which is less retractile
During puerperium
1. Subinvolution – because of bigger size of uterus
2. Infection – increased operative interference,
preexisting anemia and blood loss during
pregnancy
3. Lactation failure
Fetal complications
• Miscarriage is increased especially in monozygotic twins
• Premature rate(80%)
• Vanishing twin
loss of one fetus of multiple pregnancy have been observed
after confirmation of diagnosis in 1st trimester
• Appearing twin
where diagnosis missed on initial UsG but diagnosed as twin
in later scan
Discordant twin growth
Some degree of discordant growth is
normal in dizygotic twins. Cases of
true pathological discordance involve
estimated weight difference of 25%
or more. This may be due to twin–
twin transfusion syndrome, placental
insufficiency, IUGR or from structural
anomalies occurring in one fetus
• Intrauterine death of one fetus
loss in 1st trimester- vanishes by resorption
If 2nd trimester- fetus papyraceous or compresses
• Fetal anomalies more in monozygotic twins
Anencephaly, holoprosencephaly, neural tube defects, cardiac
anomalies, down syndrome
• Asphyxia and stillbirth
• Fetal growth restriction
result in low birth weight
Complications of monochorionic twins
• Twin to twin transfusion syndrome
Exclusively met with MCDA twins
Arteriovenous communication in placenta
Blood from one twin goes to another
donor- smaller with oligohydramnios,
Hypovolemic, anemic
Recepient- larger with polyhydramnios,
Hypervolemic,polycythemic
• Twin anemia polycythemia sequence Caused by Slow
transfusion of RBC Through very small av anastomosis
Donor -<11g/dl , MCA PSV >1.5MOM anemic
Recepient->20g/dl, MCA PSV<0.8MOM polycythemic
Twin reversed arterial perfusion
• Acardiac twin( manifest as amorphous
masses with poorly developed head
and thorax with well formed limbs
• Acardiac twin receives its blood supply
via large arterioarterial anostomosis
• Poorly deoxygenated blood from
normal twin passes through the
umbilical artery to the acardiac twin
this is called reversed perfusion
Single fetal demise
• Dead fetal syndrome
• Dead of one twin associated with poor outcome of cotwin
• Due to acute hypotension and thromboplastin from dead twin
• The surviving twin run the risk of
1. Cerebral palsy
2. Microcephaly
3. Renal cortical necrosis
4. DIC
 Conjoint twin
• Seen in 1 in 50000 to 1in 100000
• Perinatal survival depends on fusion
• Major cardiovascular anastomosis lead to mortality
•Thank you