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TABLE OF CONTENT

FORM OF AUTHORIZATION 2

PREFACE 3

TABLE OF CONTENT 4

CHAPTER I : INTRODUCTION 5

CHAPTER II : LITERATURE REVIEW

Definition 7

Epidemiology 8

Physiology 9

Etiology 11

Classification 12

Diagnosis 14

Clinical Manifestation 18

Labor Management 19

Complication 23

Prognosis 25

CHAPTER III : Conclusion 26

CHAPTER IV : Bibliography 27

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CHAPTER I

INTRODUCTION

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. The rate of twinning in different populations is determined by

racial predisposition to double ovulation and hence nonidentical twinning.

Multifetal pregnancies may result from two or more fertilization events, from a single

fertilization followed by an erroneous splitting of the zygote, or from a combination

of both. Such pregnancies are associated with increased risk for both mother and child,

and this risk increases with the number of offspring. For example, 60 percent of twins,

90 percent of triplets, and virtually all of quadruplets are born preterm.1(martin)

Fueled largely by infertility therapy, both the rate and the number of twin and

higher-order multifetal births have increased dramatically since 1980. The overall

increase in prevalence of multifetal births is of concern because the corresponding

increase in the rate of preterm birth compromises neonatal survival and increases the

risk of lifelong disability. In 2009, the infant mortality rate for multiple births was five

times the rate for singletons.2 martin These risks are magnified further with triplets or

quadruplets. In addition to these adverse outcomes, the risks for congenital

malformations are increased with multifetal gestation. For those reasons, multiple

pregnancy are considered as a high risk pregnancy.

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CHAPTER II

LITERATURE REVIEW

I. MULTIPLE PREGNANCY

1.1.1. 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.1

Twins can be classified as monozygotic, originating from the fertilization

and subsequent division of one egg, or dizygotic, originating from the fertilization

and development of two eggs. Approximately one third of twins are thought to be

monozygotic in the United States.3 malone Medscape no 1

Superfetation is the formation of a fetus while another fetus is already

present in the uterus. Essentially, it describes a situation where a woman becomes

pregnant when she is already pregnant. Superfetation occurs when ovum from two

separate menstrual cycles are released, fertilized, and implant in the uterus. It is

believed that this is a very rare event and only few cases have been reported and

verified.4

Superfecundation in the other hands is the fertilization of two or more ovum

from the same cycle by sperm from separate acts of sexual intercourse, which lead

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to twin babies from two separate biological father. Therefore this phenomenon

happens to be very rare.4

Figure 1. Twin pregnancy (Gemelli)

1.1.2. Epidemology

Thus, among the Caucasian population, twins are found in 1 in 80

pregnancies. The ratio of binovular (dizygotic) twins, to monovular (monozygotic)

twins, is around 3 to 1. In contrast, in West Africans, who have the highest rates

in the world (1 in 44 pregnancies is a case of twins) the ratio of dizygotic to

monozygotic twinning may be between 4-6 to 1. The lowest rates of twinning are

seen in Asia. The incidence of twin pregnancy has risen slightly over the last 10

years. In contrast, the rate of triplets and higher order multiple pregnancy

(quadruplets, sextuplets etc.) has increased dramatically. Theoretically by 'Heilin's

rule' the incidence of triplets should be 1 in 802 (6400) and that of quadruplets 1

in 803 (512000). In Indonesia itself, there is probability of one conjoined twins for

every 200.000 birth.

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From 1982 to 1993 the incidence of multiple pregnancies rose dramatically

due to the widespread introduction of assisted onception programmes

encompassing ovulation induction and in vitro fertilisation. Other factors that

might influencing the odds to have multifetal pregnancy are:

a. Race

In the United States, the twin birth rate was 33.3 per 1,000 births in 2009, while

in Nigeria, the rate of twinning has been reported as high as 49 per 1000 births.

In contrast, the rate of twinnin in Asia is relatively low compares to the other

country which only 1.3 per 1000 births.

b. Heredity

Non-identical twin women has the probability of given twin baby 1 out of 60

births. While a non-identical father has only 1 out of 125 births chances to have

a twin.

c. Advancing age of the mother and pariety

35-40 years old women with 4 child or more, has a bigger chance to have a twin

up to three times compared to the women around 20 years old.

d. Mothers height and weight

Non-identical twin more likely to happen in a women with big posture

compared to the women with small body. This might be more related to

differences in nutrition status among them.

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e. Fertilizing drugs and technological advances

Multiple pregnancy are more likely to occur in women who are consuming

fertility drugs during the process of ovulation induction. Clomiphene citrate

consumption has a probability of having twins up to 5-12% and 1% of triplets

or more. Almost 20% of pregnancy which occur in help of gonadotropin, are

twins. In which 5% are triplets.

1.1.3. Physiology

Multiple pregnancy has a several physiological changes such as:

a. Each of fetal weight on multiple pregnancy usualy 1000 grams lighter than a

normal single fetus.

b. Weight of newborn baby are below 2500 grams for twins (gemelli), 2000 grams

for triplets, under 1500 grams for quadruplets, and under 1000 grams for

quintuplet.

c. Weight of each fetuses usualy is not the same. Usualy they are in difference of

50-1000 grams, and because of the dividing blood circulaton, one of the fetus

might have a slight delayed of growth compared to the other one.

d. In monozygotic twin

Blood vessels of one fetuses anastomose with the other fetuses, therefore

after one of the baby has delivered, the umbilical cord has to be tied to avoid

bleeding.

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If the vascularization, growth and development of one fetuses are

compromising, the growth might be delayed and shown various anomalies

such as acardiac monstrous.

Fetal transfusion syndrome or twin-to-twin transfusion syndrome could

occur withing fetuses that receive excess blood which resulted in

hidramnion, polisitemia, and lung oedema. While the other fetuses has a

significant lower weight, anemic, dehydrated, oligohidramnion, and could

present with microcardia.

e. In dizygotic twin

One of the fetuses could be dead and one of the other keep growing until

labor.

Dead fetuses could be reabsorbed (during early pregnancy). On the late

month of pregnancy, dead fetuses becoming flat and called as fetus

papyraseus or fetus compresus.

1.1.4. Etiology

Twin fetuses commonly result from fertilization of two separate ovum and

are termed double-ovum, dizygotic, or fraternal twins. About a third as often,

twins arise from a single fertilized ovum that subsequently divides into two

similar structures, each with the potential for developing into a separate

individual. These twins are termed single-ovum, monozygotic, or identical

twins. Either or both processes may be involved in the formation of higher

numbers of fetuses. Quadruplets, for example, may arise from as few as one to

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as many as four ovum.

In order for these things to happen there are many factors influencing such

as race, heredity, age of the mother, and pariety, especially twins from 2

different ovum. Fertility drugs and hormones such as gonadotropin also play

a role in multiple pregnancy.

1.1.5. Classification of Twin Pregnancy

a. Monozygotic

Monizygotic twin is a multiple pregnancy which result from one single ovum.

Monozygotic twin also termed as identical twin, homolog, or uniovuler. 1/3

monozygotic twins has 2 amnions, 2 chorions, and 2 placenta. But sometimes

the placenta joined into one.

The outcome of the twinning process depends on when the division occurs:

If division occurs within the first 72 hours after fertilization, the inner cell mass

(morula) has yet to form and the outer layer of blastocyst has not yet committed

to become chorion. Two embryos, two amnions, and two chorions develop, and

a monozygotic, diamnionic, dichorionic twin pregnancy evolves. Two distinct

placentas or a single fused placenta may develop. If division occurs between the

fourth and eighth day, the inner cell mass has formed and cells destined to

become chorion have already differentiated, but those of the amnion have not.

From this division, two embryos develop, each in a separate amnionic sac

covered by a common chorion. This division gives rise to a monozygotic,

diamnionic, monochorionic twin pregnancy. If, however, the chorion and the

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amnion have already differentiated, by about 8 days after fertilization, division

results in two embryos within a common amnionic sac, a monozygotic,

monoamnionic, monochorionic twin pregnancy. If division is initiated even

later, that is, after the embryonic disk has formed, cleavage is incomplete and

conjoined twins result.

Figure 2. Monozygotic and dizygotic fertilization

b. Dizygotic

2/3 twin pregnancy are dizygotic or originated from 2 ovum.

Dizygotic twins are not in a strict sense true twins because they

result from the maturation and fertilization of two ovum during a

single ovulatory cycle. Dizygotic twins also called as heterolog,

binovuler, or fraternal. Sex, could be the same or different.

Dizygotic twin has 2 placenta, 2 chorion, and 2 amnion. Sometimes

those 2 placenta joined into one.

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Figure 3. Chorion and amnion on twins

c. Conjoined twin, Superfecundation dan Superfetation

Conjoined twin is a phenomenon where some body parts of the fetuses attach

to the other fetuses. Such as thoracopagus ( chest to chest), abdomenopagus

(abdomen-abdomen), craniopagus (head-head). In superfetation, an interval

as long as or longer than a menstrual cycle intervenes between fertilizations.

Superfetation requires ovulation and fertilization during the course of an

established pregnancy, which would theoretically be possible until the uterine

cavity is obliterated by the fusion of the decidua capsularis to the decidua

vera. Although known to occur in mares, superfetation is as yet unproven to

occur in humans. Most authorities believe that the alleged cases of human

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superfetation result from marked inequality in growth and development of

twin fetuses of the same gestational age. Superfecundation refers to the

fertilization of two ova within the same menstrual cycle but not at the same

coitus, nor necessarily by sperm from the same male. An instance of

superfecundation, documented by Harris (1982)

1.1.6. Diagnosis

1.1.6.1. Signs and symptoms

The diagnosis of multiple pregnancy may be suspected on history and

clinical examination: a history of infertility treatment or severe

hyperemesis in early pregnancy are suggestive.

Suspicion may be further raised if the uterus if found to be large for

dates. Clinical examination with accurate measurement of fundal height

is essential. During the second trimester, the uterine size is typically

larger than expected for the gestational age determined from menstrual

data. In women with a uterus that appears large for gestational age, the

following possibilities are considered: 1. Multiple fetuses 2. Elevation

of the uterus by a distended bladder 3. Inaccurate menstrual history

4. Hydramnios 5. Hydatidiform mole 6. Uterine myomas 7. A

closely attached adnexal mass 8. Fetal macrosomia (late in pregnancy)

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When uterine palpation leads to the diagnosis of twins, it is most often

because two fetal heads have been detected, often in different uterine

quadrants. In general, however, before the third trimester it is difficult

to diagnose twins by palpation of fetal heads, especially if hidramnions

is present.

Figure 4. Other causes of apparent abnormal uterine enlargement during early

pregnancy

During late pregnancy, the uterus is more globular and larger than

normal for the dates. Polyhydramnios may be present. It is commoner

in monozygotic than in dizygotic twins. If there is no evidence of

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polyhydramnios, an apparent'excess' of fetal parts may be noted. It may

be difficult to define the lie of the fetuses but three fetal poles (head or

breech) must be identified to be sure of the diagnosis.Clinical suspicion

of twin pregnancy must always be confirmed by ultrasound, if this has

not already been performed.

Figure 5. Excess fetal parts

1.1.6.2. Laboratory

Numbers of haemoglobin, hematocrite, and red blood cell decreasing,

which related to increasing of blood volume. Microcytic hypochromic anemia

could happen. In the second trimester, needs of iron is increasing significantly.

In multiple pregnancy, urine chorionic gonadotropin, estriole and

pregnanendiol also increasing.

1.1.6.3. Ultrasonography

Possability of twin pregnancy could be considered during 5 weeks of

gestation, by observing the numbers of gestational sac inside of uterine

cavity. Definitive fiagnosis of twin pregnancy if seen more than one

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fetus with presence of fetal heart beat. Types of chorionicity and

amnionicity could be observed during the first trimester. Until the 10th

week of pregnancy, if seen 2 gestational sac which each of them contain

living fetus, the pregnancy classified as dichorionic-diamniotic (DC-

DA). If seen only 1 gestational sac containing 2 living fetus, the

pregnancy considered as monochorionic (MC). If in monochorionic

twins, seen with 2 amniotic sac, which each of them containing living

fetuses, the pregnancy called as Monochorionic-diamniotic (MC-DA);

and if only seen 1 amniotic sac containing 2 living fetus, the pregnancy

categorized as monochorionic-monoamniotic (MC-MA).

During the second trimester, pregnancy chorionicity could be observed

by examining fetuses sex, numbers of placenta, and position of the fetus.

If the fetus has different sex, or two separated placenta, it defines DC-

DA pregnancy. While if the findings are vice fersa it is not always a

monochorionic pregnancy.

Dichorionic pregnancy, the separating barrier is thicker ( consist of 2

layers of amnion and 2 layers of chorion); while in MC-DA pregnancy,

the barrier is really thin, thus hard to identified.

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Figure 6. Ultrasonography of dizygotic pregnancy during 6 week gestation

1.1.6.4. Confirmed Diagnosis

Diagnosis of twins can be confirmed when these features are presnt:

Palpable multiple body parts; 2 heads, 2 gluteal, 1 back.

Two fetal heart beat with significant position distance with differences

10 beats per minute minimum.

Ultrasonography during the first trimester

Abdominal x-ray; but is rarely conducted.

1.1.7. Clinical Manifestation

During twin pregnancy the uterine distended moreover above the normal

uterus, and the insidence of having early labor (partus prematurus) is increasing.

The more the number of fetus the shorter the gestation period. The average weeks

of gestation of twins are 260 days, while triplets are 246 and 235 days for

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quadriplets.

Mother needs of nutrients are increasing, therefore risk of anemia, and

other nutrients deficiency are also increasing. Risk of hidramnion are 10 times

more likely than singleton pregnancy. Hidramnion makes the uterus distendes thus

could lead to early labor, inersia utri, and postpartum haemorrage.

Frequency of pre-eclampsia and eclampsia are also greater on multiple

pregnancy. This happened because distended uterus leads to ischemic condition.

The giantic size of uterus leads to shortness of breath, frequent urination, oedema,

and extremity, and vulva varices.

Figure 7. Clinical manifestation and complication of multiple pregnancy

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1.1.8. Management of multiple pregnancy

1.1.8.1.Before 20 weeks

Antenatal care is conducted in the usual fashion with particular attention to

identifying the complications mentioned above. A good diet is advised and

iron and folic acid supplementation should be prescribed. Ultrasound

enables an early diagnosis to be made but should not be shared too early with

thepatient as a significant number of apparently multiple pregnancies when

scanned at 8 weeks are singleton pregnancies at 12 weeks as a result of fetal

death. Fetal abnormality is commoner in multiple pregnancies; AFP

screening is of use in some respects since the normal range is twice that of a

singleton pregnancy and elevated values are associated with the same

abnormalities. Identification of abnormality in one of a set of twins presents

a number of difficulties. The parents are presented with one of three choices:

the first, is to await events. The second is to opt for termination of the

pregnancy and sacrifice of the healthy fetus. The third option is selective

feticide in which the heart of the abnormal fetus is injected with potassium

chloride to cause asytole. Clearly the management of such problems is very

difficult and require considerable expertise.

1.1.8.2. After 20 Weeks

Complications, such as preterm labour and pre-eclampsia, should be

managed as for singleton pregnancies but consideration given to the

problems associated with multiple pregnancy. Placentography should be

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performed to exclude placenta praevia. When fetal compromise is suspected

fetal monitoring may be more technically demanding

but current cardiotocography equipment allows tracing of both babies

simultaneously

Figure 8. cardiotocography equipment allows tracing of both babies

simultaneously

1.1.8.3. Labour and Delivery

Malpresentations are common in twin pregnancy but in 75% of cases twin

presents by the vertex. The lie of the second baby is unimportant until the

first is born. Labour is usually straight forward though the higher incidence

of malpresentation increases the risk of cord prolapse. Vaginal examination

should be carried out when the membranes rupture. Both fetal hearts should

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be monitored, the first by a scalp electrode and the second externally, ideally

using ultrasound cardiotocography. Epidural analgesia is ideal, if available,

as it permitsany necessary intervention, especially with the second twin,

during delivery. This should take place in an operating theatre with

appropriate facilities and staff available. In addition to the obstetrician and

midwives, an anaesthetist and paediatrician should be present. After the

delivery of the first baby the cord is double clamped incase there are

monozygotic twins and a risk of the second baby bleeding from the cord of

the first due to placental vascular anastomoses.

Figure 9. Malpresentation in twin pregnancy

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When the first baby is delivered, the lie of the second is checked and if

necessary corrected by external version to a vertex or a breech; if that is not

possible then internal podalic version and breech extraction is performed. If

the second baby has a satisfactory presentation and there is no evidence of

fetal distress then, although the interval between delivery of first and second

babies should not be prolonged, descent of the presenting part may be

awaited. An oxytocin infusion may be commenced as uterine activity may

reduce after delivery of twin 1. When the head or breech has descended into

the pelvis the membranes may be ruptured and delivery proceeds. If there is

evidence of fetal distress then the second baby may be delivered more

promptly by rupturing the second set of membranes and applying forceps or

the ventouse, or, if required, internal podalic version and breech extraction

may be performed. Active management of the third stage only begins at

delivery of the anterior shoulder of the second baby. Rarely the first placenta

is born before the second baby. Bleeding is not usually severe.The uterus is

actively contracting and the reduction in size of the placental site and the

pressure of the fetus on it helps to control the blood loss. Vigilance is

required during the third stage to prevent atonic post-partum haemorrhage.

If the presentation of the first baby is not vertex, the delivery process should

be done operatively per abdominal.

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Figure 10. Presentation of the first and second baby

1.1.8.2 Locked Twins

Locked twins is a very rare condition in which parts of one interlock

with the other causing an impasse. It most commonly occurs with the first

as breech and the second as a vertex. The head of the second slips down

with the shoulders of the first and prevents the engagement of the head of

the first in the pelvis. Early recognition is essential as the condition has a

high fetal mortality. The treatment is to push the lower head out of the pelvis

to free the head of the first fetus and allow delivery. If displacement is not

possible the first baby will die.

Consequently, upon diagnosis caesarean section may be undertaken. If

performed promptly this may also salvage twin 1.

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1.1.8.4. Triplets and quadriplets

Triplets and quadriplets have similar problems and difficulties.

Premature labour is much commoner. The perinatal mortality rate is higher.

Vaginal delivery is possible in triplet pregnancy although caesarean section

remains the method of choice. Delivery by caesarean section is invariably the

method of choice in quadruplet pregnancy.

1.1.9. Complications

Twin-to-twin transfusion syndrome (TTTS) is the result of an intrauterine

blood transfusion from one twin (donor) to another twin (recipient). TTTS only

occurs in monozygotic (identical) twins with a monochorionic placenta. The donor

twin is often smaller with a birth weight 20% less than the recipient's birth weight.

The donor twin is often anemic and the recipient twin is often plethoric with

hemoglobin differences greater than 5 g/dL.

The clinical features of TTTS are the result of hypoperfusion of the donor

twin and hyperperfusion of the recipient twin. The donor twin becomes

hypovolemic and oliguric or anuric. Oligohydramnios develops in the amniotic sac

of the donor twin. Profound oligohydramnios can result in the stuck twin

phenomenon in which the twin appears in a fixed position against the uterine wall.

Ultrasonography typically fails to visualize the fetal bladder because of absent

urine.

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The recipient twin becomes hypervolemic and polyuric. Polyhydramnios develops

in the amniotic sac of the recipient twin.

Either twin can develop hydrops fetalis. 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.

Figure 11. Twin-to-twin transfusion syndrome

1.1.10. Prognosis

Risk of the mother with multiple fetal pregnancy are higher than the

singleton pregnancy. This happened because during multiple pregnancy, mother

has a high risk of having anemia, pre-eclampsia, and post-partum haemorage, thus

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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.

The rate of death of the second baby are higher than the first baby because

there are a high chance of placenta circulation abnormality after the first baby born.

Moreover, the incidence of having funiculi prolapse, solusio placenta and

malformation on the second baby.

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CHAPTER III

CONCLUSION

Multiple fetal pregnancy is a pregnancy which consist of two or more embryos

or fetus. In the other classification, there are two types of twins, monozygotic and

dizygotic. Factors that influenced this phenomenon such as; race, heredity, mother age

and pariety, nutrition, and infertility. Symptoms that usualy occurs including shortness

of breath, frequent urination, edema, and varices, hyperemesis, pre-eclampsi and

eclampsia, and hidramnion. 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.

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BAB IV

DAFTAR PUSTAKA

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Obstetri Williams.Volume 1 edisi 21. Jakarta: Penerbit buku kedokteran

EGC, 2006.

3. Prof. Dr. Djamhoer M, Prof. Dr. Firman FW, Prof. Dr. Jusuf SE.

Kehamilan kembar. Dalam: Obstetri Patologi Ilmu Kesehatan Reproduksi.

Jakarta. Penerbit Buku Kedokteran ECG.Edisi 3, 2013.

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