Multiple Pregnancy1

Multiple Pregnancy
Presentation by
Prativa Dhakal
M.Sc. Nursing
Maternal Health
Nursing
Batch 2011
Powerpoint Templates
Page 1
Contents
Definition
Varieties of twin pregnancy
Incidence
Factors influencing twinning
Maternal physiological changes
Diagnosis
History and clinical examination

Symptoms
General examination
Abdominal examination
Investigations
Complications
Prognosis
Management
Nursing interventions
References
Page 2
Multiple pregnancy
When more than one fetus simultaneously develops in
the uterus then it is called multiple pregnancy.
Simultaneous development of two fetuses (twins) is the
commonest; although rare, development of three fetuses
(triplets), four fetuses (quadruplets), five fetuses
(quintuplets or six fetuses (sextuplets) may also occur.
Page 3
Twins pregnancy
Varieties:
Dizygotic twins: is the commonest (two-third) and
results from the fertilization of two ova.
Monozygotic twins (one-third)
fertilization of single ovum.
results
from
the
Page 4
Genesis of twins
Imonozygotic twins (syn. identical, uniovulvar)
Dizygotic twins (syn: fraternal, binovular
Page 5
On rare occasion, the following

possibilities may occur
If the division takes place within 72 hours after
fertilization the resulting embryos will have two separate
placenta, chorions and amnions (D/D)
If the division takes place between the 4th and 8th day
after the formation of inner cell mass when chorion has
already developed diamniotic monochorionic twins
develop (D/M)
If the division after 8th day of fertilization, when the
amniotic cavity has already formed, a monoamniotic
monochorionic twins develop (M/M)
Page 6
Page 7
Page 8
Diamniotic
Dichorionic
Separate placenta
Frequency: 35%
Mortality: 13%
Diamniotic
DiChorionic
fused placenta
Frequency 27%
Mortality 11%
Diamniotic
Monochorionic single
placenta
Frequency 36%
Mortality 32%
Monoamniotic
Monochorionic
single placenta
Frequency 2%
Mortality 44%
Page 9
Multiple pregnancy contd

On extreme rare occasions, division occurs after 2 weeks
of the development of embryonic disc resulting in the
formation of conjoined twins called-Siamese twins.
Four types of fusion may occur
Thoracopagus (commonest)
Pyopagus (Posterior fusion)
Craniopagus (cephalic)
Ischiopagus (caudal)
Page 10
Examination of placenta and

membranes
Dizygotic Twin
Monozygotic twin
Two placenta, either completely Placenta is single.

separated or more commonly fused at
the margin appearing to be one.
No anastomosis between the two fetal Varying degrees of anastomosis
vessels.
between the two fetal vessels.
Each fetus is surrounded by a amnion

and chorion
Each fetus is surrounded by a separate

amniotic sac with the chorionic layer
common to both.
Intervening membranes consist of 4 Intervening membrane consists of two

layers-amnion, chorion, chorion and layers of amnion only.
amnion.
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Anastomosis between placenta

Page 12
Sex: while twins having opposite sex are almost always

binovular and twins of the same sex are not always uniovular
but the uniovular twins are always of the same sex.
If the fetuses are of the same sex and have the same genetic
features (dominant blood groups), monozygosity is likely.
A test skin graft: Acceptance of reciprocal skin graftproof of
monozygosity.
DNA microprobe technique is more definitive.
Follow-up study between 2-4 yearsshowing almost similar
physical and behavioral features suggestive of monozygosity.
Page 13
Incidence
Varies widely. Highest in Nigeria being 1 in 20 and lowest
in Far Eastern countries being 1 in 200 pregnancies.
Monozygotic twins 1 in 250 in the world.
According to Hellins rules, the mathematical frequency
of multiple birth is twins 1 in 80 pregnancies, triplets 1 in
802, quadruplets 1 in 803 and so on.
Page 14
Factors that Influence Twinning

The causes of twin pregnancy is not known.
Race: Highest amongst Negroes (once in every 20 births),
lowest amongst Mongols and intermediate among Caucasians
Heredity: Family history in mother.
Maternal Age and Parity: Twinning peaks at age 37 years
Increasing parity: 5th gravid onwards.
Nutritional Factors: Taller, heavier womentwinning rate 25 to
30 % greater.
Pituitary Gonadotropin
Infertility Therapy
Assisted Reproductive Technology
Page 15
Terms
Superfecundation
Superfetation
Fetus papyraceous or compressus
Fetus acardius
Hydatidiform mole
Vanishing twin
Page 16
Diagnosis
History and Clinical Examination
Recent administration of either clomiphene citrate or
gonadotropins or pregnancy accomplished by ART are
much stronger associates.
Clinical examination with accurate measurement of
fundal height.
Page 17
Diagnosis contd
In women with a uterus that appears large for gestational
age, the following possibilities are considered:
Multiple fetuses
Elevation of the uterus by a distended bladder
Inaccurate menstrual history
Hydramnios
Hydatidiform mole
Uterine leiomyomas
A closely attached adnexal mass
Fetal macrosomia (late in pregnancy)
Page 18
Diagnosis contd
Symptoms
Minor symptoms of normal pregnancy are often
exaggerated.
Increased nausea and vomiting in early months
Cardio-respiratory embarrassment
Tendency of swelling in the legs, varicose veins and
hemorrhoids is greater
Unusual rate of uterine enlargement and excessive fetal
movements
Page 19
Diagnosis contd
General examination
Prevalence of anemia is more
Unusual weight gain,
preeclampsia or obesity
Evidence of
association.
not
preeclampsia
explained
is
by
common
Page 20
Diagnosis contd
Abdominal examination
Inspection: Barrel shaped and the abdomen is unduly enlarged
Palpation
Height of uterus > period of amenorrhoea
Girth of abdomen> normal average at term (100 cm)
Fetal bulk disproportionately larger in relation to the size of the
fetal head.
Palpation of too many fetal parts
Finding of two fetal heads or three fetal poles
Auscultation
Two distinct FHS at separate spots, difference in heart rates is
at least 10 beats/minute.
Page 21
Diagnosis contd
Investigations
Sonography
separate gestational sacs identified early
Confirmation of diagnosis as early as 10th week of
pregnancy
Variability of fetuses, vanishing twin in second trimester
Chorionicity (twin peak sign)
Pregnancy dating, Fetal anomalies
Fetal growth monitoring, Presentation and lie of fetuses
Twin transfusion localization, Amniotic fluid volume
Page 22
Twin peak sign

Page 23
Diagnosis contd
Biochemical Tests:
Levels of hCG in plasma and in urine are higher
Maternal serum alpha-fetoprotein level: Elevated
Unconjugated oestriol: approximately double
Radiological examination
Page 24
Complications
Maternal
During pregnancy
Nausea and vomiting
Page 25
Complications contd
During labour
Early rupture of membranes and cord
Page 26
Complications contd
During puerperium
Subinvolution
Fetal
Miscarriage
Page 27
Page 28
Complications of monochorionic twins

Twin twin transfusion syndrome (TTS)
one twin appears to bleed into other through placental
vascular anastomosis.
Receptor twin becomes larger with hydramnios,
polycythemic, hypertensive and hypervolemic
Donor twin which become smaller with oligohydramnios,
anemic, hypotensive and hypovolemic.
Donor may appear stuck due to severe oligohydramnios.
Difference of hemoglobin concentration between the twin
usually exceeds 5 gm% and estimated fetal weight
discrepancy is 25% or more.
Page 29

contd
TTTS contd..
Management
Antenatal diagnosis: ultrasound with doppler flow study
in the placental vascular bed.
Repeated amniocentesis to control polyhydramnios in
recipient twin.
prevent preterm labour and placental abruption.
Selective reduction of one twin is done when survival of

both the fetuses is at risk.
Smaller twin generally have got better outcome.
Plethoric twin: risk of CCF and hydrops.
Perinatal mortality: 70%.
Page 30
Page 31

contd
Dead fetus syndrome
Death of one twin (2-7%) is associated with poor
outcome of the Co-twin (25%) specially in monochorionic
placenta.
The surviving twin runs the risk of cerebral palsy,
microcephaly, renal cortical necrosis and DIC.
This is due to thromboplastin liberated from the dead
twin that crosses via placental anastomosis to the living
twin.
Page 32

contd
Twin reversed arterial perfusion (TRAP):
Characterized by an acardiac perfused twin having blood
supply from a normal co-twin via large arterio-arterial
anastomosis.
Conjoint twin:
Rare.
Perinatal survival depends upon the type of joint.
Major cardiovascular anastomosis leads to
mortality.
high
Page 33
Fetal acardius
Page 34
Research evidence
Twin, acardiac, outcome (GrabD, Schneider V, Keckstein J, Terinde R)
26-year-old G2P1 was initially seen in the 16th week of a twin gestation. An
acardiac-acranial twin was present. There were spontaneous movements of the
lower extremities. Chromosomal analysis of amniotic fluid showed two normal
females. Several ultrasonographic examinations showed lack of growth of the
malformed twin but appropriate growth of the normal twin. Spontaneous labor
developed at 40 weeks and a normal female, 3270g, with Apgar 9/10/10, was
delivered. The acardiac twin was approximately 10 cm long and was
spontaneously delivered out of a second amniotic cavity.
Pathologic findings
The female acardiac acephalic twin (31g, 10 cm) showed no heart or lung
development; liver, intestine, and urogenital tract appeared normal. Spleen,
pancreas and stomach were absent. The placenta was monochorionic
diamniotic, and the two umbilical cords were interconnected by a direct
anastomosis.
Page 35

contd
Monoamniocity:
Monochorionoc twins leads to high perinatal mortality
due to cord problems.
Prostaglandin synthase inhibitor used to reduce fetal
urine output, creating borderline oligohydramnios and to
reduce the excessive movements.
Page 36
Antepartum Management of Twin

Pregnancy
To reduce perinatal mortality and morbidity rates in
pregnancies complicated by twins, it is imperative that:
Delivery of markedly preterm neonates be prevented
Fetal-growth restriction be identified and afflicted fetuses
be delivered before they become moribund
Fetal trauma during labor and delivery be avoided, and
Expert neonatal care be available.
Page 37
Management contd
Diet: increased requirement of calories, protein, minerals,
vitamins, and essential fatty acids. Caloric
should be
increased by another 300 kcal/day. Supplementation with 60
to 100 mg/day of iron and1 mg/day of folic acid.
Bed Rest
Antepartum Surveillance: sonographic examinations
Tests of Fetal Well-Being
Prevention of Preterm Delivery
Hospitalization
Use of corticosteroids to accelerate fetal lung maturation.
Page 38
Management during labour

First stage:
A skilled obstetrician, presence of ultrasound machine and
experienced anesthetist
Bed rest to prevent early rupture of membrane.
Limit use of analgesic drugs
Careful monitoring
Internal examination soon after the rupture of membranes
An intravenous line with ringers solution
Availability of one unit of compatible and cross matched blood
Neonatologist:Present at the time of delivery.
Page 39
Management during labour contd..

Delivery of the first baby:
Delivery: Same guidelines as in normal labour with
liberal episiotomy.
Forceps delivery: if needed, should be done preferably
under pudendal block anaesthesia.
Do not give intravenous ergometrine with delivery of the
anterior shoulder of the first baby.
Clamp the cord at two places and cut it between.
At least 8-10 cm of cord is left behind for administration
of any drug or transfusion, if required.
The baby should be labeled one.
Page 40
Management during labour contd..

Conduction of labour after the delivery of the first baby:
Steps of management:
Step I:
Ascertain lie, presentation, size and FHS of the second
baby.
Vaginal examination: To confirm the abdominal findings
and to exclude cord prolapsed, if any to note the status
of membrane.
Page 41
Management during labour contd...

Lie longitudinal:
Step I: Low rupture of membranes, syntocinon, internal
examination to exclude cord prolapse.
Step II: If the uterine contraction is poor, 5 units of
oxytocin is added.
Step III: Is there is still a delay, interference is to be
done.
Page 42

1. Vertex: Low downforceps are applied.
. High upCPD should be ruled out.
. The possibility of hydrocephalic head should also be kept
in mind and excluded by ultrasonography.
. If these are excluded, internal version followed by breech
extraction is performed under general anesthesia.
. Ventouse: effective alternative.
2. Breech: Breech extraction.
3. Lie transverse: Correct by external version or internal
version to cephalic or podalic.
Page 43

Indication of urgent delivery of second baby:
Severe vaginal bleeding,
Cord prolapse
Inadvertent use of IV ergometrine with the delivery of
anterior shoulder of the first baby,
First baby delivered under general anesthesia,
Appearance of fetal distress.
Page 44

Delay in the birth of second twin
Birth of second twin should be completed within 45
minute of the first twin being born but with close
monitoring can be extended if there are no signs of fetal
compromise.
The risk of delays:
intrauterine hypoxia,
birth asphyxia,
sepsis
Page 45

Management of third stage
Routine administration of 0.2mg methergin IV with
delivery of anterior shoulder.
Deliver placenta by CCT
Continue oxytocin drip for at least one hour, following
delivery of second baby.
The patient is to be carefully watched for about 2 hours
after delivery.
Page 46
Indications of caesarean section

Obstetric causes:
Placenta previa
Severe preeclampsia
Previous caesarean section
Cord prolapse of the first baby
Abnormal uterine contractions
Contracted pelvis
For twins: Both fetuses or even first fetus with noncephalic presentation,
Twins with complications: IUGR, conjoint twins;
Monoamniotic twins, monochorionic twins with TTS
Page 47
Management of difficult cases of

twins
Interlocking
Commonest: Aftercoming head of first baby getting locked
with forecoming head of second baby.
Vaginal manipulation to separate chins of the fetuses
Decapitation of first baby (dead), pushing up decapitated
head, followed by delivery of second baby and lastly, delivery
of decapitated head.
Occasionally, two heads of both vertex get locked at the pelvic
brim preventing engagement of either of the head.
Disengagement of the higher head: Under general
anesthesia, If fails, caesarean section is the alternative
Page 48
Management of difficult cases of

twins contd..
Conjoined twins
Extremely rare.
Often diagnosed during delivery
Presence of a bridge of tissue between the fetuses on
vaginal examination confirms the diagnosis.
Antenatal diagnosis is important.
Benefits are: reduces maternal trauma and morbidity,
improves fetal survival, helps to plan method of delivery,
allows time to organize pediatric surgical team.
Page 49
Postnatal period
Care of the babies
Immediate care
Maintenance of body temperature,
Use of overhead heaters,
Parents given the opportunity to check the identity tag
and cuddle them.
Breastfeeding
Provide knowledge to mother regarding different
positions for breastfeeding, along with advantages,
attachment, positioning timing.
Page 50
Postnatal period contd..

Nutrition
Expressed breast milk is best (for small babies), they may need to
be fed intravenously or by nasogastric tube or cup-fed, depending
on their size and general condition.
Careful monitoring of weight gain, regular capillary blood glucose
estimations
Reassure her that lactation responds to the demands made by
babies sucking at the breast.
At feeding times, mother must be provided support and advised on
positioning and fixing babies.
Care of the mother
Slow involution of uterus, increased After pains so analgesia
should be offered.
High calorie diet.
Teach extra support to handle twin babies
Page 51
Management and Nursing

Interventions
Nutrition counseling
Fetal evaluation
Evaluate woman for signs and symptoms of obstetrical
complications
PTL prevention: explain for hospitalization
Encourage bed rest and hydration.
Institute fetal monitoring and assist with tocolytic therapy, if
ordered.
Explain to the woman that mode for delivery depends on

the presentation of the twins, maternal and fetal status,
and gestational age
Page 52
Management and nursing interventions contd

Intrapartum management
Establish I.V. access
Provide for electronic fetal monitoring for each fetus.
Double setup is recommended for delivery.
Availability of two units of crossmatched whole blood.

I.V. access with large bore catheter.
Surgical suite immediately available.
An obstetrician and assistant experienced in vaginal births of twins.
Best choice of anesthesia: epidural.
Anesthesia provider capable of administering general anesthesia.
Neonatal team for each neonate present at birth for neonatal
resuscitation.
Pitocin induction/augmentation may be required secondary to

hypotonic labor.
Postpartum hemorrhage may occur due to uterine atony.
Emotional support.
Page 53
Nursing diagnoses
Anxiety
Deficient Knowledge Regarding High-risk Situation/Preterm
Labor
Risk for Imbalanced Nutrition: Less/More than Body
Requirements
Risk for Fetal Injury
Risk for Maternal Injury
Risk for Deficient Fluid Volume
Risk for Impaired Gas Exchange
Risk for Activity Intolerance
Risk for Ineffective/Compromised Family Coping
Risk for Interrupted Family Process.
Page 54
Nursing diagnoses contd

For Cesarean Delivery
Deficient Knowledge Regarding Surgical Procedure, and
Postoperative Regimen
Anxiety (Specify Level)
Powerlessness
Risk for Acute Pain
Risk for Infection
Risk for Impaired Fetal Gas Exchange
Risk for Maternal Injury
Risk for Decreased Cardiac Output
Page 55
References
Fraser DM, Cooper MA.Myles Textbook for Midwives.15th edition.
Philadelphia:Churchill livingstone elsevier;2009
Dutta DC.Textbook of obstetrics. 6th edition.Calcutta:New central
book agency;2004
Pillitteri A. Maternal and child health nursing. Care of the
childbearing and childrearing family. Sixth edition. Philadelphia;
Lippincott Williams & Wilkins: 2010.
Cunningham, Leveno, Bloom. Williams obstetrics. 23 rd edition.
United states of America; Mcgraw Hill companies: 2010.
Nettina S.M, Mills E.J. Lippincott Manual of Nursing Practice. 8th
Edition. Philadelphia: Lippincott Williams and Wilkins; 2006
Multiple Pregnancy and Birth: Twins, Triplets, and High-order
Multiples: A Guide for Patients. Patient information series. American
Society for Reproductive Medicine. 2012
Page 56
THANK
YOU
Page 57

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Multiple Pregnancy

History and clinical examination

On rare occasion, the following

Multiple pregnancy contd

Examination of placenta and

Two placenta, either completely Placenta is single.

Each fetus is surrounded by a amnion

Each fetus is surrounded by a separate

Intervening membranes consist of 4 Intervening membrane consists of two

Anastomosis between placenta

Sex: while twins having opposite sex are almost always

Factors that Influence Twinning

Twin peak sign

Complications of monochorionic twins

Complications of monochorionic twins

Selective reduction of one twin is done when survival of

Complications of monochorionic twins

Complications of monochorionic twins

Complications of monochorionic twins

Antepartum Management of Twin

Management during labour

Management during labour contd..

Management during labour contd..

Management during labour contd...

Management during labour contd...

Management during labour contd...

Management during labour contd...

Management during labour contd...

Indications of caesarean section

Management of difficult cases of

Management of difficult cases of

Postnatal period contd..

Management and Nursing

Explain to the woman that mode for delivery depends on

Management and nursing interventions contd

Availability of two units of crossmatched whole blood.

Pitocin induction/augmentation may be required secondary to

Nursing diagnoses contd

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