Multiple Gestation

DR.A.RATHNA M.S ( O&G)

1 st YR PG
MMC &RI
OBJECTIVES:
Definition.
Incidence and epidemiology.
Clinical characteristics.
Classification.
DEFINITION:
Any pregnancy which two or more embryos or
fetuses present in the uterus at same time.
It is consider as a complication of pregnancy due
to ;
The mean gestational age of delivery of twins is
approximately 36w.
The perinatal mortality &morbidity increase.
Terminology vs. number
Singletons one fetus
Twins tow fetuses.
Triplets three fetuses.
Quadruplets four fetuses.
Quintuplets five fetuses.
sextuplets six fetuses.
Septuplets seven fetuses.
Mean gestational age of delivery
Number of babies Weeks of Gestation
1 40 weeks

2 36 weeks

3 33 weeks

4 29 weeks
Incidence & epidemiology
The incidence of multiple pregnancy in US is
approximately 3% (increase annually due to ART ).
Monozygotic twins ( approx. 4 in 1000 births ).
Triplet pregnancies ( approx. 1 in 8000 births ).
Multiple gestation increase morbidity & mortality
for both the mother & the fetuses.
The perinatal mortality in the developed countries
Twins = 5 10 % births.
Triplets = 10 20 % births.
 Demography
Race: most common in Negroes
Age: Increased maternal age
Parity: more common in multipara
Heredity - family history of multifetal
gestation
Nutritional status well nourished women
ART - ovulation induction with clomiphene
citrate, gonadotrophins and IVF
Conception after stopping OCP
 INCIDENCE
Hellins Law:
Twins: 1:89
Triplets: 1:892
Quadruplets: 1:893
Quintuplets: 1:894
Conjoined twins: 1 : 60,000
Worldwide incidence of monozygotic - 1 in 250
Incidence of dizygotic varies & increasing
Clinical characteristics:
Multiple gestation should be suspected when ;
Uterine size is greater than expected for
gestational age.
Multiple FHRs are heard
Multiple fetal parts are felt.
hCG & serum alpha-fetoprotein levels are
elevated for gestational age.
If the pregnancy is a result of ART.
Diagnosis is confirmed by US .
DDx of uterus that is greater than
expected for gestational age:
1 Polyhydramnios.
2 Macrosomia.
3 Placental abruption.
4 Gestational trophoplastic disease.
5 Uterine fibroid.
6 Ovarian mass.
 History:
Family hx of dizygotic twins.
Use of fertility drugs.
sensation of excessive fetal movements.
Exaggerated symptoms of pregnancy (hyperemesis
gravidarum ).
Examination:
GPE ( weight gain, Pre-eclampsia signs )
Abdominal examination (excessive uterine fundal
growth, and auscultation of fetal heart rates in separate
quadrants of the uterus are suggestive but not
diagnostic).
Sonographic examination ( diagnostic )
 EMBRYOLOGY

EMB
Fertilization is the union of a human egg and
sperm, usually occurring in the ampulla of the
fallopian tube. The result of this union is the
production of a zygote cell, or fertilized egg,
initiating prenatal development.
The embryo refers to the first stage of development
of a baby from the moment of fertilization. It is called
a fetus from the eighth week of conception.
Embryology
Zygote: sperm + oocyte
Embryo: prenatal period between 14 days to 9 week
Implantation occurs in form of blastocyst on 6 to 8 day
Fetus: prenatal period between 9 week to birth

Primitive uteroplacental circulation: begins at the end of

2nd week
Placenta: chorion frondosum(fetal)+decidua
basalis(maternal)
Placental borders :chorionic plate (fetal side) and
desidual plate(maternal side)
Amnion: innermost avascular layer facing fetus
embryology
 After fertilization of an egg, the zygote is formed. This is
the first in a series of complex events that conclude with
the birth of a full-grown organism.

Following fertilization, the zygote begins a series of mitotic

cell divisions know as cleavage.

Cleavage- Cells don't grow, just divide; therefore, cell size

decreases
1. Series of cell divisions after fertilization
2. Mitosis
3. Embryo-development of the zygote (one cell)
Stages of Cleavage- the number of cells doubles at each
division but no growth occurs.

1. Morula-developing embryo is solid ball of cells

2. Blastula-development of hollow center filled with fluid-

blastocoel

3. Gastrulation-"horse shoe stage" when blastula reaches

several hundred cells
 Zygote (approximately 16-20 hours after insemination) Two-cell embryo (approximately 24 hours after
insemination).

Four-cell embryo (approximately 45 hours after

insemination). Eight-cell embryo (approximately 72 hours after
insemination).
Blastula-development of hollow center filled with fluid-
blastocoel
On the 4th day after insemination an epithelial cellular
layer forms, thicker towards the outside, and its cells
flatten out and become smaller.

Fluid filled inside sphere

Yolk filled end

opening
The blastula stage is followed by the formation of the
gastrula.

During the formation of the gastrula, one side of the

blastula pushes inward forming a second, inner, layer of
cells.

The inner cell layer is called the endoderm.

The outer cell layer is called the ectoderm.

A third cell layer, the mesoderm, then forms

between the endoderm and ectoderm.
The endoderm, ectoderm and mesoderm layers continue dividing and form all the tissues,
organs and organ systems of the animal.

The process is called differentiation.

 Nervous system, epidermis, sweat glands, hair and
Ectoderm nails, lining of mouth, nostrils and anus

Bones & muscles, blood, blood vessels & heart,

Mesoderm reproductive and excretory systems, inner layer of
skin

Lining of the digestive tract, lining of the trachea,

Endoderm bronchi and lungs, liver & pancreas, thyroid,
parathyroid, and thymus, urinary bladder
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2nd Week of Development
Development of Trophoblast

Development of Bilaminar Embryonic disc

Development of Amnion

Development of Yolk sac

Development of Sinusoids

Development of Extra embryonic mesoderm

Development of Chorions

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3rd Week of Development
Gastrulation

Primitive Stalk formation, Primitive Node formation

Trilaminar Disk formation

Notochordal process, Notochord, Archentron

Oropharangeal & Cloacal membrane

Neurulation
Development of Chorionic Villi
Development of Placenta
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Extra embryonic membranes
Amnion protective fluid

Yolk sac no yolk in humans, but same name;

nourishment for non- placentals.

Chorion become embryos part of placenta

Releases human chorionic gonadotropin (hcg)
Causes corpus luteum to stay; prevents menstruation

Allantois functions in waste disposal; will

become the umbilical cord
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Type of multiple pregnancy
1. Dizygotic / binovular / fraternal
2. Monozygotic / Uniovular / identical
 Classification

Dizygotic (>70%) Monozygotic (<30%)

Dichorionic/Diamniotic
Dichorionic/Diamniotic Monochorionic/Monoamniotic
(8%( (1%)

Monochorionic/Diamniotic
(20%)

N.B. : Placentation in higher-order multiples ( triplets, quadruplets( follows the same

principles, except monochorionic & dichorionic may coexist.
1.DIZYGOTIC TWINS/ BINOVULAR

75%

Fertilisation of 2 ova by different spermatozoa.

Each twin has its own placenta, chorion , amnion.

Hence always dichorionic, diamniotic.

Important notes:
1 Monozygotic twins having same sex & blood
group.

2 Process of formation of chorion is earlier than

formation of amnion.

3 Dizygotic twins must be dichorionic/diamniotic.

4 There is no dichorionic/ monoamniotic.

Varieties
Binovular (dizygotic = non-identical) twins:
developed from two separate ova which may or
may not come from the same ovary and fertilised
by two separate spermatozoa.

The twins are of the same or different sex.

The similarity between them is not more than
that between members of the same family.
They have: two placenta, two chorions, two
amnions, two umbilical cords.
Binovular twins are 4 times more common
thanthe uniovular variety.

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DIZYGOTIC TWINS/ BINOVULAR
B- Monzygotic twins:
Constitutes 1/3 of twins
These twins are multiple gestations resulting from
cleavage of a single, fertilized ovum.
The timing of cleavage determines the
placentation of the pregnancy.
Constant incidence .
Not affected by heredity.
Not related to induction of ovulation.
MONOZYGOTIC

4-7 days
Varieties
Uniovular (monozygotic = identical) twins:
a. developed from a single ovum which after
fertilisation, by a single sperm, has undergone
division to form two embryos.

b.The twins are of the same sex.

c.They have similar physical and mental characters

as well as the blood group but not finger prints.

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CONT

d.The foetal circulations often communicate in the

placenta which results in foetofoetal transfusion
with onetwin having polycythaemia,
hypervolaemia,dominant heart, polyuria and
polyhydramnios. While the other twin will have
anaemia, hypovolaemia, microcardia, oligouria and
oligohydramnios. The latter twin may die and
retained till term where it is seen flat and
compressed and called foetus papyraceous. The
retained dead foetus may cause disseminated
intravascular coagulation.
e. The placentation and development in uniovular
twins depend on the time when division occurs as
follow:
MONOZYGOTIC TWINS
CONJOINED TWINS

conjoined twins called-Siamese twins.

Four types of fusion may occur

Thoracopagus (commonest)
Pyopagus (Posterior fusion)
Craniopagus (cephalic)
Ischiopagus (caudal)
Conjoined twins

Ventral:
1) Omphalopagus
2) Thoracopagus
3) Cephalopagus
4) Caudal/ ischiopagus
Lateral:
1) Parapagus
Dorsal:
1)Craniopagus,
2)Pyopagus
Thoracopagus Craniopagus
 Monozygotic / Uniovular / Identical
1.1/3 twins
2.1 sperm and 1 ovum
3.Identical
4.Type of placenta depends on
the time of splitting of embryo
5.Incidence is independent of
race, age, parity
Dizygotic / binovular / fraternal
1.2/3 twins
2.2 sperms and 2 ova
3.Dichorionic Diamniotic twins
4.Presence of chorionic tissue
between 2 amniotic sac
5.Incidence is dependent of
race, age, parity, and ovulation
inducing drugs
Placentation in Higher-Order Multiples ;

The relationship of placentas among triplets,

quadruplets, and higher-order multiple fetuses
generally follows the same principles, except that
monochorionic and dichorionic placentation may
coexist, and placental anomalies are more frequently
found in higher-order multiples.
Superfecundation: is fertilisation of two ova
produced inthe same menstrual cycle by two
spermatozoa deposited in two separate acts of
coitus.

Superfoetation: is fertilisation of two ova

produced in two different menstrual cycles by two
separate spermatozoa. Actually, this cannot occur
in human as ovulation is suppressed once
pregnancy occurs.

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FETUS ACARDIUS
A deformed fetus having developed no heart, and
otherwise being a shapeless lump with only
rudiments of organs, connected as a parasite to
another fetus.
Fetal acardius
Vanishing twin
A vanishing twin, also known as fetal resorption,
is a fetus in a multi-gestation pregnancy which
dies in utero and is then partially or completely
reabsorbed by the twin.
The occurrence of this phenomenon is sometimes
referred to as twin embolisation
syndrome or vanishing twin syndrome (VTS),
Thank You