Multiple Pregnancy

Kevin Andrew
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.
Superfetation:
formation of a fetus while another fetus is already present in the
uterus.
situation where a woman becomes pregnant when she is already
pregnant
occurs when ovum from two separate menstrual cycles are released,
fertilized, and implant in the uterus
Very rare
Superfecundation:
The fertilization of two or more ovum from the same cycle by sperm
from separate acts of sexual intercourse, which lead to twin babies
from two separate biological father
Therefore this phenomenon happens to be very rare.
Demography
Race: most common in Negroes, least in Asia
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
Twins
Varieties:
1. Dizygotic twins: commonest (Two-third)
2. Monozygotic twins (one-third)

Genesis of Twins:
Dizygotic twins (syn: Fraternal, binovular) -
- fertilization of two ova by two sperms.
Monozygotic twins (Identical, uniovular):
Upto 3 days - diamniotic-dichorionic
Between 4th & 7th day - diamniotic
monochorionic - most common type
Between 8th & 12th day- monoamniotic-
monochorionic
After 13th day - conjoined / Siamese
twins.
Differences in zygocity:

Monozygotic Dizygotic
1 ova + 1 sperm 2 ova + 2 sperm
Same sex Same or opposite sex
Identical features Fraternal resemblance
Single or double placenta Double or s/t fused
Same genetic features Different genetic features
DNA microprobe -same DNA microprobe - different
Conjoined twins:
Ventral:
1) Omphalopagus
2) Thoracopagus
3) Cephalopagus
4) Caudal/ ischiopagus
Lateral:
1) Parapagus
Dorsal:
1)Craniopagus,
2)Pyopagus
Differences in chorionicity with single
placenta:
D / D ( fused placenta ) M/D
Monozygotic or dizygotic Monozygotic
Thick dividing membrane > Thin dividing membrane 2mm or
2mm less
Twin peak / lambda sign T sign
Maternal Physiological Adaptation:
Increase blood volume and cardiac output
Increase demand for iron and folic acid
Maternal respiratory difficulty
Excess fluid retention and edema
Increase attacks of supine hypotension
Diagnosis of Multiple Pregnancy:
Positive family history mainly on maternal side
Positive history of ovulation induction
Exaggerated symptoms of pregnancy
Marked edema of lower limb
Discrepancy between date and uterine size
Palpation of many fetal parts
Auscultation of two fetal heart beats at two different sites with a
difference of 10 beats
Other causes of apparent abnormal uterine
enlargement during early pregnancy
Excess fetal parts
 USS:

Two sacs by 5 weeks by transvaginal USS.

Two embryos by 7 weeks by transvaginal USS
Antenatal Care
Follow Up:

Every two weeks.

Diet: additional 300 K cal per day, increased proteins, 60 to 100 mg
of iron and 1 mg of folic acid extra
Assess cervical length and competency.
Fetal surveillance by USG every 4 weeks
Hospitalisation not as routine
Corticosteroids -only in threatened preterm labour , same dose
Antenatal Care
Fetal Surveillance

Monthly USS from 24 weeks to assess fetal growth and weight.

A discordinate weight difference of >25% is abnormal (IUGR).
Weekly CTG from 36 weeks.
Management During Labour
FIRST STAGE:
blood to be cross matched and ready
confined to bed, oral fluids
intrapartum fetal monitoring
ensure preparedness
SECOND STAGE first baby
- second baby
Management During Labour
SECOND STAGE delivery of first baby
as in singleton pregnancy
start an IV line
no oxytocin after delivery of first baby
secure cord clamping at 2 places before cutting
ensure labeling of 1st baby
Delivery of second twin
FHS of second baby
lie and presentation of second twin
wait for uterine contractions
conduct delivery
Management During Labour
THIRD STAGE
- continue oxytocin drip
- monitor for 2 hours
Method Of Delivery
Vertex- Vertex (50%)
Vaginal delivary, interval between twins not to exceed 20 minutes.

Vertex- Breech (20%)

Vaginal delivary by senior obstetrician
Method Of Delivery
Breech- Vertex( 20%)
Safer to deliver by CS to avoid the rare interlocking twins( 1:1000
twins ).

Breech-Breech( 10%)
Usually by CS.
Indications of caesarean
Non cephalic presentation of first twin
Monoamniotic twins
Conjoined twins
Locked twins
Other obstetric conditions
Second twin incorrectible lie, closure of cervix
Clinical manifestation and complication
Complications of Multiple Gestation

Maternal Fetal
Malpresentation
Anemia
Placenta previa
Hydramnios
Abruptio placentae
Preeclampsia
Premature rupture of the
Preterm labour membranes
Postpartum hemorrhage Prematurity
Cesarean delivery Umbilical cord prolapse
Intrauterine growth
restriction
Congenital anomalies
Twin-to-twin transfusion syndrome
 Results from vascular anastemoses between twins vessels at the
placenta.
Usually arterio (donor) venous (recipient).
Occurs in 10% of monochorionic twins.
 Chronic shunt occurs ,the donor bleeds into the recipient so one is
pale with oligohydraminose while the other is polycythemic with
hydraminose.
If not treated death occurs in 80-100% of cases.
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.
Possible methods of treatment:

Repeated amniocentesis from recipient.

Indomethacin.
Fetoscopy and laser ablation of communicating vessels.
Prognosis
Risk of the mother with multiple pregnancy are higher than the
singleton pregnancy. Due to the high risk of having anemia, pre-
eclampsia, and post-partum hemorrhage,
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.
Conclusion:
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.
Thank you