MULTIPLE PREGNANCY

NIRAV HITESH KUMAR VALAND

Definition
• When more than one fetus simultaneously develops in the
uterus.
• Development of two fetuses is much common.
Prevalence
• Traditionally, the expected incidence was calculated using
Hellin’s rule.
• Using this rule, twins were expected in 1 in 80 pregnancies,
triplets in 1 in 802 and so on.
• According to global epidemiology, it accounts for 3% of
pregnancies.
Factors influencing twinning
• Assisted Reproductive Technique
• Increasing maternal age
• High parity
• African-American women are more likely to have twins than any
other race.
• Family history of multiple pregnancies.
• Drugs e.g. Clomiphen
• Nutrition.
Classification
• The classification of multiple pregnancy is based on:
number of fetuses: twins, triplets, quadruplets, etc.
number of fertilized eggs: zygosity;
number of placentae: chorionicity;
number of amniotic cavities: amnionicity.
Non-identical/Fraternal twins
• Dizygotic
• Due to fertilization of two separate eggs.
• Always dichorionic and diamniotic.
• Can either be the same sex or different sexes.
• The release of more than one egg is familial or racial and
increases with maternal age.
• Its incidence is influenced by race, heredity, maternal age, parity,
and, especially, fertility treatment.
 Identical twins
• Monozygotic
• Arise from fertilization with a single egg that splits into 2 identical
structures
• Always are of the same sex.
• Can monochorionic or dichorionic.
• If monochorionic, it can be diamniotic or monoamniotic.
 Identical twins
• The type of monozygotic twin depends on how long after conception
splitting occurs i.e.
Within 3 days – DCDA pregnancy
Between 4 and 8 days – MCDA pregnancy
Later splitting leads to a MCMA pregnancy
If splitting occurs after 12 days, it leads to Siamese twins
• Frequency of monozygotic twin births is relatively constant
worldwide—approximately one set per 250 births
Physiological changes.
Maternal
• All the physiological changes are exaggerated.
• These result in much greater stress in the maternal reserve.
• There’s a increased risk of maternal morbidity in the mothers
with pre-existing health issues e.g. a cardiac disease.
Fetal
• MC placentae tend develop vascular connection between to two
fetal circulations.
Complications.
1. Abortion and severe pre-term delivery
2. Perinatal mortality in twins
3. Death of one fetus
4. Fetal growth restriction.
5. Fetal abnormalities
 Complications unique to monochorionic
twins
Twin-to-twin syndrome
• There are placental vascular anastomosis between to the two fetal
vascular connections.
• Condition is due to an imbalance in the arteriovenous
communication.
• One fetus (Recipient) gets over perfused and the other (donor)
gets under perfused.
• Can be mild, moderate or severe depending on the degree of
imbalance.
Cont..
• The donor twin gets hypovolemic, oliguric and develops
oligohydramnios
• The recipient twin gets hypervolemic, has polyuria and develops
polyhydroamnios, and consequently has an increased risk of high
output cardia failure.
• End up as a miscarriage or very pre-term delivery.
Antenatal management
• Routine screening for hypertension and gestational diabetes.
• Routine supplementation of Iron and Folic acid due to increased
demand.
Determination of chorionicity
• Done by U/S scan
• In dichorionic twins, there’s a lambda/twin-peak sign seen as a V-
shaped extension of placenta into the inter-twin membrane.
• In monochorionic twins, this sign is absent, and the placenta joins
the uterine wall in a T-shape.
• Optimal age of doing this scan is by the 9-10th week.
Monitoring of fetal growth and well-being
• Done principally by U/S.
• Assessment includes;
Fetal lies
Fetal measurements
Fetal activity
Amniotic fluid volumes.
• In monochorionic twins, features of TTTS should be sought,
including discordances between fetal size, fetal activity, bladder
volumes, amniotic fluid volumes and cardiac size.
Intrapartum management
• There are more complications regarding delivery of multiple
pregnancy.
• These include;
Premature birth,
Abnormal presentations,
Prolapsed cord,
Premature separation of the placenta
Postpartum haemorrhage
• Vaginal birth if cephalic presenting part.
Vertex-vertex delivery
• The first twin is delivered in the same way as for a singleton.
• After delivery, abdominal examination for the lie of the second twin
should be done.
• Amniotomy is performed, and if delivery doesn’t take place
between 5-10 min, there is augmentation of labor with oxytocin
infusion.
Vertex – non-vertex delivery
• If second twin is breech, membranes can be ruptured once fixed in
the pelvis.
• If transverse; it should be corrected by external version into a
longitudinal lie preferably cephalic, if fails, podalic.
• If the external version fails, internal version under general
anesthesia should be done forthwith.
Management of 3rd stage.
• Oxytocin 10 IU IM after delivery of the second twin.
• Placenta delivered by CCT.
Indications for Cesarean Delivery

Maternal factors Fetal Factors

• Placenta previa. • Both non-vertex twins
• Severe PET • Monoamniotic twins
• Previous C/S • IUGR
• Cord prolapse of first twin • TTTS
• Contracted pelvis
• Abnormal uterine contractions