Multiple Pregnancy

When one or more fetus simultaneously develops in the

uterus, it is called multiple pregnancy.

TWINS

VARIETIES

• Dizygotic Twins (80%)

•Monozygotic Twins (20%)

Placenta Communicating Vessels

Intervening Membranes

Sex Genetic Features

Skin Grafting

Resemblance

Monozygotic One Present 2 amnions

Always identical

Same Acceptance Usually Identical

Dizygotic Two Absent 4 : 2 amnions,2 chorions

May differ

Differ Rejection Not identical

Monozygotic Dizygotic

The Cause of twinning is not known.

Dizygotic twin pregnancies are slightly more likely when the following factors are present in the woman:

•She is between the age of 30 and 40 years

•She is greater than average height and weight

•She has had several previous pregnancies.

•Women undergoing certain fertility treatments may have a greater chance of

dizygotic multiple births.

•The risk of twin birth can vary depending on what types of fertility treatments are

used. With in vitro fertilisation (IVF), this is primarily due to the insertion of multiple

embryos into the uterus.

•Ovarian hyperstimulation without IVF has a very high risk of multiple birth.

•Reversal of anovulation with clomifene has a relatively less but yet significant risk of

multiple pregnancy.

Predisposing factors

Maternal Physiological Changes

1. There is increase in weight gain

and cardiac output.

2. Plasma volume is increased by an

addition of 500ml.

3. There is no corresponding

increase in red cell volume

resulting in exaggerated

haemodilution and anaemia.

4. There is increased alpha

fetoprotein level, tidal volume

and glomerular filtration rate.

LIE AND PRESENTATION

Commonest lie is Longitudinal

Both Vertex (50%)

First Vertex and

second breech(30%)

First breech

and second vertex (10%)

Both Breech (10%)

Rarest oneBoth

transverse(Rule out conjoined

twins)

Diagnosis

History of ovulation inducing drugs.

Family history of Twinning

Minor ailments of normal

pregnancy are exaggerated

Abdominal examination

Internal examination

Abdominal Examination

More “barrel shaped” inspection

Abdominal girth more than 100cm.Too many fetal parts on palpation.

Two distinct fetal heart sounds on Auscultation.

Not easy due to presence

of hydramnios

Ultrasonography

Confirmation of pregnancy as early as 10th week of

pregnancy

Chorionicity

Presentation and Lie of the fetus

Viability of fetus

Fetal growth monitoring for IUGR

Fetal AnomaliesAmniotic fluid volume

Placental Localization

Twin transfusion

Lambda or twin peak sign

The sign describes the triangular appearance to chorion insinuating between the layers of the inter twin membrane and strongly suggests a dichorionic twin pregnancy. It is best seen in the first trimester (between 10-14 weeks).

In contrast the T sign refers to the appearance of the intertwin membrane in a monochorionic twin pregnancy. The sign should not be confused with the lambda sign of sarcoidosis.

A potential space exists in the intertwin

membrane, which is filled by proliferating placental villi giving rise to the twin peak

sign.

Differential Diagnosis

Hydramnios

Big Baby

Fibroid or ovarian tumour

with pregnancy.

Ascites with pregnancy

Complications

Maternal Fetal

Pregnancy

Labour

Puerperium

During Pregnancy

Anaemia

Pre-eclampsia (25%) Hydramnios

(10%)Antepartum Haemorrage

Malpresentation

Preterm Labour (50%) Mechanical

Distress

During Labour

Early Rupture of membranes and cord prolapse

Prolonged labour

Increased operative interference

Bleeding

Postpartum Haemorrhage

During Puerperium

Increased incidence of

Subinvolution.Infection.Lactation Failure.

Increased risk of miscarriage

Premature rate (80%)

Twin-twin transfusion syndrome

Placental insuffiency

IUGR

Structural anomalies

Intrauterine death of one fetus

Asphyxia and stillbirth

Management during Labour

What happens during a twin birth?

Most twins are born before 38 weeks. If you haven't gone into labour by then, you may be recommended to have your labour induced.

During labour, regular monitoring of your twins with electronic fetal monitors (EFM) is standard practice. This is used to listen to your babies' heartbeats and the intensity and frequency of your contractions. Your doctor may place a needle in a vein in your arm (a drip) in case it is needed later.

Discuss your pain relief preferences with your midwife during pregnancy and write them in your birth plan. But keep in mind that labour and birth are unpredictable. Your midwife may need to recommend a course of action at any time which is not what you had originally hoped for, but which will always be in the best interests of you and your baby.

Once your first baby is born, your midwife or doctor will check the position of your second twin by feeling your tummy and doing a vaginal examination, or an ultrasound scan.

If your second baby is in a good position to be born, the waters surrounding him will be broken. Your second baby should be born very soon after the first, because your cervix is already fully dilated. If your contractions stop after your first twin is born, hormones are added to the drip to restart them.

You'll usually be recommended to have a managed third stage. This is when the placenta is delivered with the help of a hormone injection, instead of a natural delivery. This is because there is an increased risk of bleeding when the placenta is larger, and the uterus (womb) will have been stretched by two babies.

Triplets Quadruplets

Female usually outnumber the number of male one. Perinatal loss is markedly increased due to prematurity.

Average time for delivery in quadruplets is 30-31 weeks.

Selective reduction: If there are 4 or more fetuses, selective reduction of the fetuses leaving behind only two is done to improve the outcome. This can be done by intracardiac injection of potassium chloride between 11-13 weeks.

Selective termination of a fetus with structural or genetic abnormalities may be done in a chorionic multiple pregnancy in the second trimester.

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you…