Multiple Pregnancy

Dr.V.L.DESHMUKHAssociate Professor

Deptt. Of OBGY

Multiple Pregnancy

• When more than one fetus simultaneously develops in the uterus, it is called multiple pregnancy.

• Two fetuses- twins• Three fetuses- triplets• Four fetuses- quadruplets

TWINS

• Incidence: 1 in 80 (Hellin’s rule)• Monozygotic : 4-5 per 1000.• Dizygotic : 4-50 per 1000.

AETIOLOGY

• Family history– more on maternal side• Race• Advancing maternal age• Grand multipara• IVF-ET• Ovulation induction

VARIETIES OF TWINS

• Binovular twins- results from fertilization of 2 ova

• Uniovular twins- results from fertilization of single ovum.

• Division within 72 hrs- diamniotic dichorionic• 4-8 days- diamniotic monochorionic• 9-13 days- monoamniotic monochorionic• >13 days- siamese twins

DETERMINATION OF ZYGOSITYPLACENTA

COMMUNICATING

VESSELS

INTERVENING MEMBRANE

SEX GENETIC FEATURES

SKIN GRAFTING

FOLLOW-UP

UNI-OVULAR

ONE PRESENT 2(AMNIONS)

ALWAYS IDENTICAL

SAME ACCEPTANCE

IDENTICAL

BIN-OVULAR

TWO ABSENT 4 (2 AMNIONS,2 CHORIONS)

MAY DIFFER

DIFFER REJECTION

NOT IDENTICAL

SOME DEFINITIONS

• Superfetation: fertilization of 2 ova released in different menstrual cycles.

• Superfecundation: fertilization of 2 ova released in same cycle by separate act.

• Fetus papyraceous: one of the fetus dies early.

• Fetus acardiacus: part of the fetus remains amorphous and becomes parasite without a heart.

Acardius myelacephalus

Partial developed head +

identifiable limbs

DIAGNOSIS

• History – family history, ovulation induction.• Symptoms – hyperemesis, swelling of feet,

unusual abdominal enlargement, excessive fetal movements.

• G/E: anemia, PET, unusual weight gain.• Obst. Exam: ht.of ut.>period of amenorrhea,

2 fetal heads or 3 fetal poles, 2 distinct fetal heart rates with a difference of 10 bpm by 2 observers, polyhydramnios.

• Investigations : USG

Ultrasound in Twins

8 Wks

6 Wks

Twin peak sign –projection of placental tissue extending beyond chorionic surface between layers of dividing membranes

- 16 – 24 wks

T – sign

Right angle

relationship between

membrane and

placenta with no

apparent extension

of placenta.

Presentation in twin pregnancy

• Nine possible combinations for twins

M|M during Antenatal period

• Advice – Rest, Nutrition, Fe and FA• Frequent ANC visits• Serial USG : EVERY 3 WEEK from 28

weeks Role of cervical encirclageRole of tocolyticsM\m of complication

Management during labour

• Anticipate and recognize complications• Establish IV line.• Strict FHR monitoring.• Team approach.• Do not give Inj.Ergometrine after

delivery of first baby.• Set up Oxytocin drip and do ARM after

presenting part is fixed.• Active management of third stage.

Protocol for intrapartum management of twin gestation

Role of reduction

• Selective feticide to reduce the number of fetuses in high order pregnancy.

• 1 st trimester procedure can be done by transvaginal, transabdominal and transcervical route.

• Inj.KCL intracardiac with aspiration of amniotic fluid.

Maternal Complications

1. Preterm 22 - 54%

2. PIH 12.9%

3. Anaemia 9.4%

4. A.P.H.

5. Post partum Haemorrhage

6. Hydramnios

7. Malpresentation

Fetal complications

• Prematurity• IUGR• Fetal Hypoxia• Perinatal Mortality

Discordant twin

• Incidence 15 – 29%

Detected 16 .20 wks

USG criteria

HC > 5% diff

AC >20 mm diff.

EFW > 15 – 25%

Grade I. 15 – 25%

Grade II. > 25%

Causes :

– Unequal placental mass

– Genetic syndrome

– TTS

% of larger twin wt

• Management

– Unequal placental mass • Serial NST & AFI

• Weekly betamethasone

• Fetal distress delivery

• 36 wks elective delivery

Twin Twin Transfusion Syndrome

• 5-17% of monochorionic

• Pathophysiology – Vascular communication (Art to vein)

Circulatory imbalance

Twin (donor) Twin (recipient)

* Anaemia * Polycythemia

* Oligohydramnios * Polyhydramnios

• Retarded somatic growth

•Hydrops fetalis

•Highoutput failure

• Prenatal Criteria– One placenta - AFI discrepancy

– Thin Membrane - Umbilical cord size diff

– Same sex - Gestational age < 28 wks

– EFW 20% diff.

• Postnatal Criteria -

Hematocrit Diff. > 20%

Birth Wt

Hb level Diff. > 5gm %

Management

1. Bed rest

2. Serial amniocentesis of polyhydramnitic sac

3. Preterm del with glucocorticoids

4. YAG laser coagulation

Mortality – < 28 wks 55 – 80 %

< 26 wks 100%

overall 60 – 70%

Acardiac twin TRAP (Twin Reversal Arterial Perfusion)

• Incidence - 1 in 35,000 • Mortality – 50%• Pathophysiology

Artery to artery placental shunt

Perfusion pressure of donor twin over powers That of acardiac twin

Reversal of blood flow

Acardius acephalus

Failure orDisrupted

growth of head

Acardius myelacephalus

Partial developed head +

identifiable limbs

Acardius amorphous

Failure of any recognizable structure

Treatment :

• Ligation of umbilical cord of acardiac twin

• USG guided cauterisation of umbilical vessels (18-24

wks)

1. In vanishing twin syndrome, there may be complete reabsorption of a fetus, formation of a fetus papyraceus (ie, a "mummified" or compressed fetus), or development of a subtle abnormality on the placenta such as a cyst, subchorionic fibrin, or amorphous material.

Monoamniotic Twins• One in 12,500 • Perinatal mortality -50%Causes• Umbilical cord entanglement • TTS • Congenital abnormalities • Preterm deliveryPrenatal diagnosis • No visualization of separating membrane at three

different examination • In between 22 to 26 wks of gestation • Route of delivery by caesarean section

Conjoined Twins

Incidence

• 1 in 25,000 to 100,000

Classification

• Thoracopagus – 40%

• Omphalopagus - 35%

• Pygopagus - 18%

• Ischiopagus - 6%

• Craniopagus - 2%

USG Findings

• Twins face each other

• The heads are at the same level & plane

• The thoracic cages are in unusual proximity

• Both fetal heads are hyperextended.

• No change in relative position of fetuses with movement.

• Double clutch hold. Position the babies on pillows along each side or on a nursing cushion on your lap. Their heads go at the breast, their bodies extend along your sides, under your arms. Hold each baby in close to you with enough pressure against the nape of the neck from your hands. This helps them stay latched on. Use pillows behind your back and be sure to bring the babies up to the breast rather than to hunch your shoulders forward.

• Double cradle hold. Each baby lies in the crook of your elbow on their sides so they are facing toward the breast. Their bodies criss-cross in your lap. Use pillows under your elbows for support.

• Cradle and clutch hold. Nurse one baby in cradle hold and the other in clutch hold. The head of the baby in clutch hold lines up with the feet of the baby in cradle hold.

• Lying down. Lying on your back, put two pillows under your head and shoulders. Cradle a baby in each arm, with their bodies on top of yours, their knees meeting in the center. You will need pillows at your sides to support your arms.