2. MULTIPLE GESTATION
When more than one fetus simultaneously
develops in the uterus,it is called multiple pregnancy.
Simultaneous development of two fetuses(twins) is
the commonest; although rare,development of more than
two may also occur.
3 fetuses : triplets
4 fetuses : quadruplets
5 fetuses : quintuplets
6 fetuses : sextuplets
3. TWINS
Dizygotic(2/3 rds) Monozygotic(1/3 rd)
Results from fertilization Resultsfromfertilization
of two ova of a single ovum
4.
5. out come of twinning process depends on when
division occurs:
with in 72hrs after fertilization (prior to morula stage)
diamniotic-dichorionic twins.
B/W 4th&8th day:after formation of inner cell mass &
when chorion already devoleped-diamniotic
monochorionic twins
After 8th day-monoamniotic monochorionic twins.
If the division is intiated later,i.e after the embrionic
disc has formed,
cleavage is incomplete - conjoined twins.
6.
7. INCIDENCE
Monozygotic twins : one in 250 births
Dizygotic twins : ranges from 1:20 to 1:200
In india it is 1:80
Hellin’s rule : twins 1:80
triplets 1:80 ²
quadruplets 1:80³
8. PREVALENCE AND CAUSES
Monozygotic twinning is independent of
race, heredity,age & Parity.
A.race : whites 1:100
blacks 1 :80
Nigerians 1:20
B. Heredity
9. C. Maternal age & parity : 0 @ puberty ,peak @ 37
yrs frequency of multiple gestation in first pregnancy
was 1.3% compared with 2.7% in fourth pregnancy
Twinning increased from 1:50
during first pregnancy to 1:15 in sixth.
D. Nutritional :
E. Role of gonadotrophins
10. F. Infertility therapy
Incidence-
With conventional gonadotrophin therapy-16to40%
(75% twins)
With hMG it is 25 – 30%
Ovulation induction increases both dizygotic &
monozygotic twinning
11. G.ART
Typically , pts undergo super ovulation if vitro
fertization is attempted in all retrieved ova,& 2to4
embryos are transferred to uterus
In general, the greater the no. of embryos that are
transfered ,
The greater the risk of twins & of higher order
multiple gestation
13. Diagnosis
History
Older maternal age (at peak of ovulation
38yrs)
Previous history of twinning; high parity
History of use of ovulation induction drug or
pregnancy following assisted reproductive
technique
Good maternal nutrition
Family history of twinning
14. CLINICALLY
A. Symptoms and Signs
All of the common annoyances of pregnancy are more
troublesome in multiple pregnancy. The effects of multiple
pregnancy on the patient include earlier and more severe
pressure in the
pelvis, nausea, backache, varicosities, constipation, hemorrhoids,
abdominal distention, and difficulty in breathing. A “large
pregnancy” may be indicative of twinning (distended uterus).
Fetal activity is greater and more persistent in twinning than in
singleton pregnancy.
15. (1) Uterus larger than expected (> 4 cm) for
dates.
(2) Excessive maternal weight gain that is not
explained by edema or obesity.
(3) Polyhydramnios, manifested by uterine size
out of proportion to the calculated duration of
gestation, is almost 10 times more common in
multiple pregnancy.
(4) History of assisted reproduction.
16. (5) Elevated MSAFP [maternal serum alpha-
fetoprotein]values
(6) Outline or ballottement of more than one
fetus.palpation of 2 fetal heads/presence of three fetal
poles.
(7) Multiplicity of small parts.
(8) Simultaneous recording of different fetal heart
rates, each asynchronous with the mother’s pulse and
with each other and varying by at least 8 beats per
minute. (The fetal heart rate may be accelerated by
pressure or displacement.)
(9) Palpation of one or more fetuses in the fundus after
delivery of one infant.
18. USG
1st trimester – Dating scan
- No of gestational sacs
- Chorionicity
2nd Trimester - To rule out anomalies
- No of fetuses
3rd Trimester - For fetal growth
- For amniotic fluid index every
15 days –
To detect any growth difference (TTTS /
Growth discordance)
19. ULTRASONOGRAPHIC FINDINGS
Chorionicity can be identified by USG as early as the first
trimester
Presence of two separate placentas and a thick –
generally 2mm or greater dividing membrane supports
the presumption of the diagnosis of dichorionicity
Fetuses of opposite gender are always dizygotic
“Twin – Peak” sign – Confirms dichorinic twinning
97% Sensitivity & 100 % specificity for dichorionicity
20.
21.
22.
23.
24.
25. Maternal risks Fetal risks
Nausea,vomiting, mechani Abortion
cal distress Vanishing twin/fetal
Anemia papyraceous
PIH/Preeclampsia Preterm labour
Poly/oligohydramnios Fetal anomalies
Preterm labour Discordant growth
Malpresentation Death of one fetus
APH Twin to twin transfusion
Prolonged labour syndrome
Operative interference Cord prolapse
PPH Locked twins
26. RISKS
MATERNAL Increased symptoms of early pregnancy like
nausea& vomiting
Increased risk of miscarriage ---- rate of missed abortion is twice
as high as the 2% rate seen in singletons @10-14 wks
vanishing twin syndrome
minor disorders of preg.--- backache,breathlesness,varicose
veins
anaemia
Preterm labour & delivery
Hypertension (Cont………)
27. Antepartum haemorrhage as result of placenta
previa& placental abruption
• Hydramnios
• single fetal death
• increased risk of an operative vaginal birth
• increased likely hood of cesarean birth
• post partum haemorrhage
• Maternal mortality
28. FETAL RISKS
Still birth (or) neonatal death - 10% of perinatal mortality
rate
PNMR in twins is up to
10times that in singletons
Single fetal death in twins
Preterm labour and delivery - rate 30% to 50% in twins
80 % in triplets
IUGR – 25% to 33%
Congential anomalies
29. Twin reversed arterial perfusion sequence
Conjoined twins - 1 in 200 monozygotic twins
Cord accident - due to preterm birth, PROM,
hydramnios
Mal position & mal presentation
Zygosity
Mono amniotic twins
Hydramnios
30. Twin - twin transfusion syndrome
Risk of asphyxia - 4 to 5 times that of a singleton
Operative vaginal birth, especially for the second twin
Twin entrapment – rare, 1 in 817 twin pregnancies,
associated with mono amniotic twins
Cerebral palsy – prevalence in twins is 8 times that in
singletons, and in triplets it is 47 times that in singletons
31. Twin – to – twin Transfusion syndrome
It is a complication unique to monochorionic multiple pregnancies
Hypovalemia, oliguria, and oligohydramnios develop in the donor
twin, producing “ Stuck twin” phenomena
Hypervolemia, polyuria and hydramnios evolve in the recipient
twin, who can develop circulatory over load and hydrops
TTTS usually occurs b/w 15 & 26 wks
32. Fetal risks
In untreated TTTS – mortality rate is nearly 100%
In advanced neonatal care - 63% mortality
Spontaneous abortion & extreme preterm delivery are associated
with hydramnios
Fetal death due to cardiac failure in the recipient or poor
perfusion in donor
34. Acardiac twins (Reversed-Arterial Perfusion
TRAP).
* rare 1:3500 births.
* large A-A placental shunt between umbilical
arteries in early embryogenesis,
75% monochorionic, diamniotic.
25% monochorionic monoamniotic
35. ANTEPARTUM MANAGEMENT OF TWIN
PREGNANCY
To reduce perinatal mortality and morbidity in pregnancies
complicated by twins, it is imperative that:
1. Delivery of markedly preterm infants be prevented.
2. Failure of one or both fetuses to thrive be identified and
fetuses so afflicted be delivered before they become
moribund.
3. Fetal trauma during labor and delivery be avoided.
4. Expert neonatal care be available.
36. Ante partum management
Early diagnosis (mainly by ultra sound)
Regular antenatal check up , supplementation
of folic acid & iron
Screening for maternal Hyper tension
gestational diabetes mellitus & their
treatment
Serial USG – Chorionicity, fetal No.
anomalies, fetal health ,onset of preterm
labour
37. DIET-
Caloric consumption increased by 300
kcal/day
60 to 100 mg/day of iron
1 mg of folic acid is recommended.
Bed Rest-Limited physical activity, helps in
reducing preterm births in women with multiple
fetuses
Interval of antenatal visit should be more
frequent to detect at he earliest,the evidences of
anemia,preterm labour or pre-eclampsia.
38. ANTEPARTUM SURVEILLANCE
Tests of Fetal Well-Being- serial
sonography at every 3-4 weeks interval.
Assessment of fetal growth,amniotic fliud
volume and AFI, non-stress test and doppler
velocimetry are carried out.
39. PRETERM LABOUR PREDICTION
Cervical length and fetal fibronectin levels
predicted preterm birth.
24 wks-Cx length- < 25mm –before 32 wks
28 wks- fetal fibronectin is predictive
Tocolytic Therapy
Corticosteroids for Lung Maturation
Cerclage
Women with multifetal gestation at 24 wks
>closed internal os on digital Cx ex
>normal cervical length by USG ex
>negative fetal fibronectin test
Low risk to deliver before 32 wks
40. PRETERM MEMBRANE RUPTURE
DELAYED DELIVERY OF SECOND TWIN
Expectant management for ruptured
membranes
Asynchronous birth of attempted, mother to be
evaluated and counseled for risks
1. Infection
2. Abruption
3. Congenital anomalies
41. Indication for induction of labour in
multifetal gestation:
1. Severe pregnancy induced hypertension
2. Fetal distress
3. Discordant growth with fetal distress near term
42. DURATION OF GESTATION. As the number of
fetuses increases, the duration of gestation
decreases.The mean gestational age at delivery
was 35 weeks.
PROLONGED PREGNANCY. A twin pregnancy
of 40 weeks or more should be considered
postterm.
At and beyond 39 weeks, the risk of subsequent
stillbirth was greater than the risk of neonatal
mortality.
PULMONARY MATURATION-ratio usually
exceeds 2 by 36 weeks in singleton
pregnancies, it often does so by about 32 weeks
in multifetal pregnancy.
43. IN LABOUR MANAGEMENT
Trained obstetrical attendant.
Blood should always be made available.
I.V line.
CTG monitoring.
Anesthetist C-S
Pediatrician for each fetus.
Mode of delivery depend on presentation.
44. DELIVERY OF TWIN FETUSES
LABOUR-preterm labour, uterine contractile
dysfunction, abnormal presentation, prolapse
of the umbilical cord, premature separation of
the placenta, and immediate postpartum
hemorrhage are more common
45. PRESENTATION AND POSITION
Most common presentations at admission for delivery
are cephalic-cephalic, cephalic-breech, and cephalic-
transverse
Importantly, these presentations, especially those
other than cephalic-cephalic, are unstable before and
during labor and delivery.
Compound, face, brow, and footling breech
presentations are relatively common, especially when
the fetuses are small, amnionic fluid is excessive, or
maternal parity is high
Prolapse of the cord
46. VAGINAL DELIVERY
The presenting twin typically bears the major
force of dilating the cervix and the remaining
soft tissues of the birth canal. When the first
twin is cephalic, delivery can usually be
accomplished spontaneously or with forceps.
47. LOCKED TWINS
The phenomenon of locked twins is rare
For twins to lock, the first fetus must present breech
and the second cephalic. With descent of the breech
through the birth canal, the chin of the first fetus locks
between the neck and chin of the second, cephalic
fetus. Cesarean delivery is recommended when the
potential for locking is identified.
Planned cesarean delivery does not improve
neonatal outcome when both twins are cephalic..
48. WHEN 1ST TWIN IS BREECH
When the first twin is breech, most physicians plan a
cesarean delivery
cesarean delivery is the method of choice when the first
twin is noncephalic
Except when fetuses are so immature that
their survival is of doubt, breech delivery
may be conducted
> First fetus presents as a breech, major problems are
most likely to develop if:
1. The fetus is unusually large and the aftercoming head
is larger than the capacity of the birth canal.
2. The umbilical cord prolapses.
49.
50. VAGINAL DELIVERY OF THE SECOND
TWIN
As soon as the presenting twin has been
delivered, the presenting part of the second
twin, its size, and its relationship to the birth
canal should be quickly and carefully
ascertained by combined
abdominal, vaginal, and at times intrauterine
examination
51.
52. INTERNAL PODALIC VERSION
With this maneuver, the fetus is turned to a
breech presentation by the operator's hand
placed into the uterus.The obstetrician
grasps the fetal feet to then effect delivery by
breech extraction.
53.
54. INTERVAL BETWEEN FIRST AND SECOND
TWINS
In the past, the safest interval between
delivery of the first and second twins was
commonly cited as less than 30 minutes
If continuous fetal monitoring is used, a good
outcome is achieved even when this interval
is longer.
As interval prolongs maternal & fetal
morbidity increases (Living stone & collogues
2004 )
55. ACTIVE MANAGEMENT OF 3RD STAGE
Risk of PPH can be minimised- 0.2mg
methergin i.v with delivery of the anterior
shoulder of the 2nd baby.
Placenta delivered by controlled cord traction
Oxytocin drip for atleast one hour followinfg
delivery of the second baby
56. ANALGESIA & ANAESTHESIA
1. For vaginal delivery
Epidural analgesia is preferred ,As it possible to
extended it up for purpose of Em .LSCS (Koffel 1999)
For Internal podalic version
Prefered to done under balanced
epidural G.A
3. For cesarean section
Spinal anaesthesia after adequatly
preloading the circulation (to prevent
hypotension)
4. For C.S performed for 2nd twin
spinal anaesthesia / under balanced general
aneasthesia
57. Cesarean delivery
Indications
1. First twin non cephalic presentation
2. Both twins non cephalic presentation
3. Fetal distress
4. Antepartum haemorrhage
5. Second fetus larger
6. When cervix promptly contracts & and thickens
after delivery of first infant & does not dilate
subsequently
