MULTIPLE GESTATIONS

EPIDEMIOLOGY
Hellins rule: 1 in 80n-1 pregnancies
60% are Dizygotic (dichorionic and diamniotic)
40% are Monozygotic (one in 250 births, constant
worldwide)
- 10% (dichorionic and diamniotic)
- 20% (monochorionic and diamniotic)
- 10% (monochorionic and monoamniotic)

DEFINITION & TYPES

Any pregnancy in which two or more
fetuses exist simultaneously
Types
Dizygotic (dichorionic and
diamniotic), (fraternal)
Monozygotic
0-72 hr dichorionic and diamniotic
4-8 d monochorionic and diamniotic
Incidence varies with: Ethnic group (Blacks more),
9-12 days monochorionic and
Maternal age (Older more), Parity (Multi more),
monoamniotic
>12th day conjoined (Siamese) twins, Family Hx,
COH, 10 and 20% with CC & hMG res. (Only in
1:70,000 (thorcopagus is the
dizygotic twins)
commonest)
CHORIONICITY
UNIQUE COMPLICATIONS WITH IN MONOCHORIONIC
DETERMINATION
Ultrasound
TWIN-TWIN TRANSFUSION
ACARDIAC TWIN
- 30% of twins will be of
SYNDR (TTTS)
different sex
One baby will give blood to
Two growing fetuses but only
- 23% will have monochorionic the other baby through an
one heart beating
placenta
AV anastomosis.
Cause: Living cells in the
- 27% will have same sex,
deformed baby is sustained by
dichorionic placentas, but
the healthy twins circulation.
different blood grouping
- 20% have same sex,
dichorionic placentas, and
identical blood grouping that
will require HLA or DNA PCR
analysis

FETUS PAPYRACEOUS
Fetus in a multi-gestation
pregnancy dies in-utero &
then partially/completely
absorbed by the mother or
twin.
@Twin embolization
(vanishing) syndrome

PREGNANCY
COMPLICATIONS
Hyperemesis gravidarum
Hypertensive disease, 4x
more common than
singletons
Gestational diabetes
Anaemia
Hydramnios in 12%,
primarily in monozygotic
twins
Reflux, ab discomfort, back
pain, leg swelling, bladder
sx and haemorrhoids.
APH (PP and Abruptio, as
larger placental area and
PET)
Thromboembolic disease:
appropriate prophylaxis
and Rx

PRESENTATIONS
Four principal combinations of presentations
Cephalic/cephalic
60%
Cephalic/breech
20%
Breech/cephalic
10%
Breech/breech
10%
First two, many obstetricians will allow vaginal
delivery with the same contraindications as for
singleton pregnancies
The same applies for trial of vaginal delivery in
the presence of a previous lower segment
Caesarean Section
Complication
Abortion (12-12wk)
Premature labor (2432wk)
IUGR
Fetal defects

INDICATIONS FOR ELECTIVE CSECTION

- Malpresentation of the first twin
- Second twin larger than the first
- Evidence of IUGR in one or both
twins
- Monochorionic twins
- History of fertility treatment
Anesthetic: Epidural

Singleto
n
1%
1%

Dichor
~
2%
5%

Monochor
~
12%
10%

5%
1%

10%
2%

20%
8%

LABOR MANAGEMENT
Labour management:
IV line, Delivery in theatre, Twin
CTG machine
2 resuscitation trolleys, 2
obstetricians, 2 paediatricians,
Inform SCBU
PPH: IV line, Blood grouped and
saved, Oxytocin infusion following
delivery

DIAGNOSIS OF MULTIPLE PREGNANCIES

Size and hormones
Diagnosis of multiple gestations
History, examination (4cm larger than
x1)
and investigations
ANC: Consultant-led team. More

DEATH OF ONE FETUS IN A TWIN

PREGNANCY.
Dichorionic Preterm labor
Monochorionic Hypotension
Death / Handicap of the other.
Doesnt lead to DIC as readily as
singleton.