Multiple Pregnancy

Definition
Presence in Utero or birth of more than one
fetuses.
Twin gestation accounts for 1% of all deliveries
and 10% of perinatal mortality.
Currently the incidence is increasing world wide.
Twins, Triplets, Quadruplicates and so on
incidence is calculated by HELLIN hypothesis.
Vanishing Twin Syndrome :- When one of the
twin does not grow and vanishes in utero
leading to singleton birth.
INCIDENCE
Twins : 1: 80 or 90
Triplets : 1:80 square or 1: 8000
Quadruplet : 1:80 cube or 1: 512 000
Highest in Nigeria
Lowest in japan or east Asia
Spontaneous ovulation twins 1%
Clomiphene induced ovulation 10 %
HMG (gonadotrophins) induced 30%
 The incidence of twin and higher-order
multiple gestations has increased
significantly over the past 15 years
primarily because of
The availability and increased use of
ovulation-inducing drugs and assisted
reproductive technology (ART).
(ART)
Multiple gestations now compose 3% of all
pregnancies,
pregnancies and twins compose 2530%
of deliveries resulting from ART.
ART
Associated complications
1. Antenatal
Spontaneous abortion:- Vanishing twin-12%
Hyperemesis gravidarum
Placenta previa
Pressure symptoms
Structural malformation
Teratogenic events, neural tube defect,
conjoined twins
Vascular interchange:- reverse flow acardia
Overcrowding:- congenital hip dislocation
5
 IUGR
APH
Anemia
Preterm delivery
Polyhydramnios, oligohydramnios,
TTTS
2. Intrapartum
Malpresentations & malpositions
Permature rupture of membrances
Cord accidents
6
 Locked twins
Dysfunctional uterine action
Abruption after delivery of the first
twin
Birth trauma
Cesarean section
3. Postprtum
PPH:- atony, laceration large placental
site
7
Twin pregnancy Types
Monozygotic ("identical
twins")
Fertilization of a single ovum,
Have the same sex & BG
Identical in every way including
the HLA genes
Not genetically determined
Constant in all races; its
prevalence: 1/250.
Their fingerprints differ
. Slightly more than 30% of twins are monozygotic; nearly 70% are dizygotic
Dizygotic ("fraternal twins")
Fertilization of 2 separate ova
Its etiology and prevalence
varies,
varies with racial / hereditary
difference,
Its actual prevalence is
increasing due to:
Early diagnosis by U/S.
Induction of ovulation
Change of the ages of women
experiencing their first
pregnancy and delivery ( > 35
years age).
 Approximately 75% of dizygotic twins are the same sex.
Both twins are males in approximately 45% of cases (a lesser
preponderance of males in twins than in singletons) and both
females in approximately 30%.
Dizygotic multiple pregnancy tends to be recurrent.
Women who have borne dizygotic twins have a 10-fold
increased chance of subsequent multiple pregnancy.
Dizygotic twinning probably is inherited via the female
descendants of mothers of twins; the father's genetic
contribution plays little or no part.
White women who are dizygotic twins or who are siblings of
dizygotic twin mothers have a higher twinning rate among
their offspring than do women in the general population.
Parity does not influence the incidence of dizygotic twinning
but aging does.
CLASSIFICATION:-
BY ZYGOSITY (number of ovum) :- Monozygotic:-
Monozygotic 30%.
Dizygotic:-
Dizygotic 70%.
BY CHORIONICITY (Number of placenta):-
Monochorionic (shared placenta),
placenta Dichorionic (two
placentae)
placentae
It could be either Mono or Dizygotic, Placenta fused or
separate, and septum has four layers.
AMNIOCITY Number of amniotic sacs.
BY AMNIOCITY:-
One sac-
sac Monoamnionic (Monozygotic) and increase
chances of TTT Syndrome
Two Sacs-
Sacs Diamnionic,
Diamnionic these could be mono or
dichorionic, if dichorionic then either mono or dizygotic.
dizygotic
 TWIN GESTATION TYPE :-
D C D A, M C DA, M C - M A, CONJOINED
Plac No. 2 1 1 1
Amni No. 2 2 1 1
Incidence. 1:300 1:400 1:3000 1:50,000
Time of Cleav. 0-72 hrs 4 to 8days 912 days > 12 days.
Zygosity. Diz or Mo Monozy Monozy Monozy
Rela to Ferti Rx. Yes No No No
Risk of TTTS. X Yes Yes NA
Cord Entangle X X Yes NA
Cong Anomaly Low Medium High NA
Vasa Previa Low High High NA
Placenta Previa High High High High
Preterm Delivery High High High High
--------------------------------------------------------------------------------------------------------
Notes:- DC (Dichorionic), DA(Diamnionic), MC(Monochorionic),
MA(Monoamnionic),
DC- DA :- may be Dizygo if diff gender; Same gender Di or Monozygo
---------------------------------------------------------------------------------------------------------
 MZ twins (30%) a single fertilized ovum splits
into two distinct individual after a variable
number of division
Timing of egg division Determines placentation
in twins
DC DA placentation occurs with division prior
to the morula stage (within 3 days post
fertilization)
fertilization
MC DA placentation occur with division b/n
days 4 and 8 post fertilization
MC MA placentation occurs with division b/n
days 8 and 12 post fertilization
Division at or after day 13 results in
conjoined twins
 Monozygotic Twins
Different Scenarios of Cleavage

Scenario 1
Monozygotic twin pregnancy
Bi-chorial and bi-amniotic
If the separation takes place just after the first
cellular division [1st 3 days ] both of the twins
will have their own placenta and an amniotic sac
each.

Within 72 hours(1/3 Mz)

Inner cell mass, morulla, not formed=
Outer cell layer, blastocyst, is not commited to =
become chorion
 Scenario 2
Monozygotic twin pregnancy
.Mono-chorial and bi-amniotic

Separation can also take place a little later in

the development [4-8 days]
days of the embryonic
cells but before the blastocyte has defined
the roles of each cell.
cell
Twins will be in the same placenta, but they
will have 2 amniotic sacs.
The most serious problem with monochorionic placentas is local
. shunting of bloodalso called twin-twin transfusion syndrome
The possible communications are artery to artery, vein to vein, and
combinations of these. Artery-to-vein communication is by far the most
.serious; it is most likely to cause twin-twin transfusion
 Scenario 3
Monozygotic twin pregnancy
Mono-chorial & mono-amniotic

Separation takes place at the stage

when the amniotic bag is already
being formed [day 8-14]
8-14
Twins will be in the same placenta,
and in the same amniotic sac.
sac
Approximately 1 percent of monozygotic twins are monoamnionic.
monoamnionic Their
associated high fetal death rate may result from cord entanglement,
entanglement
congenital anomaly, preterm birth, or TTT syndrome, which is
described subsequently
 Conjoined Twins
If the division occurred
just after embryonic
disc formation,
incomplete or conjoined
twins will occur.
They may be joined
Anteriorly [thoracopagus
-commonest],
Posteriorly [pyopagus]
Cephalad [craniopagus] or
Caudal [ischiopagus].
 Dyzygotic twin pregnancy
Bi-chorial and bi-amniotic
Dyzygotic twins, are descended from a
double ovulation and a double
fertilization.
The 2 eggs are completely independent.
This configuration represents two thirds
of all twin pregnancies.
Superfucundation & Superfetation
Superfucundation:
Superfucundation
Fertilization of two ova produced in the same
menstrual cycle by two spermatozoa deposited in
two separate acts of coitus
May or may not be from the same man.
Superfetation:
Superfetation
Fertilization of two ova produced in two d/t
menstrual cycle by two separate spermatozoa
Not happen in human
Maternal Complications
Increased maternal mortality.
Increased pregnancy risks:
Anemia (15%):
(15%) due to iron deficiency or folic acid deficiency
Preeclampsia- eclampsia: 3x
Glucose intolerance
Threatened or actual abortion
Polyhydramnios (12%): acute:acute more in monozygotic than dizygotic
twins.
twins OR Chronic:
Chronic not related to type.
Mechanical effects:
effects with the uterus larger than period of amenorrhea;
it may be associated with dyspnea, dyspepsia, pressure on ureter
with increased UTI, supine hypotension syndrome, increased
varicosities and lower limb edema.
edema
Premature rupture of membranes
Antepartum hemorrhage:
hemorrhage both abruption (due to PIH and folic acid
deficiency) and placenta previa (due to large placenta).
Psychological: problem of caring, prolonged rest and hospitalization.
Malpresentation and malposition
 Increased labor risks:
Preterm labor (50%): which may be
spontaneous or induced Uterine dystocia.
dystocia
Abnormal fetal presentation.
presentation
Twins entanglement and locked twins
Cord accident, Cord prolapse
Vasa Praevia (due to vilamentous insertion
of the cord).
cord
Two Vessel cord (7% especially monozygotic)
monozygotic
N.B; 1% in singelton
Postpartum Hemorrhage
Puerperal Sepsis
Fetal / Neonatal Complications
Increased abortion rate:
Increased intra-uterine fetal death (IUFD):
More in MZ > DZ.
Vanishing twin syndrome: (incidence rate 21%)
Early death = Fetus compressus (papyraceous fetus).
Later death = macerated fetus.
Death during delivery:
First fetus: [prolapsed cord],
Second fetus: [ due to excess sedation, premature
separation of placenta, constriction ring ,dystocia,
operative manipulation, hypoxia].
 Single Fetal Demise...??
First trimester Fetal loss of a twin
Does not appear to impair the development of the surviving
twin.
Midgestation fetal death occurring after (17 weeks'
gestation)
Increase the risk of IUGR, preterm labor, preeclampsia and
perinatal mortality (17-50% in MC and if TTT)
TTT
Antenatal necrosis of the cerebral white matter has been
associated with the presence of IUFD of a co-twin , artery-to-
artery, and vein-to-vein anastomosis.
anastomosis
Prompt delivery following the death of a co-twin has not
been shown to prevent neurological injury
Delivery for the purpose of preventing injury should,
therefore, be weighed against the risks of premature
delivery.
 Increased perinatal mortality (10-20%):
More in monozygotic twins.
It is mainly related to low birth weight.
weight
It may be due to
Preterm delivery
IUGR with PIH
Hypoxia (placental or cord accident)
Operative manipulation: Birth trauma and CP
Congenital malformation.
Increased low body weight:
Neonates are lighter [due to preterm or IUGR],
More in monozygotic and with increased fetal
number
Twin to Twin transfusion
Vascular communication between 2
fetuses,
fetuses mainly in monochorionic;
MA or DA placenta (10% of
monozygotic twins),
Twins are often of different sizes:
Donor twin = small, palled,
dehydrated (IUGR), oligohydramnios
(due to oliguria), die from anemic
heart failure.
Recipient twin = plethoric,
edematous, hypertensive, ascites,
kernicterus (need amniocentesis for
bilirubin), enlarged liver,
polyhydramnios (due to polyuria),
die from congestive heart failure,
and jaundice. Hemoglobin
concentrations differ by >5g/dL.
Conjoined twins
Incomplete late division of monozygotic
twins produces conjoined twins.
Conjoined twins are connected at identical
points.
o Thoracopagus - Joined at chest (40%)
40
o Xiphopagus/omphalopagus - Joined at abdomen
(34%)
34
o Pygopagus - Joined at buttocks (18%)
18
o Ischiopagus - Joined at ischium (6%)
o Craniopagus - Joined at head (2%)
Intrauterine growth Retardation
Birth weights of twins, triplets,
triplets etc. are smaller than
weights of corresponding singletons.
singletons
Most of the deficit of birth weight occurs in the final
8-11 weeks of pregnancy.
Birth weight discrepancies of more than 20-25% are
considered discordant
The cause of discordant birth weights among twins is
the difference between each twin's placental surface
area or Twin to Twin Transfusion Syndrome (TTTS).
Discordant birth weights occur in 10% of twins.
Differentiation of twins
Sex:
Sex If of different sexes, obviously
binovular.
binovular
Placenta:
Placenta
If two separated placentae, will be binovular,
binovular
If one placenta, may be monovular or
binovular.
binovular
-Examine placenta in detail for Zygosity determination.
Blood groups:
groups If doubt in dichorionic types,
check the ABO, Rh, Duffy, Kell, MN and Ss.
Ss
Typing HLA histocompatibility antigen
Diagnosis
25% of antenatal diagnosis of twin is
missed
Twin should be suspected by history and
examination
It should be confirmed by U/S (as early
as 10 wks).
To decrease PNM, it should be early
diagnosed, properly assessed antenatally
and properly managed intranatally.
 Patient profile:
Etiological factors; with positive past history and
family history specially maternal.
maternal
Early pregnancy: Hyperemesis, bleeding.
Mid-pregnancy:
Greater weight gain than expected,
Abdominal size > period of amenorrhea,
Early PIH symptoms, persistent fetal activity.
Late pregnancy:
Pressure symptoms (dyspnea, dyspepsia, UTI, piles,
edema and varicose veins in LL).
 Examination
General:
General
An early increase weight gain, Pallor
Less mid-trimisteric fall blood pressure
Early PIH
Eary edema, and varicose veins in LL.
LL
Abdominal:
Abdominal
Fundal level > amenorrhea especially in mid-pregnancy
exclude other causes.
Palpation: Multiple fetal parts 3 poles, 2 heads, small head
in relation to uterine size, fetal movement all over abdomen.
identify presentations.
Auscultation of FHS:
2 d/t recordings by 2 observers and a difference > 10 bpm
a Gallop between 2 points [ Arnoux sign]
ECG.
Pelvic: Specially during the course of labor
Small presenting part compared to abdominal size
 POSITIVE SIGNS
Palpation of multiple fetal parts
- Two FHS at same time by two diff. observer
with difference of 10 beats /mt in rate.
rate
- USG in early or late preg, more than one sac
or fetus.
fetus Or X-ray in late preg.
preg Rule out :-
Molar preg, Hydramnious, and Tumor
Biochemical parameters:-
- Beta HCG Raised but not more than 100,000miu/ml
- MSAFP Twice high level than singleton preg.
:- SUGGESTIVE FINDINGS
.Persistent hyperemesis gravidarum-
.Large for date uterus-
.Family history of multiple gestation-
.Pregnancy after ovulation induction or ART-
.Rapid growth of uterus-
.Unexplained maternal wt gain-
 Ultrasonography
Confirm fetal number [ 2 sacs or 2 fetal heads in 2
perpendicular planes].
Two gestation sacs each containing a yolk sac ( >=5.5 weeks)
Two fetus with heart beats ( >=6 weeks)
Diagnosis of vanishing twin syndrome.
Diagnose type:
Mono- vs. dizygotic twins.
In all dizygotic and in 1/3 of monozygotic twins, the dividing membrane
between two sacs in twins comprises a double layer of chorion and amnion
from each sac (dichorionic - diamniotic), separated by a triangle-like tongue of
decidua extending from the fetal surface of the placenta.
placenta This is known as twin
peak (Lambda sign) which is pathognomonic for dichorionic placentation.
In monochorionic pregnancy, the dividing thin membrane of the two sacs
(made of 2 layers of amnion only) is inserted prependicular to the fetal surface
of the placenta. This is known as the Tau sign.
The width of dividing membrane is a less reliable sign to determine the
chorionicity.
 Ultrasonography
Exclude any malformation or conjoined twins
(especially at age > 35y = genetic amniocentesis)
amniocentesis
Diagnose their presentation and position and
relation to each other
Assess fetal well-being and growth pattern for
each (need serial US); [expected fetal weight,
IUGR and discordant growth if difference > 250
grams]
grams
Diagnose any liquor abnormality.
abnormality
Needed with other procedures
ECVs
Fetal reduction
Version manipulation during labor.
History
Family history of twins particularly on the maternal side.
History of ovulation inducing therapy.
Excess maternal weight gain
Breathlessness, palpitation during later months of pregnancy
Excessive vomiting, edema.
Physical finding
A parus woman may present as a big abdomen
Anemia,
PIH (Edema all over, hypertension, proteinuria)
Fundal height is large for date
Palpation of more than one head or breech
Two fetal heart beats heard at the same time by two observers
& differing in rate by at least 10 beats per minute.
Differential diagnosis big for date uterus
Wrong date,
Fetal macrosomia,
Polyhydraminos,
Molar gestation,
Tumor with the pregnancy (myoma and
ovarian tumors being the commonest),
Full bladder
Placenta previa
MANAGEMENT
ANTEPARTUM :- Care as high risk pregnancy.
pregnancy
Nutritional counseling: Consumption of energy source should be
increased by 300 kcal/day above that of singleton pregnancy
Iron (60 - 120 mg/day) & Folic acid supplementation (1mg /day)
More ANC Visits.
Visits
Extra rest & Early work leave.
leave
Counsel on danger signs of high risk preg.
Monitor for PIH / PE, Glucose intolerance
Counsel about headache, vision disturbance and epigastric pain.
Clinical/US Fetal monitoring for wellbeing.
More frequent BPP/NST when indicated.
Fetal movt counts.
counts Not reliable
Preterm labor:
labor tocholytic agents & steroid inj. <34wks indicated.
No VBAC.
VBAC
 Ultrasound for evaluation of: Placentation
(Amninionicity & chorionicity), Number of fetuses,
fetuses
fetal amniotic fluid,
fluid placental abnormalities,
abnormalities
Growth of each fetus & presence of congenital
anomalies.
Antepartum surveillance starting from 32
weeks of gestation weekly is indicated in
complicated multifetal gestation.
Techniques-
Modified biophysical profile,
Fetal movement counting (Cardiff's count to ten
method)
Timing of delivery
All twin gestations should be delivered by
40 weeks of gestation.
Fetal lung maturity should be assessed if
elective delivery is considered before 38
wks of gestation.
Note that Induction & augmentation of
labor are contraindicated in twins.
INTRAPARTUM CARE
Route of Delivery :

If twin B is a breech and the

estimated weight >1500gm
but <3500 gram vaginal
.delivery could be allowed
Intra-partum care when vaginal delivery conducted
All preparations should be made for resuscitation & special
care for babies of low birth weight.
Follow labor using partograph
First stage of labor
Admit in early labor
Open IV line with crystalloid
Ascertain fetal number, presentations, estimated fetal
weight &placental location..
Blood transfusion products should be readily available.
Close monitoring of FHR in all fetuses.
Augmentation is contraindicated before the delivery of
the first twin.
Use minimal analgesia for labor
Second stage of labor
Following the delivery of 1st twin, Cut the cord as far out
side the vagina as possible and clamp.
Determine the lie & presentation of the second twin.twin Look
for possible occult cord prolapse or cord entanglement.
If the vertex/breech is in or over the inlet and the uterus is
contracting artificial rupture of membranes (ARM) should be
done on the second sac.
If uterine inertia has set in, start Oxytocin drip following
amniotomy.
When either twin shows signs of persistent compromise &
vaginal delivery is not imminent, proceed promptly to
cesarean delivery.
Interval between deliveries should not be unduly delayed.
Third stage of labor
Third stage of labor should be managed actively
after the delivery the last fetus.
Examine the placenta for completeness, vascular
anomalies and communications, and zygosity (mono
or Dizygotic twin)
Monozygotic twins - commonly have a transparent (thin)
septum made up of 2 amniotic membranes only
(dividing membrane 2 layers)
layers (No chorion & no
decidua)
decidua
Dizygotic twins Always have an opaque (thick) septum
(septa has five layer) made up of 2 chorions, 2 amnions,
& an intervening deciduas.
deciduas
C.S. for Multiple Pregnancy:
Indications of C.S.
More than 2 viable fetuses, if:
Weight < 2 kg,
Discordant growth ( i.e.; IUGR or TTT, or disproportionate
twins, twin B larger than A (BPD > 2 mm),
Twin A: is non-vertex.
Conjoined Twins
Single amniotic cavity (as diagnosed by U/S or amniogram).
amniogram
Previous Uterine scar.
scar
During Labor:
Labor if delayed progress, fetal distress, or if
twin B transverse and cervix is thickened (retained
second twin).
twin
Associated pregnancy complication i.e.: severe PIH,
placenta previa.
Contracted Pelvis
Lack of expertise
INTRAPARTUM CARE CONTD
Following arrangements to be made:-
Electrical fetal monitoring recommended.
To have arrangements in health set up..
Obstetric Perinatology care,
Obstetric anesthesia services &
Neonatology care.
Labor & Delivery: Confirm fetal numbers and
presentations, fetal weight, and placental location.
location
Arrange minimum 2 units of blood.
E F M during labor if available.
Secure IV line with crystalloid.
 AFTER DELIVERY OF FIRST TWIN :-
- Cut cord as far out side vagina as possible & clamp.
clamp
- Hand over delivered fetus to assistant.
- Confirm lie and presentation of 2nd twin, look for cord.
cord
- Uterus contracting and presenting part at inlet-
inlet
Do ARM on second fore bag. bag
If uterine inertia sets in start Oxytocin drip following
amniotomy and deliver fetus.
- If fetal compromise detected and vag delivery not eminent
then emergency C/S .
- Delivery interval between two should not be >30min.
- Active management of third stage.
- Placenta is delivered after 2nd twin.
twin
 When either twin signs of fetal compromise and vaginal delivery is
not imminent, promptly C/S.
Interval between deliveries should not be more than 30 minutes.
Placental examination and zygosity determination.
Placenta/s delivered after both twins have been born.
Retained Twin B
The usual time interval between delivery of twin A
and B is 15-20 minutes and should not be more than
30 minute.
If there are facilities for proper monitoring this
interval may be increased
Indications of CS for Twin B
Transverse lie
Fetal Distress
Contracted cervix
Prolapsed cord
Premature Breech
Failed Extraction
POST PARTUM CARE :-
Oxytocin drip should be on after first twin delivered or start
after delivery of placenta.
Methyl ergometrin or inj. Prostaglandin should be available
if needed for managing PPH.
COMPLICATIONS :-
1. Delayed delivery of 2nd twin.
twin
2. Discordant twins:
twins A d/ce in EFW of > 20% b/n
twin A & B expressed as %age of the larger twins
weight.
3. Twin to Twin Transfusion Syndrome:-
Syndrome
1.In the presence of placental vascular connection, if the
twins have a Hgb d/ce > 5g/dl and birth weight d/ce >
20%,
20% TTTS can be diagnosed.
2.There will be Hydraminos in the larger twin (recipient),
oligohydraminos in a growth restricted fetus(donor).
3.Rx- serial amniocentesis for hydramnios.
4. Death Of One Fetus :-
Expectant management if diagnosed during labor.
No effort to arrest labor.
labor
If no labor : clotting profile every week, fetal surveillance.
surveillance
5. Conjoined Twin:-
Twin
Conjoint twin diagnosis should be considered under the following situations
Finding of single fetal heart in multiple pregnancy
Lack of engagement when the lie longitudinal
A persistent parallel lie in (Vrtex-vertex, breech-breech)
An abnormal fetal attitude.
Diagnosis : U/S , X-ray plane film, Amniography
Management
Refer to a higher level if the diagnosis is made earlier.
Cesarean section (Lower segment vertical incision/Classical)
Destructive operations:
operations When infant dead & part of the fetus has been
born.
6. Interlocking of Twins:-
Common in first twin by breech and second being Vertex.
Vertex
Collision, Impaction and Compaction:
Avoid strong traction & fundal pressure.
Push the second twin out of the pelvis under deep
anesthesia.
Then deliver the first & the second twin in the usual way.
If the method fails & babies are alive C/S.
Chin to chin interlocking:
Avoid traction of the first twin.
Unlock the chin under anesthesia & the second twin is
pushed out of the way.
If the first baby dies, break the locking by decapitating the
first twin, delivery of the head of the first baby by traction in
most cases cesarean section may be preferable.
TRIPLETS OR MORE NUMBER OF FETUSES
Always consider the possibility whenever multiple
gestation is suspected.
- In all pregnancies following ovulation inductions.
- Ultrasound or X-ray in 2nd or 3rd trimester.
- Ante partum and post partum as twins.
- Cesarean Section in all high order multiple pregs.
- Vaginal deliveries for Immature fetuses or
Cesarean if life endangering for woman.
woman
Selective Embryo Reduction
The presence of > 3 fetuses carries the risk of
losing them all (preterm delivery).
The number is reduced to twins only by
injecting potassium chloride intracardiac
under U/S guidance (about 1.5 ml of 15%
solution).
solution
Potassium chloride may diffuse and affect
other fetuses.