MULTIPLE PREGNANCY

THAM KER CHIA

Multiple Pregnancy
Defination: More than 1 fetus develop simultaneously in the uterus Twins account for about 1% of pregnancies, with two-thirds being dizygotic and one-third monozygotic Hellins law (88 n-1) - Twins 1 in 88 *Note: Apply for natural occurrence 2 - Triplets 1 in 88 of multiple pregnancy - Quadruplets 1 in 883

Predisposing Factors
Black race ( African-American race) Maternal age (35-39) and parity(>4) Assisted reproduction techniques - Ovulation induction agents (gonadotropins) - In-vitro fertilization (IVF) Strong Family history (Maternal) Weight and height (Obese women, especially those with a body mass index over 30 and taller women, above-average height)

Monozygotic/ identical/uniovular

Dizygotic/fraternal/ Binovular (2 ova fertilised by 2 sperms) ~67%

Dichorionic Diamniotic

(1 ovum fertilized by 1sperm; 1 zygote divide into 2) ~33%

DIchorionic DIamniotic
MONOamniotic DIamniotic MONOchorionic MONOchorionic

(seperation occurs <3days)

~30%

(4-8days) ~69%

(8-14days) ~1%

*after 14 days (embryonic pole formed): conjoined twins

Differences Ovum

Monozygotic Single

Dizygotic Double

Sperm
Sex Similarity Placental

Single
Same Identical One/Two

Double
Same/different Fraternal Two

Communicating vessel
Intervening membrane Thickness of membrane

Present
Absent in monoamniotic&monocho rionic < 2 mm

Absent
Present

> 2 mm

Twin peak/lambda

Absent

Present (Lambda

How To Determine Zygosity And Chorionicity

Zygosity
Ultrasound- Gender discordance = dizygotic DNA fingerprinting, from amniotic fluid sample (amniocentesis), placental tissue (chorionic villi sampling) and fetal blood (cordocentesis) Examining the placenta. If the babies have a single outer membrane, (the chorion) they must be monozygotic.

Chorionicity
Characteristic of membrane(US)- (DC):thick amnionchorion septum, inverted V at base of septum; (MC):Tsign, 1st trimester only can see Placental examination after delivery

Thick amnion-chorion septum, Inverted V, lambda sign (extension of placental tissue into the base of the intertwin membrane) ~dichorionic

Thin amnion-chorion septum , T ~monochorionic

 Perinatal mortality rate in twins is about 5 times higher than in singletons especially in monozygotic twins
Maternal

Complications

Antenatal: Anaemia (high demand,physiological) Hyperemesis gravidarum(hCG) Pre eclampsia/Eclampsia Miscarriage (increased pressure on the pelvic floor as fetal grow->pressure on cervix>cervix spontaneously and painlessly opens) Gestational) Diabetes (Human placental lactogen is higher ->increase insulin resistance Polyhydramnios (uniovular twins, TTTS) Fetal malpresentation APH (placenta praevia,polyhydramnios,sudden decompression of uterus) PPH (uterine atony,placenta praevia)
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 Fetal -Preterm labour

infections)

(overdistended uterus, polyhydromnios, intrauterine

Complications unique to MONOCHORIONIC twins: 1.Twin to twin transfusion syndrome

Cause: abnormal artery to vein vascular anastomosis which allows communication between the 2 fetoplacental circulation. Imbalance in flow leads to one twin donating blood to another. Diagnosis : usually at 16th week. difference in birth weight descrepency is >20% Monitor: US Doppler 2 weekly Donor: hypovolaemia, hypotension and hypoxia IUGR, smaller size, oligohydramnios & high ouput cardiac failure Recipient: hypervolemia and hypertension large size, polyhydramnios, cardiomegaly, CCF More than 90% ends in miscarriage/severe preterm delivery Mx Amnioreduction every 1 - 2/52, drain amniotic fluid from recipient sac - Septotomy(cord entanglement risk) - Laser/diathermy coagulation US guided on anastomotic vessels *- corticosteriods (high pre-term labour)

2. Discordant growth
Discrepancy of weight of 20% or more, noticed aft 24th weeks. Affects 15-20% of twins pregnancy Cause : -Unequal placental mass and genetic syndrome

3. Single fetal demise

If one twin dies in-utero<14 weeks, not affected After 14 weeks- risk of neurological damage resulting from transfer of thromboplastin from the dead twinocclude the ant/middle cerebral artery of living twin-> multicystic encephalomacia(formation of multiple cystic cavities of various sizes in the cerebral cortex). Better deliver twins aft 30 weeks

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4. Congenital anomalies
More frequent in twins of the identical gender and monochorionic twins Neural tube defects and congenital heart diseases

5. Conjoined twins
1. 1 in 200 pregnancies Thoracophagus: fusion at the chest (40%) Omphalophagus: fusion at the anterior abdominal wall (33%) Pyophagus: fusion at the buttocks (18%) Ischiophagus: fusion at the ishcium (6%) Craniophagus: fusion at the heads (2%)

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6. Twin Reversed Arterial Perfusion Syndrome(TRAP)

Disruption of normal vascular perfusion and dev of one twin (recipient) due to an umbilical arterioarterio anastomosis w the other (donor or pump) twin 1 twin acardiac Receives all its blood from normal twin(pump twin) Pump twin high risk for heart failure Acardiac twin incompatible w life Dx by US Tx- (save pump twin, let go the other)
When pump twin mature enough, deliver. Stop blood flow to the acardiac twin by occlusion of the blood flow to the acardiac twin by endoscopic ligation or laser coagulation of the umbilical cord

Monoamniotic twin pregnancies (umbilical

cord entanglement (The close proximity and absence of amniotic membrane separating the two umbilical cords -> easy for the twins to entangle in each others cords, hindering fetal movement and development),congenital abnormalities,preterm labour, TTTS, Cord compression(One twin may compress the others umbilical cord))

Dx of Multiple pregnancy
Hx FHx, recent infertility treatment, excessive symptoms of pregnancy, leg swelling and varicosities, breathlessness or palpitation, excessive fetal movement and overdistended abdomen Physical exm Abdomen larger than dates, anaemia, oedema, multiple fetal poles palpable, fetal heart rate heard at multiple sites, polyhydramnios and abnormal weight gain.

Investigations
Ultrasound scan: 1. Confirmation of the number of fetus 2. Determine uniovular or biovular 3. Determine chorionicity 4. Accurate measurement of gestational age 5. Fetal heart activity (6/52) 6. Exclude placenta praevia 7. Detect twin to twin transfusion syndrome (uniovular) 8. Detect fetal abnormalities (2nd) 9. Malpresentation & IUGR (3rd)

Management
Antepartum: Visits should be 4-weekly until 28 weeks,
twice-weekly until 32 weeks, then weekly

Mother:
1st trimester: for diagnose number of fetuses,

chorionicity, dating of the pregnancy and major fetal abnormalities 2nd trimester: detect fetal abnormalities Diet reassessed to increase nutrients haematinics & adequate physical rest
3rd trimester, prevention of prematurity, monitored for signs of pre-eclampsia. Labour determine presentation and position

Indications of caesarean section Elective c. sec Emergency c. sec

Triplet pregnancy or more Malpresentation in the leading fetus esp. transverse or oblique Conjoined twin Congenital abnormality Chronic twin-twin transfusion syndrome in monochorionic twin Severe pre-eclampsia Monoamniotic twin IUGR in twin Previous caesarean section Placenta praevia Fetal distress Cord prolapsed in first baby Non-progress in labour Locking of twins (collision or interlocking) 2nd twin transverse, version failed after delivery of the first twin

Intrapartum
1. Experienced anaesthetist, 2 obstetricians, 2 paediatricians & special baby care unit must be present 2. a) Mother should be kept nil by mouth (chances of operative delivery is high) b) Maintained hydration and nutrition by IV drip c) Continuous fetal monitoring Internal CTG for the 1st twin External CTG for the 2nd twin 3. Epidural anaesthesia recommended 4. Blood grouped & cross matched 5. Vaginal delivery unless indicated caesarean section 6. Umbilical cord cut, tied and identified after 1st delivery 7. Prophylactic syntocinon infusion to reduce PPH 8. PE(Fetal lie), VE(membrane status and cord prolapse) 9. For 2nd delivery: Longitudinal lie->vaginal delivery or instrumental assistance. Transverse lie: External version, internal podalic version(1 hand into uterine cavity, identify fetal heel then grap it and executing breech extraction) , or emergency caesarian section

Intrapartum Management

3rd Stage To Prevent PPH

After delivery of the anterior shoulder of the 2nd twin, ergometrine is given to the mother IM injection. Placenta to be delivered via controlled-cord traction. After delivery of placenta : Continuous uterine massage IM carboprost should be given Large placental site and excessive uterine distension with consequent uterine atony Intravenous syntocinon infusion is continued until uterus is well contracted Blood transfusion if necessary

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