Multiple Pregnancy

1. MS AGNES MAHIMA DAVID
M.Sc. Nursing

2.  DEFINITION
When more than one fetus simultaneously
develop in the uterus
Twin = 2 fetus
Triplets =3 fetus
Quadruplets =4 fetus
Quintuplets = 5 fetus
Sextuplets =6 fetus
Septuplets =7 fetus

3. Hellin’s Law:
Twins: 1:89
Triplets: 1:892
Quadruplets: 1:893
Quintuplets: 1:894
Conjoined twins: 1 : 60,000
Worldwide incidence of monozygotic - 1 in 250
Incidence of dizygotic varies & increasing

4. • Race: most common in Negroes
• Age: Increased maternal age
• Parity: more common in multipara
• Heredity - family history of multifetal
gestation
• Nutritional status – well nourished women
• ART - ovulation induction with clomiphene
citrate, gonadotropins and IVF
• Conception after stopping OCP

5. TWINS
Simultaneous development of two fetuses is
the commonest variety of multiple pregnancy
VARIETIES
1. Binovular twins :it is the commonest variety
of multiple pregnancy (two third) and
results from the fertilization of two ova
2. Uniovular twins : (one third ) results from
the fertilization of the single ovum

6.  GENESIS OF TWINS
1. Binovular twins: (fraternal,dizygotic )results from
fertilization of two ova
 most likely ruptures from two distinct graffian follicles
usually of the same or one from each ovary by two
sperms during a single ovarian cycle
 Their subsequent implantation and development differ
little from those of a single fertilized ovum
 The babies bear only fraternal resemblance to each other

8. UNIOVULAR TWINS (identical ,monozygotic )
 They develop from the fusion of one oocyte and
one spermatozoon which after fertilization splits
into two
 These twins will be of the same sex and have the
same genes ,blood group and physical features
• Upto 3 days - diamniotic-dichorionic
• Between 4th & 7th day - diamniotic
monochorionic - most common type
• Between 8th & 12th day- monoamniotic-
monochorionic
• After 13th day - conjoined / Siamese twins.

11. CONJOINED TWINS
Ventral:
1) Omphalopagus(abdomen
2) Thoracopagus
3) Cephalopagus(head n chest
4) Caudal/ ischiopagus(pelvis
Lateral:
1) Parapagus(trunk)
Dorsal:
1)Craniopagus,(head)
2)Pyopagus(base of spine)

12. Superfecundation
Fertilization of two different ova released in the
same cycle
Superfetation
Fertilization of two ova released in different
cycles

13. Monozygotic twin Dizygotic twins
 2 ova + 2 sperm
 Same or opposite sex
 Fraternal resemblance
 Double or s/t fused
 Different genetic
features
 DNA microprobe -
different
 1 ova + 1 sperm
 Same sex
 Identical features
 Single or double
placenta
 Same genetic features
 DNA microprobe -
same

14. • HISTORY:
I. History of ovulation inducing drugs specially
gonadotropins
II. Family history of twinning (maternal side).
• SYMPTOMS:
i. Hyperemesis gravid rum
ii. Cardio-respiratory embarrassment - palpitation
or shortness of breath
iii. Tendency of swelling of the legs,
iv. Varicose veins
v. Hemorrhoids
vi. Excessive abdominal enlargement
vii. Excessive fetal movements

15. GENERAL EXAMINATION:
I. Prevalence of anaemia is more than in
singleton pregnancy
II. Unusual weight gain, not explained by pre-
eclampsia or obesity
III. Evidence of preeclampsia(25%)is a common
association.
ABDOMINALEXAMINATION:
Inspection:
• The elongated shape of a normal pregnant
uterus is changed to a more "barrel shape” and
the abdomen is unduly enlarged.

16. • Palpation:
 Fundal height more than the period of
amenorrhoea girth more than normal
 Palpation of too many fetal parts
 Palpation of two fetal heads
 Palpation of three fetal poles
• Auscultation:
Two distinct fetal heart sounds with
Zone of silence
10 beat difference

17.  Hydramnios
 Macrosomia
 Fibroid with pregnancy
 Ovarian tumor with pregnancy
 Adenexal mass with pregnancy
 Ascites with pregnancy
 Molar pregnancy

18.  Sonography: In multi fetal pregnancy it is done to
obtain the following information:
i. Suspecting twins – 2 sacs with fetal poles and cardiac
activity
ii. Confirmation of diagnosis
iii. Viability of fetuses, vanishing twin
iv. Chorionicity – 6 to 9 wks ( single or double placenta,
twin peak sign in d /d gestation or Tsign in m/d )
v. Pregnancy dating, Fetal anomalies
vi. Fetal growth monitoring (at every 3-4 weeks interval)
for IUGR

19. i. Presentation and lie of the fetuses
ii. Twin transfusion (Doppler studies)
iii. Placental localization
iv. Amniotic fluid volume
 Radiography
 Biochemical tests: raised but not diagnostic
Maternal serum chorionic
gonadotrophin,
Alpha fetoprotein
Unconjugated oestriol

20.  Maternal
Pre
eclampsia
During
Pregnancy
APH
mechanical
distress
pre term
labor
Hydraminos
Nausea &
vomiting
malpresentation
Anemia

21. During
labor
Bleeding
PPH Cord
prolapse
Early rupture
of
membranes
Increased
operative
interference

22. During
puerperium
Infection
Failing
lactation Sub-
involution
anemia

23.  Fetal
Miscarriage
rate is
increased
Fetal
anomalies
Discordant
twin
growth
Premature
StillbirthAsphyxia
Intrauterine
death

24. Antenatal
 Diet
 Increased rest
 Supplement therapy
 Interval of antenatal visit
 Fetal surveillance

25. Labor
Vaginal is allowed when both the twins are /or at
least the first twin is vertex presentation
1st stage
• A skilled obstetrician should be present
• Neonatologist (two)
• Presence of ultrasound in the labor room
• Patient should be in bed
• Use of analgesic drugs
• Careful fetal monitoring
• Internal examination should be done
• i/v line with ringer solution