Multiple pregnancies can involve twins, triplets or more. Twin pregnancies are the most common type of multiple pregnancy and can be either dizygotic (fraternal) or monozygotic (identical). Dizygotic twins result from fertilization of two eggs while monozygotic twins result from fertilization and splitting of a single egg. Risk factors for twin pregnancies include increasing maternal age, parity, infertility treatments and genetics. Complications can include preterm birth, low birth weight, fetal growth issues and birth defects. Care involves frequent monitoring and deciding whether vaginal delivery is possible based on fetal positioning.

1. MULTIPLE
PREGNANCY
FAHAD ZAKWAN

2. DEFINITION
• Multiple pregnancy- occurs when more than one fetus
simultaneously develop in the uterus.
• Twin pregnancy- Is the simultaneous development of
two fetuses.
• Although rare, Development of three fetus (triplets),
four (quadruplet), five(quintuplets), six (sextuplets)
may also occur.

3. TWIN PREGNANCY
• Twin pregnancy is the commonest variety of multiple
pregnancy.
• It is of two types:
1. Dizygotic twins (80%),which results from fertilization of two
ova leading to fraternal twin.
2. Monozygotic twins(20%),which results from fertilization of
one ova leading to identical twin.

5. RISK FACTORS OF TWIN
PREGNANCY
1. Increasing maternal age (30-35yrs)
2. Increasing parity (5 gravida onwards)
3. Nutritional factors
4. Pituitary gonadotropin
5. Infertility therapy
6. Assisted reproductive therapy
7. Genetic, hereditary
8. Race, b>w

6. Genesis of dizygotic twins
Results from Fertilization of two ova,
mostly likely rupture from two distinct
graafian follicles usually of the same or
one from each ovary, by two sperms
during single ovarian cycle.

7. •There are two placentae either completely
separated or more commonly fused at the
margin
•Each fetus is surrounded by a separate amnion
and chorion.
•Sex of the fetus may differ.
•Genetic features(blood group, finger prints)also
differs.

8. Genesis of monozygotic
•The twinning may occur at different
periods after fertilization.
•If the division takes place within 72hours
after fertilization (prior to morula stage)
resulting embryos will have two separate
placenta, chorion, amnions (diamniotic-
dichorionic)

10. •If the division takes place between 4th and 8th day
after the formation of inner cell mass when chorion
has arleady developed - diamniotic monochorionic
twins develop.
•If division occurs takes place after 8th day of
fertilization when amniotic cavity has arleady formed
(monoamniotic monochorionic twins)
•Division after two weeks of davit of embryonic disc
resulting in the formation of conjoined twin.

12. DIZYGOTIC TWINS
•Most common represents 2/3 of cases.
•Fertilization of more than one egg by more than
one sperm.
•Non identical ,may be of different sex.
•Two chorion and two amnion.
•Placenta may be separate or fused.

13. MONOZYGOTIC TWINS
•Constant incidence of 1:250 births.
•Not affected by heredity.
•Not related to induction of ovulation.
•Constitutes 1/3 of twins.
•70% are diamniotic monochorionic.
•30% are diamniotic dichorionic.

14. Results from division of
fertilized egg:
0-72 H. Diamniotic dichorionic.
4-8 days Diamniotic monochorionic.
9-12 days Monoamnionic
>12 days Conjoined twins.

15. Diagnosis of twins
pregnancy
HISTORY
1.History of ovulation inducing drugs
2.Family history of
twinning(maternal side)

16. Diagnosis of twins pregnancy
SYMPTOMS
• Minor ailments of normal pregnancy are often exaggerated. Some of
the symptoms are related to the undue enlargement of the uterus:
I. Increased nausea and vomiting in early months
II. Cardiorespiratory embarrassment – palpitations, shortness of
breath.
III. Tendency of swelling of legs, varicose veins and haemorrhoids is
greater.
IV. Unusual rate of abdominal enlargement and excessive fetal
movement may be noticed.

19. Diagnosis of twins pregnancy
GENERAL EXAMINATION:
1. increased prevalence of anemia
2. Unusual weight gain not explained by
preeclampsia or obesity
3. Evidence of preeclampsia is a common
association

20. Diagnosis of twins pregnancy
ABDOMINAL EXAMINATION
1. Elongated shape of normal pregnant uterus is changed to a more
barrel shape and the abdomen is unduly enlarged
2. Height of the uterus is more than gestation age.
3. Fetal bulk seems disproportionally larger in relation to the size of
fetal head.
4. Palpation of too many fetal parts
5. Finding two fetal heads.
6. Two distinct fetal heart sounds at separate spots with a silent area
in between.

21. Diagnosis of twins pregnancy
INVESTIGATION
1. SONOGRAPHY
•Separate gestational sacs can be identified early
in twin pregnancy
•Two fetal heads or two abdomens should be seen
in the same plane, to avoid scanning the same
fetus twice and interpreting it as twins.

22. Radiologic Examination
Not useful and may lead to an incorrect diagnosis
Biochemical Test
Amounts of chorionic gonadotropin in plasma and in
urine, on average, are higher than those found with a
singleton pregnancy, but not so high as to allow a
definite diagnosis of multiple fetuses

23. DDx. of multiple fetus
In women with a uterus that appears large for gestational age, the
following possibilities are considered:
1. Elevation of the uterus by a distended bladder
2. Inaccurate menstrual history
3. Big baby
4. Hydramnios
5. Ascites with pregnancy.
6. Hydatidiform mole
7. Uterine myomas
8. A closely attached adnexal mass

24. Complications of twin pregnancy
Maternal
During pregnancy
1. Exaggerated early symptoms (nausea, vomiting)
2. Increased miscarriage risk
3. malpresentation
4. Increased minor disorders of pregnancy (back-ache, leg pain, inability to walk
properly,hemorrhoides,palpitations dyspnoea and varicosities)
5. Anemia and placenta previa
6. Preterm labor and delivery (PTL)
7. Risk of hypertensive disease
8. Ante partum hemorrhage (APH)

27. During labour
1. PROM
2. cord prolapse
3. Prolonged labour
4. Increased op interference
5. Bleeding (intrapartum) - IPH
6. PPH

28. During puerperum
1. Subinvolusion
2. Increased risks of
infections
3. Lactation failure

29. Complications to fetus
1. Still birth/ neonatal death
2. abortion
3. Single fetal death in twin pregnancy
4. IUGR (intrauterine growth restriction)
5. SGA (small for gestational age)
6. Higher risks of congenital anomalies

30. Complications to fetus
1. Risk of cord accidents
2. Chorionicity
3. Risk of asphyxia
4. Operative vaginal delivery
5. Twin entrapment (during delivery)

31. Congenital anomalies in twin
pregnancy
1. NTD (neural tube defects)
2. Cardiac anomalies
3. Bowel Atresia
4. Conjoint twins
5. TRAP sequence (twin reversed arterial
perfusion)

33. ACARDIAC TWIN
 Twin reversed-arterial-perfusion (TRAP) sequence is a rare (1 in
35,000 births) but serious complication of monochorionic,
monozygotic multiple gestation.
 In the TRAP sequence, there is usually a normally formed donor twin
who has features of heart failure as well as a recipient twin who lacks
a heart (acardius) and various other structures.
 Caused in the embryo by a large artery-to-artery placental shunt,
often also accompanied by a vein-to-vein shunt.
 The perfusion pressure of the donor twin overpowers that in the
recipient twin, who thus receives reverse blood flow from its twin
sibling.

35. TWIN TO TWIN TRANSFUSION
 Blood is transfused from a donor twin to its recipient sibling such that
the donor becomes anemic and its growth may be restricted,
whereas the
 Recipient becomes polycythemic and may develop circulatory
overload manifest as hydrops.
 Donor twin - pale, recipient sibling – plethoric
Fetal consequences:
 circulatory overload with heart failure
 Occlusive thrombosis is also much more likely to develop in this
setting.
 Polycythemia may lead to severe hyperbilirubinemia and kernicterus

36. Pathophysiology:
• Presence of solitary, deep arteriovenous channels
within the capillary beds of the villous tissue.
• Velamentous umbilical cord insertion may contribute
to the development of unequal fetal blood volumes
because the membranously inserted cord can be
easily compressed, restricting blood flow to one twin.

37. Diagnosis:
 postnatal diagnosis:
1. weight discordancy between twins of 15 – 20%
2. hemoglobin level difference of 5 g/dL or greater
 Typically presents in the midtrimester when the donor fetus becomes oliguric
due to decreased renal perfusion.
 Develops oligohydramnios, and the recipient fetus develops severe hydramnios,
presumably due to increased urine production.
 Virtual absence of amniotic fluid in the donor sac prevents fetal motion, giving
rise to the descriptive term stuck twin.
 Hydramnios–oligohydramnios combination can lead to growth restriction,
contractures, and pulmonary hypoplasia in one twin, and premature rupture of
the membranes and heart failure in the other.

38. Management:
•amnioreduction
• septostomy
•laser ablation of vascular
anastomoses
•selective feticide

39. DISCORDANT TWINS
 Size inequality of twin fetuses, which may be a sign of pathological growth
restriction in one fetus, is calculated using the larger twin as the index.
 As the weight difference within a twin pair increases, perinatal mortality
increases proportionately.
 Restricted growth of one twin fetus usually develops late in the second and
early third trimester and is often asymmetrical.
 Earlier discordancy is usually symmetrical and indicates higher risk for fetal
demise.
 The earlier in pregnancy discordancy develops, the more serious the
sequelae.

41. Pathology
•In monochorionic twins, discordancy is usually
attributed to placental vascular anastomoses
that cause hemodynamic imbalance between
the twins.
•Dizygotic fetuses may have different genetic
growth potential, especially if they are of
opposite genders.

42. Diagnosis
•Weight of larger twin minus weight of smaller
twin, divided by weight of larger twin.
•Most useful index of size discordancy -
ultrasonographic assessment of twin discordancy:
abdominal circumference superior to head
circumference, femur length, or transverse
cerebellar diameter

43. Management
• Ultrasonographic monitoring of growth within a twin pair has become
a mainstay in the management.
• Other ultrasonographic findings, such as oligohydramnios, may be
helpful in gauging fetal risk.
• Depending on the degree of discordancy and the gestational age, fetal
surveillance may be indicated, especially if one or both fetuses exhibit
growth restriction.
• Delivery is usually not performed for size discordancy alone, except
occasionally at advanced gestational ages.

44. DEATH OF ONE FETUS
 Prognosis for the surviving twin depends on the gestational age at the time
of the demise, the chorionicity, and the length of time between the demise
and delivery of the surviving twin.
 Early demise such as a "vanishing twin" does not appear to increase the
risk of death in the surviving fetus after the first trimester.
 Later in gestation, the death of one of multiple fetuses could theoretically
trigger coagulation defects in the mother.
 Management decisions should be based on the cause of death and the risk
to the surviving fetus.
 Majority of cases of a single fetal death in twin pregnancy involve
monochorionic placentation.

45. Antenatal management
• Diet-about 350kcal/day
• Increased rest at home and early cessation of work
• Increased number of antenatal visit
• Supplementally therapy-Fe increase 100-200mg/day,
vitamins, calcium and folic acids
• Uss- frequent after every 3-4 weeks

46. •Pre term labour at a GA of less than
34weeks -give corticosteroids.
•Note: twins develop pulmonary maturity
3-4 weeks earlier than singleton

47. Management during labour
• Vaginal delivery-both or at least one baby in vertex
presentation.
• Bed rest-prevent early rupture of membrane
• Fetal monitoring (electronic)
• Internal examination should be done soon after the
rupture of the membrane to exclude cord prolapse
• Ringers lactate and 1 unit for BT-ready

48. DELIVERY OF TWIN FETUSES
Complications of labor and delivery
•preterm labor,
•uterine contractile dysfunction
•abnormal presentation, prolapse of the umbilical
cord
•premature separation of the placenta
•immediate postpartum hemorrhage

49. Method Of Delivery
Vertex- Vertex (50%)
Vaginal delivery, interval between twins not to
exceed 20 minutes.
Vertex- Breech (20%)
Vaginal delivery by senior obstetrician

50. Breech- Vertex( 20%)
Safer to deliver by CS to avoid the rare
interlocking twins( 1:1000 twins ).
Breech-Breech( 10%)
Usually by CS.

51. Vaginal Delivery
• When the first twin is cephalic, delivery can usually be accomplished
spontaneously or with forceps.
• As in singletons, when the first fetus presents as a breech, major
problems are most likely to develop if:
- fetus is unusually large and the aftercoming head is larger than the
capacity of the birth canal.
- Fetus is sufficiently small so that the extremities and trunk are
delivered through a cervix inadequately effaced and dilated to allow
the head to escape easily.
- umbilical cord prolapses.

52. 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.

53. Vaginal Delivery of the Second Twin
If the fetal head or the breech is fixed in the birth:
 moderate fundal pressure is applied and membranes are ruptured.
 digital examination of the cervix is repeated to exclude prolapse of the
cord.
 Labor is allowed to resume, and the fetal heart rate is monitored.
 With reestablishment of labor there is no need to hasten delivery unless a
nonreassuring fetal heart rate or bleeding develops.
 If contractions do not resume within approximately 10 minutes, dilute
oxytocin may be used to stimulate contractions.

54. Vaginal Delivery of the Second Twin
 If the occiput or the breech presents immediately over the pelvic inlet but
is not fixed in the birth canal
 Presenting part can often be guided into the pelvis by one hand in the
vagina while a second hand on the uterine fundus exerts moderate
pressure caudally.
 Alternatively, an assistant can maneuver the presenting part into the pelvis
using ultrasonography for guidance and to monitor heart rate.
 It is essential to have an obstetrician skilled in intrauterine fetal
manipulation and an anesthesiologist skilled in providing anesthesia to
effectively relax the uterus for vaginal delivery of a noncephalic second
twin to obtain a favorable outcome.

55. Interval between First and Second Twins
•The American College of Obstetricians and
Gynecologists (1998) has determined that the
interval between delivery of twins is not critical
in determining the outcome of the twin
delivered second.

56. Cesarean Delivery
 The American College of Obstetricians and Gynecologists (1998) has
concluded that, in general, cesarean delivery is the method of choice
when the first twin is noncephalic.
 It is important to place patients in a left lateral tilt so as to deflect the
uterine weight off the aorta to avoid hypotension.
 The uterine incision should be large enough to allow atraumatic
delivery of both fetuses.
 It is important that the uterus remain well contracted during
completion of the cesarean delivery and thereafter.
 Remarkable blood loss may be concealed within the uterus and
vagina and beneath the drapes during the time taken to close the
incisions.

57. Delivery of the first baby
• Babies are small-pose less difficulties
• Forceps delivery-if necessary should be under
pudendal block anaethesia,avoid general Anaesthesia
as the 2nd baby may be subjected effect of prolong
Anaesthesia.
• Don’t give ergometrine
• Leave 8-10cm of the cord for admn of any drugs or
transfusion

58. Delivery of the second baby
•After delivery of the first baby,the lie,
presentation and size of the second baby is
ascertained through abdominal examination
•Perform vaginal exam to exclude cord prolapse
and ascertain membrane status
•Delivery the second baby as required

59. Special case
• Twins with previous scar
• Trial of scar if twins has a first vertex should not be an absolute
contraindication
• Judicious external or internal manipulations are not contraindicated
• Prefer caesarean if tranverse / breech
• Success rate 30-75%
• Risk of uterine rupture is the same as in a singleton pregnancy

60. Complications of monochorionic
twins
Twin-twin transfussion syndrome (TTTS)
Dead fetus syndrome, survived twn-cereblal
palsy,microcephaly,DIC
Twin reverse arterial perfusion (TRAP)
Conjoint twins-
Anterior (thoracopagus)
Posterior (pygopagus)
Cephalic (craniopagus)
Caudal (ischiopagus)