2. • A multiple birth is the
culmination of one
multiple pregnancy,
wherein the mother
delivers two or more
offspring.
• A multiple pregnancy
from a single zygote is
called monozygotic, from
two zygotes is
called dizygotic, or from
two or more zygotes is
called polyzygotic.
3. Introduction
• Dizygotic twin rates have been increasing due
to ART, increasing maternal age, high parity,
black race and maternal family history.
• Triplets and higher order multiples are
increased three fold.
• Current incidence is 15.3/1000 maternities.
• Monozygous twinning rates are fairly
constant.
5. Fetal risks
• Perinatal mortality
• Preterm birth
• Intrauterine growth restriction
• Single fetal death
• Fetal anomalies
• Other fetal risks: cord accidents as cord prolapse, cord
entaglement.
Monochorionic twins have increased fetal loss rates due to
twin-twin transfusion syndrome.
6. Classification
• Based on,
• 1. number of fetuses: twins, triplets,
quadruplets.
• 2. number of fertilized eggs: zygosity
• 3. number of placentae: chorionicity
• 4. number of amniotic cavities: amnionicity
7. Dizygotic twins
• Non-identical or fraternal twins.
• Fertilization of two separate eggs.
• They have two functionally
separate placentae (dichorionic),
separate amniotic cavities
(diamniotic) and separated by
thick 3-layer membrane (fused
amnion in middle with chorion on
either side).
• Same sex or different sex.
8. Monozygotic twins
• Identical twins
• Fertilization of single egg and are always same
sex pairings.
• May have single or double placenta
• May have single or double amniotic cavities
• Dividing membrane is thin.
11. Complications of multiple pregnancy
• miscarriage and preterm delivery
1. Average gestational age is 37 weeks
2. Risk is higher in monochorionic twins as
compared to dichorionic twins. (twice
higher)
12. Perinatal mortality
• 5.5 times higher than singletons.
• Risk is higher with monochorionic twins.
• Mostly due to prematurity. However in
monozygotic twins, the additional risk is due
to unique complications of placenta.
13. Death of one fetus in twin pregnancy
Dichorionic twins
• In first trimester: Vanishing
twin phenomenon.
• 2nd-3rd trimester: may result
in preterm labour or may go
upto term uneventful.
• DIC is rare.
Monochorionic twins
• Immediate Co-twin death
(30%)
• Immediate Brain damage
with subsequent
neurodevelopment
handicap.
14. Fetal growth restriction
• 25% risk in DC twins,
50% in MC.
• Risk of FGR is increased
in twins
• The main aim of
management is to
decide time of delivery
and also to avoid
complications related to
premature delivery.
15. Fetal abnormalities
• Risk is twice in DC twins.
• Risk is 4 times in MC
twins due to vascular
events during
embryogenesis.
• Management options are
expectant, selective
fetocide by intracardiac
injections and cord-
occlusion techniques.
18. TTTS contd
• Presents in second trimester.
• Mother complaints of sudden increase in
abdominal girth
Ultrasound is diagnostic.
Management: amniocentesis, Septostomy,
Laser occlusion of A-V communication.
19. Differential diagnosis of multiple
pregnancy
• Large for dates
• Polyhydramnios
• Uterine fibroids
• Urine retention
• Ovarian masses
20. Antenatal management
• Early booking:
– determination of chorionicity best in late first
trimester.
– Screening for fetal abnormality: NT measurement at
12 weeks gestation is screening test of choice.
• Monitoring for fetal growth and well being by
serial ultrasound.
• TVS for cervical length at 20-24 weeks.
• Routine folic acid and iron supplements
• Vigilant screening for PE, GDM.
21. Threatened preterm labour
• Steroid therapy for lung maturation
• Counselling for risk and management of
preterm labour.
• No role of tocolysis.
22. Intrapartum management
• Increased risk of malpresentation, cord
prolapse, abruptio placentae, postpartum
hemorrhage.
• Fetal monitoring with ultrasound, CTG.
• Two neonatal trolleys, two obstetricians, two
paediatricians
• Prophylaxis for PPH ready
• Epidural analgesia is recommended.
23. Indications of caeserean section in
twin pregnancy
• First non-vertex presentation
• Previous caeserean section
• Monochorionic twins.
24. Higher multiples
• Antenatal care is similar
to twins.
• Caeserean section is
recommended.
• Highetened risk of
preterm labour and all
other complications of
pregnancy
• In quadruplets and higher
order, multifetal
reduction is acceptable.
