This document discusses multiple gestation pregnancies. It notes that twins occur in 15 per 1000 births, with monozygotic twins occurring in 3.9 per 1000. Risk factors for multiples include family history, increasing maternal age and parity, previous multiples, and assisted reproduction. Determining chorionicity is important as it affects risks. Ultrasound can identify the number of chorionic layers and placental masses. Complications of multiples include preterm birth, growth restriction, and congenital anomalies. Monochorionic twins additionally face risks of twin-twin transfusion syndrome and twin reverse arterial perfusion sequence.

1. MULTIPLE GESTATION
Dr. Sana Javed
Gynae & Obs Unit-II

2.  1 – Singleton
 2- Twins
 3 – Triplets
 4- Quadruplets
 5- Quintuplets
 6- Sextuplets

3. INCIDENCE
 Twins - 15/1000
 Monozygotic 3.9 /1000
 Triplets - 1/5000

5. Predisposing Factors
 Family History Autosomal Dominant , Maternal
 Increasing Parity
 Previous Multiple Pregnancy
 Increasing Maternal Age Raised FSH
<20yrs : 6/1000
>35yrs : 22/1000
>45yrs : 57/1000

6.  Ethinicity varying GnRh Levels with height and
built
Japan 7/1000 low
Nigeria 40/1000 raised
 Assisted Reproduction Techniques raised upto 8 fold
Clomiphene – 10 %
IUI - 10-20%
IVF with 2 embryo transfers – 20-30%

8. Dizygotic Twins 2/3rd
Monozygotic twins 1/3rd
2/3rd – Monochorionic Diamniotic
1/3rd - Monochorionic Monoamniotic – 1%

11. Determination Of Chorionicity
WHY EMPHASIZED ?
HOW IT IS DONE ?
WHEN IT IS DONE ?

12. Role Of Ultrasonography
 No. of constituent layers of dividing membranes
 Qualitative interpretation of membranes
 Twin Peak Sign - Dichorionic
 Presence of single placental mass or more .

20.  11-14 weeks - Chorionicity
 16-20 weeks - sex determination (medical reasons)
 18-24 weeks – mid trimester anomaly scan
 4 weekly scan - Dichorionic from 24 weeks onwards
 2-3 weekly interval – Monochorionic from 16-18 weeks

21. Physiological Adaptations
 Increased Plasma Volume 1/3rd more than singleton
 RBC mass 300 more than singleton
 Decreased PVR more drop in diastolic BP
 Increased Trophoblastic turnover - more PIH and Pre-eclampsia
 Increased GFR
 Iron and Folate stores utilization > 40%
 Deviation from natural course will pose risks and develop complications

22. RISKS ASSOCIATED
 High Risk Pregnancy


25.  Congenital Malformations
Specific Conjoined Twins
Frequent NTDs, Cardiac, GI atresias
 Early Fetal demise
First Trimester Miscarriges – Vanishing Twin 20%
Second Trimester Loss – Fetus Papyraceous
 Risk Of Down Syndrome
DC - double the risk of Maternal age
MC - Risk related to maternal age

26.  Risk Of Aneuploidy
DC – Age related risk
MC – average of the age related risk
 Intra-Uterine Fetal Death 2 - 7%
increased risk by 38 weeks
 Intra Uterine Growth Restriction 25%

27. Singleton Twins Triplets
Perinatal Mortality 5/1000 18/1000 53/1000
Intrauterine Death 8/1000 31/1000 84/1000
Cerebral Palsy 2/1000 7/1000 27/1000
Preterm Labour 7 – 15 % 10% before 32 weeks
40% before 37 weeks
15% before 30 weeks
Fetal Loss Rate 20 % 5 times 10 times

28. Complications Specific To
MCMA
 Twin Twin Transfusion TTTS 15%
 Twin Reverse Arterial Perfusion Sequence TRAP 1/35000
 Twin Anemia Polycythemia Sequence TAPS 5% of TTTS

31. TTTS
 15 % Monochorionic Monoamniotic Pregnancies
 Deep A-V shunting
 DONOR & RECIPIENT Relationship
RECIPIENT DONOR
 High flow circulation Low Blood Supply
 Polyhydramnios Oligohydramnios
 More Weight (hydrops) Restricted growth

36. Treatment
 Serial Amnioreduction , Septostomy, Selective feticide , Laser ablation of
communicating anastomoses.
 Laser Ablation < - - - - - 26 weeks - - - - - - > Amnioreduction
 Stage 1 - Amnioreduction / Expectant management
 Stage 2 – 4 Laser Ablation
Selective Feticide

38. TRAP
TRAP

39.  Large A-A anastomoses
 PUMP & PERFUSED TWIN
 PUMP Twin - Normal Circulation
 Perfused Twin – Acardiac Monster, Rudimentary heart , congenital anomaly.
 Perinatal mortality in PUMP TWIN -50% if not treated

41. Treatment
 Disruption of Acardiac twin’s cord
 Intrafetal vessel ablation
 Radiofrequency interstitial thermal ablation
 Success Rate - >70%

42. Labour And Delivery
 Increased risk of fetal death - 36 weeks
 Maximum risk of morbidity - 38 weeks
 Dichorionic Pregnancy - 37 weeks
 Monochorionic Pregnancy -
Uncomplicated - 36 weeks
Complicated - individual risk stratified (34-36 wks)
 MonoChorionic Monoamniotic - 32 weeks ( 30% sudden IUFD before 34 weeks
)
Triplets - 33- 35 weeks

43. Mode Of Delivery
 Induction not contraindicated
 Operative Delivery
Congenital anomalies (Conjoined)
MCMA
Previous Section Scars
First Twin – Breech

44. What If a Twin die Inutero ??
 First trimester - Vanished - Expectant , progesterone support if
required
 Second Trimester - Fetus Papyraceous - If no symptoms , Conservative.
 Mid Trimester Loss - Follow for secondary sequelae
Serial Scans
Pt, APTT weekly