A detailed case study of a twin pregnancy, study of the condition, genesis of twins, types of twins, usg ananlysis , medical, surgical and nursing management, helath education, complication

1. Case Presentation on Twin
Pregnancy
PRESENTED BY- TANIYA MONDAL, 4TH YEAR, ROLL NO-30

2. Identification Data
• Name- Baisakhi Sarkar
• Age- 22 years
• Sex- Female
• ID no- 200139
• Ward- Postnatal ward
• Diagnosis- Twin Pregnancy
• Under Doctor- Dr.S.Patra
• Address- Kastodanga, Haringhata, West Bengal
• Date of admission- 30-01-2020
• Hospital Name- Chittaranjan Seva Sadan
• Name and Date Of Surgery- LUCS on 30-01-2020

3. History of Illness
• Chief Complain: Mother was admitted with the complain of lower abdominal pain and
decreased movement of fetus.
• Present Illness: Mother has no significant complain except of pain and activity restriction on
surgery site is found. Mother and babies are well and under observation and medication.
• Past Medical History: No history found.
• Past Surgical History: No history found.
• Present Surgical History: LUCS done on 30-01-2020. No complication is aroused.
• Delivery Note: Two full term baby boy are born on 30-01-2020 at 7:32 pm. Cesarean section is
done. Babies cried after birth, weight of the 1st baby is 2.20 kg and weight of the 2nd baby is 2.4
kg.

4. Disease Condition
• Introduction: The term, ‘Multiple Pregnancy’ is used to describe the development of more
than 1 fetus in uterus at the same time. Families are expecting a multiple birth have different
health needs, requiring extra practical support and understanding throughout the pregnancy,
the postnatal period and the early years.
• Definition: Simultaneous development of two fetuses in the uterus is called Twin Pregnancy.
• Incidence: The incidence varies widely. It is the highest in Nigeria being 1 in 20 and lowest in
far eastern countries being 1 in 200 pregnancies. In India, the incidence is about 1 in 80.

5. Types
The common types are-
I. Binovular Twins: It is the commonest
(2/3rd ) and results from the fertilization of
two ova, most likely ruptured from two
Distinct Graffian Follicles usually of the
same or one from each ovary, by two
sperms during a single ovarian cycle. The
babies bear only fraternal resemblance to
each other (that of brothers and sisters
from different births) and hence called
fraternal twins.

6. Types
• Uniovular Twins: (1/3rd) results from the
fertilization of a single ovum. The twinning
may occur at different periods after
fertilization and this markedly influences
the process of implantation and the
formation of the fetal membranes. The
exact stage at which the separation occurs,
is probably after the formation of inner cell
mass (between 4th to 8th day).

7. USG Algorithm

8. Genesis of Twins
• Dizygotic Twins:
Diamniotic-Dichorionic
 Most common represents 2/3rd of cases. Fertilization of more than one egg by more than one sperm.
 Non identical, may be of different sex. 2 chorion and 2 amnion.
 Placenta may be separated or fused. Each fetus is contained within a complete amniotic-chorionic
membrane.
 2 completely different pregnancies.
 Risk:
 Pre-term Labour (For every extra gestation the due date is substracted by 4 weeks)
 Malpresentation (Due to lac of adequate space)
So, most cases goes under C-Section.
 PPH ( Multiple fetal centers present. So, uterus is penetrated multiple times and leads to increased
chance of PPH)

10. Genesis of Twins
• Monozygotic Twins:
Dichorionic-Diamnionic
 1 egg takes part.
 Split present (More separate twins, the earlier split)
Split occurs for this type in 0-3 days after fertilization in tubal phase.
 2 placenta present.
 2 Sacs present.

11. Genesis of Twins
Monochorionic-Diamniotic
 1 Egg Takes part.
 Split in 4-3 days in Blastocyst Phase.
 1 Placenta present.
 2 Sacs present.
 Possibility of Twin-Twin Transfusion

12. Twin-Twin Transfusion

13. Genesis of Twins
Monochorionic-Monoamnionic
 1 Egg takes part.
 1 Placenta is present.
 1 Sac is Present.
 Split present. (If in 9-12 days , UNCONJOINED. If in grater or equal to 12 days, CONJOINED)
 Risk:
 Cord Entangalment
 Conjoining of Twins.
According to my patient, Monozygotic Twins Present

14. Different Stages of Separation

15. Types of Conjoined Twins

16. Etiology
The cause of twin pregnancy is not known. The frequency of
monozygotic twins remains constant,throughout the globe and is
probably related to maternal environmental factors.
Prevalance of dizygotic twins related to:
 Race
 Heredity
 Adversing age of mother
 Influence of parity
 Iatrogenic
In case of my patient, no significant data
found related to this.

17. Clinical Features
Maternal Physiological Changes:
 Increased weight gain and cardiac output.
 Plasma volume is increased by an additional 500 ml. There is no corresponding
increase in red blood cell volume resulting exaggerated hemodialution and
anemia.
 There is increased feto-protein level, tidal volume and GFR.
According to my patient, Acute abdominal pain, pale and fatigue, severe blood
loss is present.

18. Diagnostic Procedure
 History Taking
Physical Examination
 Abdominal Palpation
Investigations
• Sonography (confirmation of diagnosis as early as 10th week of pregnancy, viability of
fetus, fetal anomalies, fetal growth monitoring, twin transfusion, placental
localization,amniotic fluid volume)
• Chorionicity of placenta (presence of lambda or twin peak sign indicates dischorionic
placenta)
• Radiography
• Biochemical Test (Maternal serum chorionic gonadotrophin, alpha- feto proteion and
unconjugated oestriol are approximately double those single tone pregnancy)
According to my patient, excessive weight gain,
fatigue found in history taking and physical
examination.
A monoamniotic-dichorionic twin pregnancy with
adequate liquor amnii with 37 week gestational age
found in USG.
In blood studies, Hb-15.2 gm/dl,FBS-90 mg/dl,
platelet-2.0 lac/cumm found.

33. Thank you