multiple pregnancy is When more than one fetus simultaneously develops in the uterus, it is called multiple pregnancy.

1. PRESENTED BY: PINGALE DIPALI
SHANTARM

2. PRESENTED BY: PINGALE DIPALI
SHANTARAM
2 ND YEAR MSC NURSING

3. OBJECTIVES
• Definition.
• Incidence and epidemiology.
• Clinical characteristics.
• Classification.
• Diagnosis.
• Complications.
• Management.

4. • When more than
one fetus
simultaneously
develops in the
uterus, it is called
multiple
pregnancy.

5. Terminology vs. number
• Singletons- one fetus
• Twins - two fetuses.
• Triplets - threefetuses.
• Quadruplets - four fetuses.
• Quintuplets- five fetuses.
• sextuplets- sixfetuses.
• Septuplets- seven fetuses.

6. Types of twins………
DIZYGOTI
C
MONOZYGOTI
C

7. Dizygotic twins (fraternal)
• 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. “each
fetus is contained within a complete amniotic-
chorionic membrane “

8. Dizygotic twins/ BINOVULAR
(fraternal)

9. Monzygotic twins
• Constitutes 1/3 of twins These twins are multiple
gestations resulting from cleavage of a single,
fertilized ovum.
• The timing of cleavage determines the
placentation of the pregnancy.
• Constant incidence .
• Not affected by heredity.
• Not related to induction of ovulation.

10. MONOZYGOTIC / UNIOVULAR/
IDENTICAL

11. MONOZYGOTIC TWINS 23%
75%
1%
<1%

12. THORACOPAGUS
ISCHIOPAGUSCRANIOPAGUS
RACHYPAGUSPYOPAGUSOMPHALOPAGUS

13. Important notes:
• 1- Monozygotic twins having same sex &
blood group.
• 2- Process of formation of chorion is earlier
than formation of amnion.
• 3-Dizygotic twins must be
dichorionic/diamniotic.
• 4- There is no dichorionic/ monoamniotic.

14. HELLIN’S RULE
Twins 1 in 80
Triplets 1 in 80^2
Quadruplets 1 in 80^3
INCIDENCE

15. Etiology
Ethnic group
Increasing
maternal age

16. Increasing parity
Family h/o twinning, esp
maternal
Ovulation induction

17. • Super fecundation: is fertilization of two ova
produced in the same menstrual cycle by two
spermatozoa deposited in two separate acts
of coitus.
• Superfoetation: is fertilization of two ova
produced in two different menstrual cycles by
two separate spermatozoa. Actually, this
cannot occur in human as ovulation is
suppressed once pregnancy occurs.

18. Maternal Physiological Adaptation
Increase blood volume and cardiac output.
Increase demand for iron and folic acid.
Maternal respiratory difficulty.
Excess fluid retention and edema.
Increase attacks of supine hypotension.

19. Lie and presentation
• Commonest lie – longitudinal (90%) but
malpresentation are quite common.
• Both vertex (50%)
• First vertex and second breech (30%)
• First breech and second vertex (10%)
• Both breech (10%)
• First vertex and second transverse and so on...

20. Diagnosis
History
* Family history of multiple pregnancy (wife
and/ or husband).
* Recent intake of ovulatory drugs.
* Increased foetal movement.

21. Diagnosis
*Inspection
More enlargement of the abdomen.
Palpation:
* Fundal level: higher than that corresponds to the
period of amenorrhoea.
* Fundal, umbilical and first pelvic grips: can detect
multiple foetal poles. At least, 3 poles should be
palpated to diagnose twin pregnancy.
* Foetal limbs: felt as multiple knobs.

22. Diagnosis
• Auscultation
* Foetal heart sounds: are heard with maximum
intensity in 2 separate points by 2 observers
with a minimum difference of 10 beats per
minute.
* Arnaux sign: occasionally, the superimposition
of two foetal heart sounds produces a
galloping rhythm.

23. Diagnosis
Ultrasonography
• Diagnosis of twins:
*At 7th week: two separate gestation sacs can be
identified.
*At 8th week: separate foetal bodies can be detected.
* At 12th week: separate heads can be distinguished.
*If routine scanning of all pregnant women is carried out
at 16 weeks twins should rarely be missed.

24. Diagnosis
Ultrasonography
Detection of:
• Presentations and positions.
• Gestational age.
• Congenital anomalies.
• Polyhydramnios.
• Placental site.

25. Diagnosis
• X-ray
If ultrasound is not available it can detect foetal
heads and vertebral columns.

26. DIAGNOSIS OF MULTIPLE PREGNANCY
Positive family history mainly on maternal
side.
Positive history of ovulation induction.
Exaggerated symptoms of pregnancy.
Marked edema of lower limb.
Discrepancy between date and uterine size.
Palpation of many fetal parts.

27. INVESTIGATION
• Number of sacs. [ before 10 weeks ]
 2 sacs – dichorionic
 Single sac - monochorionic
• Placenta
• Sex
• Intertwin membrane
 thicker and more echogenic in dichorionic
.

28. • Twin peak / Lambda sign
- characteristic of dichorionic pregnancies
- chorionic tissue between 2 layers of
intertwin membrane at the placental origin
• T Sign – in monochorionic , no chorionic tissue
• If no membrane is seen in between –
monochorionic monoaniotic

30. Maternal Complications
Antepartum Intrapartum
1.Hyperemesis 1.Dysfunctional labour
2.Hydramnios 2.Malpresentation
3.Pre-eclampsia 3.Operative delivery
4.Pressure symptoms 4.Postpartum
hemorrhage
5.Anaemia 5.Retained Placenta
6.Antepartum
hemorrhage
6.Premature separation
of placenta

31. Maternal Complications - Antepartum
Hyperemesis – increased β- hCG
Hydramnios – monoamniotic pregnancies, Twin
transfusion syndrome, major cause of prematurity
Pre- eclampsia – 3 times commoner compared to
singleton
Pressure symptoms
Anaemia – increased plasma volume expansion ,
fetoplacental demand for iron increased.
APH – Placenta praevia , Abruptio placenta.

32. Fetal Complications
Antepartum Intrapartum
1.Prematurity 1.PROM
2.IUGR 2.Cord Prolapse
3.Single fetal demise 3.Abruption in second
twin
4.Twin to Twin transfusion
syndrome
4.Interlocking (rare)
5.Vanishing Twin/abortion
6.Cong.anomalies
7.Conjoined twins

33. FETAL COMPLICATIONS
 Perinatal mortality: 6 times
 Morbidity: 2- 3 times
 Mono chorionic - morbidity/mortality twice as that of dichorionic.
- additional risk from TTS
 Monoamniotic twins - 50% mortality.
 Main cause of adverse outcome is
1. Prematurity
2. IUGR
 Cerebral palsy, neurodevelopmental impairment, lower IQ scores.
 Monochorionic twins: 1. TTTS
2 .Monoamniotic twinning
3. Conjoined twinning
4. Acardiac fetus

34. Management
• During pregnancy
* Frequent antenatal visits: to detect early any
complication mentioned before and manage it.
* Proper diet: with prophylactic supplementation of
iron and folic acid.
* Adequate rest: to improve placental blood flow
and avoid preterm labour.
* Prophylactic tocolytics or cerclage: is of no actual
benefit.

35. Management
• During labour
* Delivery should be in a hospital .
* A team of experienced obstetrician, assistant,
anaesthetist and neonatologist is necessary
for safety.

36. Management
Delivery of the first twin:
>If it is cephalic: proceed as normal usually
there is no problem.
> If it is breech: caesarean section is safer for
fear of locked twins, although vaginal delivery
may pass without this complication.
>Immediate clamping of the cord is essential
after delivery of the first twin to avoid
bleeding from a uniovular second twin.

37. Management
Delivery of the second twin: It depends upon its
presentation;
• Longitudinal lie (vertex or breech):
• Transverse or oblique lie:

38. Management
• Longitudinal lie (vertex or breech):
>Amniotomy is done during uterine contraction
which may be delayed up to 5 minutes.
>If delay is more than 5 minute, start oxytocin
drip.
>Delivery of the second twin is usually easy due
to dilatation of the maternal passages by
delivery of the first twin.

39. Management
>If there is foetal distress or cord prolapse,
rapid delivery is indicated by:
* breech extraction in breech presentation.
* Forceps delivery in engaged vertex
presentation.
* Vacuum extraction or rarely internal podalic
version and breech extraction may be
indicated in non-engaged head.

40. Management
• Transverse or oblique lie
• a. External cephalic or podalic version is done
then do amniotomy and deliver the foetus as
cephalic or by breech extraction respectively
or,
• b. Internal podalic version and breech
extraction under general or epidural
anaesthesia.

41. Management
• Caesarean section is indicated in:
> The first baby is transverse lie.
>Prolapsed pulsating cord or foetal distress in the
first stage.
> Retained second twin when it is;
a. transverse lie,
b. membranes are ruptured,
c. uterus is retracted
d. cervix is not fully dilated.

42. Management
• Caesarean section is indicated in
> Conjoined twins.
>Triplets or more are safer delivered by C.S.
> Other indications of C.S. as placenta praevia,
contracted pelvis, etc.

43. Midwifery Management
• Daily weight, abdominal girth monitoring.
• Assessment of nutrition and diet pattern and
modification.
• Health education related to diet, hygiene, and
care.
• Daily monitoring of fetal heart rate.
• Intake and output monitoring.

44. Nursing theory
• Orem’s self care theory
• Roy’s adaptation theory
• King’s goal attainment theory(safe
confinement)
• Paplau’s interpersonal theory ( postnatal)
• Nightingale’s environmental theory (Baby)

45. NURSING MANAGEMENT
• 1. Breathing difficulty related to growth of the
two foetuses.
• 2. Hyper emesis related to pressure exerted on
the stomach.
• 3. Fatigue related to exhaustion due to increase
number of vomiting.
• 4. Altered nutrition less than body requirement
related to less intake of food secondary to hyper
emesis.
• 5.Fluid volume deficit related to hyper emesis.

46. Cont..
• 6. Altered socialization related to
psychological upset due to multiple
pregnancy.
• 7. Anxiety related to outcome of pregnancy.
• 8. knowledge deficit related to the disease
condition, self care and posnatal care of the
baby.
• 9. Fear related to process of labour.

47. • 10.Ineffective coping mechanism related to
anxiety, fear due to outcome of pregnancy and
process of labour.
• 11. Increased operative inferences related to
number of fetus and position.
• 12. Risk of infection related to repeated per
vaginal examination.
• 13. Risk of trauma related to increased
operative inferences.

48. • 14.Risk of complications related to multiple
pregnancy.