Multiple px

Multiple Pregnancy
Definition: The development of more than one
fetus in utero at the same time.
• Two fetus: Twins
• three fetus: Triplets
• Four fetus: Quadruplets
• Five fetus: Quintuplets
• Six Fetus: Sextuplets etc.
1

Multiple Pregnancy Cont...
Twin pregnancy: Development of two fetus in
utero at the same time.
Types of Twin Pregnancy:
1. Monozygotic/Uniovular/Monovular/
Identical/
2. Dizygotic/Binovular/Fraternal/
2

A. Monozygotic Twins:
• Develop from one ovum and one
spermatozoon which after fertilization split in
to two.
• Are always of the same sex
• Have the same gene, blood group, and
physical features eye and hair color, ear
shapes and ear creases)
3

• Most of the time are of d/t size
• Placenta: one or two
• Chorion: one or two
• Amnion: one or two
4

B. Dizaygotic Twins:
• Develop from two separate ova that fertilizes
by different spermatozoa.
• May be of the same sex or not
• Placenta two but may be fused
• Two chorions
• Two amnions
• Tend to run in families
5

Diagnosis:
Multiple gestations should be suspected whenever
1. the uterus seems to be larger than dates,
2. auscultation of more than one fetal heart is suspected,
3. the pregnancy has occurred following assisted
conception, or
4. family history.
5. Multiple gestations may also be diagnosed
serendipitously at the time of ultrasound scanning, such
as before a genetic amniocentesis or as a result of an
elevated serum alpha-fetoprotein (AFP) level in mass-screening
programs.
6

Super fecundation: is the term used when
twins are conceived from sperm from d/t men
if a woman has had more than one partner
during a menstrual cycle.
Super fetation: is the term used when twins
conceived as a result of two coital acts in d/t
menstrual cycle.
7

Determination of Zygosity and Chorionicity
• Determination of zygotsity means deterring
whether or not twins are monozygotic or
dizygotic
• At birth monochorinic twins tend to have
great Wt variation than dichorionic ones.
• In approximately 2/3rds of monozygotic twins,
a monochorionic diamintioc placenta (MCDA)
will confirm monozygosity.
8

• If the babies have single outer membranes,
the chorion, they must be monochorionic so
monozygotic.
• In one third of monozygotic twins, the
placenta will have two chorions and two
amnions (DCDA) and either fused placenta or
separate placenta (Dichorionic), which in
indistinguishable from situation in dizygotic
twins.
9

• With monozygotic twins the type of placenta
produced is determined by the time at which
the fertilized oocyte splits;
– 0-4 days –DCDA(1/3rd )
– 4-8days –MCMA(2/3rd )
– 8-12days –MCMA (1%)
– 12-13days –(very rare) conjoined twins when the
division is incomplete.
10

Chorionicity: why is it important to know?
Because: Monochorionic twins pregnancies have 3-5 time
high-risk of perinatal mortality and morbidity than
Dichorionic ones.
• Determined by U/S preferable during 1st
TMS(difference more pronounced during this stage)
• The chorion forms a septum b/n the amniotic sac.
• If the septum has a mean thickness of 2-3mm or more
Dichorionic
• If <1.4mm monochorionic.
11

• By studying the septum at its base adjust to
the placenta
• Twin peak
• Lambda sing Dichorionic Tongue of
placenta tissue b/n the two chorion by u/s
Zygosity Determination after Birth
• DNA- the most accurate (cells taken for cheek
swab inside the mouth)
12

Diagnosis of twin pregnancy
• History: Family history of twin pregnancy
• Abdominal examination:
Inspection:
• Size of the uterus is larger than expected
• The uterus looks like broad or round
• Fetal movement may be seen over wide area
• Fresh straigravidarm
• Up to 2x normal amniotic fluid volume is normal.
13

Palpation:
• FH is greater than expected
• Presence of two fetal poles (head or breach) in
the fundus may be revealed
• Multiple fetal limbs may also be palpable
• The head may be small in relation to the size of
uterus
• Two fetal backs on lateral palpation
• Location of three poles in total is diagnostic of at
least two fetuses
14

Auscultation:
• Hearing two FHB is not a diagnostic
• Simultaneous comparison of FHB reveals a d/t of
at least 10BPM may be assumed that two hearts
are being heard.
Ultrasound:
• As early as 6 weeks of pregnancy
• Vanishing fetus syndrome( fetus papyraceons)
may happen.
15

The pregnancy
• A multiple pregnancy tends to be shorter then
singleton pregnancy
• Average gestation for twins
– 37wk-twins
– 34wk-triple
– 33wk-quaderplet
16

Management of Twin Pregnancy
Ante partum:
• Nutrition:
• Consumption of energy sources should be
increased by 300kcal/day above that of
singleton pregnancy
• Supplementation of iron and folic acid
– Iron 60 to 100mg/d
– Folic acid 1mg/d
17

Frequent prenatal visit
Rest
• Limited physical activities
• Early work leave
18

Ultrasound evaluation of:
• Placentation (aminonicity and Chorionicity)
• Number of fetus
• Fetal amniotic fluid
• Placental abnormality
• The growth of each fetus
• The presentation of congenital anomaly (ies)
19

Ante partum surveillance
• Indicated in complicated multifetal gestation
Technique:
• Modified biophysical profile
• Fetal movement counting ( count to ten chart)
Preterm labour
• Tocolytic gents; for short term prolongation of
pregnancy
• Corticosteroid administration: before 34 wk of
gestation
20

PROM
• Manage like singleton pregnancies
Corticosteroids:
• For women having impending delivery and GA
less than 34 wk Betamethasone. 12mg doses 24
hrs apart.
VBAC :Contraindicated
Timing of delivery:
• All should undergo delivery by 40 wks of
gestation
21

Intra partum:
• All preparations should have been made for
resuscitation and special care of babies of
LBW
• Labour and delivery
• Ascertain fetal number , presentation, EFW
and placental location
• Blood transfusion products should be readily
available
22

• Close monitoring of FHB in both twin
• Analgesia /anesthesia
– Use minimal analgesia for labour
• Epidural
• Pudendal block
• General anesthesia for C/S
23

Cont…
• Following the delivery of 1st twin:
– Cut the cord as far outside the vagina as possible
clamped
– Perform Leopold’s maneuver for the lie and
virginal examination to note:
– Presentation of the 2nd twin
– The presence of a second sac an occult cord prolapse or cord
entanglement
24

 If the vertex/ breech is in or over the inlet and
the uterus is contracting –ARM should be
done on the second sac.
 If uterine inertia has set in – start on oxytocin
drip with anatomy
 When either twin shows signs of persistent
compromise proceed promptly to c/s delivery.
 interval b/n deliveries 15-30minutes
25

Rout of delivery:
• Twin A-vertex/twin B vertex delivery vaginal. c/s
should only be performed for the same
indications applied to sningltoun gestation
• Twin A-vertex /Twin B Non vertex
 Twin A-vaginal
 Twin B; vaginal for neonate with an EFW greater than
1500gms option:
• ECV
• Total breech extraction
• Assisted breech delivery
• Internal podalic version
• c/s for twin B whose birth weight is less than 1500gms
 Twin A- non vertex – C/S
26

Routine cesarean delivery:
• Conjoined twin
• Placenta previa
• Mono amniotic twin
• Possible inter locking twin
Placentas:
• Delivery after both twins have been born
• Check for Chorionicity, amnionicity, number of
placenta and vascular communication
27

Zygosity:
• Examine the dividing membrane
Monozygotic: commonly have an opaque (thin)
septum made up of 2 amniotic membranes
only (no chorion and no decidua)
Dizygotic: always have an opaque (thick) septum
made up of 2 chorions 2 amnions, and
intervening decidua
28

Third stage of labour:
• Active management
Induction and augmentation
• Not recommended
Delayed (deferred) delivery of the second twin
• Candidates: patients at more than 28 wks of
gestation
29

Management:
• umbilical cord of the 1st twin legated high at the cervix
• Prophylactic antibiotics
• Bed rest
Contraindications to Deferred delivery of the 2nd twin
• Aminionitis
• Evidence of fetal compromise
• Heavy vaginal bleeding
• Monochoricity
30

Complications
1. Discordant twins:
• Definition: A difference in EFW of greater than
20% b/n twin A and twin B expressed as
percentage of the larger twins weight.
• Antepartum Evaluation:
– Serial ultrasound every 4 wks
– Biophysical profile starting from 28wks
– Termination of pregnancy when the BPS is poor
31

2. Twin to twin transfusion syndrome (TTTS)
Diagnosis one or more of the following:
• Placenta vascular connection
• Hgb differences greater than 5g/dl
• Inter twin birth weight d/t greater than 20%
• Hydramnoius in the large twin Oligohydramnious
in growth restricted fetus
• Monochorionicity and same sex.
Therapy: serial aminocentesis for hydraminus
32

3. Death of one fetus:
• Management – expectant
– Clotting profile every week
– Fetal surveillance
• No intervention aimed at arresting the labour
when the diagnosis is made during active
labour
33

4. Conjoined twin:
Suspicion provoking factor
• Finding of single fetal heart in multiple pregnancy
• Lack of engagement when the lie is longitudinal
• A similar parallel lie (vertex-vertex, breech-breech)
• An abnormal fetal attitude
34

Method of diagnosis
• Ultrasound
• Plan film of the abdomen
• Amniography
Mode of delivery:
1. C/S (lower segment vertical incision)
2. vaginal
– Babies are small
– Point and type of union permit mobility
– Infant dead
3. Destructive operation:
– When infant dead and part of the fetus has been born
35

5. Locking of twins:
• One may impede the descent of the other
Management:
a. Collision, impaction, compaction:
• Avoid strong traction and fundal pressure
• Push the second twin out of the pelvis under
deep anesthesia
• Then delivery the first and second twin in the
usual way
• If the method fails and babies are alive do C/S
36

b. Chin to chin interlocking:
• Avoid traction of the first twin
• Unlock the chin under anesthesia and the
second win is pushed out of the way
• If the first baby dies break the locking by
decapitating the first twin  delivery of the
second baby and delivery of the head of the
first baby by traction
37

6. Triplets or other higher order pregnancies
Must be considered:
• Whenever multi-fetal gestation is suspected
• In all pregnancies resulting from ovulations
induced by gonadotropins or clomiphene
Diagnosis:
• Ultrasonography
• X-ray during the late 2nd and 3rd trimester
Management:
• Similar to twins
38

Mode of delivery:
• Cesarean section; virtually for all high ordered
multiple gestation
• Vaginal delivery: for those fetuses who are
markedly immature or complications that
make cesarean delivery hazardous to the
mother.
39

Complications cont…
• Malpresentaion
• Cord prolapse
• Prolonged and obstructed labour
• Undiagnosed twins
• Fetus in fetu(part of a fetus may be locked
within another fetus)
• PPH
40

Problems associated with
pregnancy following assisted
conception
41

• Couples who achieve pregnancy following
assisted conception may be at greater risk of
complication during pregnancy than those who
conceive naturally b/s:
• The cause of the infertility may be medical
problem
• There is an increased risk of multiple pregnancy
which in form increase the risks pre term labour,
pre eclampsia and so on
• Usually in older age group increased age is
associated with pre eclampsia, multiple
pregnancy, medical problem like DM, uterine
fibroids etc.
• Therefore they need special attention
42

Quiz
1) What is zygosity? How can it determined in
intrauterine life?
2) What is the difference between acute and
chronic polyhydramious?
3) Write the physical appearance of post term
baby

Introduction
The D antigen, also called the Rh factor is the most
powerful and important of the Rh antigens. An
individual who possess it is labeled as Rh positive
and who lack it as Rh negative.
46

• Exposure of these Rh-negative people to even
small amounts of Rh-positive cells, by either
transfusion or pregnancy, can result in the
production of anti-D antibody, a condition
called Rh sensitization or isoimmunization.

Definitions
Rh incompatibility is the presence of different Rh
types in a woman and her partner. In obstetrics,
the significant incompatibility is when the woman
is Rh negative and the partner is Rh positive
Rh isoimmunization (Rh sensitization) is
production of antibody against the Rh factor by
an Rh negative woman following exposure to Rh-positive
cells
48

• The first encounter may not result in actual
antibody formation
• but the woman will be sensetised; on asecond
encounter, antibodies are produced in
abundance. Once formed, these antibodies
are permanent.

Erythroblastosis fetalis is the condition in which
large numbers of nucleated red cells are seen in
the fetal circulation, occurring in response to
excessive destruction of fetal red blood cells
Hydrops fetalis is generalized edema in the fetus
and collection of serous fluid in body cavities of
the fetus resulting from a variety of pathologic
conditions (immune hydrops and non immune
hydrops).
50

Hemolytic disease of the newborn is occurrence
of progressive anemia and hyperbilirubinemia in
a newborn caused by haemolysis of red blood
cells, in most cases antibody mediated
51

Pathogenesis
For Rh isoimmunization to occur, the following
prerequisites must be fulfilled:
I. Rh negative mother carrying Rh positive fetus
The chance of having Rh positive fetus from Rh
positive father ranges from 50% (if the father is
heterozygous) to 100% (if the father is
homozygous).
52

II. Entry of the fetal Rh positive red blood cells into
maternal circulation
 This occurs following transfusion of
incompatible blood (rare now a days because of
screening before transfusion) or more commonly
following fetomaternal hemorrhage (through
leaks in the placenta)
53

• Conditions that aggravate fetomaternal
hemorrhage are
 spontaneous or induced abortion,
 ectopic gestation,
 antepartum hemorrhage especially abruptio
placenta,
 amniocentesis, abdominal trauma, and
external cephalic version
54

III. Development of Rh antibodies by the mother
• The maternal immune system responds by
producing antibodies which are initially of IgM
type (big immunoglobulin that can not pass the
placental barrier). Fetomaternal bleeding in the
subsequent pregnancies results in the an
amenstic reaction producing an IgG type of
antibody (small antibody that can pass the
placental barrier)
55

Cont…
Effects on the fetus and the newborn
Hemolytic anemia develops, the extent of
which depends on the amount of antibody. To
compensate for the ensuing anemia the fetal
bone marrow and later the extramedullary sites
that produce RBC (liver, spleen and placenta) are
called to produce red blood cells at fast rate. This
results in the appearance of young nucleated
cells in the blood stream.
56

Cont…
• In severe cases even extramedullary
hematopoiesis can not cope with the degree of
destruction.
• This results in progressive anemia which
eventually leads to congestive heart failure and
tissue hypoxia.
• This condition is one of congestive heart failure
due to gross haemolytic anaemia.
• At birth the baby is extremely pale, has sever
edema and ascites and may be stillborn.
57

• The liver parenchyma is replaced by
hematopoietic tissue. Serum albumin falls as
the result. The combination of these causes
generalized edema of the fetus called hydrops
fetalis. Eventually fetal death occurs.

Cont…
• Before delivery the bilirubin, mainly of
unconjugated type is cleared by the placenta.
Following the delivery of the fetus, increasing
amounts of unconjugated bilirubin accumulate
in the neonatal circulation (because the limited
capacity of the liver to clear).
• The unconjugated bilirubin crosses the blood
brain barrier and damages the basal ganglia to
cause kernicterus.
59

Prevention of maternal iso-immunisation
There are three ways of preventing a woman
from producing Rhesus antibodies:
1) - avoiding transfusion of Rh positive blood
2)- prevention of avoidable fetomaternal
transfusion
3)- administration of anti- D immunoglobulin

Cont…
Management of Rh negative un sensitized
pregnancy
I. Identification of pregnancies at risk at the
initial ANC visit
 Determine blood group & Rh factor and
indirect coombs test for antibody screening for
all pregnant mothers.
II. Management of unsensitized pregnancy
Determine the blood group and Rh factor of the
partner
61

Assignment
• What is coomb’s test
– Direct
– Indirect
62

Cont…
Repeat indirect coombs test at 28 weeks and at
36 weeks. If negative consider antepartum
prophylaxis with 300 micrograms of anti D
gamma globulin at 28 weeks. If positive manage
as sensitized pregnancy.
Provide anti D prophylaxis in cases with
amniocentesis, APH, external cephalic version.
63

Cont…
Management of sensitized mother
These women need specialized care with
measurement of antibody levels in titers at
regular intervals, amniocentesis for bilirubin
levels, serial ultrasound for detection of hydrops
and management of neonatal anemia and
hyperbilirubinemia.
64

Cont…
Important points about ABO hemolytic disease
It occurs when the mother has group O blood (with
anti-A and anti-B antibodies in her serum) and fetus
is group A, B or AB.
Unlike Rh isoimmunization, 40-50% of ABO
incompatibilities occur in the first-born infant.
65

Cont…
ABO hemolytic disease is primarily manifest
following birth, when the infant becomes
jaundiced within the first 24 hours with a
variable amount of anemia and
hyperbilirubinemia which is usually mild.
Serious complications almost never occur.
The management consists of measurement of
bilirubin serially and provision of
phototherapy to the newborn.

Multiple px

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Multiple px