Multiple Pregnancy PPT

2.  Simultaneous development of more than one
fetus in the uterus is called multiple
pregnancy.
 Development of two fetuses – “twins”
(commonest)
 Development of three fetuses – “triplets”
 Development of four fetuses – “quadruplets”
 Development of five fetusus- “quintuplets”
 Development of six fetuses- ”sextuplets”

3. Simultaneous development of two fetuses in
uterus is called “twins”.
It is the commonest variety.

4.  Categorized into two:
I. Dizygotic twins (2/3) – results from
fertilization of two ova.
II. Monozygotic twins (1/3)-results from
fertilization of single ovum.

5.  Dizygotic twins (fraternal, binovular) result
from fertilization of two ova ruptured mostly
from two distinct graffian follicles usually of
the same or from each ovary, by two sperms
during a single ovarian cycle.
 They only bear fraternal resemblance to each
other(brothers & sisters from different births)
and hence called “fraternal twins”

6.  Based on various factors-
Monozygotic twins Dizygotic twins
Placenta is single
Varying degree of free
anastomosis between the
two fetal vessels.
two placenta-either
completely seperated or
more commonly fused at
the margin appearing to be
one.
No anastomosis.

7. Monozygotic twins Dizygotic twins
Each fetus is surrounded
by a separate amniotic sac
with the chorionic layer
common to both.
The intervening
membranes consist of two
layers of amnion only.
Always of the same sex
twins.
Each fetus is surrounded
by a separate amnion &
chorion.
Intervening membranes
carry four layers as amnion,
chorion, chorion & amnion.
Majority of opposite sex &
sometimes may have same
sex.

8. Monozygotic twins Dizygotic twins
Genetic features
(dominant blood group) &
DNA finger printing may
be same.
Skin grafting acceptance
Follow up usually
identical.
Genetic features & DNA
finger printing may differ.
Skin grafting rejection.
Usually not identical.

9.  High in Nigeria 1 in 20 pregnancies.
 Lowest in eastern countries-1 in 2oo
pregnancies.
 In India- 1 in 80.
 Monozygotic twins throughout globel-1 in
250.
 According to “hellin’s rule”(1895)
mathematical frequency of multiple birth in
twins 1 in 80, triplets 1 in 802 ,quadruplets 1 in
803.

10.  Exact cause is unknown.
 Frequency of monozygotic twins is related to
maternal environmental factors.
 Prevalence of dizygotic twins are related
to:
 Race – highest among Negros
- lowest among Mongols
- intermediate among Caucasians
 Hereditary-maternal side
 Age- 30-35 years.

11.  Parity-incidence Îsed with parity,specially 5th
gravida onwards.
 Iatrogenic- drugs used for induction of
ovulation may cause 20-40% &
gonadotrophin therapy of 5-6%.
 Super fecundation- is the fertilization of two
different ova related in the same cycle by
separate act of coitus within a short period of
time.

12.  Superfetation- fertilization of two ova
released in different menstrual
cycles,nidation & development of one fetus
over another until the decidual space is
obliterated by 12weeks of pregnancy.
 Fetus popyraceous or compressus- occurs if
one of the fetuses dies early ,flattened &
compressed between the membranes of the
living fetus & uterine wall ( common in
monozygotic twins)

13.  Fetus acardiacus- part of one fetus remains
amorphous & becomes parasitic without a
heart, occurs only in monozygotic twins.
 Hydatidiform mole- development of
hydatidiform mole from one placenta & a
normal fetus ,placenta from another.
 Vanishing twin- occasional death of one fetus
& continuation of pregnancy with the
surviving one, dead fetus simply “vanishes”
by resorption.

14.  history:
*intake of drugs
*family (maternal) history.
 Assessment & symptoms:
o Presence of exaggerated minor ailments of
normal pregnancy as-
*undue enlargement of uterus.
*Îsed nausea & vomiting in early pregnancy.
*cardiopulmonary embarrassment
*swelling of legs, varicose veins ,hemorrhoids.
*abdominal enlargement & excessive fetal
movements.

15.  Presence of physiological changes-
*Îsed in weight gain & cardiac output.
*Îsed plasma volume by addition of 500ml.
* Îsed fetoprotein level, tidal volume & GFR.
 Abdominal examination:
 Lie-
*longitudinal(90%).

16. *but the combination of presentation of the
fetuses are:
-both vertex(60%)
-first vertex & second breech (20%)
-first breech & second vertex(10%)
-both breech(10%)
- first vertex & second transverse ,b0th
transverse(rare).
 Inspection:
* abdomen is undulely enlarged
* shape – barrel shape

17.  Palpation:
* height of uterus is more than period of
amenorrhea.
* abdominal girth is more (100cm)
* fetal buttock disproportionately larger in
relation to fetal head.
* too many fetal parts palpable
* finding two fetal heads or three fetal poles

18.  Auscultation:
* simultaneous hearing of two distinct FHS
located at separate spots with a silent area in
between by two observers.
* the difference in heart rates is atleast
10beats/min.
 Internal examination:
* in some cases head is felt deep in the pelvis
while other located by abdominal examination.
* sometimes clinical methods fail to diagnose
prior to first baby delivery.

19.  Sonography
-conform diagnosis as early as
10th week
-estimate pregnancy dating
-detect fetal anomalies
-detect presentation & lie of fetus
-conduct twin transfusion
- monitor fetal growth
-localize the placenta
-assess amniotic fluid volume.

20.  Radiography- less often advised
-two fetal heads & spines are seen
-triplets/conjoint twins can be diagnosed
accidently.
 Biochemical tests-
-maternal serum HCG
-α fetoprotein
-unconjucated oestriol
all above present double than singleton
pregnancy.

21.  Hydromnios
 Big baby
 fibroid or ovarian tumor with pregnancy
 Ascitis with pregnancy.

22.  Îsd maternal mortality due hemorrhage,
preeclampsia, anemia.
 Îsed maternal morbidity due to surgical
interference & complications.
 Îsed perinatal mortality due to prematurity,
high in monozygotic twins due to cord
enlargement.

23.  Antenatal period-
 early diagnosis
 Advises need to be given are:
*diet-high protein
-300k.cal/day
*rest
*supplementary therapy
-iron (60-100mg/day)
-folic acid(1mg)
-vitamins , calcium.

24. *regular antenatal visits
* frequent sonographic examinations
 Hospitalization-for assessment of suspected
complications
 During labor:
 admit client in hospital with NICU.
 A skilled obstetrician with an ultrasound
machine,1 anesthetist & pediatrician.
 Provide bed rest to prevent early rupture of
membranes.

25.  Prefer epidural analgesia as it manipulates of
required during delivery of second twin.
 Careful fetal monitoring
 Internal examination should be done soon
after rupture of membranes to detect cord
proplapse
 IVF therapy(R.L.)
 Blood transfusion is kept ready.

26.  Guidelines same as normal delivery is
followed.
 Liberal episiotomy under local filtration of 1%
lignocaine.
 If needed forceps delivery should be done
under pudendal block anesthesia, avoid G.A.
 I.V. ergometrin is avoided.
 Atleast 8-10cms of cord is left behind for any
drug/transfusion if required.
 Hand over the baby by labeling it as “twin-I”.

27.  Lie, presentation, size and FHS of the 2nd
baby should be assessed by abdominal
examination or ultrasound.
 Vaginal examination-
* to exclude cord proplapse.
* to note status of membranes.

28.  After fixing the presenting part on the brim
low rupture of membranes is done.
 ‘syntocin’ may be added to achieve the
progress.
 Internal examination
- to exclude cord proplapse.
-to assess fetal condition.
 Weak contractions- 5 units oxytocin is given
If there is no progress (after 15mins)
interference is to be done.

29.  Low down forceps are applied.
 If 2nd is big ,rule out CPD / hydrocephalous
through ultrasonography.
 After excluding, Internal version followed by
breech presentation is performed under G.A.
 In such cases ventouse may be effective
 Avoid forceps application.

30. Delivery is completed by breech extraction.

31.  It should be done by external version into
cephalic or podalic.
 If fails internal version under G.A. should be
done.
 Continue oxytocin drip for atleast 1hr
following 2nd baby delivery.
 More blood loss – replace by transfusion.
 Give support to mother & family.

32.  Severe vaginal bleeding.
 Cord prolapse of 2nd baby.
 Inadvertant use of I.V. ergometrine.
 1st baby delivered under G.A.
 Fetal dystress.
Management:
 quick delivery by selecting appropriate
method.
 If head is low down deliver by forceps

33.  If head is high up deliver by internal version
under G.A.
 Breech by breech extraction.
 Transverse by internal version followed by
breech extraction under G.A.

34.  Minimize the risk of PPH by administering
0.2mg methergin with the delivery of anterior
shoulder of the 2nd baby.
 Deliver placenta by controlled cord traction.
 Blood loss- transfusion
 Support to mother & family.

35.  Obstetrical causes:
 Placenta praevia__________
 Severe preeclampsia.
 Previous caesarean section.
 Cord prolapse of 1st baby.______
 Abnormal uterine contractions.
 Contracted pelvis.

36.  Fetal causes:
 Both the fetus with non-cephalic
presentation.
 IUGR.
 Conjoint twins.
 Monoamniotic/monochorionic twins.
 Collision of both heads at brim.

37.  Interlocking –
* locking of head of 2nd baby after coming head of 1st
baby.
* vaginal manipulation- to separate chins of fetuses
* if fails section is done
* if 1st baby is dead decapitate the head of 1st baby.
* push up the decapitated head followed by delivery
of 2nd baby.
* lastly deliver the decapitated head.

38.  Occasionally, two twins of both vertex twins
get locked at brim-
* conform by intranatal ultrasonography.
* c. section is done to save fetal life.

39.  Rare
 Incidence- 1 in 1lakh to 1 in 50,000.
 In twin pregnancies 1:900 to 1:650
Diagnosis :
 Diagnosed during delivery when there is
obstruction in 2nd stage.
 Inability to move one without moving other.
 On vaginal examination- bridge of tissue
between the fetuses.

40.  Ultrasonography-
* continuous external skin contour.
* body parts of twins at the same level.
* no change in relative position of twins
on successive scans
* spines are in unusual close proximity &
are extended.
* single placenta
 Radiography- bony fusion of twins.

41.  Depends on-
* extent & site of union.
* possibility of surgical seperation.
* possibility of survival of fetuses.
 Preterm labour results in vaginal delivery.
 Destructive operation- dead fetus.
 When diagnosed in antenatal period
caesarean section is done when conjoined
twins can be surgically seperated.

42. Triplets
quadruplets

43.  Develop from fertilization of single
/two/three….Ova.
 Female fetus outnumber the male one.
 Preterm delivery is common(50%).
 Delivery occurs at 32-34wks (mean 33.5wks).
 Discordance of fetal growth is more than
twins.
 Perinatal loss depends on birth weight.
 In quadruplets average time for delivery is 30-
31wks, caesarean section is advisable.

44.  Selective reduction-
* if there is 4or more selective reduction
of fetuses leaving behind only 2 is done.
* done by intracardiac injection of
potassium chloride between 10-12wks under
ultrasonographic guidance.
* can be done transcervically/
transvaginally/ transabdominally.
*occlusion of umbilical cord of targeted
twin by lazer, fetoscopic ligation to protect the
co-twin from adverse drug effect.