Multiple pregnancies are pregnancies involving more than one fetus. Twins are the most common type of multiple pregnancy, comprising about 3% of all pregnancies. Multiple pregnancies can be either identical (monozygotic) twins originating from one fertilized egg or fraternal (dizygotic) twins from two separate eggs. Factors that increase the risk of multiples include assisted reproductive techniques, increased maternal age, high parity, family history, and certain drugs. Multiple pregnancies carry higher risks than singletons such as preterm birth, growth restriction, and complications unique to identical twins sharing a placenta. Care involves monitoring fetal growth, well-being, and complications through ultrasound screening. Vaginal delivery is aimed for

1. MULTIPLE PREGNANCY
NIRAV HITESH KUMAR VALAND

2. Definition
• When more than one fetus simultaneously develops in the
uterus.
• Development of two fetuses is much common.

3. Prevalence
• Traditionally, the expected incidence was calculated using
Hellin’s rule.
• Using this rule, twins were expected in 1 in 80 pregnancies,
triplets in 1 in 802 and so on.
• According to global epidemiology, it accounts for 3% of
pregnancies.

4. Factors influencing twinning
• Assisted Reproductive Technique
• Increasing maternal age
• High parity
• African-American women are more likely to have twins than any
other race.
• Family history of multiple pregnancies.
• Drugs e.g. Clomiphen
• Nutrition.

5. Classification
• The classification of multiple pregnancy is based on:
number of fetuses: twins, triplets, quadruplets, etc.
number of fertilized eggs: zygosity;
number of placentae: chorionicity;
number of amniotic cavities: amnionicity.

6. Non-identical/Fraternal twins
• Dizygotic
• Due to fertilization of two separate eggs.
• Always dichorionic and diamniotic.
• Can either be the same sex or different sexes.
• The release of more than one egg is familial or racial and
increases with maternal age.
• Its incidence is influenced by race, heredity, maternal age, parity,
and, especially, fertility treatment.

7. Identical twins
• Monozygotic
• Arise from fertilization with a single egg that splits into 2 identical
structures
• Always are of the same sex.
• Can monochorionic or dichorionic.
• If monochorionic, it can be diamniotic or monoamniotic.

8. Identical twins
• The type of monozygotic twin depends on how long after conception
splitting occurs i.e.
Within 3 days – DCDA pregnancy
Between 4 and 8 days – MCDA pregnancy
Later splitting leads to a MCMA pregnancy
If splitting occurs after 12 days, it leads to Siamese twins
• Frequency of monozygotic twin births is relatively constant
worldwide—approximately one set per 250 births

12. Physiological changes.
Maternal
• All the physiological changes are exaggerated.
• These result in much greater stress in the maternal reserve.
• There’s a increased risk of maternal morbidity in the mothers
with pre-existing health issues e.g. a cardiac disease.
Fetal
• MC placentae tend develop vascular connection between to two
fetal circulations.

13. Complications.
1. Abortion and severe pre-term delivery
2. Perinatal mortality in twins
3. Death of one fetus
4. Fetal growth restriction.
5. Fetal abnormalities

15. Complications unique to monochorionic
twins
Twin-to-twin syndrome
• There are placental vascular anastomosis between to the two fetal
vascular connections.
• Condition is due to an imbalance in the arteriovenous
communication.
• One fetus (Recipient) gets over perfused and the other (donor)
gets under perfused.
• Can be mild, moderate or severe depending on the degree of
imbalance.

16. Cont..
• The donor twin gets hypovolemic, oliguric and develops
oligohydramnios
• The recipient twin gets hypervolemic, has polyuria and develops
polyhydroamnios, and consequently has an increased risk of high
output cardia failure.
• End up as a miscarriage or very pre-term delivery.

19. Antenatal management
• Routine screening for hypertension and gestational diabetes.
• Routine supplementation of Iron and Folic acid due to increased
demand.

20. Determination of chorionicity
• Done by U/S scan
• In dichorionic twins, there’s a lambda/twin-peak sign seen as a V-
shaped extension of placenta into the inter-twin membrane.
• In monochorionic twins, this sign is absent, and the placenta joins
the uterine wall in a T-shape.
• Optimal age of doing this scan is by the 9-10th week.

23. Monitoring of fetal growth and well-being
• Done principally by U/S.
• Assessment includes;
Fetal lies
Fetal measurements
Fetal activity
Amniotic fluid volumes.
• In monochorionic twins, features of TTTS should be sought,
including discordances between fetal size, fetal activity, bladder
volumes, amniotic fluid volumes and cardiac size.

24. Intrapartum management
• There are more complications regarding delivery of multiple
pregnancy.
• These include;
Premature birth,
Abnormal presentations,
Prolapsed cord,
Premature separation of the placenta
Postpartum haemorrhage

25. • Vaginal birth if cephalic presenting part.
Vertex-vertex delivery
• The first twin is delivered in the same way as for a singleton.
• After delivery, abdominal examination for the lie of the second twin
should be done.
• Amniotomy is performed, and if delivery doesn’t take place
between 5-10 min, there is augmentation of labor with oxytocin
infusion.

26. Vertex – non-vertex delivery
• If second twin is breech, membranes can be ruptured once fixed in
the pelvis.
• If transverse; it should be corrected by external version into a
longitudinal lie preferably cephalic, if fails, podalic.
• If the external version fails, internal version under general
anesthesia should be done forthwith.

27. Management of 3rd stage.
• Oxytocin 10 IU IM after delivery of the second twin.
• Placenta delivered by CCT.

28. Indications for Cesarean Delivery
Maternal factors
• Placenta previa.
• Severe PET
• Previous C/S
• Cord prolapse of first twin
• Contracted pelvis
• Abnormal uterine contractions
Fetal Factors
• Both non-vertex twins
• Monoamniotic twins
• IUGR
• TTTS