Multiple pregnancies can involve more than two fetuses developing simultaneously in the uterus. The most common variety is twins, while triplets, quadruplets, and more are rare. Management of multiple pregnancies aims to monitor fetal well-being and expedite delivery of additional fetuses after the first to prevent strain from placental insufficiency. Cesarean section may be recommended depending on fetal presentation and other complications.

2. When more then one foetus simultaneously
develops in the uterus, it is called Multiple
pregnancy.
Simultaneously develop of two foetuses( TWINS)
is the most common.
Although rare , development of three
foetuses(TRIPLETS), four foetuses
(QUADRUPLETS), Five foetuses (QUINTUPLETS)
or six foetuses(SEXTUPLETS) may also occur.

3. Simultaneous development of two foetus in the
uterus is the most common variety of multiple
pregnancy.
Varieties –
i) Dizygotic (DZ) twins – It is most common (80%)
and results from the fertilization of two ova.
ii) Monozygotic(MZ) twins- (20%) results from the
fertilization of a single ovum.

4. Twins

5. It is 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.
According to Hellins Rules(1895):-
The mathematical frequency of multiple
birth is , twins 1 in 80 pregnancies , triplets 1
in 80², quadruplets 1 in 80³and so on.

6.  The cause of twinning is not known . The
frequency of monozygotic twins remains
constant throughout the globe and is
probably related to maternal environmental
factors.
Prevalence of dizygotic twins is related to:-
Race :- Highest in Negroes , lowest in
Mongols.
Hereditary:- Transmitted through maternal
side.

7. cont...
Advancing age of mother:- The max. Being
between the age of 30 yrs and 35 yrs.
Influence of parity:- Especially from 5th gravida
onword .
Iatrogenic:- Drugs used for induction of ovulation
may produce multiple foetuses to the extent of
20-40% following gonadotropin therapy, although
to a lesser extent (5-6%) following clomiphene
citrate.

8.  Superfecundation:-fertilization of two diff.
Ova released in the same cycle, by
separate acts of coitus within a short
period of time.
 Superfetation:- fertilization of two ova
released in different menstrual cycles the
development of one foetus over another
foetus theoretically possible untill the
decidual space is obliterated by 12 weeks.
 Foetus compresses:- It is a state which
occurs if one of the foetuses dies early.The
dead foetus is compressed b/w the
membranes of the living foetus and the
uterine wall . It may occur in both varities
of twins.

9. Foetus Compressus

10.  Foetus Acardiacus:- It occurs only in monozygotic
twins.
 Vanishing Twins:- serial USG imaging in multiple
pregnancy since early gestation has revealed
occasional death of one foetus and continuation of
pregnancy with the surviving one. The dead foetus
(if within 14 weeks) simply vanishes by resorption.
 Hydatidiform mole (from one placenta):-
A normal foetus and placenta(from the other
conceptus) have been observed by USG.

11. (1)There is increase in weight gain and cardiac
output .
(2)Plasma volume is increase by an addition of
500ml .there is no corresponding increase in
red cell volume resulting in exaggerated
hemodilution and anemia .
(3)There is increase α-fetoprotein level,tidal
volume and GFR rate.

12. (1) History :- (a)history of ovulation inducing
drugs.
(b)Family history of twinning .
(2)Symptoms:- (a)increased nausea and
vomiting in early months.
(b)Cardiorespiratory changes such as
palpitation or SOB.
(c)Swelling of the legs and hemorrhoids is
greater.
(d)Unusual rate of abdominal enlargement.

13.  (3.)General examination :-
 a. prevalence of anemia is more than in
singleton pregnancy.
 b. unusual weight gain , not explained by pre –
eclampsia or obesity.
 (4.) Abdominal examination :-
 a. Inspection
 b. Palpation
 c. Auscultation
 (5.) Investigations :-
 a. Sonography
 b. Bio-chemical test

14. 1. Maternal 2. Fetal
. Nausea , vomiting . Abortion
. Anemia . Vanishing twin
. Pre- eclampsia . Preterm birth
. Malpresentation . LBW babies
. Preterm labor . Cord prolapse
. Prolonged labor . Asphyxia
. PPH . Locked twins

15. PROGNOSIS
Maternal mortality – is increased in twins than
in singleton pregnancy . Death is mostly due to
hemorrhage , pre – eclampsia and anemia .
Increased maternal morbidity is due to the
prevalence of complications .
Prenatal outcome : prenatal mortality is
markedly increased mainly due to prematurity.
It is 4-5 times higher than in a singleton
pregnancy .

16. The essence of successful outcome of a twin
pregnancy is to make an early diagnosis and
through USG examination are the keys to the
diagnosis .
ADVICE :-
. Diet
.Increased rest
. Supplement therapy
. Interval of antenatal visit
HOSPITALIZATION :-
. Routine hospital admission only for bed rest is not
essential
. Emergency : development of complicating factors .

17.  Place of delivery : As the twin pregnancy is
considered a high risk , the patient should be
confined in an equipped hospital prefrably
having an intensive neonatal care unit .
 Vaginal delivery is allowed when both the
twins are atleast the first twin is with vertex
presentation
 FIRST STAGE :-
. A skilled obstetrician should be present .
. Neonatologists (two)

18. . Presence of USG in the labor ward
. The patient should be in bed
. Use of analgesics drugs
. Careful fetal monitoring
. Internal examination should be done
. An intravenous line prepaired
. One unit of compatible and cross match blood
Delivery of the first baby : the delivery should
be conducted in the same guidlines as
mentioned in normal labor .
. Extended episiotomy
. Forceps delivery , if needed
. Not to give IV ergometrine

19. Conduction of labor after the delivery of the
first baby ( delivery of second twin )
Principles : The principle is to expedite the
delivery of the second baby . The second baby
is put under strain due to placental
insufficiency caused by uterine retraction
following the birth of the first baby .
Steps of management : Step 1 – following the
birth of the first baby
. Lie
. Presentation
. Size of the second baby

20. .Both twins vertex 50%
.Twin A vertex 40%
.Twin B non vertex 40%
.Analgesia
.Careful foetal monitoring
.Conduct delivery of first
baby as usual
Deliver of the first baby vaginally
.Cord is divided in b/w two clamps
.No methergine is given
To note the lie of the second baby clinically or by
USG
Interval b/w twin A
and B should ideally
be 15 mins.

21. Transverse lie Longitudinal lie
External version ARM+ Oxytocin if necessary
Fails If delay
Vertex Breech
Breech extraction
Delivery: To guard against PPH, presence of neonatologist

22. Indication of cesarean section :
a. Obstetric indications b. for twin
. Placenta previa . Twins with
complications IUGR
. Sever pre – eclampsia . Monoamniotic twins
. Previous cesarean section . Monochorionic twins
with TTTS
. Cord prolapse of first baby
. Abdominal uterine contraction

23.  Interlocking:-The most common one being
the after coming head of the first baby
getting locked with the forecoming head of
the second baby.
 Occasionally, two heads of both vertex twins
get locked at the pelvic brim preventing
engagement of either of the head. The
possibility should be kept in mind and the
diagnosis is confirmed by intranetal
sonography.

24. Triplets may develop from fertilization of a
single ovum or two or even three ova.
Similarly with Quadruplets and Quintuplets.
Female foetus usually out number the male
one. The diagnosis is confirmed by USG or
during births.
Pre term delivery is common (50%) and usually
delivery occurs anytime between 35 and 36
weeks .
Management is similar to that outline in twins.
Average time for delivery in quadruplets is 30
-31 weeks.

25. Triplets