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Multiple Pregnancy
- 1. MS AGNES MAHIMADAVID M.Sc. Nursing
- 2. DEFINITION When morethan one fetus simultaneously develop in the uterus Twin = 2 fetus Triplets =3 fetus Quadruplets =4 fetus Quintuplets = 5 fetus Sextuplets =6 fetus Septuplets =7 fetus
- 3. Hellin’s Law: Twins: 1:89 Triplets:1:892 Quadruplets: 1:893 Quintuplets: 1:894 Conjoined twins: 1 : 60,000 Worldwide incidence of monozygotic - 1 in 250 Incidence of dizygotic varies & increasing
- 4. • Race: mostcommon in Negroes • Age: Increased maternal age • Parity: more common in multipara • Heredity - family history of multifetal gestation • Nutritional status – well nourished women • ART - ovulation induction with clomiphene citrate, gonadotropins and IVF • Conception after stopping OCP
- 5. TWINS Simultaneous development oftwo fetuses is the commonest variety of multiple pregnancy VARIETIES 1. Binovular twins :it is the commonest variety of multiple pregnancy (two third) and results from the fertilization of two ova 2. Uniovular twins : (one third ) results from the fertilization of the single ovum
- 6. GENESIS OFTWINS 1. Binovular twins: (fraternal,dizygotic )results from fertilization of two ova most likely ruptures from two distinct graffian follicles usually of the same or one from each ovary by two sperms during a single ovarian cycle Their subsequent implantation and development differ little from those of a single fertilized ovum The babies bear only fraternal resemblance to each other
- 8. UNIOVULAR TWINS (identical,monozygotic ) They develop from the fusion of one oocyte and one spermatozoon which after fertilization splits into two These twins will be of the same sex and have the same genes ,blood group and physical features • Upto 3 days - diamniotic-dichorionic • Between 4th & 7th day - diamniotic monochorionic - most common type • Between 8th & 12th day- monoamniotic- monochorionic • After 13th day - conjoined / Siamese twins.
- 11. CONJOINED TWINS Ventral: 1) Omphalopagus(abdomen 2)Thoracopagus 3) Cephalopagus(head n chest 4) Caudal/ ischiopagus(pelvis Lateral: 1) Parapagus(trunk) Dorsal: 1)Craniopagus,(head) 2)Pyopagus(base of spine)
- 12. Superfecundation Fertilization of twodifferent ova released in the same cycle Superfetation Fertilization of two ova released in different cycles
- 13. Monozygotic twin Dizygotictwins 2 ova + 2 sperm Same or opposite sex Fraternal resemblance Double or s/t fused Different genetic features DNA microprobe - different 1 ova + 1 sperm Same sex Identical features Single or double placenta Same genetic features DNA microprobe - same
- 14. • HISTORY: I. Historyof ovulation inducing drugs specially gonadotropins II. Family history of twinning (maternal side). • SYMPTOMS: i. Hyperemesis gravid rum ii. Cardio-respiratory embarrassment - palpitation or shortness of breath iii. Tendency of swelling of the legs, iv. Varicose veins v. Hemorrhoids vi. Excessive abdominal enlargement vii. Excessive fetal movements
- 15. GENERAL EXAMINATION: I. Prevalenceof anaemia is more than in singleton pregnancy II. Unusual weight gain, not explained by pre- eclampsia or obesity III. Evidence of preeclampsia(25%)is a common association. ABDOMINALEXAMINATION: Inspection: • The elongated shape of a normal pregnant uterus is changed to a more "barrel shape” and the abdomen is unduly enlarged.
- 16. • Palpation: Fundalheight more than the period of amenorrhoea girth more than normal Palpation of too many fetal parts Palpation of two fetal heads Palpation of three fetal poles • Auscultation: Two distinct fetal heart sounds with Zone of silence 10 beat difference
- 17. Hydramnios Macrosomia Fibroid with pregnancy Ovarian tumor with pregnancy Adenexal mass with pregnancy Ascites with pregnancy Molar pregnancy
- 18. Sonography: Inmulti fetal pregnancy it is done to obtain the following information: i. Suspecting twins – 2 sacs with fetal poles and cardiac activity ii. Confirmation of diagnosis iii. Viability of fetuses, vanishing twin iv. Chorionicity – 6 to 9 wks ( single or double placenta, twin peak sign in d /d gestation or Tsign in m/d ) v. Pregnancy dating, Fetal anomalies vi. Fetal growth monitoring (at every 3-4 weeks interval) for IUGR
- 19. i. Presentation andlie of the fetuses ii. Twin transfusion (Doppler studies) iii. Placental localization iv. Amniotic fluid volume Radiography Biochemical tests: raised but not diagnostic Maternal serum chorionic gonadotrophin, Alpha fetoprotein Unconjugated oestriol
- 20. Maternal Pre eclampsia During Pregnancy APH mechanical distress pre term labor Hydraminos Nausea& vomiting malpresentation Anemia
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- 24. Antenatal Diet Increasedrest Supplement therapy Interval of antenatal visit Fetal surveillance
- 25. Labor Vaginal is allowedwhen both the twins are /or at least the first twin is vertex presentation 1st stage • A skilled obstetrician should be present • Neonatologist (two) • Presence of ultrasound in the labor room • Patient should be in bed • Use of analgesic drugs • Careful fetal monitoring • Internal examination should be done • i/v line with ringer solution