Multiple pregnancies consist of two or more fetuses, with twins making up nearly all multiple gestations. Multiple pregnancies are associated with higher risks of maternal, fetal, and neonatal complications. The classification of multiple pregnancies is based on the number of fetuses, zygosity (number of fertilized eggs), chorionicity (number of placentae), and amnionicity (number of amniotic cavities). Monozygotic twins can either have separate or shared placentae and amniotic sacs depending on the timing of division after fertilization.

2.  multiple pregnancies consist of two or more fetuses
 Twins make up the vast majority (nearly 99%) of
multiple gestations.
 It associated with higher incidence of maternal, fetal
and neonatal morbidity and mortality.
 The more fetuses, the higher the complications.

3. Twins 1 in 80 live birth
Triplets 1 in 8000
Quadruplets 1 in 750,000
Higher orders are rare

4. 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.

5. 2/3rd
fertilization of two separate ova
( Dizygotic , Biovular, Non identical ) 2
separate placentae & 2 amniotic sacs
Dichorionic Diaminotic (DC DA)

6.  1/3rd
one single fertilized ovum that divides into
two structures
Monozygotic, Uniovular, Identical
 The outcome depends on the time of division

7.  If division in first three days (1/3rd
)
separate placentae and amniotic sacs
Dichorionic Diamniotic (DC DA)
 Between 4th
and 8th
days
One placenta and two amniotic sacs
Monochorionic Diamniotic (MC DA) (about 2/3rd
)
 9th
-13th
day
Monochorionic Monoamniotic (MC MA) ( < 1%)
 After day 13
Conjoined Twins

8. MC DA MC MA DC DA

12. 100 sets of twins
70
Dizygotic
30
Monozygotic
~10
Dichorionic
Diamniotic
~20
Monochorionic
Diamniotic
~0.3
Monochorionic
Monoamniotic
70
Dichorionic
Diamniotic

13.  Monozygotic twins can share later in
transplantation surgery without fear of
rejection.
 For sake of management of complications
it is important to determine the chorionicity
since complications are higher with
monochorionic twins .

14. Higher incidence of MP is related to :
 Race : Nigerian population > Asian
1 : 20 1 : 155
 Hereditary : family history in the mother
 Maternal age & parity :increased incidence
with higher parity & older age.
 Infertility therapy :
Gonadotrophins (FSH / HCG ) & Clomiphene
 IVF

15. Clinicaly
History
 induced pregnancy
 Severe morning sickness
 Family history or previous history of twins

16.  Examination
 Fundal height more than gestational age.
 Multiple fetal parts.
 Fetal hearts with rates distinct from each
other.

17.  Ultra sound
 Separate gestational sacs.
 Later two fetal heads.

21. Differential diagnosis of
MP
Polyhydramnios
Uterine fibroid
Ovarian masses
Urine retention

22.  Increased nausea and vomiting.
 Increased prevalence of maternal anaemia.
 Increased prevalence of pregnancy induced
hypertension.
 Increased incidence of polyhydramnios.
 More displacement of lung by displaced
diaphragm.
 More pressure symptoms.
 Increased incidence of Antepartum
haemorrahge.

23.  Miscarriage ( more in monozygotic).
 Congenital malformations.
 Preterm delivery.
 Low birth weight due to
 Preterm delivery
 Growth restriction
 Weight discordance

24.  It occur due to imbalance in the flow of blood
across these arteriovenous communications; so
one fetus becomes overperfused and the other
underperfused.
 The growth-restricted donor fetus suffers from
hypovolaemia and becomes oliguric develops
oligohydramnios.
 The recipient fetus becomes hypervolaemic,
leading to polyuria and polyhydramnios.

25. 1) amniocentesis every 1–2 weeks with the
drainage of large volumes of amniotic fluid.
2) fetoscopically guided laser coagulation to disrupt
the placental blood vessels that connect the
circulations of the two fetuses

26.  As monoamniotic twins share a single amniotic
cavity they are at increased risk of cord
accidents(cord entanglement).
 Many clinicians advocate elective delivery by
Caesarean section at 32–34 weeks gestation, as
this complication is usually acute, fatal and
unpredictable.

27.  Maternal risk and prognosis for the surviving twin
depends on :
 Gestational age.
 Chorionicity.
 Time between demise and delivery of
surviving twin.

28.  Early loss in the first trimester vanishing
twin with no risk to the other twin.
 In midtrimester rarely lead to coagulation
defects .
 If death late in pregnancy:
 Conservative management with close
monitoring.
 There is increased risk of coagulopathy &
neurological complications.

29.  Diet: Increase in energy sources, iron and folic
acid supplements.
 Treatment of hypertension if developed.
 Antepartum surveillance:
 More frequent visits.
 Serial ultrasound for growth & amniotic fluid
volume.
 Prevention of preterm labour complication by
administration of corticosteroid .

30. Complications of labour & delivery include:
 Preterm labour
 Uterine dysfunction
 Abnormal presentation
 Umbilical cord prolapse
 Premature separation of placenta
 Immediate postpartum haemorrhage

31.  Depend on lie and presentation of the first
Twin.
All possible combinations may be encountered.
 The most common
 Cephalic - Cephalic
 Cephalic - Breech
 Cephalic – Transverse
 Breech – Cephalic
 Breech - Breech

32.  Vaginal delivery is planned for when the
first twin is cephalic.
 If breech most clinician planned a
Caesarean delivery (risk of locked twins).
 Other presentations for elective Caesarean
Section.

33.  After delivery of the first twin clamp the
Cord
 Quick abdominal and then vaginal
examination to assess the lie , presentation
fetal heart & state of membranes.

34.  If longitudinal (cephalic or breech ):
 Rupture membranes.
 Oxytocin infusion.
 Exclude cord prolapse and monitor fetal
heart rate.
 Hasten labour if bleeding or non-reassuring
heart rate (forceps or breech extraction).

35.  If oblique or transverse with intact membranes:
 try external version (either cephalic or
podalic and continue the same way).
 If failed try internal podalic version:
 Recommended in theatre by experts.
 Rupture of membranes, grasp feet & deliver by
breech extraction.
 Associated with high risk of uterine rupture.

36.  After delivery of second twin:
 Clamp the cord with two clamps.
 Active management of the third stage of labour.
Interval between delivery is safe if ≤ 30
Minutes.

37.  Caesarean delivery of the second twin is
indicated if:
 transverse lie ( failed version or ruptured
membranes ).
 cervix contracts and thickens after
delivery of first twin.

38.  Problems
 Separation of placenta during delivery.
 Fetal heart rate monitoring during labour is
challenging.