Multiple pregnancy

2. SHRI SHANKARACHARYA COLLEGE
OF NURSING HUDCO BHILAI
SEMINAR
ON
Subject-Obstetrical and gyneocology
Topic- Multiple pregnancy
Submitted to Submitted by
Mrs Saumya Thomas Miss Monalisa kujur
Associated professor msc nursing final year
(SSCN)

3. MULTIPLE PREGNANCY
Introduction-

4. Definition
“Multiple pregnancy Is when more than one fetus
simultaneous develop in the uterus ,it is called
multiple pregnancy.”
Acc.to Dc Dutta
“When there is more than one fetus is in utero, at
term ,plural or multiple pregnancy is applied”.
Acc. To Nisha Clement

5. Incidence
The incidence widely varies, In the word it varies
from 56 to 46 per 1000 births.
 It is highest in Nigeria being 1 in 20 and lowest in
eastern countries being 1 in 200 pregnancies .
 In India , the incidence is about 1 in 80.
 While the incidence of monozygotic twins remains
constant throughout the globe ,being 1 in 250.it is
the dizygotic twins which are responsible for the
wide variation of incidence.
 Since the 1980 s there has been a rise in incidence
due to increased use of various kind of treatments
for infertility

6. Twin pregnancy
Simultaneous development of two fetus in the uterus
is most common variety of multiple pregnancy.

7. Varieties of twins

8. Dizygotic twins(Binovular )

9. Monozygotic twins(Uniovular)

10. Siamese twins ,four type of fusion may
occur
1) Thoracopagus (most common)

11. 2.Pyogagus (posterior fusion)

12. 3.Craniopagus(cephalic )

13. 4)Ischiopagus(caudal)

14. 5)Rachipagus(dorsal)

15. Etiology
 The causes of twining is not known
 Prevalence of dizygotic twins is related to-
 Race
 Hereditary
 Advancing age of mother
 Influence of parity
 Iatrogenic

16. Some other condition
 Superfecundation
 Superfeation
 Fetus papyraceous or compression
 Fetus acardiac
 Vanishing twin.

17. Sings and symptoms

18. Zygocity and chorionicity
 Zygosity refers to the genetic meckeup of the
pregnancy and chronicity refers to the placental
membrane status.
 Determination of chorionicity is essential as the
obstetrical and perinatal risks,management and
outcome depends on it.
 Chorionicity is determined by timing of embryo
division.

19. Determination of chorionicity in
monozygotic twin pregnancy
Timing of
cleavage
Placenta’s membrane
status
%of
monozygoti
c twins
272 hours Diamniotic –Dichorionic 25-30
Days 4-7 Diamniotic -monochorionic 70-75
Days 8-12 Monoamniotic-monochorionic 1-2
Day>13 Conjoined Siamese <1

20. Summary of determination of zygosity
Zygosity Placenta Communica
ting vessels
Intervening
membrane
and
thickness
Monozygosity 1 present 2(amnions)
(<2mm)
Dizygotic 2 Absent 4(2amnion
and 2
chorions)
(<2mm)

21. Summary of the determination zygosity
Zygosity Sex Genetic
features
(dominant
blood group,
DNA fingerprint)
Skin
grafting
Follow-up
Monozygoti
c
Always
identical
same accept Usually
identical
Diazygotic May differ Deferent Reject Not
identical

22. Diagnosis
 History
 History of ovulation including drugs specially
gonadotropins ,for infertility or use of ART.
 Family history of twining .
 Symptoms
Minor ailment of normal pregnancy are aften
exaggerated .Some of the symptoms are related to the
under enlargement of the uterus-
 Increased nausea and vomiting in early months.
 Cardiorespiratory embarrassment which is evident in
the later months such as palpitation or shortness of
breath . Continue….

23.  Swelling of the legs, varicose veins and haemorrhoids is greater.
 Unusual rate rate of abdominal enlargement and excessive fetal
movements may be noticed by an experienced parous mother.
 General examination
Inspection: The elongated shape of a normal pregnant
uterus is changed to a barrel shape and the
abdomen is unduly enlarged . Continue……

24.  Palpation
 The hight of the uterus is more than the period of
amenorrhea .This discrepancy may only become evident
from mid pregnancy onwards.
 The girth of the abdomen at the level of umbilicus is
more than the normal average at term (100 cm).
 Fetal bulk seems disproportionately larger in relation to
the size of the fetal head.
 Palpation of two many fetal parts .
 Finding of two fetal poles make the clinical diagnosis
almost certain.

25.  Tape Measurement
Abdominal girth at umbilicus shows measure in inches more than
corresponding measures at gestation week /kg normal at 30 week-
30 inches.
 Auscultation
Simultaneous auscultation of two distinct fetal heart sound
located at separate spots a with silent area in between by two
observers, gives a certain clue in the diagnosis of twins ,provided
the difference the in the heart rates is at least 10 beats per
minute.
The abdominal palpation and auscultations may not be
carried out so easily ,as described ,because of the presence of
hydramnios.

26.  Biochemical test
 Sonography
In multifetal pregnancy it is done to obtain the following
information:
 Confirmation of diagnosis as early as tenth week of
pregnancy.
 Viability of fetuses as vanishing twin in the second trimester.
 Chorionicity
 Pregnancy dating
 Fetal anomalies continue…..

27.  Presentation and lie of the fetuses
 Twin transfusion (Doppler studies)
 Placental localization
 Amniotic fluid volume
Radiography
It is done less often these days .Two fetal heads and spines could be seen
on x-ray.
Chorionicity of the placenta
 It is best diagnosed by ultrasound (TVS)at 11-14 weeks of gestation .
 In dichorionic twins there is a thick septum (>2mm)between the two
gestational sacs. It is best identified at the base of the membrane
,where a triangular projected is seen .

28.  This is known as lambda or twin peak sign .Presence of lambda or
twin peak sign indicates dichorionic placenta.
 Presence of one gestational sac with a thin (<2mm)dividing
membrane ,and two fetuses (T sign )suggests monochorionic
diamniotic pregnancy.

29. Complication of monochorionic twins
1.Twin –twin transfusion syndrome(TTTS)

30. Management
1. Laser photocoagulation

31. 2.Repeated amniocentesis
3.Septostomy
4.Selective reduction

32. 2. Dead fetus syndrome

33. 3.Twin reversed arterial perfusion(TRAP)

34. Conjoined twin

35. Management of multiple pregnancy
 The essence of successful outcome of a twin pregnancy is to
make an early diagnosis.
 High index of clinical suspicious and through ultrasound
examination are the keys to the diagnosis.
Antenatal management
Advice
 Diet
 Increased rest
 Supplementary
 Interval of antenatal visit.
 Fetal surveillance

36.  To prevent preterm delivery ,routine use of tocolytics,
progesterone therapy or cerclage Operation has got no
significant benefit.
 Corticosteroid (Betamethasone /Dexamethasone )fetal lung
maturation is given to the women with preterm labor less than
34 weeks.
 Prolongation of pregnancy beyond 39 weeks increase the risk.
Emergency-Development of complicating factors necessitates
urgent admission irrespective of the period of gestation

37. Indication of cesarean section
The indication are broadly divided into:
 Obstetric indications
 For twins
Obstetric indications
• Placenta previa
• Severe pre –eclampsia
• Previous cesarean section
• Cord prolapse of the first baby
• Abnormal uterine contraction
• Contracted pelvis

38. For twin
• Both the fetuses or even the first fetus
with nanocephalic presentation.
• Twins with complication:IUGR,conjoined
twins.
• Monoamniotic twins
• Monochorionic twins with TTTS.
• Collision of both the heads at brim
preventing engagement of either head

39. Management during labor
Place of delivery- Patient should be confined in an
equipped hospital preferably having an intensive
neonatal care unit .
Frist stage :Usual Conduction of the first stage as
outlined for a singleton fetus ,is followed with
additional precaution.
• Skilled obstetrician should be present .
• Neonatologist (two)should be present .
• Presence of ultrasound in the labor ward.
• The patient should be in bed .
• Use of analgesic drugs .

40. • Careful fetal monitoring .
• Internal examination should be done.
• Intravenous line with ringer’s solution should be set up for any
intravenous therapy if required .
Delivery of the first baby
• Extended episiotomy under local infiltration with 1% lignocaine.
• Forceps delivery if needed .
• Not to give intravenous ergometrine with the delivery of the first
baby.
• Clamp the cord at two places and cut in between.
• The baby is handed over to the nurse after it as labelling it as
number 1.

41. Delivery of the second twin
Step 1
 Following the birth of the first baby the lie presentation
size and FSH of the second baby should be ascertained by
abdominal examination or if required by real time
ultrasound .
 Vaginal examination is also to be made not only to confirm the
abdominal findings but to note the status of membranes and
exclude cord prolapse .

42. Lie longitudinal
Step 1
• Low rupture of the membranes is done after finding the
presenting part on the brim.
Step 2
• If the uterine contraction is poor ,5 unit of oxytocin is added
to the infusion bottle.
• The interval between deliveries should ideally between less
than 30 minutes.

43. Step -3
If there is still a delay interference is to be done.
 Vertex:
• Low down-forceps are applied
• High up –ventose or external version
 Breech: The delivery should be completed by breech
extraction
 Transverse lie
• It should be corrected by external version into longitunal lie
preferably cephalic ,if fails podalic .
• If the external version fails ,internal version under general
anaesthesia should be done.

44. Indication of urgent delivery of the second baby
 Sever vaginal bleeding
 Cord prolapse of the second baby
 Inadvertent use of intravenous ergometrine(oxytocies)with the
delivery of the first baby.
 Frist baby delivered under general anesthesia
 Appearance of fetal distress.

45. Management of the third stage
• Administration of 0.2 mg methergine IV or Oxytocin 10 IU IM
following the delivery of the second baby.
• The placenta is to be delivered by controlled cord traction.
• The oxytocin drip for at least 1 hour, following the delivery of
the second Baby.
• A blood loss more than average should be immediately
replaced by blood transfusion .
• The patient is to be carefully watched for about 2 hours after
delivery .
• Mother should be given additional support at home to look
after both the babies.

46. Management of difficult cases of twins
 Interlocking
The most common one being the after coming head of the first
baby getting locking with fore coming head of the second baby.
• Vaginal manipulation to separate the chins of the fetuses is done
,failing which caesarean section is necessary .
• Decapitated head ,followed by delivery of the second baby and
lastly ,delivery of the decapitated head ,at least saves one baby.
 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 intranantal sonography.
• Disengagement of the higher head can be possible under general
general anaesthesia . Continue…….

47. • If fails ,cesarean section is the alternative ,for fetal intraction.
Conjoined twins
It is extremely rare incidence varies from 1:100,000 to 1:50,000
Births . In twin pregnancies the incidence is from 1:900 to 1:650.
Diagnosis
 Unfortunately conjoined twins are often diagnosed during
delivery when there is obstruction in the second stage .
 Using USG ,early diagnosis can be made with the presence of
monochorionic /monoamniotic sac.
 Fetal echocardiography ,colour doppler ,MRI are useful to assess
the degree of organ sharing specially the heart .

48. Antenatal diagnosis
Antenatal diagnosis is important .Benefits are-
• Reduce maternal trauma and morbidity
• Improves fetal survival
• Helps to plan the method of delivery
• Allows time to organize the pediatric surgical team.
Management
• Extent and site of union
• Possibility of surgical separation .
• Size of the fetuses and possibility of survival and termination of
pregnancy is an option when early diagnosis has been made.
• Termination of pregnancy is an option when early diagnosis has
been made.

49. Triplets quadruplets etc
• Triplets may develop from fertilization of a single ovum
or two or even three ova ,similar single ovum or two or
even three ova ,similar with quadruplets and quintuplets
.female fetus usually outnumber the male one.
• Clinical course and complication are intensified
compared to twins.
• Preterm delivery is common usually delivery occurs
anytime between 35 and 36 weeks.
• Discordance of fatal growth is more common than twin .
• Average time for delivery is quadruplets is 30-31 weeks.
• To improve the fetal salvage ,especially in quadruplets ,it
is advisable to employ liberal caesarean section.

50. Selective reduction
• If there are 4 or more foetuses ,selective reduction of the
foetuses' leaving behind only two is done to improve outcome of
the co fetuses.
• It can be done by intracardiac injection of potassium chloride
between 11 and 13 weeks under ultrasonic guidance. It is done
transabdominally .
• Umbilical cord of targeted twin is occluded by fetoscopic ligation
or by lesser or by bipolar coagulation to protect the co-twin
from adverse drug effect .

51. Selective termination
• Selective termination of a fetus with structural or genetic
abnormality may be done in dichorionic multiple pregnancy in
the second trimester by intracardiac injection of postassium
chloride .
• In monochorionic twins ,cord occlusion or cord ablation is
done(lasser).

52. Nursing management
 Antenatal care
 At 32 bed rest to be maintained
 During labor bed rest ,respiratory support ,enema giving
,rupture of membrane is done ,vaginal examination to
exclude prolapse of cord
 In locke twins there have to sacrifiece the frist baby.
 Ceasrean section .
 Third stage prophylactic intravenous methargin given
immediately on birth of second baby.
 Pediatric care
 Brest feeding