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Multiple pregnancy
• When more than one fetus simultaneously develops in
the uterus then it is called multiple pregnancy.
• Simultaneous development of two fetuses (twins) is the
commonest; although rare, development of three fetuses
(triplets), four fetuses (quadruplets), five fetuses
(quintuplets or six fetuses (sextuplets) may also occur.
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Twins pregnancy
Varieties:
• Dizygotic twins: is the commonest (two-third) and
results from the fertilization of two ova.
• Monozygotic twins (one-third) results from the
fertilization of single ovum.
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On rare occasion, the following
possibilities may occur
• If the division takes place within 72 hours after
fertilization the resulting embryos will have two separate
placenta, chorions and amnions (D/D)
• If the division takes place between the 4th and 8th day
after the formation of inner cell mass when chorion has
already developed diamniotic monochorionic twins
develop (D/M)
• If the division after 8th day of fertilization, when the
amniotic cavity has already formed, a monoamniotic
monochorionic twins develop (M/M)
7.
8.
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Diamniotic
Dichorionic
Separate placenta
Frequency: 35%
Mortality: 13%
Diamniotic
DiChorionic
fused placenta
Frequency 27%
Mortality 11%
Diamniotic
Monochorionic single
placenta
Frequency 36%
Mortality 32%
Monoamniotic
Monochorionic
single placenta
Frequency 2%
Mortality 44%
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Multiple pregnancy contd…
• On extreme rare occasions, division occurs after 2 weeks
of the development of embryonic disc resulting in the
formation of conjoined twins called-Siamese twins.
• Four types of fusion may occur
– Thoracopagus (commonest)
– Pyopagus (Posterior fusion)
– Craniopagus (cephalic)
– Ischiopagus (caudal)
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Examination of placenta and
membranes
Dizygotic Twin Monozygotic twin
Two placenta, either completely
separated or more commonly fused at
the margin appearing to be one.
No anastomosis between the two fetal
vessels.
Placenta is single.
Varying degrees of anastomosis
between the two fetal vessels.
Each fetus is surrounded by a amnion
and chorion
Each fetus is surrounded by a separate
amniotic sac with the chorionic layer
common to both.
Intervening membranes consist of 4
layers-amnion, chorion, chorion and
amnion.
Intervening membrane consists of two
layers of amnion only.
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• Sex: while twins having opposite sex are almost always
binovular and twins of the same sex are not always uniovular
but the uniovular twins are always of the same sex.
• If the fetuses are of the same sex and have the same genetic
features (dominant blood groups), monozygosity is likely.
• A test skin graft: Acceptance of reciprocal skin graft—proof of
monozygosity.
• DNA microprobe technique is more definitive.
• Follow-up study between 2-4 years—showing almost similar
physical and behavioral features suggestive of monozygosity.
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Incidence
• Varies widely. Highest in Nigeria being 1 in 20 and
lowest in Far Eastern countries being 1 in 200
pregnancies. Monozygotic twins 1 in 250 in the world.
• According to Hellin’s rules, the mathematical frequency
of multiple birth is twins 1 in 80 pregnancies, triplets 1 in
802, quadruplets 1 in 803 and so on.
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Factors that Influence Twinning
• The causes of twin pregnancy is not known.
• Race: Highest amongst Negroes (once in every 20 births),
lowest amongst Mongols and intermediate among Caucasians
• Heredity: Family history in mother.
• Maternal Age and Parity: Twinning peaks at age 37 years
• Increasing parity: 5th gravid onwards.
• Nutritional Factors: Taller, heavier women—twinning rate 25 to
30 % greater.
• Pituitary Gonadotropin
• Infertility Therapy
• Assisted Reproductive Technology
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Diagnosis
History and Clinical Examination
• Recent administration of either clomiphene citrate or
gonadotropins or pregnancy accomplished by ART are
much stronger associates.
• Clinical examination with accurate measurement of
fundal height.
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Diagnosis contd…
• In women with a uterus that appears large for gestational
age, the following possibilities are considered:
– Multiple fetuses
– Elevation of the uterus by a distended bladder
– Inaccurate menstrual history
– Hydramnios
– Hydatidiform mole
– Uterine leiomyomas
– A closely attached adnexal mass
– Fetal macrosomia (late in pregnancy)
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Diagnosis contd…
Symptoms
• Minor symptoms of normal pregnancy are often
exaggerated.
• Increased nausea and vomiting in early months
• Cardio-respiratory embarrassment
• Tendency of swelling in the legs, varicose veins and
hemorrhoids is greater
• Unusual rate of uterine enlargement and excessive fetal
movements
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Diagnosis contd…
General examination
• Prevalence of anemia is more
• Unusual weight gain, not explained by
preeclampsia or obesity
• Evidence of preeclampsia is a common
association.
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Diagnosis contd…
Abdominal examination
Inspection: Barrel shaped and the abdomen is unduly enlarged
Palpation
– Height of uterus > period of amenorrhoea
– Girth of abdomen> normal average at term (100 cm)
– Fetal bulk disproportionately larger in relation to the size of the
fetal head.
– Palpation of too many fetal parts
– Finding of two fetal heads or three fetal poles
Auscultation
• Two distinct FHS at separate spots, difference in heart rates
is at least 10 beats/minute.
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Diagnosis contd…
Investigations
Sonography
• separate gestational sacs identified early
• Confirmation of diagnosis as early as 10th week of
pregnancy
• Variability of fetuses, vanishing twin in second trimester
• Chorionicity (twin peak sign)
• Pregnancy dating, Fetal anomalies
• Fetal growth monitoring, Presentation and lie of fetuses
• Twin transfusion localization, Amniotic fluid volume
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Complications contd…
• During labour
Early rupture of membranes and
cord prolapse
Prolonged labour
Increased operative interference
Bleeding
Postpartum hemorrhage
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Complications contd…
• During puerperium
• Fetal
Subinvolution
Infection
Lactation failure
Miscarriage
Prematurity (80%)
Growth problem (25%)
Intrauterine death
Asphyxia and still birth
Fetal anomalies
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Complications of monochorionic twins
Twin twin transfusion syndrome (TTS)
• one twin appears to bleed into other through placental
vascular anastomosis.
• Receptor twin becomes larger with hydramnios,
polycythemic, hypertensive and hypervolemic
• Donor twin which become smaller with oligohydramnios,
anemic, hypotensive and hypovolemic.
• Donor may appear stuck due to severe oligohydramnios.
• Difference of hemoglobin concentration between the twin
usually exceeds 5 gm% and estimated fetal weight
discrepancy is 25% or more.
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Complications of monochorionic twins
contd…
TTTS contd..
Management
• Antenatal diagnosis: ultrasound with doppler flow study
in the placental vascular bed.
• Repeated amniocentesis to control polyhydramnios in
recipient twin.
– prevent preterm labour and placental abruption.
• Selective reduction of one twin is done when survival of
both the fetuses is at risk.
• Smaller twin generally have got better outcome.
• Plethoric twin: risk of CCF and hydrops.
• Perinatal mortality: 70%.
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Complications of monochorionic twins
contd…
Dead fetus syndrome
• Death of one twin (2-7%) is associated with poor
outcome of the Co-twin (25%) specially in monochorionic
placenta.
• The surviving twin runs the risk of cerebral palsy,
microcephaly, renal cortical necrosis and DIC.
• This is due to thromboplastin liberated from the dead
twin that crosses via placental anastomosis to the living
twin.
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Complications of monochorionic twins
contd…
Twin reversed arterial perfusion (TRAP):
• Characterized by an acardiac perfused twin having blood
supply from a normal co-twin via large arterio-arterial
anastomosis.
Conjoint twin:
• Rare.
• Perinatal survival depends upon the type of joint.
• Major cardiovascular anastomosis leads to high
mortality.
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Research evidence
Twin, acardiac, outcome (GrabD, Schneider V, Keckstein J, Terinde R)
• 26-year-old G2P1 was initially seen in the 16th week of a twin gestation. An
acardiac-acranial twin was present. There were spontaneous movements of
the lower extremities. Chromosomal analysis of amniotic fluid showed two
normal females. Several ultrasonographic examinations showed lack of growth
of the malformed twin but appropriate growth of the normal twin. Spontaneous
labor developed at 40 weeks and a normal female, 3270g, with Apgar
9/10/10, was delivered. The acardiac twin was approximately 10 cm long and
was spontaneously delivered out of a second amniotic cavity.
Pathologic findings
• The female acardiac acephalic twin (31g, 10 cm) showed no heart or lung
development; liver, intestine, and urogenital tract appeared normal.
Spleen, pancreas and stomach were absent. The placenta was monochorionic
diamniotic, and the two umbilical cords were interconnected by a direct
anastomosis.
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Complications of monochorionic twins
contd…
Monoamniocity:
• Monochorionoc twins leads to high perinatal mortality
due to cord problems.
• Prostaglandin synthase inhibitor used to reduce fetal
urine output, creating borderline oligohydramnios and to
reduce the excessive movements.
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Antepartum Management of Twin
Pregnancy
To reduce perinatal mortality and morbidity rates in
pregnancies complicated by twins, it is imperative that:
• Delivery of markedly preterm neonates be prevented
• Fetal-growth restriction be identified and afflicted fetuses
be delivered before they become moribund
• Fetal trauma during labor and delivery be avoided, and
• Expert neonatal care be available.
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Management contd…
• Diet: increased requirement of calories, protein, minerals,
vitamins, and essential fatty acids. Caloric should be
increased by another 300 kcal/day. Supplementation with 60
to 100 mg/day of iron and1 mg/day of folic acid.
• Bed Rest
• Antepartum Surveillance: sonographic examinations
• Tests of Fetal Well-Being
• Prevention of Preterm Delivery
• Hospitalization
• Use of corticosteroids to accelerate fetal lung maturation.
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Management during labour
First stage:
• A skilled obstetrician, presence of ultrasound machine and
experienced anesthetist
• Bed rest to prevent early rupture of membrane.
• Limit use of analgesic drugs
• Careful monitoring
• Internal examination soon after the rupture of membranes
• An intravenous line with ringer’s solution
• Availability of one unit of compatible and cross matched blood
• Neonatologist:Present at the time of delivery.
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Management during labour contd..
Delivery of the first baby:
• Delivery: Same guidelines as in normal labour with
liberal episiotomy.
• Forceps delivery: if needed, should be done preferably
under pudendal block anaesthesia.
• Do not give intravenous ergometrine with delivery of the
anterior shoulder of the first baby.
• Clamp the cord at two places and cut it between.
• At least 8-10 cm of cord is left behind for administration
of any drug or transfusion, if required.
• The baby should be labeled one.
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Management during labour contd..
Conduction of labour after the delivery of the first baby:
Steps of management:
Step I:
• Ascertain lie, presentation, size and FHS of the second
baby.
• Vaginal examination: To confirm the abdominal findings
and to exclude cord prolapsed, if any to note the status
of membrane.
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Management during labour contd...
Lie longitudinal:
• Step I: Low rupture of membranes, syntocinon, internal
examination to exclude cord prolapse.
• Step II: If the uterine contraction is poor, 5 units of
oxytocin is added.
• Step III: Is there is still a delay, interference is to be
done.
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Management during labour contd...
1. Vertex: Low down—forceps are applied.
• High up—CPD should be ruled out.
• The possibility of hydrocephalic head should also be
kept in mind and excluded by ultrasonography.
• If these are excluded, internal version followed by breech
extraction is performed under general anesthesia.
• Ventouse: effective alternative.
2. Breech: Breech extraction.
3. Lie transverse: Correct by external version or internal
version to cephalic or podalic.
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Management during labour contd...
Indication of urgent delivery of second baby:
– Severe vaginal bleeding,
– Cord prolapse
– Inadvertent use of IV ergometrine with the delivery of
anterior shoulder of the first baby,
– First baby delivered under general anesthesia,
– Appearance of fetal distress.
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Management during labour contd...
Delay in the birth of second twin
• Birth of second twin should be completed within 45
minute of the first twin being born but with close
monitoring can be extended if there are no signs of fetal
compromise.
• The risk of delays:
– intrauterine hypoxia,
– birth asphyxia,
– sepsis
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Management during labour contd...
Management of third stage
• Routine administration of 0.2mg methergin IV with
delivery of anterior shoulder.
• Deliver placenta by CCT
• Continue oxytocin drip for at least one hour, following
delivery of second baby.
• The patient is to be carefully watched for about 2 hours
after delivery.
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Indications of caesarean section
Obstetric causes:
– Placenta previa
– Severe preeclampsia
– Previous caesarean section
– Cord prolapse of the first baby
– Abnormal uterine contractions
– Contracted pelvis
• For twins: Both fetuses or even first fetus with non-
cephalic presentation,
• Twins with complications: IUGR, conjoint twins;
Monoamniotic twins, monochorionic twins with TTS
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Management of difficult cases of
twins
Interlocking
• Commonest: Aftercoming head of first baby getting locked
with forecoming head of second baby.
• Vaginal manipulation to separate chins of the fetuses
• Decapitation of first baby (dead), pushing up decapitated
head, followed by delivery of second baby and lastly, delivery
of decapitated head.
• Occasionally, two heads of both vertex get locked at the
pelvic brim preventing engagement of either of the head.
• Disengagement of the higher head: Under general
anesthesia, If fails, caesarean section is the alternative
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Management of difficult cases of
twins contd..
Conjoined twins
• Extremely rare.
• Often diagnosed during delivery
• Presence of a bridge of tissue between the fetuses on
vaginal examination confirms the diagnosis.
• Antenatal diagnosis is important.
• Benefits are: reduces maternal trauma and
morbidity, improves fetal survival, helps to plan method
of delivery, allows time to organize pediatric surgical
team.
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Postnatal period
Care of the babies
• Immediate care
• Maintenance of body temperature,
• Use of overhead heaters,
• Parents given the opportunity to check the identity tag
and cuddle them.
Breastfeeding
• Provide knowledge to mother regarding different
positions for breastfeeding, along with advantages,
attachment, positioning timing.
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Postnatal period contd..
Nutrition
• Expressed breast milk is best (for small babies), they may need to
be fed intravenously or by nasogastric tube or cup-fed, depending
on their size and general condition.
• Careful monitoring of weight gain, regular capillary blood glucose
estimations
• Reassure her that lactation responds to the demands made by
babies sucking at the breast.
• At feeding times, mother must be provided support and advised on
positioning and fixing babies.
Care of the mother
• Slow involution of uterus, increased ‘After pains’ so analgesia
should be offered.
• High calorie diet.
• Teach extra support to handle twin babies
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Management and Nursing
Interventions
• Nutrition counseling
• Fetal evaluation
• Evaluate woman for signs and symptoms of obstetrical
complications
• PTL prevention: explain for hospitalization
– Encourage bed rest and hydration.
– Institute fetal monitoring and assist with tocolytic therapy, if
ordered.
• Explain to the woman that mode for delivery depends on
the presentation of the twins, maternal and fetal status,
and gestational age
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Management and nursing interventions contd…
Intrapartum management
• Establish I.V. access
– Provide for electronic fetal monitoring for each fetus.
– Double setup is recommended for delivery.
• Availability of two units of crossmatched whole blood.
• I.V. access with large bore catheter.
• Surgical suite immediately available.
• An obstetrician and assistant experienced in vaginal births of twins.
• Best choice of anesthesia: epidural.
• Anesthesia provider capable of administering general anesthesia.
• Neonatal team for each neonate present at birth for neonatal
resuscitation.
– Pitocin induction/augmentation may be required secondary to
hypotonic labor.
– Postpartum hemorrhage may occur due to uterine atony.
• Emotional support.
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Nursing diagnoses
• Anxiety
• Deficient Knowledge Regarding High-risk Situation/Preterm
Labor
• Risk for Imbalanced Nutrition: Less/More than Body
Requirements
• Risk for Fetal Injury
• Risk for Maternal Injury
• Risk for Deficient Fluid Volume
• Risk for Impaired Gas Exchange
• Risk for Activity Intolerance
• Risk for Ineffective/Compromised Family Coping
• Risk for Interrupted Family Process.
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Nursing diagnoses contd…
For Cesarean Delivery
• Deficient Knowledge Regarding Surgical Procedure, and
Postoperative Regimen
• Anxiety (Specify Level)
• Powerlessness
• Risk for Acute Pain
• Risk for Infection
• Risk for Impaired Fetal Gas Exchange
• Risk for Maternal Injury
• Risk for Decreased Cardiac Output
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References
• Fraser DM, Cooper MA.Myles Textbook for Midwives.15th edition.
Philadelphia:Churchill livingstone elsevier;2009
• Dutta DC.Textbook of obstetrics. 6th edition.Calcutta:New central
book agency;2004
• Pillitteri A. Maternal and child health nursing. Care of the
childbearing and childrearing family. Sixth edition. Philadelphia;
Lippincott Williams & Wilkins: 2010.
• Cunningham, Leveno, Bloom. William’s obstetrics. 23rd edition.
United states of America; Mcgraw Hill companies: 2010.
• Nettina S.M, Mills E.J. Lippincott Manual of Nursing Practice. 8th
Edition. Philadelphia: Lippincott Williams and Wilkins; 2006
• Multiple Pregnancy and Birth: Twins, Triplets, and High-order
Multiples: A Guide for Patients. Patient information series. American
Society for Reproductive Medicine. 2012
