multiple pregnancy

1. Multiple Pregnancy/
Multifetalpregnancy
• The presence of more than one fetus in the
gravid uterus is called multiple pregnancy
• Two fetuses (twins)
• Three fetuses (triplets)
• Four fetuses (quadruplets)
• Five fetuses (quintuplets)
• Six fetuses (sextuplets)

2. INCIDENCE
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

3. Demography
• Race: most common 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, gonadotrophins and IVF
• Conception after stopping OCP

4. Twins
Varieties:
• 1. Dizygotic twins: commonest (Two-third)
• 2. Monozygotic twins (one-third)
Genesis of Twins:
• Dizygotic twins (syn: Fraternal, binovular) -
- fertilization of two ova by two sperms.

5. Monozygotic twins (syn: Identical, uniovular):
• 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.

7. Conjoined twins
Ventral:
1) Omphalopagus
2) Thoracopagus
3) Cephalopagus
4) Caudal/ ischiopagus
Lateral:
1) Parapagus
Dorsal:
1)Craniopagus,
2)Pyopagus

8. Superfecundation
Fertilization of two different ova released
in the same cycle
Superfetation
Fertilization of two ova released in
different cycles

9. Differences in zygocity
Monozygotic
• 1 ova + 1 sperm
• Same sex
• Identical features
• Single or double placenta
• Same genetic features
• DNA microprobe -same
Dizygotic
• 2 ova + 2 sperm
• Same or opposite sex
• Fraternal resemblance
• Double or s/t fused
• Different genetic features
• DNA microprobe - different

10. Differences in chorionicity with
single placenta
D / D ( fused placenta )
• Monozygotic or dizygotic
• Thick dividing membrane
> 2mm
• Twin peak / lambda sign
M / D
• Monozygotic
• Thin dividing membrane
2mm or less
• T sign

11. Diagnosis
• HISTORY:
I. History of ovulation inducing drugs specially gonadotrophins
II. Family history of twinning (maternal side).
• SYMPTOMS:
i. Hyperemesis gravidorum
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.

12. GENERAL EXAMINATION:
I. Prevalence of 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.

13. • Palpation:
Fundal height 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

14. D/D of increased fundal height
• Full bladder
• Wrong dates
• Hydramnios
• Macrosomia
• Fibroid with preg
• Ovarian tumor with preg
• Adenexal mass with preg
• Ascitis with preg
• Molar pregnancy

15. INVESTIGATIONS
• Sonography: In multi 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,

16. i. Fetal anomalies
ii. Fetal growth monitoring (at every 3-4 weeks
interval) for IUGR
iii. Presentation and lie of the fetuses
iv. Twin transfusion (Doppler studies)
v. Placental localization
vi. Amniotic fluid volume
Sonography ( ctd )

17. • Radiography
• Biochemical tests: raised but not diagnostic
Maternal serum chorionic gonadotrophin,
Alpha fetoprotein
Unconjugated oestriol

18. Lie and Presentation
Longitudinal lie (90%)
1. both vertex (40%)
2. Vertex + breech (28%)
3. breech + vertex ( 9%)
4. both breech ( 6%)
Others
vertex + transverse
breech + transeverse
both transeverse

19. Complications
• Maternal
– Pregnancy
– Labour
– Puerperium
• Fetal
• MATERNAL: During pregnancy:
- miscarriages
– Hyperemesis gravidorum
– Anaemia
– Pre-eclampsia (25%)
– Hydramnios ( 10 % )

20. • GDM ( 2 – 3 times)
• Antepartum hemorrhage – placenta previa
and placental abruption
• Cholestasis of pregnancy
• Malpresentations
• Preterm labour (50%) twins – 37 weeks,
triplets – 34 weeks, quadruplets – 30 weeks
• Mechanical distress such as palpitation,
dyspnoea, varicosities and haemorrhoids
• Obstructive uropathy

21. During Labour:
• Prelabour rupture of the membranes
• Cord prolapse
• Incoordinate uterine contractions
• Increased operative interference
• Placental abruption after delivery of 1st baby
• Postpartum haemorrhage
During puerperium:
Subinvolution
Infection
Lactation failure

22. FETAL – more with monochorionic
• Spontaneous abortion
• Single fetal demise
Vanishing twin – before 10 weeks
Fetus papyraceous/compressus – 2nd trim
Complications in 2nd twin (depend on
chorionicity)
– neurological, renal lesions
- anaemia, DIC
- hypotension and death

23. FETAL – more with monochorionic
• Low birth weight ( 90%)
Prematurity – spontaneous or iatrogenic
Fetal growth restriction - in 3rd trimester,
asymmetrical, in both fetus
• Discordant growth - Difference of >25% in
weight , >5% in HC, >20mm in AC, abnormal
doppler waveforms -
Causes – unequal placental mass, lower
segment implantation, genetic difference,
TTTS, congenital anomaly in one

24. • FETAL COMPLICATIONS (ctd)
• Congenital anomalies – conjoined twins, neural
tube defects – anencephaly, hydrocephaly,
microcephaly, cardiac anomalies, Downs
syndrome, talipes, dislocation of hip
• TTTS -Twin to twin transfusion syndrome
- cause – AV communication in placenta – blood
from one twin goes to other – donor to recipient
- donor – IUGR, oligohydramnios
- recipient – overload, hydramnios, CHF, IUD

25. • FETAL COMPLICATIONS (ctd)
• TRAP -Twin reversed arterial perfusion
syndrome or Acardiac twin - absent heart in
one fetus with arterio-arterial communication in
placenta, donor twin also dies
• Cord entanglement and compression – more in
monoamniotic twins
• Locked twins
• Asphyxia – cord complication, abruption
• Still birth – antepartum or intrapartum cause

26. Monoamniotic twins
high perinatal morbidity, mortality.
Causes : cord entanglement
congenital anomaly
preterm birth
twin to twin transfusion syndrome

27. Antenatal Management
• Diet: additional 300 K cal per day, increased
proteins, 60 to 100 mg of iron and 1 mg of folic acid
extra
• Increased rest
• Frequent and regular antenatal visit
• Fetal surveillance by USG – every 4 weeks
• Hospitalisation not as routine
• Corticosteroids -only in threatened preterm labour ,
same dose
• Birth preparedness

28. Management During Labour
• Place of delivery: tertiary level hospital
• FIRST STAGE:
blood to be cross matched and ready
confined to bed, oral fluids or npo
intrapartum fetal monitoring
ensure preparedness
• SECOND STAGE – first baby
• - second baby

29. Management During Labour
• SECOND STAGE –delivery of first baby
as in singleton pregnancy
start an IV line
no oxytocic after delivery of first baby
secure cord clamping at 2 places before cutting
ensure labeling of 1st baby
• Delivery of second twin
FHS of second baby
lie and presentation of second twin
wait for uterine contractions
conduct delivery

30. Management During Labour
• Delivery of second twin – problems & interventions
-inadequate contraction- augmentation – ARM, oxytocin
-transverse lie – ECV, IPV
-fetal distress, abruption, cord prolapse- expedite
delivery – forceps, ventouse, breech extraction
• THIRD STAGE – AMTSL
- continue oxytocin drip
- carboprost 250µgm IM
- monitor for 2 hours

31. Indications of caesarean
• Non cephalic presentation of first twin
• Monoamniotic twins
• Conjoined twins
• Locked twins
• Other obstetric conditions
• Second twin – incorrectible lie, closure of
cervix

32. MCQs
• Text book of Obstetrics, Dr J B Sharma, 1st
edition ( 2012) page-473 to 483
• Chapter - multiple pregnancy

33. 1. Splitting of single fertilized ovum between 8
to 12 days results in
a) conjoined twins
b) monochorionic monoamniotic twin
c) dichorionic diamniotic twin
d) monochorionic diamniotic twin

34. Splitting of single fertilized ovum between 8
to 12 days results in
a) conjoined twins
b) monochorionic monoamniotic twin
c) dichorionic diamniotic twin
d) monochorionic diamniotic twin

35. 2. Twin peak sign is a feature of
a) conjoined twins
b) monochorionic monoamniotic twins
c) dichorionic diamniotic twins
d) monochorionic diamniotic twins

36. Twin peak sign is a feature of
a) conjoined twins
b) monochorionic monoamniotic twins
c) dichorionic diamniotic twins
d) monochorionic diamniotic twins

37. 3. Additional caloric requirement ( K cal per
day) of a mother in a case of twin pregnancy is
a) 300
b) 500
c) 800
d) 1000

38. Additional caloric requirement ( K cal per day)
of a mother in a case of twin pregnancy is
a) 300
b) 500
c) 800
d) 1000

39. 4. Additional iron supplementation
requirement ( mg per day) of a mother in a
case of twin pregnancy is
a) 30
b) 50
c) 100
d) 200

40. Additional iron supplementation requirement
( mg per day) of a mother in a case of twin
pregnancy as compared to singleton
pregnancy is
a) 30
b) 50
c) 100
d) 200

41. 5. Iron supplementation required by a mother
having twin pregnancy is
a) 30
b) 50
c) 100
d) 200

42. Iron supplementation required by a mother
having twin pregnancy is
a) 30
b) 50
c) 100
d) 200

43. 6. Twin pregnancy is complicated by all of the
following except
a) placenta previa
b) malpresentation
c) hydramnios
d) post term labour

44. Twin pregnancy is complicated by all of the
following except
a) placenta previa
b) malpresentation
c) hydramnios
d) post term labour

45. 7. Caesarean section is indicated in
a) monoamniotic twin
b) monochorionic twin
c) dichorionic twin
d) diamniotic twin

46. Caesarean section is indicated in
a) monoamniotic twin
b) monochorionic twin
c) dichorionic twin
d) diamniotic twin

47. • 8) 32year old G2P1 at 20 weeks pregnancy in
USG shows twin pregnancy, single placental
mass with dividing membrane having inverted
T sign. The type of twinning is
a) monochorionic monoamnionic
b) monochorionic diamnionic
c) dichorionic monoamnionic
d) dichorionic diamnionic

48. • 8) 32year old G2P1 at 20 weeks pregnancy in
USG shows twin pregnancy, single placental
mass with dividing membrane having lambda
sign. The type of twinning is
a) monochorionic monoamnionic
b) monochorionic diamnionic
c) dichorionic monoamnionic
d) dichorionic diamnionic

49. • 9) Monochorionic twin placenta has
unidirectional deep arteriovenous
communication with lack of superficial vascular
anastomoses. The likely complication is
a) twin to twin transfusion syndrome
b) twin reversed arterial perfusion
c) acute intertwin transfusion
d) twin cord entanglement

50. • 9) Monochorionic twin placenta has
unidirectional deep arteriovenous
communication with lack of superficial vascular
anastomoses. The likely complication is
a) twin to twin transfusion syndrome
b) twin reversed arterial perfusion
c) acute intertwin transfusion
d) twin cord entanglement

51. 10) Most common variety of conjoined twins is
a) craniopagus
b) thoracopagus
c) omphalopagus
d) pyopagus

52. 10) Most common variety of conjoined twins is
a) craniopagus
b) thoracopagus
c) omphalopagus
d) pyopagus