1. +
Multiple
Gestation
Prepared by:
Jumana Haider
N. H.

2. +
 Multiple pregnancies consists of ≥2 fetuses.
 Twins make up ~99%
 Pregnancies of ≥3 fetuses are referred to as “Higher Multiples”.

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Classification
 Number of fetuses: Twins, triplets, quadruplets, etc.
 Number of fertilized eggs: Zygosity
 Number of placentae: Chorionicity
 Number of amniotic cavities: Amnionicity

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 Non-identical/fraternal twins are dizygotic
 Fertilization of 2 separate eggs.
 Either same- or different sex pairings.
 Always have 2 functionally separate placetae

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 Identical twins are monozygotic
 Fertilization of a single egg
 Always same-sex pairings.
 Mono- or di- chorionic

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 In dichorionic twins, the 2 separate placentae my anatomically
fuse together and appear as a single placental mass.

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Key point
 Not all dichorionic pregnancies are dizygotic.
 All monochorionic pregnancies and monozygotic.

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Risk Factors
 Assisted reproduction techniques
 IVF
 Ovulation induction
 Increased maternal age
 High parity
 Black race
 Maternal family history

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 Type of monozygotic twin depends on how long after
contraception the splitting occurs.

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Physiological changes

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I. Maternal
 All the physiological changes will be exaggerated.
 There will be an increase in:
 Cardiac output
 Volume expansion
 Relative hemodilution
 Diaphragmatic splinting
 Weight gain
 Lordosis

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II. Fetal
 Monochorionic placentae have the unique ability to develop
vascular connections between the two fetal circulations.
 These anastomoses carry the potential for complications.

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Complications Relevant to
Twin Pregnancy

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 Miscarriages and severe preterm delivery
 Death of one fetus in a twin pregnancy
 Fetal Growth Restriction
 Fetal Abnormalities
 Chromosomal defects in twinning

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Complications Unique to
Monochrionic Twinning

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 Twin-to-twin transfusion syndrome (15%)
 Growth-restricted fetus (donor)  Hypovolaemic and oligouric
 oligohydramnios
 Recepient  hypervolaemic  polyuria polyhydramnios

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 >90% TTTS complicated pregnancies end in miscarriage or
very preterm delivery.
 With treatment, one or both babies survive (~70% of
pregnancies).

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Complications Unique to
Monoamniotic Twinning

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 Increased cord accidents, mainly through their universal cord
entanglement.
 This could be acute, fatal and unpredictable.
 Many clinicians support elective CS at 32-34 weeks.

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Differential diagnosis
 Polyhydramnios
 Uterine fibroids
 Urinary retention
 Ovarian masses

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Determination of choronicity
 In Monochorionic twins the inter twin membrane joins the
uterine wall in a T shape.

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 In dichorionic twins there is a V shape extension of placental
tissue into the base of the intertwin membrane (Lambda or twin
peak sign).

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Antenatal Management
 Screening for common conditions in twin pregnancy ,such as
hypertension and gestational diabetes.
 Increase supplementation of iron and folic acid.

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Screening for fetal abnormalities
 Screening of trisomy 21
 Procedures such as amniocentesis and chorionic villus
sampling can be done
 Screening for structural anomalies

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Monitoring fetal growth and well
being
 Measuring symphysis fundal height
 Presence of fetal movements
 Doppler investigations
 CTG

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Threatened preterm labor
Start steroid therapy
Screen for GBS and give antibiotic
therapy if needed

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Intrapartum Management
Preterm birth
Cord prolapse
Abnormal presentation
Post-partum hemorrhage

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Preparation:
Start CTG for fetal monitoring
Keep oxytocin ready in case of PPH
Give appropriate analgesia

38. +
Delivery
 Allow vaginal delivery of the first twin
 Palpate the abdomen to asses the lie of the
second twin
 Then wait for the delivery of the second twin
I. Vaginal delivery of vertex - vertex:

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 If the second twin is breech, then external
cephalic version has to be done ,and then the
delivery can proceed successfully
II. Delivery of vertex non vertex:

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 Cesarean section is done immediately
III. Non vertex first twin:

43. Questions?!