2. Multiple pregnancy
Multiple pregnancy involves more than one
embryo (fetus) in any one gestation.
Two independent mechanisms may lead to
multiple gestation:
• segmentation of a single fertile ovum
(identical, monovular, or monozygotic)
• or fertilization of separate ova by different
spermatozoa (fraternal or dizygotic)
7. Clinical findings
• A uterus larger than expected for the duration
of pregnancy (4 cm than anticipated);
• Excessive maternal weight gain not explained
by eating or edema;
• Hydramnios;
• Iron deficiency anemia;
• Maternal reports of increased fetal activity;
8. Clinical findings
• Uterus containing 3 large parts or multiple
small parts;
• Simultaneous auscultation or recording of two
fetal hearts varying 8 beats per min and
asychronous to the maternal heart
• Ultrasound confirmation
12. Feto-fetal transfusion syndrome
• This condition affects approximately 1 in 5
(20%) of all twins that share the same
placental mass (monochorionic).
• This is a highly pathological condition, which if
untreated will lead to fetal or newborn death
in excess of 95% of cases.
13. Feto-fetal transfusion syndrome
• The underlying abnormality is that the
placenta contains vascular connections that
connect the twins, in effect, making them
connected together by a continuous blood
supply.
14. Feto-fetal transfusion syndrome
• The vascular (blood supply) connection
between twins within the placenta leads to a
haemodynamic (blood flow) imbalance
between the twins, with one, the recipient,
having a relative high perfusion of blood and
the other, the donor, being under perfused
with blood.
16. Severity classification
• Stage 1. There is a difference in the amounts
of amniotic fluid surrounding the twins. The
recipient often is complicated by
polyhydramnios (excess amniotic fluid with a
maximum pool depth of around 8cms) and the
donor is complicated by oligohydramnios
(reduced amniotic fluid with a maximum pool
depth of around 2cms).
17. Severity classification
• Stage 2. In addition to the discrepancy of
amniotic fluid volumes, there is a difference in
size between the two babies (the recipient is
often larger than the donor).
18. Severity classification
• Stage 3. There are haemodynamic differences
between the twins. The recipient has evidence of
abnormal blood flow and right-sided heart strain.
The donor often demonstrates absent or reversed
blood flow in the umbilical arterial (cord) circulation.
• Stage 4. One twin shows signs of severe right-sided
heart failure.
• Stage 5. One of twin has already died.
21. Delivery
• Cesarean section is recommended for monoamniotic
twins because of the 10% delivery loss from cord
entanglement.
• Other standard indications for cesarean include: any
birth number exceeding twins (e.g., triplets), or if the
first twin is nonvertex.
• The first twin may be delivered vaginally if it presents
by the vertex.
22. Delivery
• A vaginal examination immediately after the
first delivery is performed to identify a
possible forelying or prolapsed cord
23. Delivery
• If 2nd fetus has continued as a vertex, a second
vaginal delivery may be performed.
24. Delivery
If the second fetus is anything but vertex there
are three alternatives.
● Bringing the head into the inlet by external
guidance (version); if successful, allows labor
to proceed for another vertex vaginal delivery.
● Perform cesarean section
● Complete a vaginal breech delivery
25. Delivery
• Rupture of the second sac (if present) is
accomplished as late as possible to avoid
prolapse of the cord.
