Multiple pregnancy

1. Multiple Pregnancy
Muhammad Taimur Afridi
Roll No : 08-127

2. •Incidence :
•Monozygotic twins - 4/1000 births
•Dizygotic twins – 2/3rds, race, age, assisted
conception
•Triplets – 1 in 7000 to 10,000 births
•Quadruplets – 1 in 600,000 births
• Almost every maternal and obstetric problem occurs
more frequently in multiple Pregnancy
• Perinatal mortality rate in twins is 5 times higher and
in triplets 10 times higher than in singletons

5. •Zygosity refers to the type of conception
•Chorionicity denotes the type of placentation
•Chorionicity rather than zygosity determines out
outcome
Zygosity and Chorionicity

6. Mechanism of dizygotic twinning

8.  Fertilization of a single ovum
 Similar sex
 Genetically identical
 Fertilization of 2 separate
ova

11. MONOCHORIONIC TWINS
•3-8 DAYS LATER (60-70%) Within 72 hours (18-32%)

12. MONOCHORIONIC TWINS
•8-12 DAYS LATER (1-2%)
•12-13 DAYS LATER
(0.5%)

13. Maternal responses
Cardiac output, GFR and renal blood flow
Plasma volume by 1/3 > singletons
Red cell mass 300 ml > singletons
Hematocrit and hemoglobin
Iron stores in 40% of women with twins
Multiple pregnancy

14. DIAGNOSIS
Patient profile:
 Etiological factors:
 positive past history and family history
specially maternal, race, age
 Assisted reproductive technology
 Early pregnancy:
 Hyperemesis, excessive weight gain
 minor complications of pregnancy such as
backache, edema, varicose veins,
hemorrhoids, striae, etc

15. PHYSICAL SIGNS
 General:
 Pallor, weight gain, excessive pedal edema/
varicose veins
 Pregnancy Induced Hypertension(PIH) and Pre-
eclampsia (5-10times more)
 Abdominal:
 Size > Date especially in midpregnancy
 Multiple fetal parts
 Auscultation of FHS:
 2 different recordings by 2 observers and a
difference > 10 bpm

16. Differential diagnosis
• Elevation of the uterus by a distended
bladder
• Inaccurate menstrual history
• Hydramnios
• Hydatidiform mole
• Uterine fibroids
• A closely attached adnexal mass
• Fetal macrosomia (late in pregnancy)

17. Ultrasonography
• Detect multifetal gestation 99% before
26 weeks
• Confirm fetal number [ 2 sacs or 2fetal
heads in 2 perpendicular planes]
• Diagnose type and presentation and
position and relation to each other
• Exclude congenital abnormalities/
conjoint twin

19. MATERNAL
COMPLICATIONS
Symptoms – hyperemesis, aches and pains
of pregnancy worsen
Hypertensive disease of pregnancy
Preterm delivery
Premature rupture of membranes
Polyhydramnios
Placenta praevia
Malpresentation
Delivery complications (operative delivery,
placental abruption, cord accidents)
Postpartum hemorrhage, depression

20. FETAL COMPLICATIONS
Spontaneous early pregnancy loss
Prematurity
Intra-uterine growth restriction
Cerebral palsy - related to gestational
age, 3 times in twins, > 10 times in
triplets
Intrapartum trauma
Monochorionic twins – specific
complications

22. Antenatal care
• Routine booking investigations
Folic acid supplementation
anemia – treat immediately
Support symptomatically
• Serial growth scans :
Dichorionic :4 weekly from 24 weeks
Monochorionic : 2 weekly from 18 weeks
- Liquor volume
- Doppler study of umbilical artery

24. Intrapartum management
•Presence of skilled obstetrician, anesthetist and
neonatologist available at delivery
•Reliable intravenous access
•Cardiotocograph with dual monitoring capability
•Portable ultrasound scanner
•Delivery bed with lithotomy stirrups
•Obstetric forceps or vacuum apparatus
• active management of third stage: Uterotonics
•Immediate availability of blood
•Facilities and staff for emergency cesarean section

28. Monochorionic Monoamniotic twins
•3 - 12 x perinatal mortality
•10 x cerebral necrotic lesions
•1% of monozygotic twins are monoamnionic
•Perinatal mortality rate of 30-50%, largely relates
to a risk of intrauterine death before 32 weeks
•Cord entanglement

30. Twin-Twin Transfusion Syndrome
•Incidence : 4 - 20% of MC twins
•It is characterised by an imbalance of blood flow
between the twins
•15 - 20% of perinatal deaths
•Untreated, perinatal loss rates in the mid-trimester
(80 - 100%)

32. Large volume amnioreduction

33. Amniotic Septostomy

34. Fetoscopic Laser Ablation

35. DELIVERY BY CAESAREAN SECTION
AT 34 WEEKS

36. Conjoined twins or Siamese twins
•Anterior (thoracopagus)
•Posterior (pygopagus)
•Cephalic (craniopagus)
•Caudal (ischiopagus)

38. Single intrauterine demise
•2-6% of twins pregnancies
•Up to 25% in MC twin pregnancy
• Perinatal morbidity and mortality of the surviving
co-twin
- 19% perinatal death
- 24% having serious long term sequelae

39. Treatment options
•No optimal management
•Prompt delivery -Iatrogenic prematurity risks
•Conservative treatment -Subsequent handicaps
•Intrauterine interventions

40. High order multiples
•Perinatal risk increases exponentially with increasing
number of fetuses
•Multifetal pregnancy reduction (MFPR) at 10 to 12
weeks should be recommended for quadruplets and
higher multiples
•The situation with triplets is more controversial