Multiple Pregnancy

When one or more fetus simultaneously develops in the uterus, it is called multiple pregnancy.

TWINS

VARIETIES Dizygotic Twins (80%) Monozygotic Twins (20%)

Placenta Communicating Vessels Intervening Membranes Sex Genetic Features Skin Grafting Resemblance Monozygotic One Present 2 amnions Always identical Same Acceptance Usually Identical Dizygotic Two Absent 4 : 2 amnions,2 chorions May differ Differ Rejection Not identical

Monozygotic Dizygotic

Predisposing factors The Cause of twinning is not known. Dizygotic twin pregnancies are slightly more likely when the following factors are present in the woman: She is between the age of 30 and 40 years She is greater than average height and weight She has had several previous pregnancies. Women undergoing certain fertility treatments may have a greater chance of dizygotic multiple births. The risk of twin birth can vary depending on what types of fertility treatments are used. With in vitro fertilisation (IVF), this is primarily due to the insertion of multiple embryos into the uterus. Ovarian hyperstimulation without IVF has a very high risk of multiple birth. Reversal of anovulation with clomifene has a relatively less but yet significant risk of multiple pregnancy. Predisposing factors

Maternal Physiological Changes There is increase in weight gain and cardiac output. Plasma volume is increased by an addition of 500ml. There is no corresponding increase in red cell volume resulting in exaggerated haemodilution and anaemia. There is increased alpha fetoprotein level, tidal volume and glomerular filtration rate.

LIE AND PRESENTATION Both Vertex (50%) Both Breech (10%) Commonest lie is Longitudinal First Vertex and second breech (30%) Rarest one Both transverse (Rule out conjoined twins) First breech and second vertex (10%)

Diagnosis History of ovulation inducing drugs. Abdominal examination Minor ailments of normal pregnancy are exaggerated Abdominal examination Internal examination Family history of Twinning

Abdominal Examination Not easy due to presence of hydramnios More “barrel shaped” inspection Abdominal girth more than 100cm. Too many fetal parts on palpation. Two distinct fetal heart sounds on Auscultation.

Ultrasonography Confirmation of pregnancy as early as 10th week of pregnancy Viability of fetus Chorionicity Fetal Anomalies Amniotic fluid volume Twin transfusion Presentation and Lie of the fetus Placental Localization Fetal growth monitoring for IUGR

Lambda or twin peak sign The sign describes the triangular appearance to chorion insinuating between the layers of the inter twin membrane and strongly suggests a dichorionic twin pregnancy. It is best seen in the first trimester (between 10-14 weeks). In contrast the T sign refers to the appearance of the intertwin membrane in a monochorionic twin pregnancy. The sign should not be confused with the lambda sign of sarcoidosis.

A potential space exists in the intertwin membrane, which is filled by proliferating placental villi giving rise to the twin peak sign.

Differential Diagnosis Hydramnios Big Baby Fibroid or ovarian tumour with pregnancy. Ascites with pregnancy

Complications Maternal Fetal Pregnancy Labour Puerperium

Antepartum Haemorrage During Pregnancy Anaemia Pre-eclampsia (25%) Hydramnios (10%) Antepartum Haemorrage Malpresentation Preterm Labour (50%) Mechanical Distress

During Labour Increased operative interference Early Rupture of membranes and cord prolapse Bleeding Prolonged labour Postpartum Haemorrhage

Increased incidence of Subinvolution. Infection. Lactation Failure. During Puerperium

Increased risk of miscarriage Premature rate (80%) Twin-twin transfusion syndrome Placental insuffiency IUGR Structural anomalies Intrauterine death of one fetus Asphyxia and stillbirth

Management during Labour What happens during a twin birth? Most twins are born before 38 weeks. If you haven't gone into labour by then, you may be recommended to have your labour induced.  During labour, regular monitoring of your twins with electronic fetal monitors (EFM) is standard practice. This is used to listen to your babies' heartbeats and the intensity and frequency of your contractions. Your doctor may place a needle in a vein in your arm (a drip) in case it is needed later. Discuss your pain relief preferences with your midwife during pregnancy and write them in your birth plan. But keep in mind that labour and birth are unpredictable. Your midwife may need to recommend a course of action at any time which is not what you had originally hoped for, but which will always be in the best interests of you and your baby. 

Once your first baby is born, your midwife or doctor will check the position of your second twin by feeling your tummy and doing a vaginal examination, or an ultrasound scan.  If your second baby is in a good position to be born, the waters surrounding him will be broken. Your second baby should be born very soon after the first, because your cervix is already fully dilated. If your contractions stop after your first twin is born, hormones are added to the drip to restart them.  You'll usually be recommended to have a managed third stage. This is when the placenta is delivered with the help of a hormone injection, instead of a natural delivery. This is because there is an increased risk of bleeding when the placenta is larger, and the uterus (womb) will have been stretched by two babies.

Average time for delivery in quadruplets is 30-31 weeks. Triplets Female usually outnumber the number of male one. Perinatal loss is markedly increased due to prematurity. Average time for delivery in quadruplets is 30-31 weeks. Selective reduction: If there are 4 or more fetuses, selective reduction of the fetuses leaving behind only two is done to improve the outcome. This can be done by intracardiac injection of potassium chloride between 11-13 weeks. Selective termination of a fetus with structural or genetic abnormalities may be done in a chorionic multiple pregnancy in the second trimester.

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