Multiple Pregnancy

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

According to their number, they could be categorized into: Twins (most common) Triplets Quadruplets Quintuplets Sextuplets

Types Monozygotic Dizygotic Identical/Uniovular Fertilization of a single ovum, Similar sex. Identical in every way including the HLA genes Not genetically determined Dizygotic Fertilization of 2 seperate ova Fraternal /Dizygotic

Monozygotic Twins… Different Scenarios of Cleavage Monozygotic twin  pregnancy  Di-Amniotic and Di-Chorionic or D/D If the separation takes place just after the first cellular division [1st 3 days ]/ prior to morula stage both of the twins will have their own placenta and an amniotic sac each.

Di-amniotic - Mono-chorial and or D/M Scenario 2 Monozygotic twin  pregnancy   Di-amniotic - Mono-chorial and or D/M Separation can also take place a little later in the development [4-8 days after the formation of inner cell mass when chorion has developed] of the embryonic cells but before the blastocyte has defined the roles of each cell. Twins will be in the same placenta, but they will have 2 amniotic sacs.

Mono-amniotic and Mono-chorial Scenario 3 Monozygotic twin  pregnancy   Mono-amniotic and Mono-chorial Separation takes place at the stage when the amniotic bag is already being formed [day 8-14] Twins will be in the same placenta, and in the same amniotic sac.

Conjoined Twins If the division occur after 2 weeks of the embryonic disc formation, incomplete or conjoined twins will occur. They may be joined anteriorly [thoracopagus- commonest], posteriorly [pyopagus] cephalic [craniopagus] o caudal [ischiopagus].

The 2 eggs are completely independent.     Dizygotic twin pregnancy Di-chorial and Di-amniotic. Dyzygotic twins, are descended from a double ovulation and a double fertilization. The 2 eggs are completely independent. This configuration represents two thirds of all twin pregnancies.

Superfecundation It is the fertilization of two different ova released in the same menstrual cycle,by separate act of coitus within a short period of time.

Superfetation It is the fertilization of two ova released in different menstrual cycle One fetus over another Possible until decidual space is obliterated by 12 weeks of pregnancy

Fetus papyraceous or compressus One fetus dies early Dead fetus is flattened and compressed between the membranes of the living fetus and the uterine wall

Fetus acardicus Occurs only in monozygotic twins Part of the fetus remains amorphous and becomes parasitic without a heart

Hydatidiform mole Hydatidiform mole from one placenta And a normal fetus and placenta

Vanishing twins USG in early pregnancy revealed occassional death of one fetus and continuation of pregnancy with surviving one

ETIOLOGY Race – Highest among negroes and lowest among mongols Hereditary- Transmitted through female Advancing age of the mother- Maximum between 30-35 years Parity – 5th gravida onwards Iatrogenic – Gonadotrophin(20-40%),clomephene citrate(5-6%)

Maternal physiological changes Increase weight gain and cardiac out put Plasma volume is increased by an additional of 500ml Increased fetoprotein level and GFR

History… Patient profile: Etiological factors; with positive past history and family history specially maternal. Early pregnancy Hyperemesis, bleeding. Mid-pregnancy Greater weight gain than expected Abdominal size > period of amenorrhea early PIH symptoms, persistent fetal activity. Late pregnancy Pressure symptoms (dyspnea, dyspepsia, UTI, piles, edema and varicose veins in LL).

Examination General: Abdominal: An early increase weight gain, Pallor Less mid-trimisteric fall blood pressure Early PIH Eary edema, and varicose veins in LL. Abdominal: Fundal level > amenorrhea especially in mid-pregnancy exclude other causes. Palpation: Multiple fetal identify presentations. Auscultation of FHS: 2 different recordings by 2 observers and a difference > 10 bpm a Gallop between 2 points[ Arnoux sign] Pelvic: Specially during the course of labor small presenting part compared to abdominal size

Types of Twin Lie and Presentations % 2nd twin 1st twin 35 Vertex 20 Breech 15 10 Transverse or cephalic Cephalic or transverse 5 Transverse or breech Breech or transverse Transverse

Selective Embryo Reduction The presence of > 3 fetuses carries the risk of losing them all (preterm delivery). The number is reduced to twins only by injecting potassium chloride intracardiac under U/S guidance (about 1.5 ml of 15% solution). Potassium chloride may diffuse and affect other fetuses.

Maternal Complications DURING PREGNANCY Nausea and vomiting Anaemia Pre eclampsia Hydramnios Antepartum haemorrhage Malpresentation Preterm labour Mechanical distress

Maternal Complications DURING LABOUR Early rupture of membranes and cord prolapse Prolonged labour Increased operative interference Bleeding Postpartum haemorrhage DURING PUERPERIUM Sub involution Infection Lactation failure

Fetal Complications Miscarriage rate is increased Premature rate Growth problem Intrauterine death of one fetus Fetal anomalies Asphyxia and still birth

Antenatal Management ANTENATAL ADVISES Diet – extra 300 Kcal, extra protein Increased rest at home Travel restriction Supplementary therapy – Fe 60-100mg,Additional Ca, Vitamin and Folic acid Frequent antenatal visit Prophylactic os tightening Fetal surveillance HOSPITALISATION

How are they going to be delivered?

Management During Labour DELIVERY OF THE FIRST BABY Same as singleton pregnancy Liberal episiotomy Forceps delivery Do not give IV ergometrine with the delivery of the anterior shoulder of the first baby Clamp cord at two places and cut in between Leave at leat 8-10 cm of the cord Label bay as no 1

Contd…. DELIVERY OF THE SECOND BABY External cephalic version Rupture fore water after correcting the lie Wait for 10min for spontaneous delivery Syntocinon drip Vaccum extraction or Breech extraction

Contd…. CESAREAN SECTION Severe PIH Bad obstetrics history Long history of infertility Elderly primi Preterm delivery Breech presentation

MANAGEMENT OF THIRD STAGE AND PUERPARIUM Prevention of PPH Treatment of anemia Psychological adjustment Family planning advice

Twin to Twin transfusion Vascular communication between 2 fetuses, mainly in monochorionic placenta (10% of monozygotic twins), Twins are often of different sizes: Donor twin = small, pallied, dehydrated (IUGR), oligohydramnios (due to oliguria), die from anemic heart failure. Recipient twin = plethoric, edematous, hypertensive, ascites, kernicterus (need amniocentesis for bilirubin), enlarged liver, polyhydramnios (due to polyuria), die from congestive heart failure, and jaundice.