1. Multiple Pregnancy

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

3. TWINS

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

5. 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

6. Monozygotic
Dizygotic

7. 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

9. 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.

10. 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%)

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

12. 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.

13. 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

14. 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 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.

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

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

17. Complications
Maternal
Fetal
Pregnancy
Labour
Puerperium

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

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

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

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

22. 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. 

23. 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.

24. 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 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 weeks.
Selective termination of a fetus with structural or genetic abnormalities may be done in a chorionic multiple pregnancy in the second trimester.

26. Thank you…