1. Multiple Fetal Pregnancy
Elahe.ZAREAN

2. Incidence and epidemiology
Incidence : 2-3% of all live births
Two-thirds of twins are dizygotic (non-identical) and one- third monozygotic (identical).
One-third of monozygotic twins are dichorionic (DC) and two-thirds are monochorionic (MC).
6 of 7 DC twins are dizygotic.
Rate of twins and higher-order multiple births increase by infertility therapy.
Increase neonatal & maternal morbidity and mortality rates.

3. Incidence and epidemiology
Frequency of twins:
a- Monozygotic: 1:250
b- Dizygotic: ?
Depend on race, hereditary, age, parity and fertility drugs.
Hereditary  mother important than father.
Age  peak at 37 years of age.
Parity  increase more than six times.

4. Etiology Dizygotic: It is a fertilization of two separate ovum.
Monozygotic = Identical twins: It is a single fertilized ovum that subsequently divides into two similar structures.

5. Divisions
First 72 H  two embryos, diamniotic, dichorionic and two placenta or single fused placenta.
4-8 days  two embryos,diamniotic, monochorionic.
About 8 days after fertilization  two embryos,monoamniotic and monochorionic.

7. Types of twins
zygosity refers to genetic work up of the pregnancy. Chorionicity indicate the membrane composition of the pregnancy (the chorion and amnion)

8. chorionicicity Increase risk of perinatal mortality and morbidity.
The effect of the zygosity on the outcome is less clear.
The outcome of dichorionic monozygotic seem to have the same outcome of dizygotic twins.

9. Determination of chorionicity
The best way to determine chorionicity by ultrasound at weeks’ gestation .
In DC pregnancies there is a triangular placental tissue projection (λ sign) into the base of the membranes.
With advancing gestation, there is regression of the chorion laeve and the ‘lambda’ sign becomes progressively more difficult to identify. Thus by 20 weeks only 85% of DC pregnancies demonstrate the λ sign.

11. Diagnosis of Multiple Fetuses
1.History : Family history,Advanced age, High parity, Large maternal size, Medication.
Clinical Examination.
Investigations.

12. Pregnancy dating
Spontaneous conception: use the crown-rump length of the longest fetus at weeks.
IVF conception: use the embryonic age from fertilization.

13. Complications
Maternal
Pregnancy
Labour
Puerperium
Fetal

14. Maternal complication
During pregnancy:
miscarriages
Hyperemesis gravidorum
Anaemia
Pre-eclampsia (25%)
Hydramnios ( 10 % )

15. GDM ( 2 – 3 times)
Acute fatty liver
Antepartum hemorrhage – placenta previa and placental abruption
Cholestasis of pregnancy
Malpresentations
Preterm labour (50%)
twins – 37 weeks, triplets – 34 weeks, quadruplets – 30 weeks
Mechanical distress such as palpitation, dyspnea, varicosities and haemorrhoids

16. Obstructive uropathy , UTI
Intervertebral discitis
Amniotic fluid volume abnormalities

17. During Labour:
Prelabour rupture of the membranes
Cord prolapse
Incoordinate uterine contractions
Increased operative interference
Placental abruption after delivery of 1st baby
Postpartum haemorrhage
During puerperium: Subinvolution , Infection, Lactation failure

18. Fetal complication more with monochorionic Spontaneous abortion
Single fetal demise
Vanishing twin – before 10 weeks
Fetus papyraceous/compressus – 2nd trim
Complications in 2nd twin (depend on chorionicity)
– neurological, renal lesions
- anaemia, DIC
- hypotension and death

19. Low birth weight ( 90%)
Prematurity – spontaneous or iatrogenic
Fetal growth restriction - in 3rd trimester, asymmetrical, in both fetus
Discordant growth - Difference of >20% in weight , >20mm in AC, abnormal doppler waveforms

20. TRAP -Twin reversed arterial perfusion syndrome or Acardiac twin - absent heart in one fetus with arterio- arterial communication in placenta, donor twin also dies
Cord entanglement and compression – more in monoamniotic twins
Locked twins
Asphyxia – cord complication, abruption
Still birth – antepartum or intrapartum cause

21. Problems Specific to Monochorionic twins
Twin-Twin transfusion syndrome:- * 15% of monochorionic develops * Early onset often is associated with poor prognosis * Twin-Twin transfusion can be acute or chronic * The net effect of blood flow imbalance result: a- donor  small, hypoperfused, anemic b- recipient  large, hyperperfused.

30. Antenatal Management Early diagnosis (mainly by ultra sound)
Adequate nutrition: 1- Caloric consumption increased by 300 Kcal per day Iron mg per day Folic acid 1mg per day.
Frequent prenatal visit: observe maternal and fetal complications 1- Frequent ultrasound  fetal growth, congenital anomalies, amniotic fluid Doppler BPP.

31. In Labor Management
Trained obstetrical attendant. Available blood. Good access I.V live. CTG monitoring. Anesthetist Pediatrician for each fetus. Mode of delivery depend on presentation.

32. In Labor Management
Ceph-ceph: NVD Ceph –non ceph: contraversy. Breech:cord prolaps,Head trappe,Locked twin:c/s. Second twin: 10 min and no contraction. Non fixed p.p :abdominal manipulation Second twin:internal pudalic version. Irregular FHR,VB,larger,Bx, Trans ,contract Cx: C/S