1. By: Dr Syuhadah Mentor: Dr Hasniza
Multiple pregnancy
By: Dr Syuhadah
Mentor: Dr Hasniza

2. Multiple Pregnancy
Definition: Any Pregnancy in which 2 or more embryos or fetuses occupy the uterus simultaneously
Increased incidence (assisted reproductive technology)
Twins account for about 1% of pregnancies
Hellins law (80 n-1)
- Twins → 1 in 80
- Triplets → 1 in 802
- Quadruplets → 1 in 803

3. Predisposing Conditions
↑maternal age and parity
Assisted reproduction techniques
- Ovulation induction agents (gonadotropins)
- In-vitro fertilization (IVF)
Family history

4. Monozygotic VS Dizygotic
Genesis of twin
Monozygotic VS Dizygotic

5. Types of twins Monozygotic twins (identical)
Originate by fertilization of single ovum by single sperm.
The twinning may occur at different periods after fertilization and this influences the process of implantation and the formation of the fetal membranes.

6. Types/Classification of Twinning
Monozygotic/ identical/uniovular
(1 zygote divide into 2) ~33%
Dichorionic Diamniotic
(cleavage of embryonic egg <3days )
~30%
MONOchorionic Diamniotic
(4-8days)
~69%
MONOchorionic MONOamniotic
(9-12days)
~1%

7. MONOZYGOTIC @ UNIOVULAR

8. DIZYGOTIC @ BINOVULAR Dizygotic twins (non-identical )
Results from fertilisation of two ova by two sperms.
Dichorionic and diamniotic twins.

9. Clinical Presentation
History Taking
Family history of multiple pregnancy
Recent infertility treatment
Excessive nausea and vomiting
Excessive lower limb swelling and varicosities
Excessive fetal movement and abdomen overdistension
Extremely fatigue

10. Clinical Presentation
Physical Examination
Anaemia & oedema
Raised BP
Uterus larger than dates
Polyhydramnios (> in monozygotic twins)
Multiple fetal parts & poles
> 1 heart sound with different rates
Abnormal weight gain

11. Ways to determine Zygosity, chorionicity
Ultrasound-
=> Gender discordance = dizygotic
DNA fingerprinting, from amniotic fluid sample (amniocentesis), placental tissue (chorionic villi sampling) and fetal blood (cordocentesis)
Chorionicity
Characteristic of membrane(US)-

12. A: Thick amnion- chorion septum, Twin- peak sign (lamda sign) ~dichorionic B: Thin amnion-chorion septum, The "T sign" ~monochorionic

13. Why so important to differentiate???
Prenatal diagnosis of chorionicity is important as monochorionic pregnancies have increased rates and severity of all types of obstetric complications when compared with dichorionic pregnancies.

14. Complications Maternal Fetal Single fetal death
↑ Sx of early pregnancy (↑HCG)
Miscarriage
Anaemia (↑ Fe,folate & B12 )
Polyhydramnios (uniovular twins)
PIH (↑3-5x)
APH (placenta praevia)
PPH (uterine atony d2 over stretching)
GDM (↑diabetogenic placental hormones)
Ineffective labour (malpresentation)
Thromboembolic ds (↑pelvic vein compression)
Fetal
Single fetal death
Preterm labour (d2 overdistended uterus, polyH, intrauterine infection)
IUGR (discordant growth)
Stillbirth
Congenital abnormality
Twin to twin transfusion syndrome
Asphyxia (cord entanglement)
Intrauterine death

15. TWIN-TO-TWIN TRANSFUSION SYNDROME (TTTS)

16. TTTS is found in MCMA as well as MCDA pregnancies.
TTTS is more common in MCDA pregnancies than MCMA pregnancies, possibly reflecting that there are more protective artery–artery anastomoses in the latter.
Rarely (in approximately 5% of cases), the transfusion may reverse during pregnancy, with the donor fetus demonstrating features of a recipient fetus and vice versa
Unequal placental sharing and peripheral, ‘velamentous’ cord insertions are common in TTTS

17. Affects 10-15% of monochorionic twin pregnancies.
Pathophysiology:
Result of transfusion of blood from donor to recipient twin through abnormal artery-to- vein anastomoses in the placenta
The donor suffers hypovolaemia and hypoxia → IUGR, smaller in size, oligohydramnios & high output cardiac failure
The recipient fetus exhibit hypervolemia → large size, polyhydramnios, cardiomegaly, CCF

20. More than 90% ends in miscarriage/severe preterm delivery
To monitor:
US doppler 2 weekly
Management:
Laser coagulation – occlude the vascular anastomosis between twins (presenting prior to 26weeks of gestation)
Amnioreduction every /52, drain amniotic fluid from recipient sac
Septotomy (cord entanglement risk)
Anticipate preterm delivery – corticosteroid (promote fetal lung maturity

21. SINGLE FETAL DEMISE Occur in monochorionic twin
Fetal demise <14weeks-not increase risk on the survivor twin
Confers risk to survivor twin if fetal demise after 14 weeks.
Dt transfer of thromboplastin from dead twin > produce thrombotic arterial occlusion > occlusions of ant & mid cerebral arteries > multicystic encephalomalacia & neurologic damage.
Induce consumptive coagulopathy in mother.

22. MANAGEMENT of multiple pregnancy
Antenatal
Intrapartum

23. ANTENATAL MANAGEMENT
All women with a multiple pregnancy should be offered an ultrasound examination at 10–13weeks of gestation to assess:
viability
chorionicity
major congenital malformation
nuchal translucency for designation of risk of aneuploidy and twin-to-twin transfusion syndrome.

24. Dichorionic twins
Ultrasound at 10–13 weeks: (a) viability; (b) chorionicity; (c) NT: aneuploidy
Structural anomaly scan at 20–22 weeks.
Serial fetal growth scans e.g 24, 28, 32 and then two- to four-weekly.
BP monitoring and urinalysis at 20, 24, 28 and then two-weekly.
34–36 weeks: discussion of mode of delivery and intrapartum care.
Elective delivery at 37–38 completed weeks.
Postnatal advice and support (hospital- and community-based) to include breastfeeding and contraceptive advice

25. Ultrasound at 10–13 weeks: (a) viability; (b) chorionicity; (c) NT: aneuploidy/TTTS
Ultrasound surveillance for TTTS and discordant growth: at 16 weeks and then two-weekly.
Structural anomaly scan at 20–22 weeks (including fetal ECHO).
Fetal growth scans at two-weekly intervals until delivery.
BP monitoring and urinalysis at 20, 24, 28 and then two-weekly.
32–34 weeks: discussion of mode of delivery and intrapartum care.
Elective delivery at 36–37 completed weeks (if uncomplicated).
Postnatal advice and support (hospital- and community-based) to include breastfeeding and contraceptive advice.
Monochorionic twins

26. ANTENATAL MANAGEMENT
Dietary advice: adequate caloric intake to meet increased demands, supplement of iron ( mg /day), folic acid, calcium, vitamins
Monitor for infection, anaemia, PIH, preterm labour & malpresentation
Corticosteroid if strong possibility of preterm labour (for lung maturity)

27. Criteria for vaginal delivery fulfilled
Leading twin is cephalic

28. INTRAPARTUM MANAGEMENT OF TWINS
Criteria for vaginal delivery fulfilled
Deliver the 1st twin
Clamp and cut the cord
Note lie of 2nd twin
Longitudinal lie
Transverse lie
Amniotomy with controlled oxytocin infusion if there is uterine inertia
Attempt External Cephalic Version and vaginal delivery under GA
Note presentation
Vertex
Breech
If unsuccessful C-section
Breech extraction or assisted breech delivery
Vaginal delivery or optionally outlet forceps or ventouse

29. MANAGEMENT OF THIRD STAGE OF LABOUR
In PIH and cardiac disease: give oxytocin 10 unit i.m
Syntometrine 1 ml (5 unit oxytocin and 500 mcg ergometrine i.m) with delivery of anterior shoulder of 2nd baby
Placenta delivered with controlled cord traction
In high risk of uterine atony and PPH, i.v infusion 40 units oxytocin over 6 hours after delivery)
Episiotomy/perineal repair if needed

30. INDICATION OF CAESAREAN SECTION
i) ELECTIVE
1st baby non-cephalic especially shoulder
Conjoined twins
Congenital abnormality precluding safe vaginal delivery
IUGR in dichorionic twin
Chronic TTTS
Monoamniotic twin
Placenta praevia
Triplets or more
Contracted pelvis
Previous C-section
Pre-eclampsia
ii) EMERGENCY
Fetal distress
Cord prolapse in 1st baby
Non-progress of labour
Collision of both twins
2nd twin transverse, version failed after 1st delivery of twin

31. Thank you….