1. Multiple Pregnancy
Prof Uma Singh

2. Multiple Pregnancy/ Multifetalpregnancy
The presence of more than one fetus in the gravid uterus is called multiple pregnancy
Two fetuses (twins)
Three fetuses (triplets)
Four fetuses (quadruplets)
Five fetuses (quintuplets)
Six fetuses (sextuplets)

3. INCIDENCE
Hellin’s Law: Twins: 1:89 Triplets: 1:892 Quadruplets: 1:893 Quintuplets: 1:894 Conjoined twins: 1 : 60,000 Worldwide incidence of monozygotic - 1 in 250 Incidence of dizygotic varies & increasing

4. Demography Race: most common in Negroes Age: Increased maternal age
Parity: more common in multipara
Heredity - family history of multifetal gestation
Nutritional status – well nourished women
ART - ovulation induction with clomiphene citrate, gonadotrophins and IVF
Conception after stopping OCP

5. Twins Varieties: 1. Dizygotic twins: commonest (Two-third)
2. Monozygotic twins (one-third)
Genesis of Twins:
Dizygotic twins (syn: Fraternal, binovular) -
- fertilization of two ova by two sperms.

6. Upto 3 days - diamniotic-dichorionic
Monozygotic twins (syn: Identical, uniovular):
Upto 3 days - diamniotic-dichorionic
Between 4th & 7th day - diamniotic monochorionic most common type
Between 8th & 12th day- monoamniotic-monochorionic
After 13th day - conjoined / Siamese twins.

8. Conjoined twins
Ventral: 1) Omphalopagus 2) Thoracopagus 3) Cephalopagus 4) Caudal/ ischiopagus Lateral: 1) Parapagus Dorsal: 1)Craniopagus, 2)Pyopagus

9. Superfecundation
Fertilization of two different ova released in the same cycle
Superfetation
Fertilization of two ova released in different cycles

10. Differences in zygocity
Monozygotic
Dizygotic
1 ova + 1 sperm
Same sex
Identical features
Single or double placenta
Same genetic features
DNA microprobe -same
2 ova + 2 sperm
Same or opposite sex
Fraternal resemblance
Double or s/t fused
Different genetic features
DNA microprobe - different

11. Differences in chorionicity with single placenta
D / D ( fused placenta )
M / D
Monozygotic or dizygotic
Thick dividing membrane > 2mm
Twin peak / lambda sign
Monozygotic
Thin dividing membrane 2mm or less
T sign

12. Diagnosis HISTORY: SYMPTOMS:
History of ovulation inducing drugs specially gonadotrophins
Family history of twinning (maternal side).
SYMPTOMS:
Hyperemesis gravidorum
Cardio-respiratory embarrassment - palpitation or shortness of breath
Tendency of swelling of the legs,
Varicose veins
Hemorrhoids
Excessive abdominal enlargement
Excessive fetal movements.

13. GENERAL EXAMINATION:
Prevalence of anaemia is more than in singleton pregnancy
Unusual weight gain, not explained by pre-eclampsia or obesity
Evidence of preeclampsia(25%)is a common association.
ABDOMINALEXAMINATION:
Inspection:
The elongated shape of a normal pregnant uterus is changed to a more "barrel shape” and the abdomen is unduly enlarged.

14. Palpation:
Fundal height more than the period of amenorrhoea
girth more than normal
Palpation of too many fetal parts
Palpation of two fetal heads
Palpation of three fetal poles
Auscultation:
Two distinct fetal heart sounds with
Zone of silence
10 beat difference

15. D/D of increased fundal height
Full bladder
Wrong dates
Hydramnios
Macrosomia
Fibroid with preg
Ovarian tumor with preg
Adenexal mass with preg
Ascitis with preg
Molar pregnancy

16. INVESTIGATIONS
Sonography: In multi fetal pregnancy it is done to obtain the following information:
Suspecting twins – 2 sacs with fetal poles and cardiac activity
Confirmation of diagnosis
Viability of fetuses, vanishing twin
Chorionicity – 6 to 9 wks ( single or double placenta, twin peak sign in d /d gestation or Tsign in m/d )
Pregnancy dating,

17. Sonography ( ctd ) Fetal anomalies
Fetal growth monitoring (at every 3-4 weeks interval) for IUGR
Presentation and lie of the fetuses
Twin transfusion (Doppler studies)
Placental localization
Amniotic fluid volume

18. Radiography
Biochemical tests: raised but not diagnostic
Maternal serum chorionic gonadotrophin,
Alpha fetoprotein
Unconjugated oestriol

19. Lie and Presentation Longitudinal lie (90%) both vertex (40%)
Vertex + breech (28%)
breech + vertex ( 9%)
both breech ( 6%)
Others
vertex + transverse
breech + transeverse
both transeverse

20. Complications Maternal Fetal MATERNAL: During pregnancy:
Labour
Puerperium
Fetal
MATERNAL: During pregnancy:
- miscarriages
Hyperemesis gravidorum
Anaemia
Pre-eclampsia (25%)
Hydramnios ( 10 % )

21. GDM ( 2 – 3 times)
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, dyspnoea, varicosities and haemorrhoids
Obstructive uropathy

22. 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

23. FETAL – 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

24. FETAL – more with monochorionic
Low birth weight ( 90%)
Prematurity – spontaneous or iatrogenic
Fetal growth restriction - in 3rd trimester, asymmetrical, in both fetus
Discordant growth - Difference of >25% in weight , >5% in HC, >20mm in AC, abnormal doppler waveforms -
Causes – unequal placental mass, lower segment implantation, genetic difference, TTTS, congenital anomaly in one

25. FETAL COMPLICATIONS (ctd)
Congenital anomalies – conjoined twins, neural tube defects – anencephaly, hydrocephaly, microcephaly, cardiac anomalies, Downs syndrome, talipes, dislocation of hip
TTTS -Twin to twin transfusion syndrome
- cause – AV communication in placenta – blood from one twin goes to other – donor to recipient
- donor – IUGR, oligohydramnios
- recipient – overload, hydramnios, CHF, IUD

26. FETAL COMPLICATIONS (ctd)
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

27. Monoamniotic twins high perinatal morbidity, mortality
Monoamniotic twins high perinatal morbidity, mortality. Causes : cord entanglement congenital anomaly preterm birth twin to twin transfusion syndrome

28. Antenatal Management
Diet: additional 300 K cal per day, increased proteins, 60 to 100 mg of iron and 1 mg of folic acid extra
Increased rest
Frequent and regular antenatal visit
Fetal surveillance by USG – every 4 weeks
Hospitalisation not as routine
Corticosteroids -only in threatened preterm labour , same dose
Birth preparedness

29. Management During Labour
Place of delivery: tertiary level hospital
FIRST STAGE:
blood to be cross matched and ready
confined to bed, oral fluids or npo
intrapartum fetal monitoring
ensure preparedness
SECOND STAGE – first baby
- second baby

30. Management During Labour
SECOND STAGE –delivery of first baby
as in singleton pregnancy
start an IV line
no oxytocic after delivery of first baby
secure cord clamping at 2 places before cutting
ensure labeling of 1st baby
Delivery of second twin
FHS of second baby
lie and presentation of second twin
wait for uterine contractions
conduct delivery

31. Management During Labour
Delivery of second twin – problems & interventions
-inadequate contraction- augmentation – ARM, oxytocin
-transverse lie – ECV, IPV
-fetal distress, abruption, cord prolapse- expedite delivery – forceps, ventouse, breech extraction
THIRD STAGE – AMTSL
- continue oxytocin drip
- carboprost 250µgm IM
- monitor for 2 hours

32. Indications of caesarean
Non cephalic presentation of first twin
Monoamniotic twins
Conjoined twins
Locked twins
Other obstetric conditions
Second twin – incorrectible lie, closure of cervix

33. MCQs
Text book of Obstetrics, Dr J B Sharma, 1st edition ( 2012) page-473 to 483
Chapter - multiple pregnancy

34. 1. Splitting of single fertilized ovum between 8 to 12 days results in a) conjoined twins b) monochorionic monoamniotic twin c) dichorionic diamniotic twin d) monochorionic diamniotic twin

35. Splitting of single fertilized ovum between 8 to 12 days results in a) conjoined twins b) monochorionic monoamniotic twin c) dichorionic diamniotic twin d) monochorionic diamniotic twin

36. 2. Twin peak sign is a feature of a) conjoined twins b) monochorionic monoamniotic twins c) dichorionic diamniotic twins d) monochorionic diamniotic twins

37. Twin peak sign is a feature of a) conjoined twins b) monochorionic monoamniotic twins c) dichorionic diamniotic twins d) monochorionic diamniotic twins

38. 3. Additional caloric requirement ( K cal per day) of a mother in a case of twin pregnancy is a) 300 b) 500 c) 800 d) 1000

39. Additional caloric requirement ( K cal per day) of a mother in a case of twin pregnancy is a) 300 b) 500 c) 800 d) 1000

40. 4. Additional iron supplementation requirement ( mg per day) of a mother in a case of twin pregnancy is a) 30 b) 50 c) 100 d) 200

41. Additional iron supplementation requirement ( mg per day) of a mother in a case of twin pregnancy as compared to singleton pregnancy is a) 30 b) 50 c) 100 d) 200

42. 5. Iron supplementation required by a mother having twin pregnancy is a) 30 b) 50 c) 100 d) 200

43. Iron supplementation required by a mother having twin pregnancy is a) 30 b) 50 c) 100 d) 200

44. 6. Twin pregnancy is complicated by all of the following except a) placenta previa b) malpresentation c) hydramnios d) post term labour

45. Twin pregnancy is complicated by all of the following except a) placenta previa b) malpresentation c) hydramnios d) post term labour

46. 7. Caesarean section is indicated in a) monoamniotic twin b) monochorionic twin c) dichorionic twin d) diamniotic twin

47. Caesarean section is indicated in a) monoamniotic twin b) monochorionic twin c) dichorionic twin d) diamniotic twin

48. 8) 32year old G2P1 at 20 weeks pregnancy in USG shows twin pregnancy, single placental mass with dividing membrane having inverted T sign. The type of twinning is
a) monochorionic monoamnionic
b) monochorionic diamnionic
c) dichorionic monoamnionic
d) dichorionic diamnionic

49. 8) 32year old G2P1 at 20 weeks pregnancy in USG shows twin pregnancy, single placental mass with dividing membrane having lambda sign. The type of twinning is
a) monochorionic monoamnionic
b) monochorionic diamnionic
c) dichorionic monoamnionic
d) dichorionic diamnionic

50. 9) Monochorionic twin placenta has unidirectional deep arteriovenous communication with lack of superficial vascular anastomoses. The likely complication is
a) twin to twin transfusion syndrome
b) twin reversed arterial perfusion
c) acute intertwin transfusion
d) twin cord entanglement

51. 9) Monochorionic twin placenta has unidirectional deep arteriovenous communication with lack of superficial vascular anastomoses. The likely complication is
a) twin to twin transfusion syndrome
b) twin reversed arterial perfusion
c) acute intertwin transfusion
d) twin cord entanglement

52. 10) Most common variety of conjoined twins is a) craniopagus b) thoracopagus c) omphalopagus d) pyopagus

53. 10) Most common variety of conjoined twins is a) craniopagus b) thoracopagus c) omphalopagus d) pyopagus