1. MULTIPLE GESTATIONS When more than one fetus simultaneously develops in the uterus, it is called multiple pregnancy. 2 fetus- twins 3 fetus – triplets 4 Fetus – quadruplets.

2. Twins Development of two fetus in the uterus Accounts for 1 in 94 pregnancies. Varieties : 1.Dizygotic twins – Commonest 2/3 rd. Of twins Results from fertilization of two ova 2 Monozygotic twins – 1/3 rd of twins. Results from fertilization of a single ovum.

3. Monozygotic twins can be of these types depending upon the period of twinning. -Diaminotic – dichorionic Occurs within 72 hrs after fertilization. -Diaminotic – monochironic 4 th to 8 th days offertilization -Monoaminotic – monochronic Occurs after 8 days after fertilization. -Conjoined twins Occurs after 2 wks of fertilization i.e. after development of embryonic disc.

4. DETERMINATION OF ZYGOSITY The main reason to determine zygosity antenatally is to aid. Obstetrical risk assessment and guide management of multifetal gestation.  ultrasonographic evaluation  Placental examination  Infant sex  DNA finger printing ( definitive Diagnosis)

5. ETIOLOGY The incidence of monozygotic twins remains constant 1 in 250, a wide. Variation is seen in the incidence of dizygotic twins.  Race  Hereditary  Maternal age and parity  Infertility treatment  Assisted reproductions technology.

6. MATERNAL PHYSIOLOGICAL CHANGES IN TWIN PREGNANCY 1.Increase in wt gain and cardiac output 2.Plasma volume by an addition of 500ml 3.Increase in fetoprotein level, tidal volume, GFR

7. DIAGNOSIS History and clinical Examination -Maternal family history of twins -High parity -Large maternal size -personal H/o of twins

8. -Administration of ovulation induction drugs -Pregnancy accomplished by ART. -Uterine size is larges than expected for the gestational age -On palpation two fetal heads or three fetal poles are palpated. -Two fetal heart rates. distinct from each other and from that of the mother

9. Ultrasonography : Two fetal heads or two abdomens should be seen in the same plane, to avoid scanning the same fetus twice. Twin peak sign – diachronic pregnancy T- sign – monochromic pregnancy

10. Complications Maternal PregnancyLabourPreperium  Nausea  Vomitings  Anemia  Pre-eclampsia  Hydramnios  APH  Malpresentation  Preterm labour  Mechanical distress  Early rupture of membrane  Cord prolapse   Operative  interference  Bleedings  PPH  Sub involution  Infection  lactation failure.

11. Fetal :  Abortion  Prematurity  LBW  IUD  Asphyxia and still birth

12. FETAL MALFORMATION Defects from twining itself Defets from vascular inter change From crowding  Conjoined twins  Acardic anomaly  Sirenomelia  Neural – tube defects  Holoprosencep haly Due to dramatic Blood pressure fluctuation Leads to  Microcephaly  Hydranecephal y  Talipes equinos  Congenital hip dislocation

13. Complications specific to monochoronic twins - Twin transfusion syndrome -Dead fetus syndrome -Twin reversal arterial perfusion -Conjoined twins

14. The Aim is to  Prevent delivery of markedly preterm infants.  Failure of one or both fetus to thrive be identified and fetus so afflicted be delivered before they become moribund.  Fetal trauma during labour and delivery be avoided.  To identify other associated complications maternal associated twins like HTN,anemias DM.  Expert neonatal care be available ANTEPARTUM MANAGEMENT :

15. Advise to be given on 1)Diet 2)Rest 3)Supplement therapy 4)Frequent antennal visits

16. Monitor for : 1)Maternal hypertension which more likely develops in multiple pregnancy. 2)Hydramnios development. 3)Fetal well being I,e Antepartum survillance.  Serial ultrasonography  Assessment of Amniotic fluid  Nonstress test / Biophysical profile  doppler velocimetry 4)Any prediction for preterm labour., cx length, fetal fibronectin

17. Recommendations for intrapartum management include.  An appropriately trained obstetrical attendant.  Continuous electronic monitoring of the fetus  Blood transfusion products should be readily available. -Intravenous infusion system.  Ulstrasonography machine  Experienced anesthesiologist  Neonatologist. DELIVERY OF TWIN FETUS :

18. Delivery of the 1 st Baby The delivery should be conducted in the same guidelines as in normal singleton pregnancy in addition the following steps to be followed.  Do not give intravenous ergometrine with the delivery of the anterior shoulder of the first baby.  Clamp the cord, with at least 8-10 cm of cord left behind for administration of any during transfusion.

19. Conduction of labour after the delivery of the first baby : Step I : Following the birth of the first baby, not the lie, presentation, size and FHS of the second baby by abdominal examination, vaginal examination and U/S Examination and exclude any cord prolapse. Step II : If the lie is longitudinal : Low rupture of membranes done, if the constructions have not started within 15 min of delivery of 1 st baby, oxytoxcin drip should be started

20. Wait for spontenous delivery If delayed ( Say 15 th min) Interference to be done Wait for spontenous delivery if delayed ( Say 15 min) interference to be done. Low done High up Rule out CPD If excluded Do internal vision followed by breech extraction Delivery completed by breech extraction Forceps applied VertexBreech

21. Step – III If the lie is transverse Correct by external version into a longitudinal lie. Preferably cephalic, if fails podalic If external version fails., internal version  GA done.

22. Indications of urgent delivery of the 2 nd baby: 1) Severe intrapartum vaginal bleeding 2) Cord prolapse 3) Inadvertent are of intravenous ergometrine with the delivery of the anterior shoulder of the 1 st baby. 4) First baby delivered  GA. 5) Appearance of fetal distress.

23. Management of the IIIrd stage of labour :  Administration of 0.2 mg methergin intravenously with delivery of the anterior shoulder of the 2 nd baby.  Observation, vital’s monitoring for 2 hours after delivery.

24. Indications of caesarean section in twins ObstetricsSpecific for twins 1.Placenta previa 2.Severe preeclampsia 3.Post C/S 4.Cord prolapse of the 1 st baby 5.Abnormal uterine contraction 6.Contracted pelvis 1)Both the fetus or even the 1 st fetus with non cephalic presentation. 2)Conjoined twins. 3) Collision of both heads at the brim preventing engagement of either head. 4)Monochrionic twins with TTS.

25. Management of difficult cases of twins : 1)Interlocking twins : The commonest one being the after coming head of the 1 st baby getting locked with the fore coming head of the 2 nd baby. 2)Vaginal manipulation to separate the chins of the fetuses done. 3)Failing which caesarean section done.