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%)

6. Monozygotic Dizygotic

7. 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 1.There is increase in weight gain and cardiac output. 2.Plasma volume is increased by an addition of 500ml. 3.There is no corresponding increase in red cell volume resulting in exaggerated haemodilution and anaemia. 4.There is increased alpha fetoprotein level, tidal volume and glomerular filtration rate. 1.There is increase in weight gain and cardiac output. 2.Plasma volume is increased by an addition of 500ml. 3.There is no corresponding increase in red cell volume resulting in exaggerated haemodilution and anaemia. 4.There is increased alpha fetoprotein level, tidal volume and glomerular filtration rate.

10. LIE AND PRESENTATION Commonest lie is Longitudinal Both Vertex (50%) First Vertex and second breech (30%) First breech and second vertex (10%) Both Breech (10%) Rarest one Both transverse (Rule out conjoined twins)

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

12. Abdominal Examination More “barrel shaped” inspection Abdominal girth more than 100cm. Too many fetal parts on palpation. Abdominal girth more than 100cm. Too many fetal parts on palpation. Two distinct fetal heart sounds on Auscultation. Not easy due to presence of hydramnios

13. Ultrasonogr aphy Confirmation of pregnancy as early as 10 th week of pregnancy Chorionicity Presentation and Lie of the fetus Viability of fetus Fetal growth monitoring for IUGR Fetal Anomalies Amniotic fluid volume Placental Localization Twin transfusion

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 10-14 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. 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 10-14 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. Complicati ons Maternal Fetal Pregnancy Labour Puerperium

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

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

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

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. Triplets Quadruplets Female usually outnumber the number of male one. Perinatal loss is markedly increased due to prematurity. Average time for delivery in quadruplets is 30-31 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 11-13 weeks. Selective termination of a fetus with structural or genetic abnormalities may be done in a chorionic multiple pregnancy in the second trimester. Female usually outnumber the number of male one. Perinatal loss is markedly increased due to prematurity. Average time for delivery in quadruplets is 30-31 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 11-13 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…