1. Lecture 14 MULTIPLE PREGNANCY. THE UTERINE RUPTURE
Prof. Vlad TICA, MD, PhD

2. MULTIPLE PREGNANCY

4. MULTIPLE PREGNANCY
Twin pregnancy represents 2 to 3% of all pregnancies
The PNMR is 5 times that of singleton

5. DIZYGOTIC TWINS Most common represents 2/3 of cases
Fertilization of more than one egg by more than one sperm
Non identical, may be of different sex
Two chorion and two amnion
Placenta may be separate or fused

6. FACTORS AFFECTING IT’S INCIDENCE
Induction of ovulation, 10% with clomide and 30% with gonadotrophins
Increase maternal age ? Due to increase gonadotrophins production
Increases with parity
Heredity usually on maternal side
Race: Nigeria 1:22; North America 1:90

7. MONOZYGOTIC TWINS Constant incidence of 1:250 births
Not affected by heredity
Not related to induction of ovulation
Constitutes 1/3 of twins

8. RESULTS FROM DIVISION OF FERTILIZED EGG
0-72 hours Diamniotic dichorionic
4-8 days Diamniotic monochorionic
9-12 days Monoamnio monochorionic
>12 days Conjoined twins

9. RESULTS FROM DIVISION OF FERTILIZED EGG

10. MONOZYGOTIC TWINS 70% are diamniotic monochorionic
30% are diamniotic dichorionic

11. DETERMINATION OF ZYGOSITY
Very important as most of the complications
occur in monochorionic monozygotic twins

12. During pregnancy by USS
Very accurate in the first trimester, two sacs, presence of thick chorion between amniotic membranes
Less accurate in the second trimester the chorion become thin and fuse with the amniotic membranes

13. Different sex indicates dizygotic twins
Separate placentas indicates dizygotic twins

14. DETERMINATION OF ZYGOZITY AFTER BIRTH
By examination of the MEMBRANES, PLACENTA, SEX, BLOOD group
Examination of the newborn DNA and HLA may be needed in few cases

15. COMPLICATIONS OF MULTIPLE GESTATION
Maternal
Fetal
Malpresentation
Placenta previa
Abruptio placentae
Premature rupture of the membranes
Prematurity
Umbilical cord prolapse
Intrauterine growth restriction
Congenital anomalies
Anemia
Hydramnios
Preeclampsia
Preterm labour
Postpartum hemorrhage
Cesarean delivery

16. SPECIFIC COMPLICATIONS IN MONOCHORIONIC TWINS
TWIN-TWIN transfusion
Results from vascular
anastomosis between
twins vessels at the placenta
Usually arterio (donor) venous (recipient)
Occurs in 10% of monochorionic twins

17. SPECIFIC COMPLICATIONS IN MONOCHORIONIC TWINS
TWIN-TWIN transfusion
Chronic shunt occurs, the donor
bleeds into the recipient so one is
pale with oligohydraminos while
the other is polycythemic with
hydraminos
If not treated death occurs in % of cases

18. SPECIFIC COMPLICATIONS IN MONOCHORIONIC TWINS
Possible methods of treatment:
Repeated amniocentesis from recipient
Indomethacin
Fetoscopy and laser ablation
of communicating vessels

19. OTHER COMPLICATIONS IN MONOCHORIONIC TWINS
Congenital malformation. Twice that of singleton.
Umbilical cord anomalies. In 3 – 4 %.
Conjoined twins. Rare 1:70000 deli varies. The majority are thoracopagus
PNMR of monochorionic is 5x that of dichorionic twins (120 vs. 24 / 1000 births)

20. OTHER COMPLICATIONS IN MONOCHORIONIC TWINS
- thoracopagus
- pigopagus

21. OTHER COMPLICATIONS IN MONOCHORIONIC TWINS
- craniopagus
craniopagus parasiticus
- xyphopagus

22. MATERNAL PHYSIOLOGICAL ADAPTATION
Increase blood volume and cardiac output
Increase demand for iron and folic acid
Maternal respiratory difficulty
Excess fluid retention and edema
Increase attacks of supine hypotension

23. DIAGNOSIS OF MULTIPLE PREGNANCY
Positive family history mainly on maternal side
Positive history of ovulation induction
Exaggerated symptoms of pregnancy
Marked edema of lower limb
Discrepancy between date and uterine size
Palpation of many fetal parts

24. DIAGNOSIS OF MULTIPLE PREGNANCY
Auscultation of two fetal heart beats at two different sites with a difference of 10 beats
USS
Two sacs by 5 weeks by TV USS
Two embryos by 7 weeks by TV USS

25. ANTENATAL CARE
AIM
Prolongation of gestation age, increase fetal weight
Improve PNM and morbidity
Decrease incidence of maternal complications

26. ANTENATAL CARE Follow Up Every 2 weeks
Iron and folic acid to avoid anemia
Assess cervical length and competency

27. ANTENATAL CARE Fetal Surveillance Monthly USS from 24 weeks to
assess fetal growth and weight
A discordinate weight difference of >25% is abnormal (IUGR)
Weekly CTG from 36 weeks

28. 3D USS – TWIN PREGNANCIES

29. METHOD OF DELIVERY Vertex-Vertex (50%)
Vaginal delivery, interval between
twins not to exceed 20 minutes
Vertex-Breech (20%)
Vaginal delivery by senior obstetrician

30. METHOD OF DELIVERY Breech-Vertex (20%)
Safer to deliver by CS to avoid the
rare interlocking twins (1:1000 twins)
Breech-Breech (10%)
Usually by CS

31. PERINATAL OUTCOME
PNMR is 5 times that of singleton (30-50/1000 births)
RDS accounts for 50% 0f PNMR. 2nd twin is more affected
Birth trauma – 2nd twin is 4 times affected than 1st
Incidence of SB is twice that of singleton

32. PERINATAL OUTCOME Congenital anomalies is responsible for 15% of PNMR
Cerebral hemorrage and birth asphyxia are responsible for 10% of PNMR
Cerebral palsy is 4 times that of singleton
50% of twins babies are born with low birth (<2500 gms) from prematurity & IUGR

33. INTRAUTERINE DEATH OF ONE TWIN
Early in pregnancy usually no risk
In 2nd or 3rd trimester:
Increase risk of DIC
Increase risk of thrombosis in the a live one
The risk is much higher in monochorionic than in dichorionic twins

34. The a life baby should be delivered by 32-34 weeks in monochorionic twins

35. HIGH RANK MULTIPLE GESTATION
Spontaneous triplets 1:8.000 births
Spontaneous quadruplets 1: births
The main risk is sever prematurity
CS is the usual and safe mode of delivery
High PNMR of / 1000 births

36. COMPLICATIONS OF MULTIPLE PREGNANCY
A. MATERNAL:
Anemia due to increase demand
Increase incidence of PET(5 times)
Polyhydramnios in monochorionic monozygotic twins
Increase incidence of premature labor

37. COMPLICATIONS OF MULTIPLE PREGNANCY
A. MATERNAL:
Increase incidence of CS. And operative delivery
Increase incidence of placenta praevia and abruptio placentae
Increase incidence of hypotonic postpartum hemorrhage

38. COMPLICATIONS OF MULTIPLE PREGNANCY
B. FETAL:
Increase perinatal morbidity and mortality
Prematurity with / without rupture of membrane
Increase incidence of malpresentation

39. COMPLICATIONS OF MULTIPLE PREGNANCY
B. FETAL:
Increase incidence of cord prolapse
Higher incidence of IUGR
Increase incidence of congenital anomalies

40. THE UTERINE RUPTURE

41. DEFINITION Separation of the muscular wall of the uterus
Usually occurs during labor
Occasionally happen during
the later weeks of pregnancy

42. CAUSES During pregnancy Weak scar after previous
operations on the uterus
History of cesarean section (VBAC - vaginal birth after C-section)
Myomectomy
Excision of a uterine septum
Previous perforation of uterus (D&C, hysteroscopy, forceps delivery

43. CAUSES During labor: uterine hyper-stimulation (oxytocin
with pitocin induction or
augmentation of labor)
obstructed labor (macrosomia, fetopelvic disproprotion)
intrauterine manipulation (internal version, manual removal of an adherent placenta)
forcible dilatation (cervical tear)
a weak scar (C-section or other
operations)

44. TYPES Incomplete rupture Complete rupture Depending on whether the
peritoneal coat is torn
through or not

47. SYMPTOMS AND SIGNS 1. Rupture of scar
be gradual that symptom is very slight in incomplete rupture
abdominal pain wrongly attributed to the onset of labor
severe pain and shock occurs in complete (suddenly pain)
fetal distress
bleeding in vagina

48. SYMPTOMS AND SIGNS 2. Spontaneous rupture during obstructed labor
prolonged labor
violent uterine actions
pathologic retraction ring
disporpotion, malpresentation(transverse lie)
fetal distress
a sharp, tearing pain in lower abdomen
pulse rapid
blood pressure fall
fetus may be felt in the abdominal cavity

49. PATHOLOGIC RETRACTION RING

50. SYMPTOMS AND SIGNS 3. Rupture by oxytocin drugs:
be follow the administration of oxytocin
the danger is less if the drug is given as a dilute intravenous drip given in an increasing fashion

51. PROGNOSIS
has a high mortality
peri-natal morbidity is high

52. TREATMENT Women’s general condition must be improved
giving morphine, blood transfusion, glucose solution)
immediate laparotomy
hysterectomy
wide-spectrum antibiotics

53. THANKS FOR YOUR ATTENTION !