Dr. Sharifa Al Sibiani
MULTIPLE PREGNANCY
Introduction:
Multiple pregnancy is a complicated pregnancy associated with high risk of mortality and
morbidity for both mother and fetus.
Types:
1. Twins
Monozygotic
Diazygotic
2. Triplets
3. Quadruplets
4. Etc.
TWIN PREGNANCY
TYPES:
1. Monozygotic
2. Diazygotic
INCIDENCE:
Twin Diazygotic 1.80 in UK
 Higher multiples follow Hellin’s Law
 Triplets
= 802
 Quadruplet
= 803
Monozygotic : relatively constant world wide 1.250 birth independent of associated
factors.
Incidence of diazygotic twin is influenced largely by:
 Race (Negro > White)
 Hereditary (maternal side)
 Maternal age (> 35 years)
 Maternal size of length (large and tall > small and short)
 Parity (mulliparous > nulliparous)
 Fertility drugs (injection > oral)
 Soon after stop long term OCP (Rebound birth secretion)
 Blood group A & O ? unknown
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Dr. Sharifa Al Sibiani
Genesis of Twinning
1. Diazygotic (biovulular, fraternal, non-identical) twin
Two separate ova fertilized by two different sperms
2. Monozygotic (monovular, indentical) twin
One ovum fertilized by one sperm
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If division occurs within 5 days i.e. at two cell stage (before the inner mass
formation)
Two embryo, two amnions and two chorions  Diamniotic dichorionic
(30% of twins)
Between (5 – 10 days) after fertilization i.e. at blastocyst stage (after the inner
mass formation)
Two embryo, two amnion and one chorion  Diamniotic monochorionic
Monochorionic (70% of twins)
About (10 to 14th day) after fertilization
(After amnion and chorion formation)
Two embryo, one amnion and one chorion  Monoamniotic monochorionic (1%
of twins)
Later (? 14 days) after embryonic disk formation, cleavage is incomplete
(conjoined twins) (1% of monozygotic twins)
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Dr. Sharifa Al Sibiani
DIAGNOSIS OF MULTIPLE PREGNANCY
I – History
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FH + ve
Past History
Fertility drugs
Excessive vomiting in early pregnancy
II – Examination
 Bigger uterus
 Two separate fetal heart at 18-20 weeks
 After 30 – 32 weeks 3 fetal pole may be identified
(two head and one breech)
III – Investigations
1. Ultrasound - > 80% of twins are diagnosed before labour
(10% of multiple pregnancy are missed)
 2 x gestational sac 6 – 7 weeks scan
 2 x embryos 7
– 8 weeks scan
 A definitive diagnosis at 16 weeks scan
As commonly one pair twin diagnosed early doesn’t develop and observed later
(vanishing twin)
AS number of fetuses ↑ → ↑ accuracy of diagnosis of number of fetuses.
2. Biochemical test
Higher hormones of pregnancy
HCP, PL, α FP, PP
But there is no biochemical test will differentiate clearly between one and more
than one fetus.
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Dr. Sharifa Al Sibiani
COMPLICATIONS
Most pregnancy related problems are common and more severe. These cause high
morbidity and mortality to both mother and fetus.
I - FETAL COMPLICATIONS
I – ANTEPARTUM
1. Risk of spontaneous abortion
 2x as singleton pregnancy
 Vanishing twin
 Only 50 % of twins diagnosed by early ultrasound continue to delivery
2. Preterm Labour
 Over all twins account for about 10% of all prematurity
 20 – 50% of multiple pregnancies don’t reach 37th week
 In general as the number of fetuses ↑ -> the duration of pregnancy ↓
(singleton 280 days (40 weeks), twin 260 days (37 weeks) triplet 247
days (35 weeks)
 Prematurity is the most important factor in increasing prenatal
mortality and morbidity.
3. Growth retardation
 50% of all twins weight < 2500 grams
 In general, the larger number of fetuses  the greater degree of growth
retardation
 More in monozygotic
 Discordant twins
- IUGR of one of fetuses
- > 25 % difference in weight
 Weight difference = 250 grams
 U/S difference BPD = 5 mm, HC = 5%, AC = 20 mm
- 15 – 30% of twin pregnancy
- Cause higher perinatal mortality
- Cause by placental insufficiency
Twin – twin transfusion
4. Congenital anomalies
- Major and minor malformation x 2 as singleton (major = 1% in singleton 2%
in twin)
- More in monozygotic twins
5. Increased Perinatal Mortality
- 2 x more than singletons (10 – 15% most report)
- More neonatal mortality > still birth (due to prematurity)
- Monozygotic > diazygotic
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Dr. Sharifa Al Sibiani
- More in monozygotic (intertwining of cord)
- Causes – Mainly prematurity
Other - Congenital malformation
- IUGR
- Twin – twin transfusion
- Birth trauma or hypexia
6. Twin – twin transfusion Syndrome (Fetal – fetal haemorrhage)
- Limited to those with monochorial placenta
- 15% of monozygotic twin
Results when one placental cotyledon is fed by artery from the first twin and
drained by a vein that lead to the second twin .
- C/F varies (mild-moderate-severe)
- Full blown picture
Hyperfused Twin ----→ Polycylthemic, ↑ BP, Cardiac hypertrophied,
Oedema, polyhydramnios
Hypoperfused Twin ---→Anaemic, ↓BP, IUGR, Oligohydraminase
The hallmark is rapid polyhydraminase and discordant fetal growth.
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PMR close to100% if develop before 26 weeks. If one fetus dies,
usually the recipient from CHF & hydrops. This can cause a
consumption coagulopathy or emboli to the remaining twin.
Management: “Depend as gestational age and severity”
 Daily F.M. chart and CTG
 Weekly ultrasound + BPD
 ↓ Polyhydramnios by  : Therapeutic amniocentesis
 : PG synthetase inhibitors (indomethacin)
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Abnormal CTG  stop Rx  delivery : C/S if fetal hydrops develops
Laser photocoagulation of the placental vessels
7. The antepartum death of one twin (single fetal demise in uterus)
 Can occur at any trimester (1st, 2nd, 3rd)
 Frequency : varies
 Monozygotic at highest risk
 Theoretically maternal coagulopathy could be trigged (> 5 weeks after
fetal death)  Hypofibronogenema, DIC (rare)
 Neonatal morbidity or mortality higher in the remaining twin (from
emboli)
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Dr. Sharifa Al Sibiani
Management” “ Conservative with frequent antenatal surveillance of the living
fetus”
 Maternal coagulation check up weekly
 Serial ultrasound – to evaluate growth . A.F., placental grade
 CTG + BPD
 Delivery for the usual obstetric indication
II - MATERNAL COMPLICATIONS
1. PIH
- 3-5 singleton
- earlier and more severe as compared with singleton
- equal frequency in mono and diazygotic twin
2. G.D.M.
3. Anemia – especially iron deficiency anemia (because of ↑ fetal iron requirement)
Rarely megaloblastic anemia
4. Polyhydramnios
 10 – 12%
 Can occur in one or both sacs
 More common un monozygotic (usually from twin – twin transfusion)
5. Risk of APH
 Placenta previa ? due to large placental surface
 Abruptio placentae may occur with sudden decompression of the uterus
immediately after delivery of the first twin
6. Cord accidents (cord prolapse, entwinement, vasa previa)
Cord prolapse may occur with malpresentation especially with 2nd twin at
time when its membrane rupture.
Cord entwining especially in monozygotic monoamniotic
7. In effective labour due to:
 Over distended uterus
 Malpresentation
8. Malpresentation
 Main factor leading to more frequent use of C/S in twin
 Cephalic – cephalic ---- 45 %
 Cephalic – breech ----- 24%
1st twin (leading twin) is cephalic in 80%
 Cephalic trans - ------ 10%
 Breech – cephalic ------ 10%
 Breech – breech ------ 10%
9. PPH
 Uterine atony (owing to inability of over distended uterus to contracted well)
 Operating delivery (instrumental or C/S)
 Placental accident (previa or abruption)
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Dr. Sharifa Al Sibiani
10. High rate of operative delivery (instrumental or C/S)
11. Delay in delivery of twin II
12. Locked twins
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Very rare complication of twin delivery (1/800)
May occur when first twin present as breech and second as cephalic
Usually managed by C/S or decapitation head of first twin
13. High risk of birth asphyxia and neonatal depression, due to :
 Prematurity
 Malpresentation and cord accident
 Complicated delivery
 Operative delivery
 A.P.H.
Management of multiple Pregnancy
I. In pregnancy
Proper antenatal care should be included:
1. Early diagnosis
2. Frequent antenatal visits
 At least every 2 weeks from 20 –30 weeks then weekly
 To allow prevention of possible or early detection and treatment of
complication
3. Serial ultrasound for fetal growth to detect IUGR
4. Prevention (if possible) early detection and aggressive of preterm labour
 Bed rest
 Prophylactic beta symphathomometric drugs?
 Prophylactic cervical cerclage?
5. Screening
6. Additional calories (another 300 kcal / day)
7. Iron supplementation 60 – 100 mg / day + 1 mg folic acid
8. Regular B.P. monitoring
9. Hospitalization – routine admission at 26 – 30 weeks ? now not common
If * any complication
* CX is effused or dilated
* The mother is tired
10. Watching and Rx of less complications as twin – twin transfusion
II – Labour
Twin
Should be in well equipped hospital
o Two obstetricians (one should be skilled in intrauterine manipulation)
o Two Pediatricians (one should be expert in neonatal resuscitation)
o Anesthesiology
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Dr. Sharifa Al Sibiani
The first stage
Managed in the ordinary way with special care include.
o NPO
o IVF
o Cross match at least two units of blood Continuous fetal monitoring
o Ensure twin I is longitudinal
o If twin I is transverse  C/S
o Check for cord prolapse when membrane rupture
(Often early in labour) Insert internal fetal electrode
o Progress is usually uneventful with monitor both externally after ROM one
internal and other external
Fetal hearts
o If woman wants, an epidural anesthetic is useful for it allows any maneuvers that
may be required for twin in the second stage.
NB:
Ceph I – ceph II – SVD
Ceph I – breech II – SVD or CS
Breech I – breech II – CS ?? SVD
Second Stage
o Episiotomy
o Make sure that nobody give syntometrine after the delivery of the twin I
o Clamp cord I and hand baby to Paediatrician
o Immediately check lie of twin II abdominally and check presenting part vaginally
If obligue or transverse  make longitudinal external version or internal version
NB:
Twin II delivered within 20 minutes, usually start contracting again 5 minutes first
delivery.
If not  IV oxytocin augmentation
3rd Stage
o Give Syntometrine with delivery of twin II and continue Oxytocin infusion for
another hour
o Deliver placentae after delivery of twin II
NB:
PPH due to atony uterus or trained placenta is common
II -
Triplets or more
 CS
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