Multifetal Gestation
(Multiple Pregnancy)
Prof. Hend Shalaby
Definition
• Pregnancy that resulted in more
than one fetus.
Prevalence
• Twins account for 1.5% of all
pregnancy
• 90% of multiple pregnancy
• Higher multiple pregnancy occurs
in 1/2500 pregnancies.
Risk factors
Age : 20- 30 years more common.
• Parity : more common in multiparity.
• Hereditary factors ( wife or husband).
• Ovulatory drugs and assisted reproduction.
• Race: more in black.
Classification
• The classification of multiple pregnancy is based on:
• number of fetuses: twins, triplets,quadruplets, etc.
• number of fertilized eggs: zygosity
• number of placentae: chorionicity
• number of amniotic cavities: amnionicity.
Types of Twin Pregnancy
Binovular (non identical) :
• 2 ova fertilized by 2 sperms
resulting in 2 fetuses , 2 amniotic
sacs and 2 placentae.
2. Monovular (monozygotic or identical)
One ovum fertilized by one
sperm :
• first 3 days after fertilization --
- dichorionic diamniotic.
• 4th – 8th day after fertilization---
-- monochorionic diamniotic.
• 8th- 12th day after fertilization
monochorionic monoamniotic.
• After 12 days ---- conjoined
twins.
Presentations
• Cephalic cephalic : 38% Cephalic
breech : 21%
• Breech cephalic : 14%
• Breech breech : 10%
• Cephalic transverse : 9%
• Breech transverse : 7%
• Transverse transverse : 2%
Complications of Multiple Pregnancy
Maternal
• Increased maternal mortality:
higher than in singleton, due to:
• Bleeding
• Infection.
• Anemia
• Preeclampsia-eclmpsia
• Abortion
• Hyperemesis gravidarum.
• Polyhydramnios
• Exagerated Pressure symptoms:
• Dyspnea.
• Dyspepsia.
• Pressure on the ureters with increased urinary tract
infections.
• Supine hypotension syndrome.
• Increased varicosities.
• Lower limb edema due to compressions of inferior
vena cava.
Increased labor risks:
• Complicated labor: is related to:
• The number of fetuses.
• Abnormal uterine action.
• Abnormal fetal presentation.
Fetal and Neonatal Risks
• Abortion
• Intrauterine Fetal Death
• Increased Perinatal
Mortality
• Intrauterine Growth
Restriction
• Preterm
• Feto-fetal transfusion syndrome.
• Discordant growth of twins
• Conjoined twins (Disomata)
• Locked twins
• Death of one fetus (single fetal
demise)
Diagnosis during pregnancy
1. History:
• Search for etiological factors.
• Positive past history and family history especially maternal history of
twin pregnancy.
• Early pregnancy: Hyperemesis or bleeding.
• Mid-pregnancy: Greater weight gain than expected, uterine size is
larger than period of amenorrhea, early PIH
• Late pregnancy: Pressure symptoms (dyspnea, dyspepsia, urinary
frequency, piles, edema and varicose veins in lower limbs).
2. Clinical Examination:
• A. General: Early increase weight gain, pallor, loss of mid-
trimester fall of blood pressure, early PIH, edema, and
varicose veins in lower limbs.
• B. Abdominal:
• Fundal level is higher than period of amenorrhea,
especially in mid-pregnancy.
• Palpation:
• Multiple fetal parts as 3 poles, 2 heads.
• Small head in relation to fetal size.
• Fetal movement all over the abdomen.
• Auscultation of FHS:
• By 2 observers at the same time and the difference
is > 10 beats/min.
• C. Pelvic examination: During the course of labor, it
reveals small presenting part compared to
abdominal size.
3. Ultrasound examination: role of US ??
1. Confirm number of gestational sacs, embryos,
fetuses
2. Diagnosis of early embryonal demise (vanishing
twin syndrome).
3. Confirm viability of fetuses.
4. Diagnosis of type of twins (mono, or dizygotic
twins)
5 - Exclude any congenital malformation:
• Fetal nuchal translucency measurement.
• Anatomical survey.
• Genetic amniocentesis (in mothers above 35 years of age).
• Assessment of conjoined twins.
• Diagnosis of single fetal demise and its sequelae.
6-Diagnosis and management of twin to twin transfusion syndrome.
7-Diagnosis of any liquor abnormality.
8-Diagnosis of their presentation and position and relation to each
other.
9-Assess fetal well-being and growth pattern for each
Diagnosis during Labor
The same as diagnosis during pregnancy in addition
to:
• Palpation of small presenting part in relation to the
size of the abdomen.
• Palpation of 2 sacs.
• Palpation of presenting part and intact sac.
Differential Diagnosis
• uterus larger than period of amenorrhea
• Polyhydramnios.
• Uterine fibroid.
• Urinary retention.
• Ovarian tumor.
Management
Antenatal Intrapartum Postpartum
I. Antenatal
Antenatal visits more frequent (some advise a
special twin clinic) high risk pregnancy
• Asses fetal growth &fetal well-being
• Prophylactic extra-iron and folic acid.
Proper delivery timing:
• Prevention of prematurity and pre-term delivery:
• more bed rest.
• Monitoring uterine activity and possible use of
tocolytic drugs.
• Prophylactic cerclage may help.
• The use of steroids to hasten lung maturity in
threatened pre-term labor
II. Intra-partum
CS VD
Pre-
indication
requests
•Indications of CS ??????
• >2 viable fetuses.
• First twin is non-cephalic.
• Second twin larger than first twin.
• Monoamniotic twin.
• Conjoined twins.
• Previous uterine scar.
• During labor: If delayed progress, fetal distress, retained second
twin.
• Associated pregnancy complications: severe PIH
•Prerequisites for VD
• Room & Theatre
• Doctors : Anesthetist, Senior obstetrician, Neonatologists
• Midwives
• Twin resuscitaires
• Ventouse/forceps to hand
• Blood grouped and saved
• Intravenous access
• Pre-mixed oxytocin infusion ready
Delivery of First Twin
• Spontaneous delivery
• Clamp &immediately cut the cord
• No ergometrine
• Assess second twin i.e presentation, position,
exclude mono-amniotic pregnancy or cord prolapse.
Delivery of Second Twin
• Cephalic: ventouse or low forceps.
• Breech: breech extraction.
• Transverse: bring down a leg and breech extraction.
1. If the lie is longitudinal
a. Fetal head or breech fixed in the birth canal
Wait – Pitocin – guide spotanous or assisted delivery
b. Fetal head or breech is not fixed in the birth canal
• Guide the presenting part in the pelvis ,Intrapartum
external cephalic version in non cephalic
• Fetal heart rate monitoring.
• If these failed, cervix fully dilated, membrane intact
do internal podalic version by skilled Obstetrician
•2. If the lie is transverse or oblique
• External cephalic version.
• If failed internal podalic version.
•3. If neglected shoulder: CS
Complications
Retained Second Twin :
• It is failure of delivery of the second twin for more
than 30 minutes
• Risks of Retained Second Twin:
• Reformation of the cervix.
• Placental separation.
• Fetal distress.
• Infection.
III. Postpartum
• Atony
• Retained placenta
• Postpartum hge
• Birth injury
• Genital tract laceration
• Neonatal complications of prematurity
Triplets or More
Incidence
• Triplets 1:6000 birth
• Quadruplets 1:40.000.000
• widespread use of assisted reproductive technique.
• Complications: with increased incidence of preterm
labor (85%) and neonatal death (20%).
Selective & non selective fetal reduction
•Non selective as early as 8 weeks
•Selective at 12-14 weeks
• CS is accepted by most obstetricians except in cases
with severe prematurity where vaginal delivery is
accepted.
Thank you
