Multiple pregnancy and
associated complications.
By: [Link]
Obstetric II course
Definition
Multiple pregnancy is known twin pregnancy that
mother have two or more pregnancy.
Varieties:
1. Dizygotic twins: commonest (Two-third) (non
identical twins)
2. Monozygotic twins (one-third) (identical
twins)
Genesis of Twins:
Dizygotic twins
- fertilization of two ova by two sperms.
Superfecundation
Fertilization of two different ova released in the
same cycle: twins conceived from sperm from
different man (Terasaki et al 1978).
Superfetation
Fertilization of two ova released in different
cycles. Or the result two coital act in different
cycles (Rhine & Nace 1976)
Differences in zygocity
Monozygotic
1 ova + 1 sperm
Same sex
Identical features
Single or double placenta
Same genetic features
DNA microprobe -same
Dizygotic
2 ova + 2 sperm
Same or opposite sex
Fraternal resemblance
Double or s/t fused
Different genetic features
DNA microprobe - different
Diagnosis
HISTORY:
I. History of ovulation inducing drugs
specially gonadotrophins
II. Family history of twinning (maternal
side).
SYMPTOMS:
i. Hyperemesis gravidorum
ii. Cardio-respiratory embarrassment -
palpitation or shortness of breath
i. Tendency of swelling of the
legs,
ii. Varicose veins
iii. Hemorrhoids
iv. Excessive abdominal
enlargement
v. Excessive fetal movements.
GENERAL EXAMINATION:
I. Prevalence of anaemia is more than in
singleton pregnancy
II. Unusual weight gain, not explained by pre-
eclampsia or obesity
III. Evidence of preeclampsia(25%)is a common
association.
ABDOMINALEXAMINATION:
Inspection:
The elongated shape of a normal pregnant
uterus is changed to a more "barrel shape”
and the abdomen is unduly enlarged.
Palpation:
Fundal height more than the period of
amenorrhoea
girth more than normal
Palpation of too many fetal parts
Palpation of two fetal heads
Palpation of three fetal poles
• Auscultation:
Two distinct fetal heart sounds with
Zone of silence
10 beat difference
D/D of increased fundal height
Full bladder
Wrong dates
Hydramnios
Macrosomia
Fibroid with preg
Ovarian tumor with preg
Adenexal mass with preg
Ascitis with preg
Molar pregnancy
INVESTIGATIONS
Sonography: In multi fetal pregnancy it
is done to obtain the following
information:
i. Suspecting twins – 2 sacs with fetal
poles and cardiac activity
ii. Confirmation of diagnosis
iii. Viability of fetuses, vanishing twin
iv. Pregnancy dating,
Sonography ( ctd )
i. Fetal anomalies
ii. Fetal growth monitoring (at every 3-4
weeks interval) for IUGR
iii. Presentation and lie of the fetuses
iv. Twin transfusion (Doppler studies)
v. Placental localization
vi. Amniotic fluid volume
Lie and Presentation
Longitudinal lie (90%)
1. both vertex (40%)
2. Vertex + breech (28%)
3. breech + vertex ( 9%)
4. both breech ( 6%)
Others
vertex + transverse
breech + transeverse
both transeverse
Complications
Maternal
Pregnancy
Labour
Puerperium
MATERNAL: During pregnancy:
- miscarriages
Hyperemesis gravidorum
Anaemia
Pre-eclampsia (25%)
Hydramnios ( 10 % )
Cont...
GDM ( 2 – 3 times)
Antepartum hemorrhage – placenta previa
and placental abruption
Malpresentations
Preterm labour (50%) twins – 37 weeks,
triplets – 34 weeks, quadruplets – 30 weeks
Mechanical distress such as palpitation,
dyspnoea, varicosities and haemorrhoids
Obstructive labour
During Labour:
Prelabour rupture of the membranes
Cord prolapse
Incoordinate uterine contractions
Increased operative interference
Placental abruption after delivery of 1st
baby
Postpartum haemorrhage
During puerperium:
Subinvolution
Infection
Lactation failure
PPH
Fetus complication
Low birth weight ( 90%)
Prematurity – spontaneous or
iatrogenic
Fetal growth restriction - in 3rd
trimester, asymmetrical, in both fetus
Discordant growth - Difference of
>25% in weight , >5% in HC, >20mm in
AC, abnormal doppler waveforms -
Locked twins
Congenital anomalies – conjoined twins,
neural tube defects – anencephaly,
hydrocephaly, microcephaly, cardiac
anomalies, Downs syndrome, dislocation of hip
TTTS -Twin to twin transfusion syndrome
- cause – AV communication in placenta – blood
from one twin goes to other – donor to
recipient
- donor – IUGR, oligohydramnios
- recipient – overload, hydramnios, IUD
Monoamniotic twins
high perinatal morbidity,
mortality.
Causes : cord entanglement
congenital anomaly
preterm birth
twin to twin transfusion
syndrome
Antenatal managements
Diet: additional 300 K cal per day, increased
proteins, 60 to 100 mg of iron and 1 mg of
folic acid extra
Frequent and regular antenatal visit
Fetal surveillance by USG – every 4 weeks
Hospitalisation not as routine
Corticosteroids -only in threatened preterm
labour , same dose
Birth preparedness ased rest
Management During Labour
Place of delivery: tertiary level hospital
FIRST STAGE:
blood to be cross matched and ready
confined to bed, oral fluids or npo
intrapartum fetal monitoring
ensure preparedness
SECOND STAGE – first baby
- second baby
SECOND STAGE –delivery of first baby
as in singleton pregnancy
start an IV line
no oxytocic after delivery of first
baby
secure cord clamping at 2 places
before cutting
ensure labeling of 1st baby
Delivery of second twin
FHS of second baby
lie and presentation of second twin
wait for uterine contractions
conduct delivery
Indications of caesarean
Non cephalic presentation of first twin
Monoamniotic twins
Conjoined twins
Locked twins
Other obstetric conditions
Second twin – incorrectible lie, closure of
cervix
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