Multiple Pregnancy

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Multiple Pregnancy

• Prof Uma Singh

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Multiple Pregnancy/ Multifetalpregnancy

• The presence of more than one fetus in the gravid
  uterus is called multiple pregnancy
• Two fetuses (twins)
• Three fetuses (triplets)
• Four fetuses (quadruplets)
• Five fetuses (quintuplets)
• Six fetuses (sextuplets)

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INCIDENCE

• Hellins Law
• Twins 189
• Triplets 1892
• Quadruplets 1893
• Quintuplets 1894
• Conjoined twins 1 60,000
• Worldwide incidence of monozygotic - 1 in 250
• Incidence of dizygotic varies increasing

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Demography

• Race most common in Negroes
• Age Increased maternal age
• Parity more common in multipara
• Heredity - family history of multifetal gestation
• Nutritional status well nourished women
• ART - ovulation induction with clomiphene
  citrate, gonadotrophins and IVF
• Conception after stopping OCP

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Twins

• Varieties
• 1. Dizygotic twins commonest (Two-third)
• 2. Monozygotic twins (one-third)
• Genesis of Twins
• Dizygotic twins (syn Fraternal, binovular) -
• - fertilization of two ova by
  two sperms.

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• Monozygotic twins (syn Identical, uniovular)
• Upto 3 days - diamniotic-dichorionic
• Between 4th 7th day - diamniotic monochorionic
  - most common type
• Between 8th 12th day- monoamniotic-monochorion
  ic
• After 13th day - conjoined / Siamese twins.

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Conjoined twins

• Ventral
• 1) Omphalopagus
• 2) Thoracopagus
• 3) Cephalopagus
• 4) Caudal/ ischiopagus
• Lateral
• 1) Parapagus
• Dorsal
• 1)Craniopagus,
• 2)Pyopagus

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• Superfecundation
• Fertilization of two different ova released in
  the same cycle
• Superfetation
• Fertilization of two ova released in different
  cycles

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Differences in zygocity

• Monozygotic

• Dizygotic

• 1 ova 1 sperm
• Same sex
• Identical features
• Single or double placenta
• Same genetic features
• DNA microprobe -same

• 2 ova 2 sperm
• Same or opposite sex
• Fraternal resemblance
• Double or s/t fused
• Different genetic features
• DNA microprobe - different

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Differences in chorionicity with single placenta

• D / D ( fused placenta )

• M / D

• Monozygotic or dizygotic
• Thick dividing membrane gt 2mm
• Twin peak / lambda sign

• Monozygotic
• Thin dividing membrane 2mm or less
• T sign

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Diagnosis

• HISTORY
• History of ovulation inducing drugs specially
  gonadotrophins
• Family history of twinning (maternal side).
• SYMPTOMS
• Hyperemesis gravidorum
• Cardio-respiratory embarrassment - palpitation or
  shortness of breath
• Tendency of swelling of the legs,
• Varicose veins
• Hemorrhoids
• Excessive abdominal enlargement
• Excessive fetal movements.

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• GENERAL EXAMINATION
• Prevalence of anaemia is more than in singleton
  pregnancy
• Unusual weight gain, not explained by
  pre-eclampsia or obesity
• 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.

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• 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

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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

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INVESTIGATIONS

• Sonography In multi fetal pregnancy it is done
  to obtain the following information
• Suspecting twins 2 sacs with fetal poles and
  cardiac activity
• Confirmation of diagnosis
• Viability of fetuses, vanishing twin
• Chorionicity 6 to 9 wks ( single or double
  placenta, twin peak sign in d /d gestation or
  Tsign in m/d )
• Pregnancy dating,

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Sonography ( ctd )

• Fetal anomalies
• Fetal growth monitoring (at every 3-4 weeks
  interval) for IUGR
• Presentation and lie of the fetuses
• Twin transfusion (Doppler studies)
• Placental localization
• Amniotic fluid volume

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• Radiography
• Biochemical tests raised but not diagnostic
• Maternal serum chorionic
  gonadotrophin,
• Alpha fetoprotein
• Unconjugated oestriol

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Lie and Presentation

• Longitudinal lie (90)
• both vertex (40)
• Vertex breech (28)
• breech vertex ( 9)
• both breech ( 6)
• Others
• vertex transverse
• breech transeverse
• both transeverse

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Complications

• Maternal
• Pregnancy
• Labour
• Puerperium
• Fetal
• MATERNAL During pregnancy
• - miscarriages
• Hyperemesis gravidorum
• Anaemia
• Pre-eclampsia (25)
• Hydramnios ( 10 )

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• GDM ( 2 3 times)
• Antepartum hemorrhage placenta previa and
  placental abruption
• Cholestasis of pregnancy
• Malpresentations
• Preterm labour (50) twins 37 weeks, triplets
  34 weeks, quadruplets 30 weeks
• Mechanical distress such as palpitation,
  dyspnoea, varicosities and haemorrhoids
• Obstructive uropathy

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• 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

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• FETAL more with monochorionic
• Spontaneous abortion
• Single fetal demise
• Vanishing twin before 10 weeks
• Fetus papyraceous/compressus 2nd trim
• Complications in 2nd twin (depend on
  chorionicity)
• neurological, renal lesions
• - anaemia, DIC
• - hypotension and death

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• FETAL more with monochorionic
• Low birth weight ( 90)
• Prematurity spontaneous or iatrogenic
• Fetal growth restriction - in 3rd
  trimester, asymmetrical, in both fetus
• Discordant growth - Difference of gt25 in weight
  , gt5 in HC, gt20mm in AC, abnormal doppler
  waveforms -
• Causes unequal placental mass, lower
  segment implantation, genetic difference, TTTS,
  congenital anomaly in one

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• FETAL COMPLICATIONS (ctd)
• Congenital anomalies conjoined twins, neural
  tube defects anencephaly, hydrocephaly,
  microcephaly, cardiac anomalies, Downs syndrome,
  talipes, 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, CHF, IUD

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• FETAL COMPLICATIONS (ctd)
• TRAP -Twin reversed arterial perfusion syndrome
  or Acardiac twin - absent heart in one fetus
  with arterio-arterial communication in placenta,
  donor twin also dies
• Cord entanglement and compression more in
  monoamniotic twins
• Locked twins
• Asphyxia cord complication, abruption
• Still birth antepartum or intrapartum cause

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• Monoamniotic twins
• high perinatal morbidity,
  mortality.
• Causes cord entanglement
• congenital anomaly
• preterm birth
• twin to twin transfusion
  syndrome

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Antenatal Management

• Diet additional 300 K cal per day, increased
  proteins, 60 to 100 mg of iron and 1 mg of folic
  acid extra
• Increased rest

• 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

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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

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Management During Labour

• 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

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Management During Labour

• Delivery of second twin problems
  interventions
• -inadequate contraction- augmentation ARM,
  oxytocin
• -transverse lie ECV, IPV
• -fetal distress, abruption, cord prolapse-
  expedite delivery forceps, ventouse, breech
  extraction
• THIRD STAGE AMTSL
• - continue oxytocin drip
• - carboprost 250µgm IM
• - monitor for 2 hours

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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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MCQs

• Text book of Obstetrics, Dr J B Sharma, 1st
  edition ( 2012) page-473 to 483
• Chapter - multiple pregnancy

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• 1. Splitting of single fertilized ovum
  between 8 to 12 days results in
• a) conjoined twins
• b) monochorionic monoamniotic twin
• c) dichorionic diamniotic twin
• d) monochorionic diamniotic twin

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• Splitting of single fertilized ovum between 8
  to 12 days results in
• a) conjoined twins
• b) monochorionic monoamniotic twin
• c) dichorionic diamniotic twin
• d) monochorionic diamniotic twin

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• 2. Twin peak sign is a feature of
• a) conjoined twins
• b) monochorionic monoamniotic twins
• c) dichorionic diamniotic twins
• d) monochorionic diamniotic twins

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• Twin peak sign is a feature of
• a) conjoined twins
• b) monochorionic monoamniotic twins
• c) dichorionic diamniotic twins
• d) monochorionic diamniotic twins

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• 3. Additional caloric requirement ( K cal per
  day) of a mother in a case of twin pregnancy is
• a) 300
• b) 500
• c) 800
• d) 1000

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• Additional caloric requirement ( K cal per day)
  of a mother in a case of twin pregnancy is
• a) 300
• b) 500
• c) 800
• d) 1000

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• 4. Additional iron supplementation
  requirement ( mg per day) of a mother in a case
  of twin pregnancy is
• a) 30
• b) 50
• c) 100
• d) 200

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• Additional iron supplementation requirement (
  mg per day) of a mother in a case of twin
  pregnancy as compared to singleton pregnancy is
• a) 30
• b) 50
• c) 100
• d) 200

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• 5. Iron supplementation required by a mother
  having twin pregnancy is
• a) 30
• b) 50
• c) 100
• d) 200

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• Iron supplementation required by a mother
  having twin pregnancy is
• a) 30
• b) 50
• c) 100
• d) 200

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• 6. Twin pregnancy is complicated by all of the
  following except
• a) placenta previa
• b) malpresentation
• c) hydramnios
• d) post term labour

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• Twin pregnancy is complicated by all of the
  following except
• a) placenta previa
• b) malpresentation
• c) hydramnios
• d) post term labour

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• 7. Caesarean section is indicated in
• a) monoamniotic twin
• b) monochorionic twin
• c) dichorionic twin
• d) diamniotic twin

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• Caesarean section is indicated in
• a) monoamniotic twin
• b) monochorionic twin
• c) dichorionic twin
• d) diamniotic twin

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• 8) 32year old G2P1 at 20 weeks pregnancy in USG
  shows twin pregnancy, single placental mass with
  dividing membrane having inverted T sign. The
  type of twinning is
• a) monochorionic monoamnionic
• b) monochorionic diamnionic
• c) dichorionic monoamnionic
• d) dichorionic diamnionic

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• 8) 32year old G2P1 at 20 weeks pregnancy in USG
  shows twin pregnancy, single placental mass with
  dividing membrane having lambda sign. The type of
  twinning is
• a) monochorionic monoamnionic
• b) monochorionic diamnionic
• c) dichorionic monoamnionic
• d) dichorionic diamnionic

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• 9) Monochorionic twin placenta has unidirectional
  deep arteriovenous communication with lack of
  superficial vascular anastomoses. The likely
  complication is
• a) twin to twin transfusion syndrome
• b) twin reversed arterial perfusion
• c) acute intertwin transfusion
• d) twin cord entanglement

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• 9) Monochorionic twin placenta has unidirectional
  deep arteriovenous communication with lack of
  superficial vascular anastomoses. The likely
  complication is
• a) twin to twin transfusion syndrome
• b) twin reversed arterial perfusion
• c) acute intertwin transfusion
• d) twin cord entanglement

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• 10) Most common variety of conjoined twins is
• a) craniopagus
• b) thoracopagus
• c) omphalopagus
• d) pyopagus

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• 10) Most common variety of conjoined twins is
• a) craniopagus
• b) thoracopagus
• c) omphalopagus
• d) pyopagus