Dr. Hazem Al-Mandeel

1
Multiple Pregnancy

• Dr. Hazem Al-Mandeel
• OB/GYN Rotation-course 481

2
Introduction

• A pregnancy with two or more embryos/fetuses that
  exist simultaneously
• The perinatal mortality and morbidity are
  increased disproportionately with number of
  fetuses
• Maternal mortality and morbidity are also
  increased
• Twin gestation is the most common type

3
Etiology and Classification of Twinning

• Occurs as result of the division of one
  fertilized egg (monozygotic) or fertilization of
  two eggs (dizygotic). Both processes can occur in
  other multiple gestation
• Dizygotic (Fraternal) twins will always have two
  amnions and two chorions
• In Monozygotic (Identical) twins, the number of
  membranes depend on the time of cleavage of the
  fertilized egg
• 70 of MZ twins are monochorionic (mostly
  diamniotic) and 30 are diamniotic dichorionic

4
Incidence of Twin Preganacy

• Not constant throughout the world (varies
  according to race, hereditary factors, maternal
  age, parity, and the use of fertility agents)
• Incidence of MZ twins is 1 per 250 births
• DZ twins increases with increased family Hx of
  twinning, maternal age, and increased parity
• Multiple gestation occurs in 10-30 of women
  following the use of induction of ovulation
  agents
• Spontaneous triplets is 1 in 8000 pregnancies and
  quadruplets I in 800,000. In ART 1 in 3000 births

5
Determination of Zygosity

• Obstetrical ultrasound can often determine
  zygosity (esp. if done before 14 weeks)
• Determination of number of amnions and chorions
  are VERY important for management
• After delivery, zygosity should be confirmed
• No. of membranes, no. of placentas and gender are
  essential in determining zygosity

6
Abnormalities of Twinning Process

• Occurs only in monochorionic (MZ) twins
• Conjoined Twins
• Twin-Twin Transfusion Syndrome (TTTS)
• Umbilical Cord Abnormalities

7
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

8
Diagnosis of Multiple gestation

• Signs and Symptoms maternal sensation of larger
  abdomen, sensation of excessive fetal movement,
  excessive weight gain, palpation of more fetal
  parts, ausculation of more than one fetal heart
• Ultrasound should be done routinely in all
  pregnancies (usually between 18-20 weeks)
• Failure of early Dx of multiple gestation leads
  to increased perinatal morbidity and mortality

9
Antepartum Management

• Goal is to minimize perinatal mortality and
  morbidity and to prevent maternal complications
• More frequent visits for antenatal care
• Assessment of the cervical length frequently
• Bed rest for the mother in the late pregnancy is
  suggested
• Fetal surveillance is essential monthly
  obstetrical ultrasound in the late pregnancy
  period and non stress test in the last month

10
Intrapartum Management

• Prevention and treatment of preterm labour
• Patient should be delivered in a hospital with
  NICU facility
• Mode of delivery for twins depends on the fetal
  presentations (Vx/Vx, Vx/Br, Br/Vx, or Br/Br)
• Time interval between twin delivery is
  controversial (less than 30min)
• For other multiple pregnancy, caesarean section
  is the safest mode of delivery

11
Causes of Perinatal Morbidity and Mortality

• Congenital anomalies
• Prematurity
• Birth hypoxia/Asphyxia
• Respiratory Distress Syndrome
• Cerebral hemorrhage
• Birth Trauma
• Stillbirths
• Retained dead fetus Syndrome