This document discusses multiple pregnancy (twins, triplets, etc.), including causes, complications, diagnosis and management. It notes that the incidence of multiple pregnancies has increased due to assisted reproductive technologies. Complications can include preterm birth, anemia, pregnancy-induced hypertension, and increased risk of stillbirth. Diagnosis involves ultrasound to determine chorionicity and number of fetuses. Management includes careful surveillance, diet supplementation, and deciding when to perform a cesarean delivery versus attempting a vaginal birth.

1. Prof. M.C.Bansal
MBBS., MS., FICOG., MICOG.
Founder Principal & Controller,
Jhalawar Medical College & Hospital Jjalawar.
MGMC & Hospital , sitapura ., Jaipur

2. Nomenclature
 Plural Pregnancy
 Multiple Pregnancy
Twins
Triplets
Quadruplets

3. .Incidence
The incidence of multiple pregnancy Increased in recent
yrs .
 Incidence is highest in black race and as frequent as 1:19
in Nigerians
 India & UK 1:80-90 ; while it is 1:155 in Japan
 Increased incidence in present era owes to IVF(50%) &
GIFT technique.
 CC7-10% ,FSH30-40%,GNRH induces 1% Multiple
pregnancy. 75% pregnancies are dizygotic and 25% are
monozygotic at constant rate of 4/1000 world over.
 Hellins Law it is 1:80. N2:(80) 2 ,N3: (80)3 and so on.
N for Twin pregnancy, 1:N2 for Triplets and N3 for
Quadruplet and so on

4. Aetiology
 True incidence is twice in early pregnancy then that in
late pregnancy.USG Study show Twin
Gestation, followed by disappearance of one Sac.
 Age & Parity : advancing age>35 , and parity>4
 Dizygotic twin : pregnancy runs in family.
 Drugs used in induction of ovulation & Assisted
Reproductive Techniques (ART)
 Local environmental disturbances in early embryonic
stage result in Monozygotic twin pregnancy.

5. Pathology
 Fertilization of two separate ova in same menstrual
cycle ---results in Binovular-
Dizygotic(DZ)Dichorionic-Diamniotic twin
pregnancy.
 They are not identical and behave as
different siblings in the family. Their sex may be same
or different . 98 % have separate placenta and 4 layers
of amnion

6. Monozygotic Several varieties of MZ twins
are possible depending upon the number of days after
fertilization when the zygote splits.
Division upto Day- 3 results Dichorionic-Diamniotic
 If cleavage occurs after formation of inner cell mass
(4-7days after fertilization)Monochorionic –Diamniotic
.
Division between Day 8-12 the amnion is already
formed by the time split occurs,Monochorionic
Monoamniotic twin develops 1%.
 Split after 13-14 days—results in Conjoined twins.
MZ twins are identical in sex, genetically and
acquire the same diseases in later life.

7. Cont-------
 Entaglementof cord may end in IUFD.
 Locked twins can also occur.
 Conjoined twins are rare (1:60,000)-
Thoracophagus,craniophagus,ischiophagus.
 The incidence of abnormities in twins is high
2.7%compared to 1.4% in singletons and 6.1% in
triplets.
 Acute hydramnios occurs in MZ in 2nd trimester and
leads to spontaneous abortion.

8. Positions of the fetuses
 VX—VX  38%
 VX—Breech  25%
 Breech—VX  10%
 Breech—Breech 5%
 VX –Transverse
 Breech-Transverse
 Transverse-Transverse

9. Unfavourability of MZ twins
 Sharing of blood supply between two fetuses in MZ---a
varying degree of anastomosis will cause discordant
blood flow=>one fetus will be growing
bigger, Polycythaemic and develops polyhydramnios.
The donor fetus is growth retarded and at times
shrinks(fetus papyraceous or compresses) dies in
utero. Twin to Twin Transfusion Syndrome (TTTS)
occurs in 10% cases of MZ. It is Rx—
amniocentesis/laser ablation of anastomosing blood
vessels.

10. TWIN to TWIN TRANSFUSION
SYNDROME
 QUINTERO STAGES
 STAGE I : Oligohydramnios 1st Twin,
Polyhydramnios 2nd Twin
 STAGE II : Supra, Absence of Bladder in donor
Twin
 STAGE III : Supra, Additionally Doppler studies
Show critical abnormalities i.e.
absent/reverse end diastolic velocity in
Umbilical artery, reverse flow in ductus
venosus, pulsatile flow in Umbilical vein

11. TWIN to TWIN TRANSFUSION
SYNDROME
 QUINTERO STAGES
 STAGE IV: Supra, Recipieny Twin shows
evidence of heart failure & fetal
hydrops
STAGE V : In addition to above, one of the twins
has died. Usually donor twin first to
die, but death can occur in either twin.

12. TWIN REVERSED ARTERIAL PERFUSION SYNDROME
(TRAP Syndrome) OR ACARDIAC TWIN
 Unusual form of TTTS. Incidence 1: 15,000 pregnancies
 As name suggests one twin develops normally, while the other develops
without a heart as well as other body structures.
 Features : Cardiac structures are absent or non-functional & the head,
upper body and extremities are poorly developed. The lower body and
lower extremities are more or less normal. The Acardiac twin acts as a
recipient & depends on the donor pump for obtaining its blood supply
via TRANSPLACENTAL ANASTOMOSES and RETROGRADE
PERFUSION of the UMBILICAL CORD.
 Deoxygenated Umbilical Artery blood flows from the Donor to the
Recipient via it’s Umbilical Artery with direction reversed.
 The Umbilical Cord of the Acardiac Twin arises as a branch from the
normal twin. Thus the Circulatory load on the donor twin becomes
extremely large resulting in heart failure, Polyhydramnios. 50 %
mortality of the pump twin.
 Radio-frequency ablation of a major blood vessel in acardiac twin.

13. Complications of twin Pregnancy
 Maternal -------
 Hyperemessis, abortions,hydramnios befre 20 wks(1;;200)
 Anaemia-Iron deficiency and Nutritional.
 PIH 25% as compared to 5-7% in singleton
 APH (accidental & placenta praevia) more common.
 Coagulation failure ---Accidental hemorrhage and
retained IUFD.
 Preterm labor----hydramnios, over distended
uterus, incompetent os—50%.
 PPH –atonic ,traumatic---uterine inertia,large
placenta, following APH.
 Puerperium---feeding problem, sub involution,several
psychiatric problems.

14. Overall Perinatal mortality is 10-15% (4-6 times higher)
Abortion ,IUFD occurs in 2% cases .
25% of surviving babies develop necrotizing enterocolitis, neurological ,renal
lesions.
50% mortality is due to cord entanglement in monozygotic twins
IUGR and Preterm births –spontaneous or iatrogenic are on account of APH
PIH ,Placenta praevia occurs in 40% cases of twins as compared to5-7% in
singleton .
Fetal anomalies are noted in 2-3%.>1%in general
Cord presentation & prolapse are more common.
Asphyxia ---intra natal death of fetus
2nd of twins suffer more asphyxia due to direct pressure of uterine contraction
and pre mature separation of placenta.
Neonatal asphyxia,RDS, Feeding problems may increase morbidity
Mental ,physical and intellectual maybe more in infancy—5-10%
MZ twins are less favorable than DZ.
Perinatal loss is 3 times more in MZ.

15. Diagnosis a previous delivery of multiple
 Family history,
pregnancy and treatment by assisted reproduction.
 1st trimester---Hyperemesis,Threatened Abortion
occur more. uterine size larger than period of
amenorrhea.(d/d—wrong dates, H. mole, Acute
Hydramnios and presence of fibroids.)
 2nd trimester---unduly enlarged uterus ,multiple fetal
parts palpable . Audible fetal hearts at different and
10cm apart areas with at least 10-20beats/min
difference in FHR.
 USG---confirms all above ,incompetent /dilated os its
length--indicating premature labor.

16. USGin 10-14 wks helps in identifying number of
 USG
fetuses ,sex(discordant indicating Zygocity) ,their
growth pattern and maturity.
 Placental localization,presence of hydramnios
 Any congenital anomalies other than conjoined twins
their nature can be identified
 The study of chorionicity and identification of
monozygous twins at 10-14 wks pregnancy is
important.
 Doppler will help in diagnosing vascular anastomosis.

17. Management during Pregnancy
 Feto-reduction----If >2 fetus ,one of the fetus is malformed and is
unable to be corrected by surgery —intra cardiac injection of KCl.
Risk Factor are failure of technique, abortion, IUFD of healthy
fetus, trauma to another fetus, placenta, amnionitis, structural or
neurological damage to co-twin .
 Diet—Woman with multiple pregnancy should be advised to take
extra 300 calories along with extra Iron, Folic acid, vitamins
minerals and proteins in diet.
 Hydramnios– paracentesis in acute and Sulidac 400 mg / day to
chronic cases. It is NSAID . It reduces fetal urine out put,reduces
hydramnios,prevents preterm delivery
 Strict surveillance of mother and fetus is more frequent.Ante natal
clinics by USG, EFCTD..colour doppler,biophysical profile at 30-32
wks.
 Preterm delivery--adequate rest ,controlling
hydramnios,PIH,Anaemia,Tocolytic drugs. Dexamethasone 12mg
at 12 hrs interval injection at 30 -34 wks for lung maturity.

18. Indications for L.S.C.S.
 Transverse lie or Breech presentation of 1st baby.
 Big babies.
 Placenta praevia.
 Conjoined twins.
 Pr. LSCS.
 Mono-amniotc twins if alive.
 Emergency LSCS
 Cord prolapse of 1st baby. Fetal distress.
 Abruptio placenta
 Persistent transverse lie of the 2nd twin and failed version.
 Locked twins---1:30,000 to 1:70,000.

19. Delivery
 Institutional delivery.
 Post dates very rare—if so –LSCS.
 Vaginal delivery-induction and acceleration of labor --- in woman
with no previous CS, 1st fetus in vertical lie, average weight of fetus
and normal gyneacoid pelvis.
 Pt should be kept lying in left lateral position to avoid PROM.
 PV examination as soon as membranes rupture---to note cord
prolapse, cervical dilatation, position and level of presenting part.
 Partogram should be maintained.
 To cut short 2nd stage of labor outlet Forceps may also be used,
assisted vaginal delivery for breech under Pudendal block and
wide episitomy is a must.

20. Delivery======
 Maintain good hydration of mother.
 Prophylactic IV line may be kept at slow rate.

21.  Injection Methergin should be withheld till the delivery of
2nd child.
 Umbilical cord is clamped at 2 places and divided in
between 2 clamps
 PLACENTA OF 1ST BABY USUALY FOLLOWS THE
DELVERY OF 2ND CHILD.it rarely gets separated and
expelled before.
 If Profuse bleeding and fetal asphyxia occurs .
 Then 2nd fetus is delivered expeditously.
 After delivery of 1st fetus palpate the abdomen to identify
lie, presentation and position of fetus in utero.
 If it is transverse external version should be done before
rupture of membranes.If one fails do ECV, then do internal
podalic version on rupture of membranes.Conduct the
assisted breech delivery.

22.  In case of vertical lie , as soon as presenting part gets
engaged , ARM is done and delivery is conducted. if
needed uterine action may be augmented.
 An inteval of >20 minutes between delivery of 1st and
2nd fetuses----increases asphyxia and mortality of 2nd
fetus.
 Injection methergin 0.2mg iv is given with delivery of
2nd fetus. Syntocinon 20 units shall be continued for 2-
3 hrs after delivery.
 3rd stage is managed actively to avoid PPH.
 Placenta and membranes are examined carefully.