4. When more than one fetus simultaneously
develops in the uterus, it is called multiple
pregnancy.
Simultaneous development of two fetuses
(twins) is the most common; although rare,
development of three fetuses (triplets), four
fetuses (quadruplets), five fetuses
(quintuplets) or six fetuses (sextuplets)may
also occur.
5. 1. Define the multiple pregnancy.
2. List down the incidence of multiple pregnancy.
3. Classify the types of multiple pregnancy.
4. Enlist the risk factors of multiple pregnancy.
5. Enumerate the etiology.
6. Describe the diagnostic evaluation.
7. Discuss the clinical manifestation.
8. List down the complication of multiple
pregnancy.
9. Explain the management of multiple pregnancy.
10. Discuss The prognosis.
6. Simultaneous development of two fetuses in
the uterus is the most common variety of
multiple pregnancy.
7. multiple gestations → 12% of total
conceptions
14% of these survive to term
THE “VANISHING TWIN”
8.
9. Monozygotic = identical twins ( 80% )
- a single fertilized ovum
Dizygotic = fraternal twins (20%)
- two separate ova
10. Dizygotic twins 80% (Syn: fraternal, binovular)
result from fertilization of two ova,
most likely ruptured from two distinct Graafian
follicles usually of the same or one from each
ovary, by two sperms during a single ovarian
cycle. Their subsequent implantation and
development differ little from those of a single
fertilized ovum. The babies bear only fraternal
resemblance to each other (that of brothers and
sisters from different births) and hence called
fraternal twins.
11. 20% (Syn: identical, uniovular), the twinning
may occur at different periods
after fertilization and this markedly influence
the process of implantation and the
formation of the fetal membranes.
12.
13.
14. 1. Race - high in blacks, less in Asians
2. Heredity - mother more important
than father
3. Age - peak incidence → 30-40 years
4. Parity
5. Drugs - inductors of ovulation
6. Assisted Reproductive Techniques
(ART)
7. Season - frequent in summer
16. Determination of ZYGOSITY and
CHORIONICITY
“twin peak” sign, ”T” sign
fetal gender
placental examination
17. Zygosity : refers to the genetic makeup of twin
pregnancy.
Diagnosis of zygosity can be made by: examining fetal
genders (different genders = dizygotic), placenta
(monochorionic → monozygotic) and by genetic testing.
Chorionicity : refers the placenta’s membrane status.
Chorionicity is determined by the timing of embryo
division. Determination of chorionicity is essential as
the obstetrical and perinatal outcome depends on it. It
is diagnosed reliably by ultrasonography in the first
trimester
18.
19.
20. Zygosity Placenta Comm
unicati
ng
vessels
Interve
ning
membr
anes
Sex Geneti
c
feature
s
(domin
ant
blood
group)
DNA
fingerp
rinting
Skin
grafting
(Reciproc
al)
Follow-
up
Monozygotic One Present 2
(amnions
)
Always
identic
al
same Acceptabl
e
Usually
identical
Dizygotic Two
(most
often
fused)
Absent 4 (2
amnions
2
chorions)
May
differ
Differ Rejected Not
Identical
21.
22.
23.
24.
25. (1) There is increase in weight gain and
cardiac output.
(2) Plasma volume is increased by an addition
of 500 mL. There is no corresponding
increase in red cell volume resulting in
exaggerated hemodilution and anemia.
(3) There is increased a-fetoprotein level,
tidal volume and glomerular filtration rate.
26. The most common lie of the fetuses is longitudinal
(90%) but malpresentations are quite common.
The combination of presentation of the fetuses
are—(1) both vertex (50%),
(2) first vertex and second breech (30%),
(3) first breech and second vertex (10%),
(4) both breech (10%),
(5) first vertex and second transverse and
so on, but rarest one, being both transverse
when the possibility of conjoined twins should be
ruled out.
29. Family history (maternal side)
History of ovulation induction
High parity
Advanced maternal age
Greater weight gain than expected
Abdominal size >duration of amenorrhea
Pressure symptoms (dyspnea, dyspepsia)
Marked edema of lower limb.
30. (i) increased nausea and vomiting in early
months,
(ii) cardio respiratory embarrassment which is
evident in the later months—such as
palpitation or shortness of breath,
(iii) tendency of swelling of the legs,varicose
veins and hemorrhoids is greater,
(iv) unusual rate of abdominal enlargement
and excessive fetal movements may be
noticed by an experienced parous mother.
31. (i) Prevalence of anemia is more than in
singleton pregnancy.
(ii) Unusual weight gain, not explained by
preeclampsia or obesity, is an important
feature.
(iii) Evidence of preeclampsia (25%) is a
common association
32. Inspection: The elongated shape of a normal
pregnant uterus is changed to a more “barrel
shape” and the abdomen is unduly enlarged.
Palpation:
(i) The height of the uterus is more than the
period of amenorrhea. This discrepancy may only
become evident from mid-pregnancy onward.
(ii) The girth of the abdomen at the level of
umbilicus is more than the normal average at
term (100 cm).
33. (iii) Fetal bulk seems disproportionately
larger in relation to the size of the fetal
head.
(iv) Palpation of too many fetal parts.
(v) Finding of two fetal heads or three fetal
poles makes the clinical diagnosis almost
certain.
34. Simultaneous hearing of two distinct fetal
heart sounds (FHS) located at separate spots
with a silent area in between by two
observers, gives a certain clue in the
diagnosis of twins,provided the difference in
I.heart rates is at least 10 beats per minute.
II.The abdominal palpation and auscultation
may not be carried out so easily, as
described,because of the presence of
hydramnios.
35. In some cases, one head is felt deep in the
pelvis, while the other one is located by
abdominal examination.
On occasions, the clinical methods fail to
detect twins prior to the delivery of the first
baby.
36. Ultrasound examination
→ the number of fetuses
→ type of presentation
→ fetal size and possible anomalies
→ position and relation to each other
→ fetal well-being and growth pattern for
each
→ guidance to perform some maneuvers:
amniocentesis, villous sampling
37. Biochemical tests
1. hCG in plasma and in urine
2. AFP level (alone is not diagnostic)
3. estriol
4. HPL
38. 1. Hydramnios.
2. Hydatidiform mole.
3. Uterine myomas / ovarian cyst.
4. Fetal macrosomia (single pregnancy)
5. Elevation of the uterus by distended
bladder.
39. Maternal responses
Cardiac output
Plasma volume by 1/3 > singletons
Red cell mass 300 ml > singletons
Pre-eclampsia 5-10 times more
Postpartum depression
↓Hematocrit and hemoglobin
↓Renal blood flow
↓Iron stores
40. i. Nausea and vomiting occurs with increased frequency and
severity.
ii. Anemia.
iii. Preeclampsia (25%)
iv. Hydramnios (10%)
v. Antepartum hemorrhage.
vi. Malpresentation.
vii. Preterm labor (50%)
viii. Mechanical distress,
such as palpitation, dyspnea, varicosities and hemorrhoids,
may be increased compared to a singleton pregnancy.
41. i. Early rupture of the membranes and cord prolapse
ii. Prolonged labor ( This is because of parous women with
smaller babies.)
iii. Increased operative interference ( malpresentation)
iv. Bleeding (intrapartum) following (due to separation of the
placenta following reduction of placentalsite.)
v. Postpartum hemorrhage is the real danger in twins. It is due
to:
(a) atony of the uterine muscle due to over distension of the
uterus,
(b) a longer time taken by the big placenta to separate,
(c) bigger surface area of the placenta exposing more uterine
sinuses,
(d) implantation of a part of the placenta in the lower segment
which is less retractile.
42. There is increased incidence of:
(1) Sub-involution — because of bigger size of the
uterus
(2) infection because of increased operative
interference, preexisting anemia and blood loss
during delivery
(3) Lactation failure—this is minimized by
reassurance and giving her additional support.
43. Spontaneous early pregnancy loss rate
Discordant twins
Twin to twin transfusion syndrome (TTTS)
Intertwining of umbilical cords (monoamniotic twins)
Conjoined twins
Twin-reversed arterial perfusion sequence (TRAP) =
acardiac twin
Intrauterine growth restriction (IUGR)
Preterm labour
Cerebral palsy > 3 times > in twins
10 times > in triplets
44. It is a clinicopathological state, exclusively met with in
monozygotic twins, where one twin appears to bleed into the
other through some kind of placental vascular anastomosis.
Clinical manifestations of twin transfusion syndrome occur
when there is hemodynamic imbalance due to unidirectional
deep arteriovenous anastomoses. As a result the receptor
twin becomes larger with hydramnios, polycythemic,
hypertensive and hypervolemic, at the expense of the donor
twin which becomes smaller with oligohydramnios , anemic
,hypotensive and hypovolemic. The donor twin may appear
“stuck” due to severe oligohydramnios. Difference of
hemoglobin concentration between the two, usually exceeds
5 g% and estimated fetal weight discrepancy is 25% or more.
45.
46. Antenatal diagnosis is made by ultrasound with Doppler blood flow
study in the placental vascular bed.
(a) Repeated amniocentesis to control polyhydramnios in the
recipient twin is done.
(b) Septostomy (making a hole in the dividing amniotic
membrane).
(c) Laser photocoagulation to interrupt the anastomotic vessels on the
chorionic plate can give some success.
(d) Selective reduction (feticide) of one twin is done when survival of
both the fetuses is at risk .The smaller twin generally has got better
outcome. The plethoric twin runs the risk of congestive cardiac
failure and hydrops. Congenital abnormalities (neural tube defects,
holoprosencephaly) are high (2–3 times). Perinatal
mortality in TTTS is about 70%
47.
48.
49.
50. Death of one twin (2–7%) is associated with
poor outcome of the co-twin (25%) especially
in monochorionic placenta. The surviving
twin runs the risk of cerebral palsy,
microcephaly, renal cortical necrosis and DIC.
This is due to thromboplastin liberated from
the dead twin that crosses via placental
anastomosis to the living twin.
51. is characterized by an “acardiac perfused twin”
having blood supply from a normal co-twin via
large arterio-arterial or vein to vein anastomosis
. In majority the co-twin dies (in the perinatal
period) due to high output cardiac failure. The
arterial pressure of the donor twin being high,
the recipient twin receives the “used” blood from
the donor. The perfused twin is often
chromosomally abnormal. The anomalous twin
may appear as an amorphous mass. Management
of TRAP is controversial. Ligation of the
umbilical cord of the acardiac twin under
fetoscopic guidance has been done.
52.
53. Monoamniocity (2% of all twins) in
monochorionic twins leads to high perinatal
mortality due to cord problems. prostaglandin
synthase inhibitor has been used to reduce fetal
urine output, creating borderline
oligohydramnios and to reduce the excessive
movements.
Conjoined twin is rare (1.3 per 100,000 births).
Perinatal survival depends upon the type of joint
Major cardiovascular connection leads to high
mortality.
55. Early diagnosis
Adequate nutrition:
1- Caloric consumption increased by 300 Kcal per day.
2- Iron 60-100 mg per day.
3- Folic acid 1mg per day.
Frequent prenatal visits - observe maternal and fetal
complications
1- Frequent ultra sound fetal growth, congenital
anomalies, amniotic fluid.
2- Doppler.
56. MANAGEMENT
Trained obstetrical attendant.
Available blood.
Good access I.V line.
Cardiotocography monitoring.
Anesthetist.
Pediatrician for each fetus.
Mode of delivery - presentation of the first baby.
57.
58. Obstetric indication:
(1) Placenta previa
(2) Severe preeclampsia
(3) Previous cesarean section
(4) Cord prolapse of the first baby
(5) Abnormal uterine contractions
(6) Contracted pelvis
59. For twins:
(i) Both the fetuses or even the first fetus with noncephalic
(breech or transverse) presentation
(ii) Twins with complications: IUGR, conjoined twins
(iii) Monoamniotic twins
(iv) Monochorionic twins with TTTS
60. 40% of 0P and 60% of parous women present in
labor with a cervix dilated more than 3 cm.
The latent phase is shorter.
The active phase is longer.
Uterine over distension ▬ hypotonic uterine
dysfunction.
Increased risk of postpartum hemorrhage (uterine
atony).
61. The interval between delivery of the first and
second twin is commonly cited to be safest if less
than 30 minutes.
Internal podalic version – for 2-nd twin
If separation of the placenta is delayed or
bleeding is brisk, extract the placenta manually
after the final delivery.
Postpartum hemorrhage is common.
Hypotony should be treated promptly with
oxytocin by rapid intravenous infusion and
massage of the fundus.
62.
63. Maternal mortality is increased in twins than in a
singleton pregnancy. Death is mostly due to
hemorrhage (before, during and after delivery),
preeclampsia and anemia. Increased maternal
morbidity is due to the prevalence of complications
and increased operative interference.
Perinatal mortality is markedly increased mainly
due to prematurity. It is 4–5 times higher than in
singleton pregnancy. It is extremely high in
monoamniotic monozygotic twins due to cord
entanglement.
64. One-third loss is due to stillbirth and two-third due to
neonatal death. During delivery the second baby is
more at risk (50%) than the first one due to:
(i) retraction of uterus leading to
placental insufficiency,
(ii) increased operative
interference and
(iii) increased incidence of cord
prolapse.
Because of increased risk to both the mother and the
baby, compared to that of a singleton pregnancy.
69. What is the indication for c.s in multiple
pregnancy?
70. What is the clinical manifestation of multiple
pregnancy?
71. What is the complication of twins pregnancy?
72.
73. Write down about the management of Twin
reversed arterial perfusion (TRAP). ( 5 )
date of submission : 28.01.2019
74. It is the presence of more then one featus in
the abdomen of the mother.
Twin pregnancy is a high risk one. Maternal
and perinatal morbidity and mortality are
significantly high compared to a singleton
pregnancy.
75. 1.Baskar Nimma ,Midwifery and Obstetrical
nursing ,2nd edition,jaypee,New Delhi.
2.Brar Kaur Navdeep ,text book of advanced
nursing practice 3rd edition,jaypee,New Delhi.
3. D.C Dutta's ,textbook of Obstetrics ,8th
edition,Hiralal Konar,New Delhi,P-28 - 36
