DR POLY BEGUMMBBS; FCPS (OBST & GYNAE).ASSISTANT PROFESSORDEPARTMENT OF OBSTETRICS & GYNAECOLOGYDIABETIC ASSOCIATION MEDICAL COLLEGE

When more than one fetus simultaneously develops in the uterus it is called Multiple Pregnancy.

Two fetuses (twin) ;three fetuses(triplets);four fetuses(quadruplets);five fetuses(quintuplets)

Twin pregnancy represents 2 to 3% of all pregnancies.

Induction of ovulation, 10% with clomide and 30% with gonadotrophins.

Increase maternal age .due to increase gonadotrophins production.

Increases with parity. Heredity usually on maternal side. Race; Nigeria 1:20, North America 1:90,

India 1:80.

Most common represents 2/3 of cases. Fertilization of more than one egg by

more than one sperm. Non identical ,may be of different sex. Two chorion and two amnion. Placenta may be separate or fused.

Constant incidence of 1:250 births. Not affected by heredity. Not related to induction of ovulation. Constitutes 1/3 of twins.

Results from division of fertilized egg:0-72 H. Diamniotic dichorionic.4-8 days Diamniotic monochor.9-12 days Monoamnio.monochor.>12 days Conjoined twins.

70% are diamniotic monochorionic.

30% are diamniotic dichorionic.

Very important as most of the complications occur in monochorionic monozygotic twins.

Very accurate in the first trimester, two sacs, presence of thick chorion between amniotic memb.

Less accurate in the second trimester the chorion become thin and fuse with the amniotic memb.

Different sex indicates dizygotic twins.

Separate placentas indicates dizygotic twins

By examination of the MEMBRANE, PLACENTA,SEX , BLOOD group .

Examination of the newborn DNA and HLA may be needed in few cases.

Anemia Hydramnios Preeclampsia Preterm labour Postpartum

hemorrhage Cesarean delivery

Malpresentation Placenta previa Abruptio placentae Premature rupture of

the membranes Prematurity Umbilical cord prolapse Intrauterine growth

restriction Congenital anomalies

Maternal Fetal

TWIN-TWIN transfusion.Results from vascular anastomosis

between twins vessels at the placenta.Usually arterio (donor) venous (recipient).Occurs in 10% of monochorionic twins.

TWIN-TWIN transfusion Chronic shunt occurs ,the donor bleeds

into the recipient so one is pale with oligohydraminose while the other is polycythemic with hydraminose.

If not treated death occurs in 80-100% of cases.

Possible methods of treatment:

Repeated amniocentesis from recipient. fetoscopy and laser ablation of

communicating vessels.

Other Complications in Monochorionic Twins:

Congenital malformation. Twice that of singleton.

Umbilical cord anomalies. In 3 – 4 %.

Conjoined twins. Rare 1:70000 deli varies. The majority are thoracopagus.

PNMR of monochorionic is 5 times that of dichorionic twins(120 VS 24/ 1000 births)

Increase blood volume and cardiac output.

Increase demand for iron and folic acid. Maternal respiratory difficulty. Excess fluid retention and edema. Increase attacks of supine hypotension.

+ve family history mainly on maternal side.

+ve history of ovulation induction. Exaggerated symptoms of pregnancy. Marked edema of lower limb. Discrepancy between date and uterine

size. Palpation of many fetal parts.

Auscultation of two fetal heart beats at two different sites with a difference of 10 beats

USG

Two sacs by 5 weeks by TV USS.Two embryos by 7 weeks by TV USS.

AIM

Prolongation of gestation age, increase fetal weight.

Improve PNM and morbidity.Decrease incidence of maternal

complications.

Follow Up

Every two weeks. Iron and folic acid to avoid anemia.Assess cervical length and competency.

Fetal Surveillance

Monthly USS.from 24 weeks to assess fetal growth and weight.

A discordinate weight difference of >25% is abnormal (IUGR).

Weekly CTG from 36 weeks.

HOSPITAL DELIVERYSKILLED OBSTERRICIAN

NEONATOLOGIST

Vertex- Vertex (50%) Vaginal delivery, interval between twins

not to exceed 20 minutes.

Vertex- Breech (20%)Vaginal delivery by senior obstetrician

Breech- Vertex( 20%)Safer to deliver by CS to avoid the rare

interlocking twins( 1:1000 twins ).

Breech-Breech( 10%)Usually by LUCS.

PNMR is 5 times that of singleton (30-50/1000 births).

RDS accounts for 50% 0f PNMR.2nd twin is more affected.

Birth trauma . 2ND twin is 4 times affected than 1st .

Incidence of SB is twice that of singleton.

Congenital anomalies is responsible for 15% of PNMR.

Cerebral haemorrhage and birth asphyxia are responsible for 10% of PNMR.

Cerebral palsy is 4 times that of singleton .50% of twins babies are borne with low

birth(<2500 gms.) from prematurity & IUGR.

Early in pregnancy usually no risk.

In 2nd or 3rd trimester: Increase risk of DIC . Increase risk of thrombosis in the a live

one The risk is much higher in

monochorionic than in dichorionic twins