Presenter:- DR MAUFI

MD 3 Presentation.
Contents:
 Introduction
 Epidemiology
 Causes
 Diagnosis
 Complication
 Management
 Prevention
 Is a pregnancy with more than one foetus i.e the
development of more than one foetus in utero at
the same time.
 Most multiple pregnancies are cases of Twins
(two foetus)
 The incidence of twin pregnancy in EUROPE 1 in
80 pregnancies.
 The highest is in west Africa i.e 1:44 pregnancies
 The lowest in Asia
 Due to the rise of Infertility treatments and
ovulation stimulating drugs the number of
multiple pregnancies is on the rise.
AETIOLOGY OF MULTIPLE PREGNANCY
 Monozygotic twinning

 It occurs from one ovum and one

spermatozoon.
 It appear to be a chance event.

 Dizygotic twinning

 It occurs from two separate ova and two

separate spermatozoan.
 RACE: frequency is highest in black race
compared to other race and lowest in
MONGOLS
 HEREDITARY:
• More transmitted through the FEMALE
(Maternal side) AND
• Doesn’t appear to have male factors.
 MATERNAL AGE: Increased incidence with
advancing maternal age; maximum between
30-35 years of the mother.
 PARITY: Increases especially from the 5th
pregnancy onwards.
IATROGENIC DRUGS:
 Drugs used to induce ovulation

 20-40% After Gonadotropin

 5-6% After CLOMIPHENE

 Twins - 2 fetuses
 Triplets - 3 fetuses
 Quadruplets - 4 fetuses
 Quintuplets - 5 fetuses
 Sextuplets - 6 fetuses
 Septuplets - 7 fetuses
 Octuplets – 8fetuses
 Nonuplets – 9fetuses
 Decaplets – 10fetuses
 Undecaplets – 11fetuses
 Duodecaplets – 12fetuses
 Tredecaplets – 13fetuses
 Quatrodecaplets – 14fetuses
 Quindecaplets – 15fetuses
 Sexdecaplets – 16fetuses
 Septdecaplets – 17fetuses
 Octdecaplets – 18fetuses
 Nondecaplets – 19fetuses
 Vigintuplets – 20fetuses
Surviving octuplets born to Nkem Chukwu, right,
celebrate their 10th birthday in Houston, Texas.
 All prenatal intrapartum and post partum
complications are more common than single
tone pregnancies.
 High incidence of prematurity and fetal
abnormalities is almost six time more in
perinatal mortality.
 Families expecting a multiple pregnancy birth
have different health needs requiring extra
practical support during pregnancy and even
after delivery.
 Twins will be either MONOZYGOTIC or DIZYGOTIC
 MONOZYGOTIC TWINS-Also called UNIOVULAR or
IDENTICAL Twins
 Develop from the fusion of ONE OVUM and ONE
SPERMATOZOON which after fertilization split into
TWO
 These twins will be of
 SAME SEX
 Have the same Genes
 Same blood group
 Same physical features e.g. Eye and Hair color Same ear
shapes, Same palm crease

NOTE: They may be of different SIZES and sometimes

have different personalities.
 In MONOZYGOTIC TWINS:twinning may
occur at different period after fertilization

 If division takes place within 72Hrs after

fertilization resulting embryo will have
SEPARATE PLACENTA i.e. DIAMNIOTIC –
DICHORIONIC

 If division takes place between 4th and 8th day

(after formation of inner cell mass when
CHORION has already developed i.e.
DIAMNIOTIC MONOCHORIONIC TWIN.
 If division occur AFTER 8TH Day of fertilization
(when the AMNIOTIC cavity has already
formed ) i.e. MONOAMNIOTIC –
MONOCHORIONIC TWIN DEVELOP.

 On extremely rare occasions DIVISIONS occurs

after 2 WEEKS (Of development of embryonic
Disc) Resulting in the formation of CONJOINED
TWINS called SIAMESE TWINS.
 Types of Fusion of CONJOINED TWINS.

 Thoracophagus(commonest)
 Pyopagus (posterior fusion)
 Craniopagus(Cephalic)
 Ischiopagus(caudal
 Monochorionic
Dichorionic
diamnionic
diamnionic

Monochorionic
Monochorionic
monoamnionic
monoamnionic
conjoined twins
 Developed from TWO OVA that are fertilized
by two different SPERMATOZOAN( also
called identical twin)
 They are no more alike than any other brother
or sister and can be of the same or different sex.
NOTE: Because in any pregnancy there is a 50:50
chance of a Girl or a Boy Half of Dizygotic twin
will be BOY GIRL pairs
 ¼(25%) of Dizygotic twin will be both BOYS

 ¼(25%) will be both Girls.

 SUPERFECUNDATION:
 Is when twins are conceived from sperm from
DIFFERENT MEN,If a women has had More
than one parterner sex during a menstrual
cycle.
 SUPERFETATION:
 Is when Twins are conceived as a result of two
coital act in DIFFERENT menstrual cycle (this
is very rare condition)
 This is possible until the decidual space is
obliterated by 12 weeks of pregnancy.
FOETUS PAPYRACEOUS
 Occurs when one of the foetus died early

 The dead foetus is flattened and compressed

between the membrane of the living foetus and
the uterine wall.
 May occur in both varieties of twins but more
common in monozygotic twins.
 Is usually discovered after delivery .
FOETUS ACARDIACUS
 Part of one Foetus remains amorphus and
becomes PARASITIC without a heart .
 Occurs only in MONOZYGOTIC TWINS

VANISHING TWINS
 Serial U.S.S imaging in MULTIPLE pregnancy
since early gestation has reveled occasional
DEATH of one FOETUS and
CONTINUATION pregnancy with
SURVIVING ONE.
 The dead Foetus (If within 14 weeks)simply
VANISHES by RESORPTION.
 IN EARLY PREGNANCY
 History of multiple pregnancy in the family
 History of Infertility treatment
 Severe hyperemesis gravidarum
 The uterus is larger than dates
 IN LATE PREGNANCY
 Inspection:The uterine size is larger than the
gestation age.
 Excessive fetal movement
 Palpation:Fundal height greater than the gestational
age.
 More than two fetal poles palpated
 Palpation of multiple fetal parts.
 Ascultation:Presence of more than one fetal
heart beats listened spontaneously with a
different of at least 10 beats per minute.
 NOTE:The best diagnosis is by ULTRASOUND.
 Wrong date
 Wrong examination
 Big foetus
 Polyhydramnious
 Pregnancy with uterine fibroids
 Pregnancy with ovarian cyst
 Hydatid form mole
 Retension of urine (Full bladder
MATERNAL
 Anaemia

 Premature labor

 Growth restriction

 Intrauterine death

 Placenta praevia

 Pre eclampsia /eclampsia

 Post partum haemorrhage

 Malpresentation

 Polyhydramnious

 Mechanical Distress:Dyspnoea,Palpitation.
 Premature labour and Premature rupture of
membrane due to bulky of pregnancy and
polyhydramnios
 Malpresentation
 Post partum haemorrhage due to large placenta
site
 Prolapse of the cord
 Fetal abnormality e.g. CONJOINED TWINS and
LOCKED TWINS.
 Abortion

 Vanishing twin

 Preterm Birth

 Foetal anomalies

 Intrauterine death of one twin

 Twin twin transfusion syndrome

 Cord prolapsed

 Locked twins

 Increased perinatal mortality.

 twin-to-twin transfusion syndrome
Twin-to-twin syndrome is a condition of the placenta that
develops only with identical twins that share a placenta.

 Blood vessels connect within the placenta and divert blood

from one fetus to the other.

 It occurs in about 15 percent of twins with a shared

placenta.
 Complication during pregnancy:
 Nausea and vomiting

 Anaemia

 Pre eclampsia (25%)

 Polyhydramnious

 A.P.H

 Malpresentation

 Pre term labor

 Mechanical distress.
 During labor:
 Early rupture of membrane and cord prolapse

 Prolonged labour

 Intrapartum haemorrhage

 P.P.H
 During Puerperium:

 Sub involution of the uterus

 Infection

 Lactation failure
 BEFORE 20 WEEKS
 Early detection by U/S
 Inform the parent
 Normal ANC
 No need for hospital admission
 Encourage fully balanced diet
 Start supplimentation of IRON and FOLIC
ACID
 AFTER 20 WEEKS
 Manage as before 20weeks

 Early detection and management of possible

complications:
• Pre term labor

• Pre eclampsia

 Regular Fetal growth assesments

i.e. Identification of IUGR

 Malpresentation in multiple pregnancy is common:

 Vertex and vertex -45%

 Vertex and breech -37%

 Breech and breech -10%

 Vertex and transverse -5%

 Breech and transverse -2%

 Trans verse and transverse -0.5%

 Labor is usually straightforward
 There is a risk of CORD PROLAPSE
 Check the lie of second twins after delivery of
first twin if necessary:
 Correct by EXTERNAL VERSION of the
VERTEX or INTERNAL PODALIC VERSION.
 Vigilance during the THIRD STAGE to prevent
Atonic Post partum Haemorrhage.
 Although Twins occur in about 1% of all
pregnancies but contribute to almost 10% of
perinatal mortality and morbidity

 The main causes of Mortality:

 Intrauterine Growth restriction

 Prematurity

 Trauma

 Asphyxia during delivery

 Malpresentations are common in Twins pregnancy
but 75% of cases .Twin A presents by VERTEX.

 The most common presentation in Twin Birth are:

 Vertex/vertex 40%

 Vertex/Non vertex 40%

 Non vertex /other 20%

 Delivery of first twin should be as in normal
labor

 Do not give oxytocin with the delivery of

anterior shoulder of the first baby.

STEP OF MANAGEMENT AFTER FIRST BABY

 Check for the

 LIE

 PRESENTATION

 SIZE

 FHR of the second Fotus abdominally.

 Do VAGINAL EXAMINATION
 To exclude cord prolapse

 State of the membrane

 If the second twin is CEPHALIC or BREECH hold the

Head or Breech in Pelvic brim then perform
A.R.M(artificial rupture of membrane)

 IF TRANSVERSE LIE: Perform EXTERNAL CEPHALIC

OR PODALIC VERSION

 If EXTERNAL VERSION fails perform INTERNAL

VERSION and breech extraction is indicated.
 NOTE: For non vertex first twin and 2nd
presentation cephalic or breech DELIVER BY
CAESARIAN SECTION.

 INTRAPARTUM COMPLICATION:

 LOCKED TWINS: Very rare (about 1:1000

deliveries)

 Occurs when twin A BREECH and TWIN B

VERTEX Combination.
 Primary prevention should be aimed for limiting the
number of embryos transferred in IVF and close
counselling/monitoring of those using ovulation-
induction therapies.

 Since 2001, the Human Fertilisation and Embryology

Authority has determined the maximum number of
embryos to be transferred per cycle of IVF as two to
limit risk of multiple pregnancies.
 Secondary prevention is in the form of multifetal pregnancy
reduction (MFPR) for high numbers of fetuses, performed
early in pregnancy usually between 9 and 12 weeks.

 This procedure involves injecting one or more fetuses with a

lethal medication(potassium chloride) guided with a TV
ultrasound, causing fetal death.

 The objective of multifetal reduction is that by reducing the

number of fetuses in the pregnancy, the remaining fetuses
may have a better chance for health and survival.
INTE DOMINO SPERO