Multiple Pregnancy

M1, FMBS
Dr. DOHBIT SAMA.
HGOPY - FMBS
Objectives

At the end of this lecture, the student should

be able to:
1. Define monozygotic and dizygotic twins
2. State clearly the physiology and clinical
presentation of multiple pregnancy
3. Describe 5 foetal and 5 maternal
complications of multiple pregnancy
4. Diagnose and manage multiple pregnancy
Plan

Introduction
Pathogenesis
Clinical presentation
Diagnosis
Complications
Management
Conclusion
Introduction

Pregnancy carrying more than one foetus.

Monozygotic twins are identical twins, result
from the division of one fertilized ovum
Occurs in about 2 4 of 1000 pregnancies in
all races
About 30% of twins
It is random
Does not fit any genetic pattern
Introduction 2

Dizygotic or fraternal twins result from

separately fertilized ova
70% of twins
Has hereditary determinants, familial
tendencies.
Ethnicity; Bamilekes, Ewondos in Cameroon
Traditional approximation does exist
Introduction 3

Traditional approximation is:

Twins (2 foetuses) = 1:80
Triplets (3 foetuses) = 1:80 = 1:6400
Quadruplets (4 foetuses) = 1:80 = 1:512,000
Has significantly increased during the last 15
years.
Introduction 4

The increase is due to the use of ovulation

induction drugs and medically assisted
reproductive techniques (ART)
Multiple pregnancies now constitute 3% of all
pregnancies
Twins comprise 25 30% of deliveries
resulting from ART
Introduction 5

There are foetal and maternal effects and

also an increase in the cost of delivery.
Maternal morbidity and mortality rates are
much higher due to preterm labour,
haemorrhage, pregnancy induced
hypertension, urinary tract infections etc.
2/3 end up as singleton within the 1st 10
weeks
Introduction 6

Perinatal mortality rate of twins is 3 4 times

higher as a result of:
Chromosomal abnormalities
Prematurity
Anomalies
Hypoxia
Trauma
Particularly true of monozygotic twins
Factors increasing the incidence

Racial: more in black women.

Familial: whether the wifes or the husbands
family has a history of multiple pregnancies.
Induction of ovulation: particularly with
gonadotrophins.
Multiparas than primiparas.
Maternal age: incidence increases with
increasing age up to 40 years.
Factors increasing the incidence 2

Previous multiple pregnancy: the incidence

of another multiple pregnancy is 10 times the
normal incidence.
Pathogenesis

Monozygotic: result from the fertilization of a

single ovum by a single sperm, are always of
the same sex.
The earliest splits may vary in chromosomal
abnormalities
They share the same genetic material.
Their fingerprints differ
Pathogenesis 2

In monozygotic twinning, if division occurs

within 72 hours, we get 2 chorions and 2
amnios (Bi Bi)
Division between the 3rd and the 8th day:
monochorionic, diamniotic
 Pathogenesis 3
Day post- fertilisation Placentation Incidence
0-3 2 placentas, 2 chorions, 2 amnions & 2 23%
umbilical cords as binovular twins but
2 identical twins (monozygotic).

4-7 One placenta, one chorion, 2 amnions 75%

& 2 umbilical cords with vascular
connections.

8-11 One placenta, one chorion, one amnion 1%

& 2 umbilical cords (monoamniotic
monochorionic).
Higher foetal loss due to cord
entanglement.

>11 Conjoined twins (monsters), joined by <1%

the head (craniopagus), chest
(thoracopagus), abdomen
(omphalopagus), back (pygopagus) or
pelvic (ischiopagus). Sometimes the
viscera or limbs are shared.
Diagnosis of Chorionicity

By ultrasound examination in the first

trimester
Look for the tee T and the lamda signs
The T will be in the monochorionic,
diamniotic twin gestation
The sign will correspond to Bichorionic
biamniotic gestation
Pathogenesis (Mono Bi)
Pathogenesis (Mono Mono)

Division occurs on the 8th day, we obtain

monochorionic, monoamniotic twins. That is
one amniotic sac and one chorionic sac.
Pathogenesis 5

If division occurs much later, after the

formation of the inner cell mass, it is usually
incomplete.
The resultant twins are monsters or
SIAMESE twins. They are usually fused.
Siamese Twins

Late divisions will lead to fused twins:

Fusion at the head is craniopagus

Fusion at the thorax is thoracopagus
Fusion at the abdomen is omphalopagus
Pathogenesis 6

Monozygotic triplets result from repeated

twinning (supertwinning)
Possibility of trizygotic twinning, etc.
Quadruplets could result from 1 to 4 ova
Pathogenesis 7

DIZYGOTIC: product of 2 ova and 2 sperms.

Ova from 2 follicles or rarely from the same
Significant differences among them
About 75% are the same sex
Dizygotic Twinning

Many factors do influence dizygotic twinning;

It varies with race, mostly among the blacks,
hispanics, Indians.
2/100 deliveries in Cameroon, Bamileke and
Ewondos
3/100 deliveries in Nigeria, mostly the Ibos
and Yurobas
2/3 of all twin pregnancies
Dizygotic Twinning 2

Also influenced by:

Advanced maternal age, 36 yrs and above
Parity 6 and above
Heredity
Medically assisted procreation (ART)
Determination of zygosity

Monozygotic Dizygotic
Sex same different or same
Membranes:
common/sep separate
Placenta:
common/sep separate
Blood group same different +/-
Genotype same different
HCLA same different
Morphology same different +/-
Clinical Presentation

At ANC
History
Family history of multiple pregnancy (wife
and/ or husband).
Recent intake of ovulation drugs.
Increased foetal movement.
How she feels
Symptoms

Exaggerated pregnancy symptoms

Excessive vomiting
Hyperemesis gravidarum
Exaggerated foetal kicks
Exaggerated other sympathetic signs of
pregnancy
Signs

Exaggerated uterine size

Multiple foetal parts
Multiple foetal heart tones
Very large abdomen (UH>age of pregnancy)
Investigations

Ultrasound: 2 sacs, 2 foetal heart beats, 2

foetal poles
Chorionicity determined in the 1st trimester

+/- Biochemistry: HPL, urinary oestriol etc.

Differential Diagnosis

Molar pregnancy (Vomiting, PEC)

Polyhydramnios (Abdominal size and UH)
Wrong dates
Macrosomia
Uterine fibroids
Large ovarian cyst
Complications

Foetal:
Malformations
Foetal demise, Vascular communications
Polyhydramnios
Premature labour, PROM
Placenta praevia/Placenta abruptio,
Cord prolapse
Abnormal lie, Retained second twin etc.
Artero-venous vascular communication

Donor foetus: Recipient foetus:

Anaemia Polycythermia
Microcephaly Macrocephaly
Microcardia Cardiomegaly
Hypotrophic Hypertrophy
Foetal death ( Foetal survival
compressus , May develop heart
papyraceous) failure
And die ( hydrops
foetalis)
Complications 2

Maternal complications:
_ Hyperemesis gravidarum
Anaemia
Hypertensive disorders
Post partum haemorrhage (PPH)
Uterine rupture
Increased risk of caesarean section
Management

History
Clinical evaluation
Para clinical evaluation
Refocused antenatal care
Delivery
ANC

Pregnancy with risk factor

Respect the four components of good quality
care
Preventive
Curative
Health promotion
Preparation for delivery
Preventive

TPI
VAT
Iron + folate supplements
Vitamin supplements
Laboratory ( Blood group,FBC,urinalysis,
stool,syphilis,HIV etc)
Premature labour taken care of in the hospital
Curative

Treat current diseases like:

Anaemia
Malaria
Diabetes
Urinary tract infection
Health Education

To promote health
Topics on:
Vaccination
Nutrition
Family Planning
Breast feeding
Personal hygiene
Care of the newborn etc.
Preparation for Delivery

Counseling to prepare for delivery from the

first visit and throughout pregnancy
Financial arrangements as early as possible
Pregnancy does always end successfully
Delivery in an equiped health facility
Preparation for delivery 2

By a qualified personnel
Live closer the hospital
A one hour walking distance
Involve the husband,family,community
Person of her choice to accompany her
Explain these every visit
Conduct of Labour

Use the partogramme always

A patent IV line for security
Monitor closely
Avoid prolonged labour
Avoid induction/augmenting labour because
of excessive uterine distension.
Delivery

Vaginal delivery is allowed only when the 1st

twin is in cephalic presentation
In all other presentations of the 1st twin, C/S
is indicated
About 45 - 50% of both twins are cephalic
35-40% are cephalic breech
Vagina delivery is possible in 80-90% of
cases
Delivery of Second Twin

After delivery of the 1st twin, the assistant

performs Leopolds maneuvers to identify
the lie and presentation of the 2nd twin
If cephalic or breech, rupture the
membranes and start syntocinon infusion
If transverse , rupture membranes,
perform internal ( podalic) version and
breech extraction
Conclusion

Twin pregnancy is a high risk gestation, that

requires particular care.
The risk of preterm delivery is very high
Appropriate diagnosis must be made in the
early pregnancy
At delivery, there must be a minimum of 4
qualified personnel
Conclusion 2

The use of syntocinon drip to aid the delivery

of the second twin should be well tapered
The complications of twin delivery can be
reduced by close monitoring of the labour
and assisted delivery
References

1. Current Gynecologic and Obstetric

Diagnosis and Treatment. 9th edition, 2007
2. William Obstetrics, 22nd edition
3. www.gfmer.ch
4. www.thecochranelibrary.org
Thank you

Merci