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Multiple Pregnancy

Multiple Pregnancy. Dr. Hazem Al- Mandeel OB/GYN Rotation-course 481. Introduction. A pregnancy with two or more embryos/fetuses that exist simultaneously The perinatal mortality and morbidity are increased disproportionately with number of fetuses

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Multiple Pregnancy

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  1. Multiple Pregnancy Dr. Hazem Al-Mandeel OB/GYN Rotation-course 481

  2. Introduction • A pregnancy with two or more embryos/fetuses that exist simultaneously • The perinatal mortality and morbidity are increased disproportionately with number of fetuses • Maternal mortality and morbidity are also increased • Twin gestation is the most common type

  3. Etiology and Classification of Twinning • Occurs as result of the division of one fertilized egg (monozygotic) or fertilization of two eggs (dizygotic). Both processes can occur in other multiple gestation • Dizygotic (Fraternal) twins will always have two amnions and two chorions • In Monozygotic (Identical) twins, the number of membranes depend on the time of cleavage of the fertilized egg • 70% of MZ twins are monochorionic (mostly diamniotic) and 30% are diamniotic dichorionic

  4. Incidence of Twin Preganacy • Not constant throughout the world (varies according to race, hereditary factors, maternal age, parity, and the use of fertility agents) • Incidence of MZ twins is ≈ 1 per 250 births • DZ twins increases with increased family Hx of twinning, maternal age, and increased parity • Multiple gestation occurs in 10%-30% of women following the use of induction of ovulation agents • Spontaneous triplets is 1 in 8000 pregnancies and quadruplets I in 800,000. In ART: 1 in 3000 births

  5. Determination of Zygosity • Obstetrical ultrasound can often determine zygosity (esp. if done before 14 weeks) • Determination of number of amnions and chorions are VERY important for management • After delivery, zygosity should be confirmed • No. of membranes, no. of placentas and gender are essential in determining zygosity

  6. Abnormalities of Twinning Process • Occurs only in monochorionic (MZ) twins • Conjoined Twins • Twin-Twin Transfusion Syndrome (TTTS) • Umbilical Cord Abnormalities

  7. Complications of Multiple Gestation • 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

  8. Diagnosis of Multiple gestation • Signs and Symptoms: maternal sensation of larger abdomen, sensation of excessive fetal movement, excessive weight gain, palpation of more fetal parts, ausculation of more than one fetal heart • Ultrasound should be done routinely in all pregnancies (usually between 18-20 weeks) • Failure of early Dx of multiple gestation leads to increased perinatal morbidity and mortality

  9. Antepartum Management • Goal is to minimize perinatal mortality and morbidity and to prevent maternal complications • More frequent visits for antenatal care • Assessment of the cervical length frequently • Bed rest for the mother in the late pregnancy is suggested • Fetal surveillance is essential: monthly obstetrical ultrasound in the late pregnancy period and non stress test in the last month

  10. Intrapartum Management • Prevention and treatment of preterm labour • Patient should be delivered in a hospital with NICU facility • Mode of delivery for twins depends on the fetal presentations (Vx/Vx, Vx/Br, Br/Vx, or Br/Br) • Time interval between twin delivery is controversial (less than 30min) • For other multiple pregnancy, caesarean section is the safest mode of delivery

  11. Causes of Perinatal Morbidity and Mortality • Congenital anomalies • Prematurity • Birth hypoxia/Asphyxia • Respiratory Distress Syndrome • Cerebral hemorrhage • Birth Trauma • Stillbirths • Retained dead fetus Syndrome

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