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Understanding Multiple Pregnancy: Types, Complications & Management

Learn about the different types of multiple pregnancy, including monozygotic and dizygotic twins, and the potential complications for both the mother and the fetuses. Explore various scenarios of monozygotic twin pregnancies and understand selective embryo reduction. Discover maternal complications during pregnancy and labor.

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Understanding Multiple Pregnancy: Types, Complications & Management

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  1. Multiple Pregnancy

  2. DEFINITION • When more than one fetus simultaneously develops in the uterus ,it is called multiple pregnancy.

  3. According to their number, they could be categorized into: • Twins (most common) • Triplets • Quadruplets • Quintuplets • Sextuplets

  4. Types • Monozygotic • Identical/Uniovular • Fertilization of a single ovum, • Similar sex. • Identical in every way including the HLA genes • Not genetically determined • Dizygotic • Fertilization of 2 seperate ova • Fraternal /Dizygotic

  5. Monozygotic Twins…Different Scenarios of Cleavage Scenario 1 Monozygotic twin  pregnancy  Di-Amniotic and Di-Chorionic or D/D If the separation takes place just after the first cellular division [1st 3 days ]/ prior to morula stage both of the twins will have their own placenta and an amniotic sac each.

  6. Scenario 2 Monozygotic twin  pregnancy   Di-amniotic - Mono-chorial and or D/M • Separation can also take place a little later in the development [4-8 days after the formation of inner cell mass when chorion has developed] • of the embryonic cells but before the blastocyte has defined the roles of each cell. • Twins will be in the same placenta, but they will have 2 amniotic sacs.

  7. Scenario 3 Monozygotic twin  pregnancy   Mono-amniotic and Mono-chorial Separation takes place at the stage when the amniotic bag is already being formed [day 8-14] Twins will be in the same placenta, and in the same amniotic sac.

  8. Conjoined Twins • If the division occur after 2 weeks of the embryonic disc formation, incomplete or conjoined twins will occur. • They may be joined • anteriorly [thoracopagus-commonest], • posteriorly [pyopagus] • cephalic [craniopagus] o • caudal [ischiopagus].

  9. Dizygotic twin pregnancy Di-chorial and Di-amniotic. Dyzygotic twins, are descended from a double ovulation and a double fertilization. The 2 eggs are completely independent. This configuration represents two thirds of all twin pregnancies.

  10. Superfecundation • It is the fertilization of two different ova released in the same menstrual cycle,by separate act of coitus within a short period of time.

  11. Superfetation • It is the fertilization of two ova released in different menstrual cycle • One fetus over another • Possible until decidual space is obliterated by 12 weeks of pregnancy

  12. Fetus papyraceous or compressus • One fetus dies early • Dead fetus is flattened and compressed between the membranes of the living fetus and the uterine wall

  13. Fetus acardicus • Occurs only in monozygotic twins • Part of the fetus remains amorphous and becomes parasitic without a heart

  14. Hydatidiform mole • Hydatidiform mole from one placenta • And a normal fetus and placenta

  15. Vanishing twins • USG in early pregnancy revealed occassional death of one fetus and continuation of pregnancy with surviving one

  16. ETIOLOGY • Race – Highest among negroes and lowest among mongols • Hereditary- Transmitted through female • Advancing age of the mother- Maximum between 30-35 years • Parity – 5th gravida onwards • Iatrogenic – Gonadotrophin(20-40%),clomephene citrate(5-6%)

  17. Maternal physiological changes • Increase weight gain and cardiac out put • Plasma volume is increased by an additional of 500ml • Increased fetoprotein level and GFR

  18. History… • Patient profile: • Etiological factors; with positive past history and family history specially maternal. • Early pregnancy • Hyperemesis, bleeding. • Mid-pregnancy • Greater weight gain than expected • Abdominal size > period of amenorrhea • early PIH symptoms, persistent fetal activity. • Late pregnancy • Pressure symptoms (dyspnea, dyspepsia, UTI, piles, edema and varicose veins in LL).

  19. Examination General: • An early increase weight gain, • Pallor • Less mid-trimisteric fall blood pressure • Early PIH • Eary edema, and varicose veins in LL. Abdominal: • Fundal level > amenorrhea especially in mid-pregnancy • exclude other causes. • Palpation: Multiple fetal • identify presentations. • Auscultation of FHS: • 2 different recordings by 2 observers and a difference > 10 bpm a Gallop between 2 points[ Arnoux sign] Pelvic: Specially during the course of labor • small presenting part compared to abdominal size

  20. Types of Twin Lie and Presentations

  21. Selective Embryo Reduction • The presence of > 3 fetuses carries the risk of losing them all (preterm delivery). • The number is reduced to twins only by injecting potassium chloride intracardiac under U/S guidance (about 1.5 ml of 15% solution). • Potassium chloride may diffuse and affect other fetuses.

  22. Maternal Complications DURING PREGNANCY • Nausea and vomiting • Anaemia • Pre eclampsia • Hydramnios • Antepartum haemorrhage • Malpresentation • Preterm labour • Mechanical distress

  23. Maternal Complications DURING LABOUR • Early rupture of membranes and cord prolapse • Prolonged labour • Increased operative interference • Bleeding • Postpartum haemorrhage DURING PUERPERIUM • Sub involution • Infection • Lactation failure

  24. Fetal Complications • Miscarriage rate is increased • Premature rate • Growth problem • Intrauterine death of one fetus • Fetal anomalies • Asphyxia and still birth

  25. Antenatal Management • ANTENATAL ADVISES • Diet – extra 300 Kcal, extra protein • Increased rest at home • Travel restriction • Supplementary therapy – Fe 60-100mg,Additional Ca, Vitamin and Folic acid • Frequent antenatal visit • Prophylactic os tightening • Fetal surveillance • HOSPITALISATION

  26. How are they going to be delivered?

  27. Management During Labour • DELIVERY OF THE FIRST BABY • Same as singleton pregnancy • Liberal episiotomy • Forceps delivery • Do not give IV ergometrine with the delivery of the anterior shoulder of the first baby • Clamp cord at two places and cut in between • Leave at leat 8-10 cm of the cord • Label bay as no 1

  28. Contd…. • DELIVERY OF THE SECOND BABY • External cephalic version • Rupture fore water after correcting the lie • Wait for 10min for spontaneous delivery • Syntocinon drip • Vaccum extraction or Breech extraction

  29. Contd…. • CESAREAN SECTION • Severe PIH • Bad obstetrics history • Long history of infertility • Elderly primi • Preterm delivery • Breech presentation

  30. MANAGEMENT OF THIRD STAGE AND PUERPARIUM • Prevention of PPH • Treatment of anemia • Psychological adjustment • Family planning advice

  31. Twin to Twin transfusion • Vascular communication between 2 fetuses, mainly in monochorionic placenta (10% of monozygotic twins), • Twins are often of different sizes: • Donor twin = small, pallied, dehydrated (IUGR), oligohydramnios (due to oliguria), die from anemic heart failure. • Recipient twin = plethoric, edematous, hypertensive, ascites, kernicterus (need amniocentesis for bilirubin), enlarged liver, polyhydramnios (due to polyuria), die from congestive heart failure, and jaundice.

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