MULTIPLE PREGNANCY

Presented by:

Dr.Deepika Baranwal

AYURVEDIC VIEW

भिनत्ति यावत् बहुधा प्रपन्न: शुक्रार्तवं वायुरतिप्रवØ®È।

तावन्त्यपत्यानि यथाविभागं कर्मात्मकान्यस्ववशात् प्रसूते॥

(च.शा.२/१४)

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बीजेÅन्तर्वायुना भिन्ने ²Éæ जीवÉæ कुˤÉमागतौ ।

यमावित्यभिधीयेते धर्मेतरपुरस्सरौ ॥

(सु.शा.२/४०)

• यस्या: मध्ये निम्नं द्रोणीभूतमुदरं सा युग्मं प्रसूयत इति॥

(सु.शा.३/३२)

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आचार्य डल्हण-

रोमराजी भवेन्निम्ना यस्या: सा सूयते यमौ इति॥

• Acharya Kashyapa has described following Asadhya jataharinies ( Ka. Kalpa 6 )
• Karkotaki –

When woman conceives, one child of twins dies and other suffers from balgraha

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2. Indravadva –

Woman whose one or both the children of twins die is known as Indravadva.

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3. Badvamukhi –

When one child of nabhija twin dies first and subsequently second also dies .

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MODERN VIEW

Definition

• The presence of more than one fetus in the gravid uterus is called multiple pregnancy
• Two fetuses (twins)- commonest variety
• Three fetuses (triplets)
• Four fetuses (quadruplets)
• Five fetuses (quintuplets)
• Six fetuses (sextuplets)

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Varities

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1.Dizygotic twins/Fraternal/Binovular

2.Monozygotic twins/Identical/Uniovular

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DIZYGOTIC TWINS�

• Fertilisation of 2 ova by different spermatozoa
• Babies bear only fraternal resemblance to each other
• Each twin has its own placentae,either completely seperated or more commonly fused at the margin
• No anastomosis between the two fetal vessels
• Each fetus is surrounded by a separate amnion &chorion ,hence always dichorionic, diamniotic

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MONOZYGOTIC TWINS

• Results from fertilization of a single ovum with single spermatozoa
• Twining may occur at different periods after fertilization
• The placenta is single
• Varying degree of free anastomosis between the two fetal vessels
• Each fetus is surrounded by a separate amniotic sac with the chorionic layer common to both

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• On rare occasions,division occurs after 2wks of the development of embryonic disc resulting in the formation of conjoined twins called-Siamese twin
• Four types of fusion may occur:
• Thoracopagus-commonest
• Pyopagus
• Craniopagus
• Ischiopagus

Maternal Physiological changes

• Increase in weight gain and cardiac output
• Increase in plasma volume but no increase in RBC resulting in haemodilution and anemia
• Increase in fetoprotein , tidal volume and GFR
• Excess fluid retention and oedema
• Maternal respiratory difficulty
• Increase attacks of supine hypotension

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DIAGNOSIS

• History:
• H/o ovulation inducing drugs
• Family history of twinning

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• Symptoms: Minor ailments often exaggerated

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• General examination :
• Anaemia
• Unusual weight gain

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• Abdominal examination:

Inspection - Barrel Shape

Palpation - Ht of uterus is more than period of

amenorrhoea

Palpation of too many fetal parts

Finding of two fetal heads or three fetal

poles

Auscultation- Simultaneous hearing of 2 distinct FHS located at separate spots by two observers with difference of 10 beats/ min – Arnoux sign

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Investigations

• Ultrasound – Two gestational sacs can be detected as

early as 10 th wk of pregnancy.

• USG done to detect
• Viability
• Vanishing twin in second trimester
• Fetal anomalies
• Fetal growth monitoring for IUGR
• Presentation and Lie
• Placental localisation
• AFI
• Twin transfusion ( Doppler studies )
• Chorionicity

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Ultrasound Determination of � Chorionicity

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• Number of Sacs-(before 10 weeks)

Two sacs – dichorionic

Single sac – monochorionic

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• Intertwin membrane-thicker and more echogenic in dichorionic

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Twin peak / Lambda sign�

• Chorionicity of placenta is best diagnosed by USG at

6-9wks of gestation.

• In dichorionic twins there is a thick septum between

the chorions sacs. It is best identified at the base of the

membranes, where a triangular projection is seen.

• Presence of Lambda or twin peak sign indicates

dichorionic placenta.

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T Sign

In monochorionic-

no chorionic tissue

made of 2 layers of amnion only inserted perpendicular to fetal surface

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If no membrane is seen in between – monochorionic monoamniotic

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Complications

Maternal- complications are more in

monochorionic twins

• During pregnancy-

Nausea and Vomiting

Anemia

Pre-eclampsia

Hydramnios

APH

Malpresentation

Preterm labour

Mechanical stress

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During labour:

• Early rupture of the membranes and cord prolapse
• Prolonged labour
• Increased operative interference
• Intrapartum bleeding
• Postpartum haemorrhage

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During puerperium-

• Subinvolution
• Infection
• Lactation failure

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• Fetal complication-
• Miscarriage
• Growth problem
• Intrauterine death of one fetus
• Fetal anomalies
• Asphyxia and stillbirth

Antenatal managment

• Make an early diagnosis
• Diet
• Increased rest
• Supplement therapy-Additional iron,folic acid,calcium,vit.
• Frequent antenatal visit
• Rest in lateral decubitus for 2 hrs each morning & afternoon ; sleep for 10 hrs each night
• In cases of one fetal death, check well being of second twin & look for coagulopathy
• Serial sonography at every 3-4weeks interval
• Assessment of fetal growth,AFI,NST,Doppler velocimetry

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Optimal time of delivery

• Singleton pregnancy mostly deliver between 39 – 40 weeks
• Twins deliver between 37 - 38 weeks
• Triplets deliver at 36 weeks
• Fetal lung maturity occurs at an earlier gestation in multiple pregnancy
• Fetal monitoring should be performed between 35 – 38 weeks in case of twins

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Concerns about labour/ delivery � management

• Induction of labor in cases of : PIH, IUGR
• Preterm labour/PROM -Steroids for lung maturity
• Continuous fetal heart monitoring for both twins
• Epidural analgesia
• Mode of delivery depending on presentations & other associated risk factors.

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• Careful consideration of
• Gestational age
• Weight of twins
• Chorionicity
• Presentation - Vertex – Vertex

Vertex – Breech

Breech – Vertex

Breech – Breech

Vertex – Transverse

and so on

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Prerequisites for Safe Delivery

• Knowledge of lie, presentation & weight of each fetus
• Portable ultrasound scanner & a CTG with dual monitors
• Preferable to monitor one fetus externally & other internally by scalp electrode
• Intravenous access
• Availability of cross matched blood
• Two skilled obstetricians & neonatologists
• Continuous epidural analgesia is a good option due to frequent manipulative procedures
• Lithotomy position

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Vertex-Vertex

• Always perform an episiotomy
• Don’t give IV ergometrine with delivery of anterior shoulder of first baby.
• After delivery of first twin clamp & cut umbilical cord of twin A
• Assess twin B abdominally and vaginally i.e lie, presentation, FHS and cord prolapse or by USG if required

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Vaginal Delivery of Second Twin

• Assess twin B

If lie is longitudinal –

• Low rupture of membranes when head engages
• Oxytocin infusion if there is no contraction within 10 min
• If there is still delay then

Vertex – Low down - Forceps applied

High up - Internal version done

under GA F/b breech

extraction

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• If lie is transverse –
• external cephalic version/ podalic version

If external version fails, int. version under GA F/b breech extraction

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• Time interval between deliveries of twins is important
• Longer the interval between delivery, greater is the risk of hypoxia
• LSCS for obstetric indication cord prolapse, fetal distress , Placental abruption

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Vertex- Non vertex

• External cephalic version of 2^nd twin is an option
• Breech extraction if version fail

• Caesarean section – failed version, fetal distress, cord

prolapse or placental abruption

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Non vertex- Non vertex

• Caesarean section
• 1st breech – vaginal delivery may be attempted if wt >1.5kg
• Vaginal delivery of first twin - managed like singleton pregnancy

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Complications of Breech Vaginal � Delivery

• Fetal anoxia
• Fetal injury (dislocated hips)
• Head entrapment
• Inadvertent hand delivery with shoulder presentation
• Placental abruption
• Cord accident
• Maternal trauma ; ruptured uterus

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Fetal Head Entrapment�

• Avoided by LSCS
• If occurs at vaginal delivery - Try pushing presenting twin up to release chins or to deliver second cephalic twin first !!!!!!! (hypothetical )

Complications of head entrapment

• Death of first twin
• Asphyxia of both twins
• Maternal risk - LSCS, general anesthesia

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Vaginal Breech Extraction of 2nd � Twin

• Operator must be experienced in vaginal breech delivery
• Should be avoided if - EFW of Twin B > Twin A by 500 gm
• EFW of Twin B > 1500 gm

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Indications of CS

• Obstetric indication
• Placenta praevia
• Severe pre eclampsia
• Previous CS
• Cord prolapse
• CPD
• Abnormal uterine contractions

• For twins
• Both fetuses or first fetus with non cephalic presentation
• IUGR and conjoint twins
• Monoamniotic twins
• Monochorionic twins with TTS

Third stage

• Most dangerous
• Risk of PPH
• Large placenta – longer time to separate
• May occupy lower segment ( insufficient retraction )
• Uterine inertia following over distension of uterus
• Active management of 3^rd stage, use of oxytocics

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� Twin – twin transfusion syndrome�

• Acute or chronic
• Placental vascular anastomosis between both fetal placentae with net flow in one direction.
• Clinical manifestation occur when there is haemodynamic imbalance due to unidirectional deep arteriovenous anastomoses
• Discordant fetal size and amniotic fluid volume between both fetuses.
• Discordant Hb > 5 gm/dl
• Discordant EFW > 25% or more

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• Acute TTS – occur in third trimester or in labour – sudden death of one twin
• Diagnosed antenatally by USG with doppler blood flow study

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MANAGEMENT

• Serial therapeutic amniocentesis – reduces preterm labour , PROM and hydrostatic pressure
• Indomethacin to reduce AF
• Laser ablation of placental vascular anastomosis
• Selective foeticide using intracardiac injection of KCL under U/S guidance

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Vanishing twin

• Spontaneous cessation of cardiac activity in a previously viable fetus of multiple gestation
• If loss occurs in first trimester, affected fetus vanishes by resorption

When fetal death occur after first trimester,results in thin parchment like body called fetus papyraceous or compressus

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� Cord entanglement�

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Acardiac fetus

• Rare
• Bizarre form of monochorionic twinning
• One fetus is normal
• Other twin is severely malformed – no heart, absent development of upper part of body
• Twin reversed arterial perfusion sequence –

Pump Twin - high output cardiac failure, hydrops, polyhydramnios and death

Perinatal mortality of pump twin is 50%

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PUMP TWIN

ACARDIAC TWIN

CONJOINT TWINS�

• Always monozygotic
• very rare
• Incomplete division occurring after 13 days
• Diagnosed antenatally for termination and planning operation
• Surgical separation in some cases
• Elective CS at 38 wks gestation

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Thank

you