MULTIPLE PREGNANCY
PRESENTED BY
MS. SHWETA SINGH
M.SC NURSING II YEAR
Globally multiple pregnancies pose challenges to the Obstetrician. This is mainly due to increased maternal and foetal complications both in developed and developing countries. There has been a widespread increase in multiple pregnancies in recent years mainly due to late childbearing age, use of ovulation-inducing drugs and Assisted reproductive techniques (ART). The worldwide incidence of multiple pregnancies varies considerably and it is around 2-20 per 1000 births.
When more than one foetus simultaneously developed in the uterus, it is called as multiple pregnancy. Simultaneous development of two foetuses (twins) is the commonest; although rare, development of three foetuses (triplets), four foetuses (quadruplets), five foetuses (quintuplets or six foetuses (sextuplets) may also occur.
DEFINITION:
When more than one foetus simultaneously develops in the uterus then it is called multiple pregnancy. -D.C. Dutta
TWINS PREGNANCY: VARIETIES:
Dizygotic twins: is the commonest results from the fertilization of two ova.
Monozygotic twins: (one-third) results from the fertilization of single ovum.
Dizygotic twins 80% (Syn: fraternal, binovular) result from fertilization of two ova, most likely ruptured from two distinct Graafian follicles usually of the same or one from each ovary, by two sperms during a single ovarian cycle. Their subsequent implantation and development differ little from those of a single fertilized ovum. The babies bear only fraternal resemblance to each other (that of brothers and sisters from different births) and hence called fraternal twins.
In monozygotic (MZ) twins 20% (Syn: identical, uniovular), the twinning (cleavage of fertilized ovum) may occur at different periods after fertilization and this markedly influences the process of implantation and the formation of the fetal membranes.
In Monozygotic Twin
On rare occasion, the following possibilities may occur:
ZYGOSITY
Zygosity refers to the genetic makeup of twin pregnancy.
DETERMINATION OF ZYGOSITY:
With the advent of organ transplantation, the identification of the zygosity of the multiple foetuses has assumed much importance
♦ Examination of placenta and membranes:
Dizygotic twins:
Monozygotic twins:
(i) The placenta is single. There is varying degree of free anastomosis between the two foetal vessels.
(ii) Each foetus is surrounded by a separate amniotic sac with the chorionic layer common to both in D/M.
(iii) As such the intervening membranes consist of two layers of amnion only. However, on rare occasions, the uniovular twins may be D/D OR M/M
CLINICAL MANIFESTATION:
LIE AND PRESENTATION:
The most common lie of the foetuses is longitudinal (90%) but malpresentations are quite common. The combination of presentation of the foetuses are
1. both vertex (50%),
2. first vertex and second breech (30%),
3. first breech and second vertex (10%),
4. both breech (10%),
5. first vertex and second transverse and so on,
but rarest one, being both transverse when the possibility of conjoined twins should be ruled out.
HISTORY:
‣ H/O ovulation inducing drugs specially gonadotropins, for infertility or use of ART.
‣ Family history of twining (more present in the maternal side).
SYMPTOM: some of the symptoms are related to undue enlargement of the uterus
‣ Increase nausea & vomiting in early months
‣ Cardiorespiratory embarrassment which is evident in the later months such as palpitation or shortness of breath
‣ Tendency of swelling of the legs, varicose veins & haemorrhoids is greater
‣ Unusual rate of abdominal enlargement & excessive foetal movements may be noticed by an experienced porous mother.
GENERAL EXAMINATION:
* Prevalence of anaemia is more
* Unusual weight gain, not preeclampsia or obesity
* Evidence of preeclampsia is common association.
ABDOMINAL EXAMINATION:
Inspection: Barrel shaped and the abdomen is unduly enlarged
Palpation:
* Height of uterus > period of amenorrhoea
* Girth of abdomen> normal average at term (100 cm)
* Foetal bulk disproportionately larger in relation to the size of the
* foetal head.
* Palpation of too many foetal parts
* Finding of two foetal heads or three foetal poles
Auscultation:
Two distinct FHS at separate spots, difference in heart rates is at least 10 beats/minute.
INTERNAL EXAM:
* In some cases, one hand is felt deep o the pelvis, while other hand is located by
abdominal examination.
* On occasions, the clinical methods fail to detect twins prior to the delivery of the baby.
MATERNAL COMPLICATIONS:
During pregnancy
o Nausea and vomiting
o Anaemia
o Pre-eclampsia
o Hydramnios
o Antepartum haemorrhage
o Malpresentation
o Preterm labour
o Mechanical distress
During labour:
o Early rupture of membranes and cord prolapse
o Prolonged labour
o Increased operative interference Bleeding
o Postpartum haemorrhage
o During puerperium:
o Sub involution
o Infection
o Lactation failure
Foetal:
o Miscarriage
o Prematurity
o Growth problem
o Intrauterine death
o Asphyxia and still birth
• Maternal mortality: is increased in twins than in a singleton pregnancy. Death is mostly due to haemorrhage (before, during & after delivery), preeclampsia & anaemia. Increased maternal morbidity is due to the prevalence of complications & increased operative interference.
• Perinatal mortality: is markedly increased mainly due to prematurity. It is 4-5 times higher than in a singleton pregnancy. It is extremely high in monoamniotic monozygotic twins due to cord entanglement. One third loss is due to stillbirth & two third due to neonatal death.
COMPLICATIONS OF
MONOCHORIONIC TWINS
To reduce perinatal mortality and morbidity rates in pregnancies complicated by twins, it is imperative that:
* Diet: increased requirement of calories, protein, minerals, vitamins, and essential fatty acids. Caloric should be increased by another 300 kcal/day. Supplementation with 60 to 100 mg/day of iron and1 mg/day of folic acid.
* Interval of antenatal visit should be frequent to detect earliest, the evidence of its complication
* Bed Rest:
* Antepartum Surveillance: sonographic examinations
* Tests of Foetal Well-Being
* Prevention of Preterm Delivery
* Hospitalization
MANAGEMENT DURING LABOUR
FIRST STAGE:
* A skilled obstetrician, presence of ultrasound machine and experienced anaesthetist
* Bed rest to prevent early rupture of membrane.
* Limit use of analgesic drugs
* Careful monitoring
* Internal examination soon after the rupture of membranes
* An intravenous line with ringer's solution
*Availability of one unit of compatible and cross matched blood
* Neonatologist: Present at the time of delivery.
DELIVERY OF THE FIRST BABY:
Same guideline as normal delivery. Usually the baby is small so not usually pose any problem.
(i) Libaral episiotomy under L/A.
(ii) Forceps delivery: if needed, should be done preferably under pudendal block anaesthesia.
(iii) Do not give intravenous ergometrine with delivery of the anterior shoulder of the first baby (iv Clamp the cord at two places and cut it between.
(v) At least 8-10 cm cord is left behind for any drug administration or blood transfusion, if required.
(vi)The baby is handed over to the nurse after labelling it as 1st baby or No. 1.
CONDUCTION OF LABOUR
AFTER DELIVERY OF 1ST BABY
INDICATION OF CAESAREAN SECTION
Divided into two - obstetric cause & for twins
• Obstetric indication
1.Placenta Praevia
2.Severe preeclampsia
3.Previous caesarean section
4.Cord prolapse of 1st baby
5.Abnormal uterine contraction
6.Contracted pelvis.
For twins
1. Both the foetuses or 1st foetus with non-cephalic presentation
2.Twin with complications: IUGR, Conjoint twins,
3.Monoamniotic twins
4.Monochorionic twins with TTS
5.Collision of the heads at brim preventing engagement of either head.
1st baby breech and 2nd baby cephalic there will be locked twin or interlocking.
MANAGEMENT OF DIFFICULT CASES OF TWINS:
STATEMENT: Multiple Pregnancy among Deliveries in a Tertiary Care Center: A Descriptive Cross-sectional Study
ABSTRACT-
Introduction:
Multiple pregnancy is associated with increased obstetric complications as well as poor perinatal outcomes in developing countries because of the increased risk to both mother and baby. So better understanding of the risk factors is required to improve the quality of perinatal care. The aim of the study was to find out the prevalence of multiple pregnancies among deliveries in a tertiary care centre
Methods:
A descriptive cross-sectional study was done among total deliveries in the Department of Obstetrics and Gynaecology of a tertiary care centre from inpatient records starting from 15 August 2020 to 15 February 2021 after obtaining ethical approval from the Institutional Review Committee (Reference number: 1208202005). Convenience sampling was done. Point estimate and 95% Confidence Interval were calculated.
Results:
Out of 4400 deliveries, multiple pregnancy was seen in 35 (0.79%) (0.53-1.06, 95% Confidence Interval).
Author- Bajagain Rupa et al.
Year- 2022
I prepared seminar on Multiple pregnancy. In this topic I discussed about multiple pregnancy, definition, verities, genesis of twins, zygosity , difference between monozygotic and dizygotic ,incidence ,etiology ,clinical manifestations ,diagnosis ,Maternal and foetal complications , prognosis, complications of monochorionic twins, antepartum management of twin pregnancy, Indication of caesarean section and management of difficult cases of twins
It is the presence of more than one foetus in the abdomen of the mother. Twin pregnancy is the high risk one, maternal and perinatal morbidity and mortality are significantly high compared to singletone pregnancy. Cerclage for women with twin pregnancies: a systematic review and meta-analysis.
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