2. Definition (Multi-fetal Gestation) MULTIPLE PARITY -Twins (two babies) -Monozygotic(Division of 1 ova fertilized by the same sperm) -Dizygotic(Fertilization of 2 ova by 2 sperm) -Triplets (three babies) -Quadruplets (four babies) I

3. Incidence Twins - 1 in 100 births –African Americans: 1 in 70 –Caucasians: 1 in 88 –Japanese: 1 in 150 –Chinese: 1 in 300 Triplets are about 1 in 7,500 births Quadruplets are about 1 in 650,00 births

4. Predisposing Factors Maternal age and parity Maternal height and weight Genetic and racial factors Prior use of oral contraceptive agents Social class Seasonality

5. Causes of Multiple Gestation Spontaneously In Vitro fertilization –Intrauterine insemination –Assisted Hatching –GIFT, ZIFT –Frozen Embryo Transfer, Blastocyte Embryo Transfer Fertility Drugs –Clomiphene citrate (clomid, serrophene) –Gonadotropins (GonalF, follistim, humagon)

6. Twins Dizygotic twins (66% of US twins) –Dichorionic – separate chorion (placenta) –Diamniotic – separate amnion (amniotic sac)

7. Monozygotic twin (33% of US twins) Ova division: < 72 hours: Dichorionic, diamniotic 4-8 days: Monchorionic, diamniotic 8-13 days: Monochorionic, monoamniotic > 13 days: conjoined twins

8. Conjoined Twins Craniopagus Pygopagus Thoracopagus Cephalopagus Epholothoracopagus Craniopagus Pygopagus Thoracopagus Cephalopagus Epholothoracopagus

9. Average age of gestation Number of babies Weeks of Gestation 1 40 weeks 2 35 1/2 weeks 3 33 weeks 4 29 ½ weeks http://www.bestdoctors.com/en/con ditions/g/gestation/gestation_100200.htmhttp://www.bestdoctors.com/en/con ditions/g/gestation/gestation_100200.htm

10. Peripartum Complications Prematurity-major cause of neonatal death 50% of twins 90% of triplets and higher Spontaneous abortion Increased anomalies Cord Prolapse IUGR, discordant growth Intracranial Hemorrhage Locked Twins Description: Twins lock heads 1st twin breech, 2nd twin vertex

11. Problems of Prematurity HMD/BPD Pneumothorax Apnea ICH CP Blindness/Retinopathy LBW PDA Hypertension/Hypotension

12. Problems of Prematurity Bradycardia Anemia Hyperbilirubinemia NEC Metabolic disorders Hypothermia HIE Hypotonia Infections

13. Neonatal Management (Multiple Gestation) Team for each fetus Examine for prematurity and IUGR Examine for congenital anomalies Determine zygosity, examine placenta Assess family support

14. In ICN RDS Apnea/Asphyxia Hct and BP Wt difference NEC Head Sono + Glucose Blood typing

15. Second Twin Risks Asphyxia due to premature separation of placenta Fetus papyraceous -twin fetus that died in utero, become flattened and mummified Fetal transfusion Syndrome Placental AV shunt in monozygotic twins (~15%) Arterial twin pumps blood to other twin, starves self Other twin is bulky and plethoric Operative or difficult delivery

16. Monozygotic twins (physical characteristics) Same sex Features alike, including teeth and ears Hair identical Eyes same color and shade Skin same texture and color Hands and feet same conformation and same size Anthropometric values closely agree

17. Twin-Twin Transfusion Syndrome Monozygotic twins share one placenta 1 placenta causes one baby to receive more blood. One baby (donor) smaller and other larger. Larger baby: excess urine, polyhydramnios. Donor stops producing urine, oligohydramnios. This can lead to pre-term delivery (~24 weeks).

18. Problems for Monoamnionicity Rare < 1%. Mortality 20-50%. Cord entanglement. Perinatal mortality. Preterm Delivery. Growth restriction. Congenital anomalies. Conjoined twins  Siamese twins * Anterior (thoracopagus). * Posterior (pygopagus). * Cephalic (craniopagus). * Caudal (ischopagus).

19. Problems for Monoamnionicity 1.Acardiac twins (Reversed-Arterial Perfusion TRAP). * rare 1:3500 births. large A-A placental shunt between umbilical arteries in early embryogenesis, 75% monochorionic, diamniotic. 25% monochorionic monoamniotic.

20. Maternal Complication 1.Acute fatty liver. 2.Anemia. 3.Abnormal placentation. 4.Amniotic fluid volume abnormalities. 5.Preeclampsia. 6.Operative vaginal delivery and C-section. 7.Premature rupture of membrane. 8.Postpartum hemorrhage. 9.Umbilical cord prolapse.

21. Prevention (Multiple Gestation) Moniter treatment with fertility drugs Limit embryos transferred during IVF Counseling risks and long-term sequelae Fetal reduction if not against religion

22. Management 1.Antenatal. 2.In Labor. Antenatal Management ●Early diagnosis (mainly by ultra sound) ●Adequate nutrition:- 1- Caloric consumption increased by 300 Kcal per day. 2- Iron 60-100 mg per day. 3- Folic acid 1mg per day. ●Frequent prenatal visit:- observe maternal and fetal complications 1- Frequent ultra sound  fetal growth, congenital anomalies, amniotic fluid. 2- Doppler. 3- BPP.

23. In Labor Management ●Trained obstetrical attendant. ●Available blood. ●Good access I.V live. ●CTG monitoring. ●Anesthetist  ER C-S ●Pediatrician for each fetus. ●Mode of delivery depend on presentation.

24. Presentation ☻Cephalic - Cephalic 42% ☻Cephalic - Breech 27% ☻Cephalic - Transverse 18% ☻Breech - Breech 5% ☻Other 8% Management in First stage Second stage Third stage (PPH)

25. In Labor Management ●Ceph-ceph: NVD ●Ceph –non ceph: contraversy. ●Breech:cord prolaps,Head trappe,Locked twin:c/s. ●Second twin: 10 min and no contraction. ●Non fixed p.p :abdominal manipulation ●Second twin:internal pudalic version. ●Irregular FHR,VB,larger,Bx, Trans,contract Cx: C/S.

26. In Labor Management ●Trained obstetrical attendant. ●Available blood. ●Good access I.V live. ●CTG monitoring. ●Anesthetist  ER C-S ●Pediatrician for each fetus. ●Mode of delivery depend on presentation.