Diagnosis of twin pregnancy -This is usually through ultrasound examination. - Diagnosis can be made as early as 6 weeks, particularly for women who have had treatment for infertility, but usually at the early scan between 11 weeks and 13 weeks and 6 days -If the pregnancy is diagnosed at 6 weeks, the woman should be told about the risk of ‘vanishing twin syndrome’

The differences between the two types of placenta are more pronounced in the first trimester, so it is important to establish chorionicity at the early scan. -The chorions forming the septum between the amniotic sacs can be seen more clearly and the membrane thickness measured

- or by studying the septum at its base adjacent to the placenta where a tongue of placental tissue is seen ultrasonically between the two chorions; this is termed the lambda or T-sign -Once a multiple pregnancy has been diagnosed nomenclature should be assigned to each baby (e.g. A and B, or upper and lower). -The news that a woman is expecting a multiple pregnancy should be broken to the couple in a sensitive manner as it may be a huge shock.

- At diagnosis the mother must be given relevant information about the pregnancy, be referred to a specialist multiple pregnancy clinic, -given website addresses or telephone numbers of local and national support organizations

-Since the advent of routine ultrasound scanning, it is very rare for a woman to get to term with undiagnosed twins, but this will not apply in areas where this technology is unavailable, or where the mother declines.

The pregnancy A multiple pregnancy tends to be shorter than a single pregnancy. -The average gestation for twins is 37 weeks - triplets 34 weeks - quadruplets 32 weeks.

Antenatal screening A healthcare professional experienced in twin and triplet pregnancies should offer information and counselling before and after every screening test. Screening for Down syndrome is by the combined test .

Amniocentesis can be performed in twin pregnancies, usually between 15 and 20 weeks. It should be performed in a specialist fetal medicine unit. Most obstetricians prefer to do a dual needle insertion so there is no chance of contamination between the two sac

Such procedures should only be performed after detailed counseling The role of chorionic villus sampling (CVS) with dichorionic placentas remains controversial because of a relatively high risk of cross-contamination of chorionic tissue, which may lead to false-positive or false-negative results. Such procedures should only be performed after detailed counseling 9

Ultrasound examination Monochorionic twin pregnancies should be scanned every 2 weeks from 16 to 24 weeks to check for :

1-discordant fetal growth 2- signs of twin-to-twin transfusion syndrome (TTTS). 3-A detailed cardiac scan should be included with the anomaly scan due to increased incidence of cardiac problems with MZ twins; if uncomplicated after 24 weeks, then the same as dichorionic twins. Dichorionic twin pregnancies should be scanned monthly from 16 weeks, with the anomaly scan between 18+0 to 20+6 weeks.

Antenatal care and preparation -Early diagnosis of a twin pregnancy and of chorionicity is extremely important in order to give parents the specialist support and advice they will need. -Clinical care for women with twin and triplet pregnancies should be provided by a nominated multidisciplinary team consisting of: Core team :

*a specialist obstetricians, specialist midwives and ultrasonographers, all of whom have experience and knowledge of managing multiple pregnancies. -*An enhanced team for referrals should include: a women's physiotherapist, an infant feeding specialist, a dietitian and a perinatal mental health professional. - The type of care pathway the woman will follow for her antenatal care will depend on whether she is expecting monochorionic or dichorionic twins.

Women expecting an uncomplicated monochorionic twin pregnancy should be offered at least nine antenatal appointments with healthcare professionals from the core team. -At least two of these should be with the specialist obstetrician. Women with uncomplicated dichorionic twin pregnancies should be offered at least eight antenatal appointments with a healthcare professional from the core team, and two of these with the specialist obstetrician .

Parent education -Routine parent education classes should be offered earlier for women expecting twins, ideally around 22–24 weeks' gestation. - A specialist class for couples expecting a multiple birth would be the ideal participate in the classes and talk on the practical issues such as coping with two or more babies, equipment and breastfeeding (Leonard and Denton 2006). Suggestions for class topics are listed in

To pics f o r pa r e nt e duca t io n cla sse s Facts and figures on twins and twinning Diet and exercise Parental anxieties about obstetric complications Labour, pain relief and the birth Possibilities of premature labour and birth the outcome Visit to the special care baby unit

Breastfeeding and bottle-feeding Zygosity Equipment (prams and buggies, car seats, layette, etc.) Coping with newborn twins or more Development of twins including individuality and identity Sources of help.

-The news a multiple pregnancy is expected can come as a considerable shock and the midwife should give couples the opportunity to discuss any worries or problems they have, as two babies will add a considerable financial burden to any family's income).

Preparation for breastfeeding -how they are going to feed their babies, not only from the nutritional but also from the practical point of view, as feeding will take up a large amount of their time during the first 6 months. Women should be encouraged right from the beginning that it is not only possible to breastfeed two, and in some cases three babies

-many mothers manage to combine breast and bottlefeeding very successfully. -Early in the antenatal period the woman should be given full information and advice about both breast- and bottlefeeding, so she can make an informed choice on how to feed her babies.

-Both parents should have the opportunity to ask questions and be encouraged to meet another mother who is successfully breastfeeding her babies (Box 14.2). Introductions can usually be made through a local twins group (

Suppo r t ne e de d by t he br e a st f e e ding m o t he r o f t wins o r m o r e Consistent professional advice Reassurance of her ability to produce enough milk to satisfy her babies Encouragement from professionals and family in her ability to cope with feeding two or more

Support from her partner Help at home with household chores Help with older siblings A high calorie and high protein diet

Abdominal examination Inspection On inspection, the size of the uterus may be larger than expected for the period of gestation, particularly aher the 20th week. -The uterus may look broad or round and fetal movements may be seen over a wide area, although the findings are not diagnostic of twins.

Fresh striae gravidarum may be apparent. Up to twice the amount of amniotic fluid is normal in a twin pregnancy but polyhydramnios is not an uncommon complication of a twin pregnancy, particularly with monochorionic twins.

Palpation -, the fundal height may be greater than expected for the period of gestation. -The presence of two fetal poles (head or breech) in the fundus of the uterus may be revealed on palpation and multiple fetal limbs may also be palpable. -The head may be small in relation to the size of the uterus and may suggest that the fetus is also small and therefore there may be more than one present.

-Lateral palpation may reveal two fetal backs, or limbs on both sides. -Pelvic palpation may give findings similar to those on fundal palpation, although one fetus may lie behind the other and make detection difficult. - Location of three poles in total is diagnostic of at least two fetuses.

Auscultation Hearing two fetal hearts is not diagnostic as one can ohen be heard over a wide area in a singleton pregnancy. -If simultaneous comparison over one minute of the heart rates reveals a difference of at least 10 bpm, it may be assumed that two hearts are being heard beating.