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 Dizygotic 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
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. Di-amniotic - Mono-chorial and or D/M
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. Mono-amniotic and Mono-chorial
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. The 2 eggs are completely independent.
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.

11. 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.

12. 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

13. 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

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

15. Hydatidiform mole Hydatidiform mole from one placenta
And a normal fetus and placenta

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

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

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

19. 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).

20. Examination General: Abdominal:
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

21. Types of Twin Lie and Presentations%
2nd twin
1st twin 35
Vertex 20
Breech 15 10
Transverse or cephalic
Cephalic or transverse 5
Transverse or breech
Breech or transverse
Transverse

22. 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.

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

24. 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

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

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

27. How are they going to be delivered?

28. 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

29. 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

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

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

32. 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.