1. Dr. MSc. Raul Hernandez Canete
Multiple Gestation
Dr. MSc. Raul Hernandez Canete

2. Type of multiple gestation
Results from the ovulation and subsequent fertilization of more than one oocyte: Dizygotic (the fetuses are genetically different)
Result from the splitting of one embryonic mass to form two or more genetically identically fetuses (Monozygotic).

3. Dizygotic twins: Diamniotic and Dichorionic.
Monozygotic Twins:
- Monochorionic, Monoamniotic
- Monochorionic , Diamniotic
- Dichorionic, Diamniotic.

4. Monozygotic twins:
Single embryonic mass splits into two within three days of fertilization: Diamniotic and Dichorionic.
When embryonic splitting occurs after the 3rd day following fertilization: Monochorionic and Diamniotic
Embryonic splitting after the 9th day following fertilization: Monoamniotic and Monochorionic.
Splitting after 12th days: Conjoined Twins.

5. Zygosity and Chorionicity
Zygosity refers to whether the twins have come from the same ovum or from different ova, in other words whether they are identical or non-identical.
Chorionicity refers to the number of placentae.

6. Incidence (by Clinical Obstetrics and Gynaecology, Drife/Magowan, 2004)
54/1000 in Nigeria
4/1000 in Japan
12/1000 in UK
Identical twins: 3/1000
Preterm delivery: 40%
The incidence is higher after ovulation induction

7. Etiology: Familial factors (dizygotic +; monozygotic is rare).
Parity and maternal age: increase with the parity and maternal age(dizygotic).
Ovulation induction
In vitro fertilization and embryo transfer

8. Clinical features: Increased uterine size Hyperemesis gravidarum
Early oedema
At physical exam two poles and two different fetal heart

9. Diagnosis:
History (Assisted conception, family history, increased symptoms of pregnancy, abdomen larger than expected for gestation)
Clinical examination
USG

10. Complications of twin pregnancy:
Miscarriage
APH
Polyhydramnios
Preeclampsia
Anemia
Gestational diabetes
Preterm labour
IUGR
Fetal abnormalities and chromosomal defects
IUFD
Twin to Twin transfusion syndrome

11. Management of pregnancy
Early booking
Proper antenatal care
Health education
USG
Prevention of anemia
Assessment of fetal wellbeing
Prevention of preterm delivery
Early diagnosis of complications

12. Management of Twin delivery:
IV line
To identify the presentation
< 34 weeks: Caesarean section
CTG if is possible
Work in team
Oxytocin infusion could be necessary after delivery of the first twin.
No ARM until advanced cervical dilatation.

13. Cont…….
External version of the second twin is if necessary, if it fail: breech extraction
No more than 30 mtes between delivery of the first baby and the second.
First twin in breech and second in cephalic presentation have risk of locked twins
Be ready for possible post partum hemorrhage