OBSTETRIC 2017-2018 4th year

Assistant professor: Dr.Esraa AL-Maini

 DEFINITION
 Multiple pregnancy consist of two or more
fetuses ,rare exceptions such as twin
gestation of (viable and complete mole).
 Twins 97%_98% .
 Three or more fetuses referred as higher
multiples
 EPREVELENCE
 1.5% -2.5% of all pregnancy twins represent
 1:2500 higher multiple
 AETIOLOGY
 1-increased maternal age
 2-Family history of dizygotic twins in maternal side.

 3-IVF
 4-ovulation induction clomide6-8% ,gonadotrophins 20-
30%.
 5-high parity
 6-black race
 Monozygotic twins has the same incidence 1:250 , after
IVF increase for unknown cause.
The type of
monozygotic twins
depends on how long
after conception the
split occurs:
when the split occurs
with in 3 days of
conception ,two
placentas and two
amniotic cavities
result, giving rise to a
dichorionic
diamniotic
pregnancy .
 when splitting occurs
between days 4-8, only the
chorion differentiated a
monochorionic diamniotic
pregnancy result.
 Later splitting 9-12
days ,after the amnion has
differentiated leads to both
twins developing in a single
amniotic cavity, a
monochorionic
monoamniotic pregnancy
 .

 If splitting delayed
beyond day 12, the
embryonic disc has also
formed ,and conjoined
or Siamese twin will
result.
 Clasiffication :depend on:
 1-no. of fetuses twin,triplets….
 2-no. of fertilized eggs zygosity
 3-no.of placenta chorionicity
 4-no. of amiotic cavities amionicity
Non identical or fraternal
twins are dizygotic: 2/3
of spontaneous
pregnancy
Resulted from the
fertilization of two
separate eggs have
always two functionally
separate
placentas(dichorionic)
the placentas can
become anatomically
fused together and
appear to the naked eye
as a single placental mass
 They always have separate
amniotic cavities
(diamniotic) and the two
cavities are separated by a
thick 3 layer membrane
(fused two amnion in the
middle with a chorion on
either side) the fetus can
either same sex or
different sex pairing.
Identical twins are
monozygotic: 1/3 of
spontaneous pregnancy
Arise from fertilization of a
single egg , and are always
same sex pairing, may share
single placenta , or two placetas
can become anatomically fused
together and appear to the
naked eye as a single placental
mass 30% vast majority of
monochorionic twins have two
amniotic 69%occasionaly,
monochorionic twins may share
a single sac (monoamniotic)
1%.
 Cavities( diamniotic) ,but
dividing membrane is thin
single layer of fused two
amnion .
 30% dichorionic diamniotic
 69%monochorionic daimniotic
 1% monochorionic monoamniotic
In dichorionic twins there is extension of
placental tissue the base of intertwin
membrane (lambda sign) which absent in
monochorionic twin
 Physiological changes of pregnancy
 All the physiological changes of
pregnancy(increase cardiac out put, volume
expansion 3L and more versus 2L in singleton
pregnancy ,relative haemdilution increase risk
of anaemia, diaphragmatic splinting ,weight gain
,loredosis ,orthostatic hypotension ,compromise
renal function due to compression of uterus.
 The minor symptoms of pregnancy may be
exaggerated.
 General complications of
multiple gestations
Maternal
 Anemia
 Hydramnios
 Hypertension
 Premature labor
 Post partum hemorrhage
 Preeclampsia
 C.S
FETAL
 1-Malpresentation
 2-placenta previa
 3-Abruptioplacentae
 4-PROM
 5-Prematurity
 6-Umblical cord prolapse
 7-IUGR
 8-Congenital anomalies
 9-increased perinatal mortality and morbidity:
a-RDS
b-Brain truma
c-Cerebral hemorrhage
d-Brain anoxia
e-Congenital anomalies
f-Stillbirth
G-Prematurity
 COMPLECATION RELEVANT TO TWIN
PREGNANCY
 1-Miscarriage and sever preterm delivery
 Where the average gestation at delivery is at 37
weeks ,therefore about half of all twins delivery
preterm.
 After32 weeks do well, most befor 23weeks die
 most interest are late miscarriage (12-23) and very
pretem (24-32)
 1%in singleton pregnancy, 2%in
dichorionic ,more increase in monochorionic
twins
 2-perinatnl mortality in twins
 Perinatal mortality rate for twins is around 6
times higher than for singletons related to
preterm in monochorionic the risk twice as
high as in dichorionic.
 3- death of one fetus in a twins It is unusual for one twin
to die in utero remote from term ,where as the remaining
twin and pregnancy continues to be viable .

 If the demise occurs before 12 weeks gestation

the dead fetus is absorbed.
 Between 12-20 weeks the fetus shrink and become
dehydrated and flattened (fetus papyraceus)
 During 2nd and 3rd trimester (after 20 weeks)
the intrauterine death of one fetus in a twin
pregnancy may be associated with a poor out
come for the remaining co-twiin dichorionic:
 labour may start
 or pregnancy may continue uneventfully and
delivery at term
 in monochorionic death of one twin may
result in immediate complications in the
survivor 25% death due to hypotensive
episode 2nd to placental vascular
anastamoses, or if pregnancy continue for
more than 3 weeks 50% brain damage and
neurodevelopmental handicap, maternal
complication DIC (the retained dead fetus
syndrome) so platelet and plasms fibrinogen
level should checked weekly.
 4-intrauterin growth restriction

 In dichorionic twin pregnancy if one fetus is IUGR so

preterm delivery may result in iatrogenic complication in
healthy co twin.
 Delivery should be avoided before 32weeks,even if
imminent death of co twin.
 this may not applicable in monochorionic,as damage
happens at moment of death of the first twin,
 below 32w aim to prolonged pregnancy as far as possible
with out risking of death of the IUGR
 5-.fetal abnormality
 The risk is twice compared to singleton pregnancy in
dichorionic,
 in monochorionic the risk increase 4 times due to higher
vascular accident during embryonic life.
 Abnormality in one fetus manage expectantly or selective
fetocid if abnormality is non lethal, the risk of loss of co-
twin is 25%, if lethal abnormalities so avoid such risk to
healthy fetus unless the abnormality threat the survival of
healthy twin,
 fetocid
 either by intra cardiac injection or by cord occlusion
technique.
 6- chromosomal defect and twining
 The risk of chromosomal abnormality
increase with age , the rate of dizygotic twin
increase with age, IVF increase ,which
increase the dizygotic twin, IVF increase in
older age women ,so increase chromosomal
deffect in dizygotic twin
 In monozygotic twin either both or non
affected
 In dizygotic twin risk twice
7-complecation unique to monochorionic twining
Due to Inter placental vascular anastamoses:in90% arterio-
arterial and arterio-venous, veno- venous less common
.
a-arterio-arterial anastamoses cause fetal structural abn.due
to poor oxygenated blood to recipient cause under
developed of cephalad part of body (a cardiac twin)
b-Cord abn.
absence of one of UMBLICAL ARETRIES and associated with
other abn.,marginal or welamentous cord insertion more
frequent
 C-Imbalance in the flow of blood across the
arteriovenous anastamoses between to
placenta circulations results in twin twin
transfusion syndrome the donor fetus suffers
from both hypovolemia ,hypotension due to loss
of blood and hypoxia due to placental
insufficiency, may become growth restricted and
oliguric
 The recipient fetus become
hypervolaemic,polyuria,polyhyrdminion ,there is
risk of myocardial damage polycythemia and
high out put failure sever disease evident at 18-
24 weeks. End in miscarriage and sever preterm
labour
 Diagnosis by ultrasound
 Treated by amniocentesis every 1-2 weeks,
prolonged pregnancy improve
survival,fetoscopically guided laser
coagulation to disrupt the placental blood
vessels that coagulation to disrupt the
placental blood vessels that connect the
circulation of the two fetuses
 8-complecation unique to Monoaminiotic
twins share single amniotic cavity no dividing
membrane between two fetuses increase risk of
cord accedents ,elective delivery at 32-34 by
C.S, Mortality rate of 50%.
9-Conjoined twins:
Classified according to
anatomic location of
incomplete splitting

Thoracopagus
anterior ,pygopagus-
posterior , craniopagus-
cephalic , ischiopagus-
caudal, all delivery by C.S
 ANTE NATAL MANAGEMENT
 1-Screen for HT, DM more common in twins
 APH ,TE ,minor complication of pregnancy
are more common
2-DETERMINATION OF CHORIONICITY:
Is critical to good management reliably by US,
In the late first trimester.
Dichorionic twins, there is v-shaped extension of placental
tissue in to the base if the inter-twin membrane,
(lambda)or twin peak sign
Monochorionic twin, absent, inter twin membrane join
uterine wall in T shape
Later in pregnancy :
 -Lambda sign become less accurate,
 -depend on the character of the membrane between the
two amniotic sac, thick amnion –chorion septum
suggestive of dichorionic
 and thin membraine monochorionic each can
result from monozygotic
 -Different sex –dizygotic ,dichorionic,
 same sex two saperated placenta dichorionic but
may be monozygotic or dizygotic,
 Two placentas dichorionic but mono or dizygotic
 Some time even after delivery need to determine
the zygosity if single placenta so monozygotic,
 if different sex so dizygotic,if 2 placenta same sex
but different blood group so dizygotic if same
blood group need HLA typing-
 3-screen of abnormality
 Screening for trisomy 21 using maternal serum
biochemistry is not effective in multiple
gestation
 The optimal method of screening is by US
nuchal translucency at 12weeks in individual
fetuses ,if prenatal diagnosis is required, if
monochorionic mean monozygotic so one
sample required, amniocetesis and chorion villus
sample can be performed both fetuses should be
sampled ,screen for structural anomalies is done
at20 weeks
 4-monitoring fetal growth and well being
 By US
 -In monochorionic twins ,features of TTTS should be sought
 - fetal growth monitoring every 4-6weeks by US scan in dichorionic in
monochorionic fortnight, from 24 week non stress test and biophysical
profile, if poor growth screen for PE and from 36 week, weekly tests and
Doppler if tests are non reassuring.
 5-thretened preterm labour
 High risk patients should screen for bacterial vaginosis ,screen for
group B streptococcal ,steroid therapy to enhance fetal lung
maturity,trasvaginal US predict PTL between 16-22 week patient seen at
2 week interval for cervical length estimation cerclage ? beta agonists
risk of serious complication.
 INTRAPARTUM MANAGEMENT
 PREPERATION
 Delivery Should be in 2nd or 3rd center, delivery room should
equipped for immediate C.S birth if necessary.
 I.V line ,blood should available,
 Portable US should be available ,epidural analgesia is
recommended, fetal heart rate monitoring should be continuous
throughout labour ,fetal scalp sampling as for singleton pregnancy
but delay after delivery of 2nd twin, non reassuring pattern in 2nd
twin will usually necessitate delivery by c.s.
 Two obstetrician two pediatrician and nurses should available
 Complications in labour are more common with multiple
gestation ,preterm birth ,abnormal presentations ,prolapsed
cord ,premature separation of placentas post partum haemorrhage.
 VAGINAL DELIVERY OF VERTEX –VERTEX
 Delivery of first twin in usual manner 2nd twin
deliver with in 15 minutes after delivery of first
twin ,abdominal palpation should be performed
to assess the lie of the 2nd twin US for con
formation , also FHR , in longitudinal lie with
cephalic presentation one should wait until the
head is descending and amniotomy with
contraction if no contraction with in 5-10 minute
after 1st twin then oxytocin infusion should be
started if assisted vaginal delivery needed so
vacuum extractor has no. of advantages.
 DELIVERY OF VERTEX –NONVERTEX
 If 2nd twin is non vertex ,occur in 40%of twins if
2nd twin is breech ,the membranes can be
rupture d once breech fix d in the birth canal .a
total breech extraction may be performed if fetal
distress occurs or if footling , if fetus transverse
lie so external cephalic version monitoring of
fetal heart US help ,if fail so internal cephalic
version keep the membrane intact to reduce the
complication.
 INTERNAL PODALIC VERSION
 A fetal foot is identified by recognizing a heel
through intact membranes . the foot is
grasped and pulled gently and continuously in
to the birth canal.
 The membranes are ruptured as late as
possible this procedure is easiest when the
transvers lie is with back superior or posterior.
US helpful.
 NON VERTEX FIRST TWIN
 When first twin breech presentation so C.S delivery
because of increase risks of associate with singleton
breech vaginal delivery, risk of rare inter looking twin
 PRETERM TWIN
 No significant differences in perinatal out come in mode
of delivery
 A2nd twin between C.S and breech extraction
 in low birth weight twin ,the method of delivery in
relation to presentation will have no effect on neonatal
mortality
 HIGHER MULTIPLES
 The median gestational age at birth is
33weeksC.S is usually advocated for delivery due
to the difficult of intrapartum fetal
monitoring,vaginal birth have reported
comparable neonatal out come
 Multifetal reduction around 11-12 weeks allows
for spontaneous reduction to occur and for
screening and diagnosis of major fetal
abnormalities and chromosomal defects, fetus
and placenta spontanously absorbed