Multiple Pregnancy

Multiple Pregnancy

1. Multiple Pregnancy MS AGNES MAHIMA DAVID M.Sc. Nursing

2. DEFINITION When more than one fetus simultaneously develop in the uterus Twin = 2 fetus Triplets =3 fetus Quadruplets =4 fetus Quintuplets = 5 fetus Sextuplets =6 fetus Septuplets =7 fetus

3. Hellin’s Law: Twins: 1:89 Triplets: 1:89 2 Quadruplets: 1:89 3 Quintuplets: 1:89 4 Conjoined twins: 1 : 60,000 Worldwide incidence of monozygotic - 1 in 250 Incidence of dizygotic varies & increasing INCIDENCE

4. Race: most common in Negroes Age: Increased maternal age Parity: more common in multipara Heredity - family history of multifetal gestation Nutritional status – well nourished women ART - ovulation induction with clomiphene citrate, gonadotropins and IVF Conception after stopping OCP Demography

5. TWINS Simultaneous development of two fetuses is the commonest variety of multiple pregnancy VARIETIES Binovular twins :it is the commonest variety of multiple pregnancy (two third) and results from the fertilization of two ova Uniovular twins : (one third ) results from the fertilization of the single ovum

6. GENESIS OF TWINS Binovular twins: ( fraternal,dizygotic )results from fertilization of two ova most likely ruptures from two distinct graffian follicles usually of the same or one from each ovary by two sperms during a single ovarian cycle Their subsequent implantation and development differ little from those of a single fertilized ovum The babies bear only fraternal resemblance to each other

7. UNIOVULAR TWINS (identical ,monozygotic ) They develop from the fusion of one oocyte and one spermatozoon which after fertilization splits into two These twins will be of the same sex and have the same genes ,blood group and physical features Upto 3 days - diamniotic-dichorionic Between 4 th & 7 th day - diamniotic monochorionic - most common type Between 8 th & 12 th day- monoamniotic-monochorionic After 13 th day - conjoined / Siamese twins.

8. CONJOINED TWINS Ventral: 1) Omphalopagus (abdomen 2) Thoracopagus 3) Cephalopagus (head n chest 4) Caudal/ ischiopagus (pelvis Lateral: 1) Parapagus (trunk) Dorsal: 1) Craniopagus ,(head) 2) Pyopagus (base of spine)

9. Superfecundation Fertilization of two different ova released in the same cycle Superfetation Fertilization of two ova released in different cycles

10. Differences in zygocity Monozygotic twin Dizygotic twins 2 ova + 2 sperm Same or opposite sex Fraternal resemblance Double or s/t fused Different genetic features DNA microprobe - different 1 ova + 1 sperm Same sex Identical features Single or double placenta Same genetic features DNA microprobe -same

11. HISTORY: History of ovulation inducing drugs specially gonadotropins Family history of twinning (maternal side). SYMPTOMS: Hyperemesis gravid rum Cardio-respiratory embarrassment - palpitation or shortness of breath Tendency of swelling of the legs, Varicose veins Hemorrhoids Excessive abdominal enlargement Excessive fetal movements Investigation

12. GENERAL EXAMINATION: Prevalence of anaemia is more than in singleton pregnancy Unusual weight gain, not explained by pre- eclampsia or obesity Evidence of preeclampsia(25%)is a common association. ABDOMINALEXAMINATION: Inspection: The elongated shape of a normal pregnant uterus is changed to a more "barrel shape” and the abdomen is unduly enlarged.

13. Palpation: Fundal height more than the period of amenorrhoea girth more than normal Palpation of too many fetal parts Palpation of two fetal heads Palpation of three fetal poles Auscultation: Two distinct fetal heart sounds with Zone of silence 10 beat difference

14. Hydramnios Macrosomia Fibroid with pregnancy Ovarian tumor with pregnancy Adenexal mass with pregnancy Ascites with pregnancy Molar pregnancy Differential diagnosis

15. Sonography : In multi fetal pregnancy it is done to obtain the following information: Suspecting twins – 2 sacs with fetal poles and cardiac activity Confirmation of diagnosis Viability of fetuses, vanishing twin Chorionicity – 6 to 9 wks ( single or double placenta, twin peak sign in d /d gestation or Tsign in m/d ) Pregnancy dating, Fetal anomalies Fetal growth monitoring (at every 3-4 weeks interval) for IUGR INVESTIGATIONS

16. Presentation and lie of the fetuses Twin transfusion (Doppler studies) Placental localization Amniotic fluid volume Radiography Biochemical tests : raised but not diagnostic Maternal serum chorionic gonadotrophin , Alpha fetoprotein Unconjugated oestriol

17. Maternal COMPLICATION Pre eclampsia During Pregnancy APH mechanical distress pre term labor Hydraminos Nausea & vomiting malpresentation Anemia

18. During labor Bleeding PPH Cord prolapse Early rupture of membranes Increased operative interference

19. During puerperium Infection Failing lactation Sub-involution anemia

20. Fetal Miscarriage rate is increased Fetal anomalies Discordant twin growth Premature Stillbirth Asphyxia Intrauterine death

21. Antenatal Diet Increased rest Supplement therapy Interval of antenatal visit Fetal surveillance Management

22. Labor Vaginal is allowed when both the twins are /or at least the first twin is vertex presentation 1 st stage A skilled obstetrician should be present Neonatologist (two) Presence of ultrasound in the labor room Patient should be in bed Use of analgesic drugs Careful fetal monitoring Internal examination should be done i/v line with ringer solution