MULTIPLE PREGNANCIES

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MULTIPLE PREGNANCIES
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• When more than one fetus develops in the uterus
  it is called multiple pregnancy.
• Simultaneous development of
• Two fetuses Twins
• Three fetuses Triplets
• Four fetuses Quadruplets
• Five fetuses Quintuplets
• Six fetuses - Sixtuplets

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Twins

• It is the commonest variety of multiple
  pregnancy.
• It can be Dizygotic twins 2/3
• Monozygotic twins 1/3
• Twins resulting from fertilization of two ova
  during a single ovarian cycle are called as
  DIZYGOTIC TWINS. (fraternal, binovular)

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Monozygotic twins(identical, uniovular)

• Twins arise from a single fertilized ovum that
  subsequently divides into two similar structures
  each with the potential for developing into a
  separate individual.
• The process of monozygotic twinning is in a sense
  a teratogenic event and monozygotic twins have an
  increased incidence of discordant malformations.
• The division of the fertilized ovum may result
  from a delay in the timing of the normal
  developmental events.
• Delayed ovum transport through the tubes
  increases the risk of twinning - because
  progestational agents, O.C. Pills decreases the
  tubal motility, delay tubal transport and
  implantation. They are believed to increase the
  risk of twinning in pregnancies conceived in
  close temporal proximity to contraceptive use.
• Minor trauma to the blastocyst during Assisted
  Reproductive Techniques( ART ) may possibly lead
  to increased incidence of twinning.
• INCIDENCE OF MONOZYGOTIC TWINS IS 1 250 BIRTHS

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• Prevalence of Dizygotic Twins
• a) Race Highest among Negroes
• Lowest among Mongols
• b) Heredity More transmitted through the
  female
• 
  (Maternal side)
• c) Age Maximum between the ages of 30
  to 37
• 
  years
  
  
• d) Parity Incidence increases from fifth
  gravida
• 
  (6.6)
• e) Nutritional Taller , heavier women have
  25 to
• 30 greater twinning
  rate than
• shorter nutritionally
  deprived women
• f) Iatrogenic Drugs used to treat
  infertility
• - Clomiphen Citrate (
  5-6)
• - Gonadotrophin
  theraphy(20-40)

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Physical changes in Mother

• Excess than that is seen in singleton pregnancy.
• There is an increased weight gain and increased
  cardiac output (20)
• Plasma volume is increased and there is no
  equivalent increase in red cell volume resulting
  in exaggerated hemodilution and anaemia.
• The uterus and non-fetal contents may achieve a
  volume of 10 liters or more and weigh excess
  especially in monozygotic twins leading to acute
  hydramnios.

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• Patient may present as
• Advanced Maternal age
• High parity
• Exaggerated pregnancy symptoms like nausea and
  vomiting due to increased HCG levels
• Unusual enlargement (distension) of the uterus
• In multi-intelligent mother may notice increased
  fetal movements
• In the later months of pregnancy, patient
  presents with cardio respiratory embracement
  which is evident as palpitations, shortness of
  breath
• Due to the pressure of the enlarged uterus over
  the veins swelling of the limbs varicose veins
  and even hemorroids may be present.
• Symptoms of anemia
• Patient may be asymptomatic and present as
  preterm labour with undiagnosed twins.

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• History of Ovulation inducing drugs
• Family history of twinning
• In multi fetal gestations complicated by
  hydramnios renal function may be seriously
  impaired due to obstructive uropathy

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• G.P.E .
• Usually multi, with high parity, tall women
• Anemia
• Pedal oedema
• Evidence of preecclampsia (25)
• Weight gain during each visit is more than
  expected

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Abdominal examination

• Inspection
• Abdomen is unduly enlarged with barrel shape
• May be associated with hydramnios (10) with
  tense shiny skin over the abdomen
• Palpation
• Height of uterus is more than the period of
  amenorrhoea which is evident from mid trimester
• Girth of the abdomen is more
• Multiple fetal parts can be felt
• Fetal bulk seems disproportionately larger to the
  size of the fetal head.
• Finding of two fetal heads or three fetal poles
  is diagnostic
• Hydramnios (10) is common in monozygotic twins .
  This is due to the increased renal perfusion with
  increased urinary output which accompanies the
  hypervolumia of larger twin.
• Malpresentations Usual presentations are
• Both vertex 60
• First vertex and
  second breech 20
• First breech and
  second vertex 10
• Both breech 10
• First vertex and
  second transverse rare
• Lastly both
  transverse - conjoined twins to be ruled out
• Placenta previa due to bigger size of placenta
• Auscultation

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• Internal examination
• One head may be felt deep in pelvis and other is
  located by abdominal examination
• Patient may present with preterm labour