MULTIPLE PREGNANCIESMULTIPLE PREGNANCIES

When more than one fetus develops in the When more than one fetus develops in the uterus it is called multiple pregnancy.uterus it is called multiple pregnancy.

Simultaneous development of Simultaneous development of

Two fetuses – TwinsTwo fetuses – Twins

Three fetuses – TripletsThree fetuses – Triplets

Four fetuses – QuadrupletsFour fetuses – Quadruplets

Five fetuses – QuintupletsFive fetuses – Quintuplets

Six fetuses - SixtupletsSix fetuses - Sixtuplets

TwinsTwins

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

Monozygotic twinsMonozygotic twins(identical, uniovular)(identical, uniovular)

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

INCIDENCE OF MONOZYGOTIC TWINS IS 1 : 250 BIRTHSINCIDENCE OF MONOZYGOTIC TWINS IS 1 : 250 BIRTHS

Prevalence of Dizygotic Twins:Prevalence of Dizygotic Twins: a) Race – Highest among Negroesa) Race – Highest among Negroes Lowest among MongolsLowest among Mongols b) Heredity – More transmitted through the femaleb) Heredity – More transmitted through the female (Maternal side)(Maternal side) c) Age – Maximum between the ages of 30 to 37c) Age – Maximum between the ages of 30 to 37 years years

d) Parity – Incidence increases from fifth gravidad) Parity – Incidence increases from fifth gravida (6.6%)(6.6%) e) Nutritional – Taller , heavier women have 25% toe) Nutritional – Taller , heavier women have 25% to 30 % greater twinning rate than30 % greater twinning rate than shorter nutritionally deprived womenshorter nutritionally deprived women f) Iatrogenic – Drugs used to treat infertilityf) Iatrogenic – Drugs used to treat infertility - Clomiphen Citrate ( 5%-6%)- Clomiphen Citrate ( 5%-6%) - Gonadotrophin theraphy(20%-40%)- Gonadotrophin theraphy(20%-40%)

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

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

History of Ovulation inducing drugsHistory of Ovulation inducing drugs

Family history of twinningFamily history of twinning

In multi fetal gestations complicated In multi fetal gestations complicated by hydramnios – renal function may by hydramnios – renal function may be seriously impaired due to be seriously impaired due to obstructive uropathyobstructive uropathy

G.P.E .G.P.E .

Usually multi, with high parity, tall Usually multi, with high parity, tall womenwomen

Anemia Anemia

Pedal oedemaPedal oedema

Evidence of preecclampsia (25%) Evidence of preecclampsia (25%)

Weight gain during each visit is Weight gain during each visit is more than expected more than expected

Abdominal examinationAbdominal examinationInspectionInspection: :

Abdomen is unduly enlarged with barrel shapeAbdomen is unduly enlarged with barrel shapeMay be associated with hydramnios (10%) with tense shiny skin over the abdomenMay be associated with hydramnios (10%) with tense shiny skin over the abdomen

PalpationPalpation::Height of uterus is more than the period of amenorrhoea which is evident from mid Height of uterus is more than the period of amenorrhoea which is evident from mid trimestertrimesterGirth of the abdomen is moreGirth of the abdomen is moreMultiple fetal parts can be feltMultiple fetal parts can be feltFetal bulk seems disproportionately larger to the size of the fetal head.Fetal bulk seems disproportionately larger to the size of the fetal head.Finding of two fetal heads or three fetal poles is diagnostic Finding of two fetal heads or three fetal poles is diagnostic Hydramnios (10%) is common in monozygotic twins . This is due to the increased Hydramnios (10%) is common in monozygotic twins . This is due to the increased renal perfusion with increased urinary output which accompanies the hypervolumia renal perfusion with increased urinary output which accompanies the hypervolumia of larger twin.of larger twin.Malpresentations: Usual presentations areMalpresentations: Usual presentations are

Both vertex 60%Both vertex 60% First vertex and second breech 20%First vertex and second breech 20% First breech and second vertex 10%First breech and second vertex 10% Both breech 10%Both breech 10% First vertex and second transverse rareFirst vertex and second transverse rare Lastly both transverse - conjoined twins to be ruled outLastly both transverse - conjoined twins to be ruled out

Placenta previa: due to bigger size of placentaPlacenta previa: due to bigger size of placentaAuscultationAuscultation: :

Simultaneous hearing of two distinct heart sounds located at separate spots with a Simultaneous hearing of two distinct heart sounds located at separate spots with a silent area in between by two observers provided the difference in heart rate is at silent area in between by two observers provided the difference in heart rate is at least 10 beats/minleast 10 beats/min

Internal examination:Internal examination:

One head may be felt deep in pelvis One head may be felt deep in pelvis and other is located by abdominal and other is located by abdominal examinationexamination

Patient may present with preterm Patient may present with preterm labourlabour