15 - Multiple Pregnancy

King Khalid University Hospital
Department of Obstetrics & Gynecology

Course 482
MULTIPLE
PREGNANCY
Multiple pregnancy
Objectives:
-Incidence
-Diagnosis of multiple pregnancy
-Mechanism of twinning & Zygosity
-Complication of multiple pregnancy
-Causes of perinatal mortality & morbidity
-Twin to twin transfusion
-Antenatal management of multiple pregnancy
-Assessment of chorionicity by ultrasound
-Management of labour in multiple pregnancy
Incidence of multiple pregnancy
-The natural rate of twinning is 1:90
-Slightly higher in blacks than whites
-In USA the incidence is 3%
The incidence is increasing due to Assisted
reproduction technique(ART)and ovulation induction
-The incidence of monozygotic twins is constant and
is 4:1000 pregnancies
-The incidence of dizygotic twins increase with age,
parity, weight, height, and is higher in some families
Diagnosis of multiple pregnancy
Suspected if:
-Large for date uterine size
-Multiple fetal heart rates are detected
-Multiple fetal parts are felt
-HCG & maternal serum alpha-fetoprotein is elevated
for gestational age
-Pregnancy with ART
-Confirmed by ultrasound
Zygosity
Dizygotic:
Diamniotic/Dichorionic
70-80% of all twins
Fertilization of two ova
Each fetus will be surronded by amnion &
chorion( each fetus has its own placenta)
Zygosity
Monozygotic: 20-30% of all twins
Result from cleavage of a single fertilized ova
The timing of cleavage determines placentation
Dichorionic/diamniotic monozygotic twins:
Cleavage in the first 3 days after fertilization
Each fetus will be surrounded by amnion & chorion(
each fetus has its own placenta)like dizygotic twins
Has the lowest mortality rate of monozygotic twins
<10% of all monozygotic twins
Zygosity
Monochorionic/diamniotic:
Cleavage between day 4 and 8 after fertilization
Share single placenta but separate amniotic sac
The mortality is 25%
Monochorionic/monoamniotic:
< 1% of cases
Cleavage after the 8th day (day 9-12)
Share single placenta & single sac
Mortality is 50-60%, usually before 32 weeks
Zygosity
Conjoined twins:
Cleavage after day 12
Incidence is 1: 70,000deliveries
The fetuses may fuse in a number of ways, most
commonly chestand/or abdomen
Mechanism of twining
Monozygotic twins
Complications of multiple
pregnancy
-High perinatal mortality & morbidity (3-4 times higher than singleton pregnancy)
-Abortion(<50% of twins diagnosed in the first trimester result in live birth(vanishing
twin))
-Nausea & vomiting
-Preterm labour (50%)(twins delver at 37 weeks, triples at 33 weeks, Quadruplets at
29 weeks)
-IUGR
-PET (3 times higher than singleton)
-Polyhydramnios ( in 10%)
-Congenital anomalies
-Postpartum hemorrhage
-Placental abruption, placenta previa
-Discordant twin growth ( more than 20%discrepacy in fetal weights)
-Malpresentation, cord prolapse, Operative delivery
Causes of perinatal mortality &
morbidity
- -Prematurity (Respiratory distress syndrome)
-Birth trauma
-Cerebral hemorrhage
-Birth asphyxia
-Congenital anomalies
-Still birth
Twin-twin transfusion (TTN)
-Occur in 20-25% of monochorionic twins
-One fetus donate blood to the other due to vascular
anastomosis
-The recipient fetus will have heart failure,
polyhydramnios, and hydrops
-The donor will have IUGR & oligohydramnios
Twin-twin transfusion (TTN)
Management includes amnio-reduction of the
receipient twin, intra-uterine blood transfusion for the
donor twin, selective fetal reduction,fetoscopic laser
ablation of placental anastomosis
Antenatal management of multiple
pregnancy
-Adequate nutrition (300 additional calories per day per fetus)
-Prevent anemia
-More frequent antenatal visits
-Ultrasound:
Assess chorionicity at 9-10 weeks
Nuchal translucency at 12-13+ weeks
Assessment of fetal growth & fetal wellbeing every 3-4 weeks from 23 weeks
onward
-Multifetal reduction may offered for high order multiple gestation in the first
trimester
-Preterm labour risk:
Serial cervical length assessment
Steroids for fetal lung maturation
ASSESSMENT OF
CHORIONICITY BY
ULTRASOUND
Multiple gestational sacs in first trimester
Assessment of Chorionicity
Conjoined twins 2 yolk sacs
 2 gestational sacs
Assessment of chorionicity
T sign
Twin Peak Sign (Lambda) Monochorionic twin
Dichorionic twins
Management of labour in multiple
pregnancy
-Contoversial
-Depends on presentation , gestational age, presence
of fetal complications, experience of the obstetrician
-usually if the first fetus is cephalic– normal delivery
-Non vertex first twin--- cesarean section
-Locked twins: Breech-vertex twins ---- cesarean
section
- Active management of third stage to prevent PPH
Pre-requisite for intra-partum
management of multiple pregnancy
Secondary or tertiary center
Well functioning large-bore IV line
Availability of emergency C/S –anesthesia- blood
bank
Continuous simultaneous fetal heart rates
monitoring
Availability of NICU beds- paediatrician
Imaging technique (ultrasound)
Multiple pregnancy
Recommended books:
-Essentials of obstetrics & gynecology (Hacker
and Moore’s) P 160-172
-Current diagnosis & treatment –Obstetrics &

gynecology (p301-3100)

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King Khalid University Hospital

Department of Obstetrics & Gynecology

-Current diagnosis & treatment –Obstetrics &

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