Incidence\

Rule of 80: Previously, incidence of twin pregnancy used to occur ..... birth, triplets at....and so on. Since 1980s this rule was disrupted by the widespread use of ....... i.e. Several ova in one cycle. 1:80 1:802 drugs for ovarian superstimulation Predisposing factors

1.... 2. . 3. Higher maternal age: above .... years, due to ..... reproductive techniques. -Genetic predisposition -37, diminished antimullarian hormone levels, which normally allow the selection and maturation of one ovum only. Types Dizygotic: 2 ova are fertilized, each embro has separate placenta[.....] and amniotic sac [....], and may be of different sexes. -.Ovarian super-stimulation and assisted

Much more common than monozygotic twins.

Monozygotic: One ovum is fertilized, .....occurs to give 2 identical embryos: Day 1-3: .... Day 4-6:.....

Day 7:..... Day 8: ...... cleavage Day 1-3: dichorionic, diamniotic. Day 4-6: monochorionic, diamniotic. Day 7:monochorionic, monoamniotic. Day 8: Conjoint twins. Diagnosis 1....... 2. ...... 3. ......: as early as ....weeks, ....... sonogram can diagnose multiple gestation. dichorionic,diamniotic

Chorionicity and amnionicity can be easily diagnosed in the ......trimester. 2. Positive pregnancy test.

1. Amenorrhea.

3. Ultrasonogram: as early as 5-6 weeks, transvaginal sonogram can diagnose multiple gestation.

Chorionicity and amnionicity can be easily diagnosed in the first trimester. Clinical picture

1......This is due to .... 2. .....................................larger than dates. 1.Exaggerated symptoms of pregnancy: morning sickness, hyperemesis, distension, drowsinessetc. This is due to higher levels of pregnancy hormones: HCG, progesterone, relaxin and others. 2.Abdominal distension, dyspnea, lower limb oedema and fundal level larger than dates. :Complications

1......: due to higher levels of hyperglycemic pregnancy hormones e.g. human placental lactogen. 2........: due to higher probability of insufficient trophoblastic implantation to provide adequate blood supply to the fetuses. 3......: due to multiple /or larger placentae, with higher chance of one getting implanted over the lower uterine segment. 4. Higher incidence of ....: due to increased requirements. 5. ....: due to over-distension of the uterus by multiple fetuses. 6. Abnormal presentations: e.g. ..... 7......... [rare]: could occur if first is breech and the second is cephalic. 8. .......: after delivery of first twin, due to sudden decompression of the uterine cavity. 9. ...... 10. Increased incidence of.... Pre-eclampsia Placenta previa anemia Preterm labour breech Locked twins Accidental hemorrhage Increased atonic and traumatic postpartum hemorrhage. congenital anomalies. Complications specific to monozygotic twins Gestational diabetes

1........: in monochorionic twins. One fetus[recepient] gets more blood supply than the other [donor]; due to ......

......: bigger, surrounded by ...., becomes polycythemic and could develop heart failure, hydrops fetalis and die.

........ : smaller [intrauterine growth restricted], surrounded by ...., could die of hypoxia.

2. .......: Occurs in 25% of cases of monoamniotic twins.

3. ......: Hypoxia and possible brain injury occurs in the other twin in monochorionic type. .... may occur to the mother if the death twinis retained for one month or more. 1. - Twin-totwin transfusion syndrome, abnormal anastomoses inside their common placenta -Recepient twin, polyhydramnios -Donor twin, oligohydramnios

2. Cord entanglement

3. Death of one twin, DIC Management

1. Adequate supplements to the mother: ...... 2. Closer ..... and more frequent ...... 3. .... and management of complications. 2. follow up, antenatal visits 3. Screening Management of complications 1. iron, calcium, proteins, caloriesetc.

1. Gestational diabetes: ...... 2. Preterm labour: ....

Corticosteroids are adminstered in cases of ..... 1. diet control and insulin 2. -Calcium channel blockers. -Progesterone. -Cervical cerclage [debatable]. -Early treatment of vaginal infections.

preterm labour 26-34 weeks to enhance lung maturity of the fetuses. Delivery Delivery is preferred at .....

In cases of twin pregnancy with first fetus in ...., vaginal is allowed if there is no other indication for caeserian delivery.

In cases of higher order gestation or twin pregnancy with the first in ...., caeserian section is the choice. -full term -cephalic presentation -breech presentation Outcome

Increase in maternal morbidity due to ..... Increased neonatal morbidity and mortality due to .... hemorrhage and other complications. -increased operative interference, postpartum

-prematurity, low birth weight and congenital anomalies.