Ghadeer Al-Shaikh, MD, FRCSC

Assistant Professor & Consultant

Obstetrics & Gynecology
Urogynecology & Pelvic Reconstructive
Surgery
Department of Obstetrics & Gynecology
College of Medicine
King Saud University
MULTIPLE PREGNANCY
Twin pregnancy represents 2 to 3% of all
pregnancies.
The PNMR is 5 times that of singleton
DIZYGOTIC TWINS
Most common represents 2/3 of cases.
Fertilization of more than one egg by more
than one sperm.
Non identical ,may be of different sex.
Two chorion and two amnion.
Placenta may be separate or fused.
Factors affecting its
incidence
Induction of ovulation, 10% with clomide and
30% with gonadotrophins.
Increase maternal age ? Due to increase
gonadotrophins production.
Increases with parity.
Heredity usually on maternal side.
Race; Nigeria 1:22 North America 1:90.
MONOZYGOTIC TWINS
Constant incidence of 1:250 births.
Not affected by heredity.
Not related to induction of ovulation.
Constitutes 1/3 of twins.
Results from division of
fertilized egg:
0-72 H. Diamniotic dichorionic.
4-8 days Diamniotic monochor.
9-12 days Monoamnio.monochor.
>12 days Conjoined twins.
MONOZYGOTIC TWINS

70% are diamniotic monochorionic.

30% are diamniotic dichorionic.

Determination of
zygosity
Very important as most of the complications
occur in monochorionic monozygotic twins.
During pregnancy by USS
Very accurate in the first trimester, two sacs,
presence of thick chorion between amniotic
memb.

Less accurate in the second trimester the

chorion become thin and fuse with the
amniotic memb.
Different sex indicates dizygotic twins.

Separate placentas indicates dizygotic twins

Determination of zygozity
After Birth
By examination of the MEMBRANE,
PLACENTA,SEX , BLOOD group .

Examination of the newborn DNA and HLA

may be needed in few cases.
Complications of Multiple
Gestation
Maternal Fetal
Malpresentation
Anemia
Placenta previa
Hydramnios
Abruptio placentae
Preeclampsia
Premature rupture of
Preterm labour the membranes
Postpartum Prematurity
hemorrhage Umbilical cord prolapse
Cesarean delivery Intrauterine growth
restriction
Congenital anomalies
Specific Complications in
Monochorionic Twins
TWIN-TWIN transfusion.
Results from vascular anastemosis between
twins vessels at the placenta.
Usually arterio (donor) venous (recipient).
Occurs in 10% of monochorionic twins.
TWIN-TWIN transfusion
Chronic shunt occurs ,the donor bleeds into
the recipient so one is pale with
oligohydraminose while the other is
polycythemic with hydraminose.

If not treated death occurs in 80-100% of

cases.
Possible methods of treatment:

Repeated amniocentesis from recipient.

Indomethacin.
Fetoscopy and laser ablation of
communicating vessels.
Other Complications in Monochorionic Twins:
Congenital malformation. Twice that of
singleton.

Umbilical cord anomalies. In 3 4 %.

Conjoined twins. Rare 1:70000 deli varies. The

majority are thoracopagus.

PNMR of monochorionic is 5 times that of

dichorionic twins(120 VS 24/ 1000 births)
Maternal Physiological
Adaptation
Increase blood volume and cardiac output.
Increase demand for iron and folic acid.
Maternal respiratory difficulty.
Excess fluid retention and edema.
Increase attacks of supine hypotension.
DIAGNOSIS OF MULTIPLE
PREGNANCY
+ve family history mainly on maternal side.
+ve history of ovulation induction.
Exaggerated symptoms of pregnancy.
Marked edema of lower limb.
Discrepancy between date and uterine size.
Palpation of many fetal parts.
 Auscultation of two fetal heart beats at two
different sites with a difference of 10 beats

USS

Two sacs by 5 weeks by TV USS.

Two embryos by 7 weeks by TV USS.
Antenatal Care
AIM

Prolongation of gestation age, increase fetal

weight.
Improve PNM and morbidity.
Decrease incidence of maternal
complications.
Antenatal Care
Follow Up

Every two weeks.

Iron and folic acid to avoid anemia.
Assess cervical length and competency.
Antenatal Care
Fetal Surveillance

Monthly USS.from 24 weeks to assess fetal

growth and weight.
A discordinate weight difference of >25% is
abnormal (IUGR).
Weekly CTG from 36 weeks.
Method Of Delivary
Vertex- Vertex (50%)
Vaginal delivary, interval between twins not to
exceed 20 minutes.

Vertex- Breech (20%)

Vaginal delivary by senior obstetrician
Method Of Delivary
Breech- Vertex( 20%)
Safer to deliver by CS to avoid the rare
interlocking twins( 1:1000 twins ).

Breech-Breech( 10%)
Usually by CS.
Perinatal Outcome
PNMR is 5 times that of singleton (30-50/1000
births).
RDS accounts for 50% 0f PNMR.2nd twin is
more affected.
Birth truma . 2ND twin is 4 times affected than
1st .
Incidence of SB is twice that of singleton.
Perinatal Outcome
Congenital anomalies is responsible for 15%
of PNMR.
Cerebral hemorrage and birth asphyxia are
responsible for 10% of PNMR.
Cerebral palsy is 4 times that of singleton .
50% of twins babies are borne with low
birth(<2500 gms.) from prematurity & IUGR.
INTRAUTERINE DFATH OF ONE
TWIN
Early in pregnancy usually no risk.

In 2nd or 3rd trimester:

Increase risk of DIC .
Increase risk of thrombosis in the a live one
The risk is much higher in monochorionic
than in dichorionic twins
The a life baby should be delivered by 32-34
weeks in monochorionic twins.
HIGH RANK MULTIPLE
GESTATION
Spontaneous triplets 1:8000 births.
Spontaneous quadruplets 1:700,000 births.
The main risk is sever prematurity .
CS is the usual and safe mode of delivary.
High PNMR of 50-100 / 1000 births
Thank you.
COMPLICATIONS OF MULTIPLE
PREGNANCY
A] MATERNAL:

1. Anemia due to increase demand.

2. Increase incidence of PET(5 times).
3. Polyhydramniose in monochorionic
monozygotic twins.
4. Increase incidence of premature labour.
5. Increase incidence of CS. And operative
delivary.
6. Increase incidence of placenta previa and
abruptio placenta.
7. Increase incidence of atonic postpartum
hemorrhage.
B] FETAL :
1. Increase perinatal morbidity and mortality.
2. Prematurity with or without rupture of
membrane.
3. Increase incidence of malpresentation.
4. Increase incidence of cord prolapse.

5. Higher incidence of IUGR.

6. Increase incidence of congenital anomalies.