SHRI SHANKARACHARYA COLLEGE

OF NURSING HUDCO BHILAI

SEMINAR
ON
Subject-Obstetrical and gynecology
Topic- Multiple pregnancy
Submitted to Submitted by
Mrs Saumya Thomas Miss Monalisa kujur
Associated professor msc nursing final year
(SSCN)
 MULTIPLE PREGNANCY

Introduction-
Definitio
n
“Multiple pregnancy Is when more than
one fetus simultaneous develop in the
uterus ,it is called multiple pregnancy.”
Acc.to Dc
Dutta

“When there is more than one fetus is in

utero, at term ,plural or multiple
pregnancy is applied”.
Acc. To Nisha
Clement
Incidence
The incidence widely varies, In the word it varies
from 56 to 46 per 1000 births.
 Itis highest in Nigeria being 1 in 20 and lowest
in eastern countries being 1 in 200 pregnancies
.
 In India , the incidence is about 1 in 80.
 While the incidence of monozygotic twins
remains constant throughout the globe ,being
1 in 250.it is the dizygotic twins which are
responsible for the wide variation of incidence.
 Since the 1980 s there has been a rise in
incidence due to increased use of various kind
of treatments for infertility
 Twin
pregnancydevelopment of two fetus in
Simultaneous
the uterus is most common variety of
multiple pregnancy.
Varieties of twins
Dizygotic twins(Binovular )
Monozygotic twins(Uniovular)
Verities of monozygotic
twin
Siamese twins ,four type of fusion may occur

1) Thoracopagus (most common)

2.Pyogagus (posterior fusion)
3.Craniopagus(cephalic )
4)Rachipagus(dorsal)
Etiology
 The causes of twining is not known
 Prevalence of dizygotic twins is related
to-
 Race
 Hereditary
 Advancing age of mother
 Influence of parity
 Iatrogenic
Sings and symptoms
1.Size of the uterus
2.Pressure symptoms
3.Anemia
4.Edema
5.Pre eclamptic Toxemia
6.Malposition
Physiological
Adaptation
Weight
 Increase cardiac output
 Increase GFR
 Increase tidal volume
Some other condition
 Superfecundation
 Superfetation
 Fetus papyraceous or compression
 Fetus a cardiac .
 Vanishing twin.
 Zygocity and chorionicity
 Zygosity refers to the genetic meckeup of the
pregnancy and chronicity refers to the
placental membrane status.
 Determination of chorionicity is essential as
the obstetrical and perinatal
risks,management and outcome depends on
it.
 Chorionicity is determined by timing of
embryo division.
Determination of chorionicity
in monozygotic twin pregnancy

Timing Placenta’s membrane

%of
of status
monozyg
cleavag
otic
e
twins

72 hours Diamniotic –Dichorionic 25-30

Days 4-7 Diamniotic - 70-75
monochorionic
Days 8-12 Monoamniotic- 1-2
monochorionic
Summary of determination of zygosity

Zygosity Placenta Communi Interveni

cating ng
vessels membran
e and
thickness
Monozygosit 1 present 2(amnions
y )
(<2mm)

Dizygotic 2 Absent 4(2amnion

and 2
chorions)
(<2mm)
 Summary of the determination zygosity

Zygosity Sex Genetic Skin Follow-up

features grafting
(dominant
blood group,
DNA
fingerprint)
Monozygo Always same accept Usually
tic identical identical

Diazygoti May differ Deferent Reject Not

c identical
Diagnosi
s
 History
 History of ovulation including drugs specially
gonadotropins ,for infertility or use of ART.
 Family history of twining .
 Symptoms
Minor ailment of normal pregnancy are aften
exaggerated .Some of the symptoms are related to
the under enlargement of the uterus-
 Increased nausea and vomiting in early months.
 Cardiorespiratory embarrassment which is
evident in the later months such as palpitation
or shortness of breath .
Continue….
 Swelling of the legs, varicose veins and haemorrhoids
is greater.
 Unusual rate of abdominal enlargement and excessive
fetal movements may be noticed by an experienced
parous mother.

 General examination
Inspection: The elongated shape of a normal pregnant
uterus is changed to a barrel shape and the
abdomen is unduly enlarged . Continue……
 Palpation
 The Hight of the uterus is more than the period of
amenorrhea.
 The abdominal girth of the abdomen at the level
umbilicus is more than normal average at term.
 Palpation of too many fetal parts .
 Auscultation

Simultaneous auscultation of two distinct fetal heart

sound located at separate spots a with silent area in
between by two observers, gives a certain clue in the
diagnosis of twins ,provided the difference the in the
heart rates is at least 10 beats per minute.
The abdominal palpation and auscultations may
not be carried out so easily ,as described ,because of the
presence of hydramnios.
 Biochemical test

 Sonography
In multifetal pregnancy it is done to obtain the
following information:
 Confirmation of diagnosis as early as tenth week
of pregnancy.
 Viability of fetuses as vanishing twin in the
second trimester.
 Chorionicity
 Pregnancy dating
 Fetal anomalies
continue…..
 Presentation and lie of the fetuses
 Twin transfusion (Doppler studies)
 Placental localization
 Amniotic fluid volume
Radiography
It is done less often these days .Two fetal heads and spines
could be seen on x-ray.
Chorionicity of the placenta
 It is best diagnosed by ultrasound (TVS)at 11-14 weeks of
gestation .
 In dichorionic twins there is a thick septum
(>2mm)between the two gestational sacs. It is best
identified at the base of the membrane ,where a triangular
projected is seen .
 This is known as lambda or twin peak sign .Presence of
lambda or twin peak sign indicates dichorionic
placenta.
 Presence of one gestational sac with a thin
(<2mm)dividing membrane ,and two fetuses (T
sign )suggests monochorionic diamniotic pregnancy.
Complications
A)Maternal
 Pregnancy
 Labor
 Puerperium
 Pregnancy
 Nausea and Vomiting
 Anemia
 Pre eclampsia
 APH
 Preterm Labor
 Mechanical distress
 During labor
 Early rupture of membranes
 Prolonged labor
 Increase Operative interference
 Bleeding
 PPH

 During Puerperium
 Subinvolution
 Infection
B)Fetal
 Miscarriage
 Premature Baby
 Discordant twin
 Intrauterine death of fetus
Complication of monochorionic twins
1.Twin –twin transfusion syndrome(TTTS)
2. Dead fetus syndrome
3.Twin reversed arterial
perfusion(TRAP)
Conjoined twin
 Manageme
1.nt
Laser photocoagulation
2.Repeated amniocentesis
3.Septostomy
4.Selective reduction
Management of multiple
pregnancy
 The essence of successful outcome of a twin
pregnancy is to make an early diagnosis.
 High index of clinical suspicious and through
ultrasound examination are the keys to the
diagnosis.
Antenatal management
Advice
 Diet
 Increased rest
 Supplementary
 Interval of antenatal visit.
 Fetal surveillance
 To prevent preterm delivery ,routine use of
tocolytics, progesterone therapy or cerclage
Operation has got no significant benefit.
 Corticosteroid (Betamethasone
/Dexamethasone )fetal lung maturation is given to
the women with preterm labor less than 34 weeks.
 Prolongation of pregnancy beyond 39 weeks increase
the risk.
Emergency-Development of complicating factors
necessitates urgent admission irrespective of the
period of gestation
Indication of cesarean section
The indication are broadly divided into:
 Obstetric indications
 For twins
Obstetric indications
• Placenta previa
• Severe pre –eclampsia
• Previous cesarean section
• Cord prolapse of the first baby
• Abnormal uterine contraction
• Contracted pelvis
For twin
• Both the fetuses or even the first
fetus with nanocephalic
presentation.
• Twins with
complication:IUGR,conjoined
twins.
• Monoamniotic twins
• Monochorionic twins with TTTS.
 Management during labor

Place of delivery- Patient should be

confined in an equipped hospital preferably
having an intensive neonatal care unit .
Frist stage :Usual Conduction of the first
stage as outlined for a singleton fetus ,is
followed with additional precaution.
• Skilled obstetrician should be present .
• Neonatologist (two)should be present .
• Presence of ultrasound in the labor ward.
• The patient should be in bed .
• Use of analgesic drugs .
• Careful fetal monitoring .
• Internal examination should be done.
• Intravenous line with ringer’s solution should be set up
for any intravenous therapy if required .
Delivery of the first baby
• Extended episiotomy under local infiltration with 1%
lignocaine.
• Forceps delivery if needed .
• Not to give intravenous ergometrine with the delivery
of the first baby.
• Clamp the cord at two places and cut in between.
• The baby is handed over to the nurse after it as
labelling it as number 1.
Delivery of the second twin
Step 1
 Following the birth of the first baby the lie
presentation size and FSH of the second baby
should be ascertained by abdominal examination
or if required by real time ultrasound .
 Vaginal examination is also to be made not only to
confirm the abdominal findings but to note the
status of membranes and exclude cord prolapse .
Lie longitudinal
Step 1
• Low rupture of the membranes is done after
finding the presenting part on the brim.
Step 2
• If the uterine contraction is poor ,5 unit of
oxytocin is added to the infusion bottle.
• The interval between deliveries should ideally
between less than 30 minutes.
Step -3
If there is still a delay interference is to be done.
 Vertex:
• Low down-forceps are applied
• High up –ventose or external version
 Breech: The delivery should be completed by
breech extraction.
 Transverse lie
• It should be corrected by external
version into longitunal lie preferably
cephalic ,if fails podalic .
• If the external version fails ,internal
version under general anaesthesia
should be done.
Indication of urgent delivery of the second
baby
 Sever vaginal bleeding
 Cord prolapse of the second baby
 Inadvertent use of intravenous
ergometrine(oxytocies)with the delivery of the first
baby.
 Frist baby delivered under general anesthesia
 Appearance of fetal distress.
Management of the third stage
• Administration of 0.2 mg methergine IV or Oxytocin
10 IU IM following the delivery of the second baby.
• The placenta is to be delivered by controlled cord
traction.
• The oxytocin drip for at least 1 hour, following the
delivery of the second Baby.
• A blood loss more than average should be
immediately replaced by blood transfusion .
• The patient is to be carefully watched for about 2
hours after delivery .
• Mother should be given additional support at home
to look after both the babies.
Management of difficult cases of twins
 Interlocking
The most common one being the after coming head
of the first baby getting locking with fore coming head
of the second baby.
• Vaginal manipulation to separate the chins of the
fetuses is done ,failing which caesarean section is
necessary .
• Decapitated head ,followed by delivery of the second
baby and lastly ,delivery of the decapitated head ,at
least saves one baby.
•
 Two heads of both vertex twins get locked at
the pelvic brim preventing engagement of
either of the head .
• The possibility should be kept in mind and the
diagnosis is confirmed by intranantal
sonography.
• Disengagement of the higher head can be
possible under general general anaesthesia .
If fails ,cesarean section is the
alternative ,for fetal intraction.
• If fails ,cesarean section is the alternative ,for fetal
intraction.

Conjoined twins
It is extremely rare incidence varies from 1:100,000 to
1:50,000
Births . In twin pregnancies the incidence is from 1:900 to
1:650.
Diagnosis
 Unfortunately conjoined twins are often diagnosed during
delivery when there is obstruction in the second stage .
 Using USG ,early diagnosis can be made with the presence of
monochorionic /monoamniotic sac.
 Fetal echocardiography ,colour doppler ,MRI are useful to
assess the degree of organ sharing specially the heart .
Antenatal diagnosis
Antenatal diagnosis is important .Benefits are-
• Reduce maternal trauma and morbidity
• Improves fetal survival
• Helps to plan the method of delivery
• Allows time to organize the pediatric surgical team.
Management
• Extent and site of union
• Possibility of surgical separation .
• Size of the fetuses and possibility of survival and
termination of pregnancy is an option when early
diagnosis has been made.
• Termination of pregnancy is an option when early
Triplets quadruplets etc
• Triplets may develop from fertilization of a single ovum
or two or even three ova ,similar single ovum or two or
even three ova ,similar with quadruplets and
quintuplets .female fetus usually outnumber the male
one.
• Clinical course and complication are intensified
compared to twins.
• Preterm delivery is common usually delivery occurs
anytime between 35 and 36 weeks.
• Discordance of fatal growth is more common than twin .
• Average time for delivery is quadruplets is 30-31
weeks.
• To improve the fetal salvage ,especially in
quadruplets ,it is advisable to employ liberal caesarean
section.
Selective reduction
• If there are 4 or more foetuses ,selective reduction of the
foetuses' leaving behind only two is done to improve
outcome of the co fetuses.
• It can be done by intracardiac injection of potassium
chloride
between 11 and 13 weeks under ultrasonic guidance. It
is done
transabdominally .
• Umbilical cord of targeted twin is occluded by fetoscopic
ligation
or by lesser or by bipolar coagulation to protect the co-
twin from adverse drug effect .
Selective termination
• Selective termination of a fetus with structural or
genetic abnormality may be done in dichorionic
multiple pregnancy in the second trimester by
intracardiac injection of postassium chloride .
• In monochorionic twins ,cord occlusion or cord
ablation is done(lasser).
 Nursing
management
Antenatal care
 At 32 bed rest to be maintained
 During labor bed rest ,respiratory support ,enema
giving ,rupture of membrane is done ,vaginal
examination to exclude prolapse of cord
 In
locke twins there have to sacrifiece the frist
baby.
 Ceasrean section .
 Thirdstage prophylactic intravenous methargin
given immediately on birth of second baby.
 Pediatric care
 Brest feeding