MULTIFETAL

PREGNANCIES

MULTIFETAL OR MULTIPLE
->PREGNANCY
Dizygotic 1 in 80
mothers age ,
parity,
family history
race
assisted reproduction technique,

-(ovulation)
-IVF more than one embryo transferred
->Monozygotic - 3-5 in 1000

 Dizygotic - fertilization of two ova during a single

ovulatory cycle

Monozygotic

- division of one fertilized zygote into two

- outcome of the monozygotic twinning process depends
on when division occurs

TYPES OF PLACENTATION

MONOZYGOTIC TWIN STAGES

OF DIVISION

DICHORIONIC DIAMNIOTIC
TWIN PREGNANCY
Ultrasound features

First trimester
Features supporting a DCDA pregnancy:
presence of two gestational sacs with a thick echogenic chorion
surrounding each embryo
a thick inter twin membrane
twin peak sign or lambda sign(The twin peak represents a wedge-shaped
projection of placental tissue extending above the fused chorionic surface
and separating the diamniotic, dichorionic intertwin membrane)
two yolk sacs may be seen
Second trimester
a finding of two different genders for each twin is a definitive feature for a
dizygotic pregnancy which in turn will invariably mean a DCDA pregnancy.

describes the triangular appearance of chorion insinuating

between the layers of the inter twin membrane

The drawing illustrates how the placenta can insert between the two sacs
producing the lambda sign

MONOCHORIONIC DIAMNIOTIC
TWIN PREGNANCY

Ultrasound features
First trimester
a thin inter twin membrane may be seen.(Inter-twin
membrane joins the uterine wall in a T shape.)
Second trimester
Findings noted on a 2nd trimester scan includes
often a single placenta is seen : differentiating from
a DCDA pregnancy
inter twin membrane
present : differentiating from a MCMA pregnancy
but appears very thin : differentiating from
a DCDA pregnancy (although this assessment
becomes increasingly difficult with the progression of
pregnancy)

Both embryos will share the chorion, the placenta will not
be able to infiltrate between the two gestational sacs
and the membrane insertion will have the T
appearance.

MONOCHORIONIC
MONOAMNIOTIC TWIN
PREGNANCY

Ultrasound features
First trimester
shows a twin pregnancy with a single gestational sac
there is no inter twin membrane : theoretically this
differentiates from a DCDA and MCDA pregnancy.

however, even in a MCDA pregnancy the intertwin membrane

may be difficult to see.
therefore non- visualisation of the intertwin membrane is not in
itself diagnostic.

Second trimester
Features noted on a 2nd trimester scan includes
specific to a MCMA pregnancy

there can be presence of cord entanglement :

there can be presence of cord fusion

PHYSICAL EXAMINATION
General:
1.

Sign of anemia (may exhibit pallor of extreme degrees)

2.

Sometimes may show high BP and proteinuria before twenty

weeks of gestation (early onset of preeclampsia). Check at
each antenatal appointment

Abdominal Examination:
3.

Uterus is more globular (in late pregnancy) and larger than

dates

4.

>2 poles

5.

2 Fetal heart beats(varying by at least 10bpm)

6.

Excessive maternal weight gain

ULTRASOUND FINDINGS
Confirmation test, nearly all multiple pregnancy are now

diagnosed in the first trimester by ultrasound

1.

Multiple fetuses

2.

Placentas: Number and site, fuse or separate (Placenta

previa more common in twin pregnancy)

3.

Zygosity

4.

Lie and presentation of twin

ULTRASOUND EXAMINATION
Offer women with twin pregnancies a first trimester ultrasound scan

between 11 weeks 0 days and 13 weeks 6 days to estimate age,

determine chorionicity
If monochorionic twin refer to hospital with feto-maternal services.
If dichorionic twin continue follow up at peripheral clinic and refer

to O&G specialist at 28 weeks.

Late/End 1st trimester u/s nearly 100% correct before 14 weeks
Label each twins from early of pregnancy so that serial growth

measures can be applied correctly to each twin.

Perinatal screening for:
-conjoined twins
-cardiac/cranial problems
-liquor volume

 In all hospitals in the state of Kedah, antenatal follow up is

done every 2 weeks, whereby a serial ultrasound scan is done

to determine fetal growth and well being.

SIGNIFICANT U/S FINDINGS:

1.

Dating of pregnancy crown-rump length measurement

2.

Chromosomal abnormalities- nuchal translucency

<3.4mm 95% chances of normal birth

3.

Structural abnormalities- Eg: Cardiac abnormalities . Do

an anomaly scan and growth scan

4.

IUGR: Estimate fetal weight using ultrasound from 20

weeks, difference of 25% or greater is clinically important

5.

Assessment of amniotic fluid : Polyhydramnios when

deepest vertical pocket >8cm. Oligohydramnios when
deepest vertical pocket <2cm

6.

Feto-fetal transfusion syndrome(FFTS) : start

diagnostic monitoring from 16 weeks. Repeat monitoring
fortnightly until 24 weeks. Weekly monitoring in twin
pregnancy with membrane folding or other early signs of
FFTS

MATERNAL
During

antenatal period

Anemia
Hyperemesis

gravidarum

Hypertension
Gestational

diabetes mellitus
Pre-eclampsia
Antepartum hemorrhage
Malpresentation
Polyhydramnion
Pre-term labour

During labour
Early Rupture of Membrane
Cord prolapse
Postpartum haemorrhage

During puerperium (as that time

taken for a women to have

returned physiologically ,to her
non-pregnant state)
Infection
Failing lactation

FETAL
Miscarriage
Prematurity
Intrauterine death usually seen in cases of

monoamniotic twin as intertwining of their umbilical cord

causes death
Intrauterine growth restriction
Congenital abnormalities
Twin-to-twin transfusion
malpresentation

MANAGE
MENT

Ultrasound examination
Multiple foetuses
Multiple placenta
Twin peak sign

ANTENATAL PERIOD
Steps for prevention of preterm

labour
Bed rest
Administration of tocolytic agents
Regular monitoring of uterine activity

Increased daily requirement for

dietary calories, proteins and

mineral supplements
Increased frequency of antenatal

visit.
Increased fetal surveilance

INTRAPARTUM PERIOD
Management at the time of delivery
Delivery of the first baby
Conducted according to the guidelines for normal pregnancy
Ergometrine is not to be given at the birth of the first baby.
Cord of the first baby should be clamped and cut

Delivery

of second baby
An abdominal and vaginal examination
should be performed-to confirm the lie
,presentation of the second baby.

 External version-can be attempted at the time of

abdominal examination ,in case the lie is transverse.

Vaginal examination also helps in diagnosing cord

prolapse.

MANAGEMENT OF THIRD STAGE

OF LABOUR
IV syntocinon should be administered with the

delivery of the anterior shoulder of 2nd twin

Oxytocin drip can be continued for about 1hr

following delivery
Delivery of placenta must be by controlled cord

traction
Blood transfusion-in case of excess blood loss.

MODE OF DELIVERY
A twin pregnancy does not mean that your only option for giving birth is a Cesarean section. The
best mode of delivery depends on a variety of factors, including:
The type of twins
Fetal positions
Gestational age
Fetal size
The obstetric care providers experience

Monoamniotic-monochorionictwins should always be delivered by Cesarean section.

This avoids umbilical cord complications for the non-presenting twin at the time of the first twins
delivery.
In uncomplicated dichorionic diamnioticand monochorionic-diamniotic pregnancies between
32-38 6/7 weeks with one twin in a vertex position (head down, pointing toward the birth canal),
a planned Cesarean delivery did not decrease the risk of fetal or neonatal death, or serious
neonatal morbidity, compared with a planned vaginal delivery.
A woman carrying Di-Di or Mo-Di twins may be a good candidate for a vaginal birth if:
One twin is in a vertex position.
Your obstetric care provider has experience delivering twins and with vaginal breech delivery of

TIMING OF BIRTH FOR

DICHRORIONIC TWIN PREGNANCIES
Women having spontaneous preterm birth and elective preterm

birth are in increased risk of admission to a special care baby unit.

Women with uncomplicated pregnancies wherein elective birth

from 37 weeks 0 days do not appear to be associated with an

increased risk of serious adverse outcomes.

Continuing uncomplicated twin pregnancies beyond 38 weeks and

0 days increases the risk of fetal death.

Uncomplicated pregnancies mothers should have elective birth

from 37 weeks 0 days.

For women who decline elective birth , offer weekly appointments

with the specialist obstetrician. .At each appointment offer

ultrasound scan and perform weekly biophysical profile
assessments and every 2 weeks for fetal growth scans.

TIMING FOR MONOCHORIONIC

TWIN PREGNANCIES
Women having spontaneous preterm birth and elective

preterm birth are in increased risk of admission to a

special care baby unit.

Women with uncomplicated pregnancies wherein elective

birth from 37 weeks 0 days do not appear to be

associated with an increased risk of serious adverse
outcomes.

Continuing uncomplicated twin pregnancies beyond 38

weeks and 0 days increases the risk of fetal death.

Offer women with uncomplicated pregnancies elective

birth from 36 weeks 0 days after a course of antenatal

corticosteroids has been offered.

 Intrapartum management
Management of First stage labour
1. A twin CTG machine should be used for fetal monitoring
2.
3.

4.

5.
6.

and a portable ultrasound machine

Blood should be taken for group and save,as significant
blood loss is more likely in multiple pregnancy
Cont.electronic fetal heart rate montoring should be done.
An abnormal fetal heart rate pattern in the first twin may be
assessed using fetal scalp electrode
A standard oxytocin solution for augmentation should be
prepared, run through an intravenous giving set and clearly
labelled for augmentation for use for delivery of the second
twin, if required.
A second high-dose oxytocin infusion should also be
available for the management of PPH
Epidural analgesia is recommended for intrauterine
manipulations for delivery of second twin

 Management of Second stage of labour

1. After delivery of the first baby label,clamp and cut the

cord as normal
2. Palpate the maternal abdomen,ensure longitudinal lie,
syntocinon should be commenced
alert:maternal contraction may cease after the first
delivery ,majority of second twins will be delivered
within 15 mins
3. If fetal lie is longitudinal with a cephalic presentation ,one
should wait until the head is descending and then perform
amniotomy with a contraction.
4. can add oxytocin infusion if no contration and if needed
intrumental delivery can be done in certain cond.
5. if the second twin is non vertex,the membranes can be
ruptured once the breech is fixed in the birth canal.A total
breech extraction may be performed if fetal distress occurs or
if footling brech is encountered, but requires expertise.
6. If fetus is transverse, external cephalice version can be
done.If unsuccessful internal podalic version can be done.
7. Non-vertex first twin recommend elective Caeserean section.