MULTIFETAL PREGNANCY

AND COMPLICATIONS.
• DEFINITION
Multifetal pregnancy is the presence of two or
more fetuses in utero

INTRODUCTION:-

Twining has been recogniced for a longtime

even in the Bible times.

Twining is important socially ,economicaly,

traditionaly and in obstetrics.
• Socially ,it is a deviation from the normal more
so when it is triplet, quadriplets or quintiplets
Economically , multiple pregnancy destabilises
the finances of the existing children and parents
Traditionally ,Multiple foetuses are abomination
in some communities therefore they left in the
ant hill to die.

• In obstetric practrice,maternal morbidity and

mortality is raised.
• Also pregnancy wastage and perinatal morbidity
and mortality are increased

• INCIDENCE

The Incidence of multiple pregnancy varies

between races.
Hellen’s law of 1895 is usually qouted which states

that the frequency of twins is 1/89 births, triplets

1/892 quadruplets 1/893 and so on.
• In Asia the incidence is 1/150
• Cuacasians 1/80-1/90
• Negros 1/50-1/44
There are more dizygotic twins than
monozygotic twins.
The incidence of monozygotic twins is 1/250
and is the same all over the world.
• The ratio of dizygotic to monozygotic twins is 3
to 1 in general but in West Africa it is 6 to 1.
• Nylander reported the incidence of triplets
among Yorubas as 1.6 per 1,000 maternities in
Lagos while it is 2.15 peer 1,000 in UCH Ibadan.
• In UPTH Port Harcourt twining is 29 per 1,000
maternities i.e 1in 34 wile triplets is 1,3 per
1,000.
• Generally the incidence of multifetal pregnancies
has increased over the last 10 yeas due to wide
spread use of ovulation induction and invitro
fertilization for infertility
• AETIOLOGY
• Dizygotic twins are affected by:-
• Race – more in blacks than white or Asians
• Family history
• Age > 35 years
• High parity (related to age)
• Ovulation drugs
• Tall and fat women
• Social class does not affect twins
• Blood group O and A are prone to twining
caucasians
• Late ovulation in the late menstrual cycle
• Those who stop COC after long term use
(Due to rebound GNRH effect).
• MONOZYGOTICS:-
• Appear to the chance event.
• Not affected by above factors
• It is uniform all over the world 1:250
• Possibly noxious influences at the time of
early cleavage may be responsible.
• PATHOGENESIS
• Monozygotic Twin:-
• Single Ovum and Single Sperm fertilization and
division leads to twins of the same sex.
• The twins share the same physical characteristics –
skin, hair, eye colour, body build.
• Genetic features – blood group, M,N, Haptoglobin,
serum, histocompatibility genes.
• But finger prints defer.
• Monozygotic triplets –
• It is due to repeated twining also called super
twining of a single ovum.
• Trizygotic Triplets
• Develops by individual fertilisation of 3 ova.
• It could be twining of two ova and elimination of
one of the fourth twins.
• Dizygotic Twins (Fratanal Twins):-
• Two ova fertilised by two sperm cells
• The ova are released from separate follicles or
really from the same at the same time.
• Characters:-
• May be of the same sex.
• blood group may be different.
• 75% are of the same sex.
• Both male 45%
• Both female 30%
• OTHER FORMS OF MULTIPLE
• Dispermia fertilization of two ova of the same oocyte.
• Fertilization by one ovum by two sperms.
• Polar body twining
• Superfecundation in fertilization of 2 ova released at
about the same time, but they are fertilised by sperms
from two different intercourse. (Perhaps from two
different male partners).
• Superfetation is the fertilization of two ova released in
two different menstrual cycles. (this is impossible
because the corpus lutium formed will suppress
ovulation of the ovary 1 month later.
• PATHOLOGIC FACTORS ASSOCIATED WITH
TWINNING
• Greater demand for iron for the festus leads to Anacus.
• Placenta dipnema common because of large placenta
• Abruptio
• UTI
• PET and Eclampsia
• Uterine inertia
• PPH
• PLACENTA AND CORD:-
• Division prior to morular stage (3 days) after fertilization
leads to:-
• Complete Separation to 2 chorion, 2 amnions or may be
fused in 30%.
• Division after differentiation of tropholblast, but before
formation of amnion 4 – 8 days leads to single placenta,
• Monochroniom placenta prone to disease process due to
vascular anastomosis (twin --twin transmission)
• Arterioveinous anastomosis is the most serious.
• Valenmentous insertion is 7%
• Vasa praevia is possible
• plolage cord is common
FETAL:-
• Spontaneous Abortion
• Twice compare to singleton pregnancy
• Vanishing twins
• It is estimated that only 50% of altrasound diagnosed.
• Congenital Malformation
• It is twice as frequent compared to singleton pregnancy
• It is more in monozygotic twins
• Conjoint Twins
• Are describe by site of union
• By pyopagus – at the sacrum
• Thoracopagus – chest
• Craniopagus at the head
• Omphalopagus at the abdomen
• Curiously conjoint twins usually are females
• A fetus acardiacus is a paracytic monodygotic
without a heart.
• Fetus papyraceous is a small blighted and mumified
fetus is usually discovered at delivery.
• Prematurely is the major cause of neonatal death.
• Abnormal presentation and position is common
• IUGR
• 2/3 of twins have IUGR
• One or both twins may be affected IUGR is due to
placenta insufficiency
• IUGR is common in monozygotic
• Twin – twin transfusion
• Perinatal mortality
• X5 compare to singleton
• More in monodygotic due to prematurity
• Chromosomal abnormalities
• CLINNICAL FEATURES MULTIFETAL PREGNANCY
• Symptoms:-
• Exaggerated early pregnancy symptoms
• Severe pressure in the pelvis, backache, varicosities,
constipation, haemorroid
• Increased fetal activities
• Signs:-
• FH > GA by > 2 weeks
• Excessive maternal weight gain
• Polyhydramenius
• Elevated MSAFP
• Ballotmen of more than two fetal poles and multiple fetal
parts.
• Simultaneous recording of different fetal heart rate and
• DIAGNOSIS
• BASED ON HISTORY, CLINICAL FEATURES AND
INVESTIGATIONS
• INVESTIGATION
• HB and blood film to determine anaemia and the type
• Urinalysis
• FBS – to determine hypoglyceania or hyperglyceania
• Ultrasound scan – is the preferred imaging modality for
diagnosis as early as 4 weeks using the vaginal probe.
• DETERMINATION OF ZYGOSITY AND CHORONICITY
• ZYGOSITY
• Ultrasound scan will show the same sex. But if the
membrane separating the twin is more than 2 cm
then dizygotic twin is probable.
• Zygocity can also be determine by DNA from
• Amniotic fluid sampling
• Chorionic villa biopsy
• Fetal blood
• Chromosomal studies give 100%
• CHORIONICITY
• This can be determined by ultrasound which
relies on
• Fetal gender
• Number placenta
• And characteristics of the membrane and the
two amniotic sacs.
• In dichronic twins the inter twin membrane is composed
of a central layer of chronic tissue soundwich between
two layers of amnion called the lambda sign.
• Whereas in mono zygotic there is no chorion.

• DIFFERENTIAL DIAGNOSIS OF MULTIPLE

PREGNANCY
• Inaccurate date
• large fetus
• Polyhydraminous
• Hydatidiform mole
• Abdominal tumous eg uterine fibroid, Ovarian tumour,
distended bladder and full rectum.
• COMPLICATIONS
• Hyperemesis gravidarum, hypertension
• Pet, eclampsia, HELLP SYNDROME
• Diabetes
• APH
• Thromboembolism
• Manupulations and Operative Procedures