multiple pregnancy

Multiple pregnancy

Assist.prof. Andrii Berbets

Multiple pregnancy

Multiple pregnancy involves more than one embryo (fetus) in any one gestation.

Two independent mechanisms may lead to multiple gestation:

• segmentation of a single fertile ovum (identical, monovular, or monozygotic)

• or fertilization of separate ova by different spermatozoa (fraternal or dizygotic)

BENSON & PERNOLL’SHANDBOOK OF OBSTETRICS AND GYNECOLOGY

Maternal complications

• anemia; • urinary tract infection; • preeclampsia-eclampsia, • hydramnios, • uterine inertia (overdistention);• hemorrhage (before, during, and after

delivery).

Fetal complications

• prematurity• fetal growth retardation• congenital anomalies (18% higher)• abnormal presentations• cord prolapse (5 times increased)• collision of twins• fetus-fetus tranfusion syndrome

Clinical findings

• A uterus larger than expected for the duration of pregnancy (4 cm than anticipated);

• Excessive maternal weight gain not explained by eating or edema;

• Hydramnios;• Iron deficiency anemia;• Maternal reports of increased fetal activity;

Clinical findings

• Uterus containing 3 large parts or multiple small parts;

• Simultaneous auscultation or recording of two fetal hearts varying 8 beats per min and asychronous to the maternal heart

• Ultrasound confirmation

Two-vertex twins presentation

One vertex and one breech presentation

Locked twins

Feto-fetal transfusion syndrome

• This condition affects approximately 1 in 5 (20%) of all twins that share the same placental mass (monochorionic).

• This is a highly pathological condition, which if untreated will lead to fetal or newborn death in excess of 95% of cases.

Feto-fetal transfusion syndrome

• The underlying abnormality is that the placenta contains vascular connections that connect the twins, in effect, making them connected together by a continuous blood supply.

Feto-fetal transfusion syndrome

• The vascular (blood supply) connection between twins within the placenta leads to a haemodynamic (blood flow) imbalance between the twins, with one, the recipient, having a relative high perfusion of blood and the other, the donor, being under perfused with blood.

Feto-fetal transfusion syndrome

Severity classification

• Stage 1. There is a difference in the amounts of amniotic fluid surrounding the twins. The recipient often is complicated by polyhydramnios (excess amniotic fluid with a maximum pool depth of around 8cms) and the donor is complicated by oligohydramnios (reduced amniotic fluid with a maximum pool depth of around 2cms).

Severity classification

• Stage 2. In addition to the discrepancy of amniotic fluid volumes, there is a difference in size between the two babies (the recipient is often larger than the donor).

Severity classification

• Stage 3. There are haemodynamic differences between the twins. The recipient has evidence of abnormal blood flow and right-sided heart strain. The donor often demonstrates absent or reversed blood flow in the umbilical arterial (cord) circulation.

• Stage 4. One twin shows signs of severe right-sided heart failure.

• Stage 5. One of twin has already died.

Feto-fetal transfusion syndrome

TreatmentFetoscopy and placenta laser ablation

Delivery

• Cesarean section is recommended for monoamniotic twins because of the 10% delivery loss from cord entanglement.

• Other standard indications for cesarean include: any birth number exceeding twins (e.g., triplets), or if the first twin is nonvertex.

• The first twin may be delivered vaginally if it presents by the vertex.

Delivery

• A vaginal examination immediately after the first delivery is performed to identify a possible forelying or prolapsed cord

Delivery

• If 2nd fetus has continued as a vertex, a second vaginal delivery may be performed.

Delivery

If the second fetus is anything but vertex there are three alternatives.

● Bringing the head into the inlet by external guidance (version); if successful, allows labor to proceed for another vertex vaginal delivery.

● Perform cesarean section● Complete a vaginal breech delivery

Delivery

• Rupture of the second sac (if present) is accomplished as late as possible to avoid prolapse of the cord.

Thank You!