MULTIPLE
GESTATION/PREGNANCY
DEFINITION
• When more than one fetus simultaneously
develops in the uterus then it is called multiple
pregnancy.
• Simultaneous development of two fetuses
(twins) is the commonest; although rare,
development of three fetuses (triplets), four
fetuses (quadruplets), five fetuses (quintuplets)
or six fetuses (sextuplets) may also occur.
Twins pregnancy
Varieties
• Twin pregnancy is the commonest variety of multiple
pregnancy.
• It is of two types:
1. Dizygotic twins (80%),which results from fertilization of
two ova leading to Fraternal twin or Binovular twins
2. Monozygotic twins(20%),which results from fertilization
of one ova leading to Identical twin or Uniovular twins.
Genesis of dizygotic twins
• Results from Fertilization of two ova, mostly
likely rupture from two distinct graafian
follicles usually of the same or one from each
ovary, by two sperms during single ovarian
cycle.
Cont…..
• There are two placentae either completely
separated or more commonly fused at the
margin
• Each fetus is surrounded by a separate
amnion and chorion.
• Sex of the fetus may differ.
• Genetic features (blood group, finger prints)
also differs.
Genesis of monozygotic
• The twinning may occur at different
periods after fertilization.
• If the division takes place within 72 hours
after fertilization the resulting embryos will
have two separate placenta, chorions and
amnions (D/D)
Cont…
• If the division takes place between the 4th and
8th day after the formation of inner cell mass
when chorion has already developed diamniotic
monochorionic twins develop (D/M)
• If the division after 8th day of fertilization, when
the amniotic cavity has already formed, a
monoamniotic monochorionic twins develop
(M/M)
Cont…
• Division after two weeks of davit of embryonic
disc resulting in the formation of conjoined twin.
Factors that Influence Twinning
• The causes of twin pregnancy is not known.
• Race: Highest amongst Negroes (once in every 20 births),
lowest amongst Mongols and intermediate among
Caucasians
• Heredity: Family history in mother.
• Maternal Age and Parity: Twinning peaks at age 37 years
• Increasing parity: 5th gravid onwards.
• Nutritional Factors: Taller, heavier women—twinning rate
25 to 30 % greater.
• Pituitary Gonadotropin
• Infertility Therapy
• Assisted Reproductive Technology
Diagnosis
History and Clinical Examination
• Recent administration of either clomiphene
citrate or gonadotropins or pregnancy
accomplished by ART are much stronger
associates.
• Clinical examination with accurate
measurement of fundal height.
Diagnosis contd…
In women with a uterus that appears large for gestational
age, the following possibilities are considered:
Multiple fetuses
Elevation of the uterus by a distended bladder
Inaccurate menstrual history
Hydramnios
Hydatidiform mole
Uterine leiomyomas
A closely attached adnexal mass
Fetal macrosomia (late in pregnancy)
Diagnosis contd…
Symptoms
• Minor symptoms of normal pregnancy
exaggerated. are often
• Increased nausea and vomiting in early months
• Cardio-respiratory embarrassment
• Tendency of swelling in the legs, varicose veins
and hemorrhoids is greater
• Unusual rate of uterine enlargement and
excessive fetal movements
Diagnosis contd…
General examination
• Prevalence of anemia is more.
• Unusual weight gain, not explained by
preeclampsia or obesity.
• Evidence of preeclampsia is a common
association.
Diagnosis contd…
Abdominal examination
Inspection: Barrel shaped and the abdomen is unduly enlarged
Palpation
Height of uterus > period of amenorrhoea
Girth of abdomen> normal average at term (100 cm)
Fetal bulk disproportionately larger in relation to the size of the fetal
head.
Palpation of too many fetal parts
Finding of two fetal heads or three fetal poles
Auscultation
• Two distinct FHS at separate spots, difference in heart rates is at least 10
beats/minute.
Diagnosis contd…
Investigations (Sonography)
• separate gestational sacs identified early
• Confirmation of diagnosis as early as 10th week of
pregnancy
• Variability of fetuses, vanishing twin in second trimester
• Chorionicity (twin peak sign)
• Pregnancy dating, Fetal anomalies
• Fetal growth monitoring, Presentation and lie of fetuses
• Twin transfusion localization, Amniotic fluid volume
Diagnosis contd…
Biochemical Tests:
• Levels of hCG in plasma and in urine are higher
• Maternal serum alpha-fetoprotein level:
Elevated
• Unconjugated oestriol: approximately double