MULTIPLE PREGNANCY

 “Development of more than one fetus in uterus in simultaneously

Types:-

(1) Monozygotic/Uni ovular/identical/true:-

Twins due to fertilization of single ovum by two sperm

(found 33% of all twins)

(2) Dizygotic/Bi-ovular:-

Twins due to fertilization of two ovum by two sperms

(67% of all twins)

Etiology:- Causes is not known

Predisposing factors:- MZ twins:-

Maternal factor

Environmental factor

DZ twins:- Highest among black Americans

Lowest in Mongols

Hereditary

Advancing age of mother (30 to 35 year)

Influence of parity

Drugs for induction of ovulation

Clinical Features:-

Increase weight gain

Increase cardiac out put

Increase plasma- volume

Increase nausea & vomiting

Unusual enlargement of uterus

Excessive fetal movement

Swelling of legs

Varicose vein & hemorrhoids

Palpitation

Despines

Anemia

Evidence of Pre – eclampsia

Diagnosis:-

(A) By History:-

Sign & Symptom of pregnancy 

Nausea & vomiting in early preg.

Palpitation or shortness of breath

Swelling of legs varicose vein

Excessive fetal movement

Anemia

(B) Abdominal examination:-

(1) Inspection:- Excessive enlargement

Becomes barrel shapes

(2) Palpitation:- Height of uterus is more than period of amenorrhea

Girth of abdomen at umbilical level is more

Palpation of too many fetal parts

Finding of two fetal head/ three fetal pole

(3) Auscultation:-

Hearing of two distinct FHS

Located at separate spots with a silent area in between

Investigation:- USG

Radiography

Bio-chemical test

Complications:-

(1) Maternal:- (i) Pregnancy

Nausea & vomiting

Anemia

Pre-eclsmpsia

Hydromnias

APH

Mal presentation

Pre term labour

Mechanical distress

(ii) Labour:-

Early rupture of membrane

Card prolapsed

Prolonged labour

IPH & PPH

(iii) Puerperium:-

Sub involution

Infection

Lactation failure

(2) Fetal:- sed miscarriage rate

Sed premature rate

Growth problem

Intra uterine death of one fetus

Anomalies- Hydrocephalous, cardiac anomalies

Asphyxias

Still birth

Locked twins

Vomiting twins

Management:-

(1) Antenatal Management:- 

 Diet

Rest

Iron 60-100 ml/day

Restrict activities

Frequent antenatal visit

Sonography every 3-4 weeks

Hospitalization

(2) During Labour:-

Delivery should be hospitalized

Bed rest

Need of skilled obstetrical

Sonography regular

Prevent early rupture of membrane

Continue fetal monitoring

Per vaginal exam to detect card prolapsed

Blood is arranged

Take help of neonatologist

(1) 1st baby delivery:-

(i) St Stage: - Enema

Diazepam (Orally with water)

Dextrose

Close maternal & fetal monitoring

Preparation of genital area

(ii)2nd stage:- Delivery of body is spontaneous

Timely episiotomy

Oxytocin drip- slow labour

On birth clamp the card to prevent bleeding

               Check body for lie presentation & face abdominally & vaginally

(2) 2nd Body delivery:-

Spontaneous delivery in case of longitudinal lie

Wait for 15-20 min.’s

Contractions will start again

Delivery occurs

Active management:- By inducing labor if contractions does not occur then

Artificial rupture of membrane

Start oxytocin drip

Indication for C.S:- No cephalic Presentation

Card Prolepses

Breech person station/transverse lie of IInd baby

Locked twins

Fetal distress

IIIrd Stage:- IV methargin

Expel placenta & membranes by controlled card traction

Examine placenta & membranes

Place sterile vulva pad

IV Stage:- Observe vitals uterine contractions & any abnormal vaginal bleeding

After delivery:-

Place preterm in NICU

Ensure clear airway

Maintain body temp.

Assess temp.

Don’t over expose babies

Rest

Prevent infection

Ask mother to wash hard before handling the baby