Multiple Pregnancy- COMPLICATION AND MANAGEMENT

• Prematurity is the main cause of increased mortality and morbidity in twins.
• Length of gestation tends to be inversely related to the number of fetuses. 
• The mean age at delivery for singletons is 38.8 weeks, for twins 35.3 weeks, for triplets 32.2 weeks, and for quadruplets 29.9 weeks. 
• The prematurity rate in multiple gestations is 5–10 times that of singletons, with 50% of twins and 90% of triplets born before 37 weeks.

Frequent complications associated with multiple pregnancy:

• Polyhydramnios
• Pregnancy-induced hypertension
• Premature rupture of membranes
• Abnormal fetal presentations
• Prolapsed umbilical cord

• They are always monozygous and same sex.
• Can be diamniotic or monoamniotic.
• They are risk for twin twin transfusion, congenital anomalies, neurodevelopmental problems, and cerebral palsy.

• They can be either dizygous or monozygous.
• Can have growth restriction due to abnormal placental implantation.
• They are not at risk for twin transfusion syndrome and have less risk for anomalies and neurodevelopmental problems than monochorial twins.

Ans. is c i.e. 25% with the larger twin as index

Unequal sizes of twin fetuses with a difference of 25% (larger twin being used as the index), is called as Discordant growth.

• It is a sign of pathological growth restriction in the smaller fetus.
• As the weight difference within a twin pair increases and the earlier the growth discordance is evident, perinatal mortality increases.
• Most common cause of discordance :

In dichorionic twins – unequal placental mass.

mr,nochnrinnic ftviriS – Twin – twin transfusion syndrome/Genetic syndrome

• Hazards of discordant growth. The smaller fetus is at increased risk of perinatal mortality due to :

Respiratory distress

Intra ventricular hemorrhage

–  Seizure

Sepsis

– Periventricular leukomalacia

Necrotising enterocolitis

At a difference of more than 30% – Risk of fetal death increases.

Extra Edge :

• Besides weight – other ultrasonographic parameters indicating discordance. Difference in Bipanetal diameter is 6 mm or more.

–   Difference in Head circumference is 5% or more.

–   Difference in Abdominal circumference is 20 mm or more. On colour doppler ultrasound in umbilical arteries systolic to diastolic (S/D) ratio difference -is 15% or more.

but amongst all cnterias best is Fetal weight difference i.e. more than equal to 25°

• Route of delivery : In case of discordant growth vaginal delivery is indicated if

–   Cervix is ripe

–   Presentation is vertex / vertex

–   Weight of smaller twin is > 1500gms

50%

Twin to twin transfusion

First baby – Vertex and second baby transverse lie

Cesarean section

Second twin in transverse lie position

Ans. is B. i.e. Oligohydramnios

Maternal complications of twin pregnancy:

• Anemia
• Pre-eclampsia (25%)
• Polyhydramnios (10%)
• Malpresentations
• Preterm labor (50%)
• Early rupture of membranes
• Prolonged labor
• Postpartum hemorrhage due to uterine atony
• Sub-involution of uterus
• Antepartum hemorrhage