1. Introduction:

Multiple pregnancy is the term used when more than fetus is present in the uterus.

Incidence:(1:80)

• There is high incidence of multiple pregnancy among woman taking ovulation induction drugs.
• The incidence of monovular twins is the same in all races
• The incidence of binovular twins is influenced by:
  • Age.
  • Parity.
  • Hereditary biovular twins greater in negro.

1.1. UNIOVULAR:

• Developed from one ovum.
• Division may occur in early stage of segmentation or later when two germinal areas are formed.
• Same sex, gene & same blood group.
• Usually each twins has his own amnion & chorion but sometimes there is only one chorion but separated amniotic sacs.
• When the process of division of single germinal area incomplete some form conjoined twins may occur with many varieties.

1.2. BINOVULAR:

• From 2 separated ova.
• More common than uniovular twins.
• Same or different sex.
• Gene material is different.
• Separated placenta.
• Each fetus has its own amnion & chorion.

2. Diagnosis of twins:

• Family history of twins.
• Symptoms of early pregnancy are more pronounced (morning sickness).
• PIH is common.
• Abdomen is large with excessive fetal movement & chances of polyhydramnios are more common.
• Anemia (iron + folic acid) is more common.
• Edema of legs.

3. On examination:

• Uterus bigger than date.
• Multiple fetal parts are found (2heads, 2breeches).
• 2 fetal heart  sound are heard by 2 different examiner.

4. Investigation:

• Low Hb.
• Proteinuria.
• USS (is very diagnostic):
  • Vertex-vertex 45% (commonest).
  • Vertex-breech 37%.
  • Breech-breech 10%.
  • Vertex-transverse 5%.
  • Breech-transverse 2%.

5. Complications:

5.1. During pregnancy:

1. Congenital malformation.
2. Anemia.
3. Polyhydramnios.
4. PIH with eclampsia is more common.
5. IUGR.
6. Placenta praevia.

5.2. During labour:

1. Preterm labour.
2. Malpresentation.
3. PPH.
4. Cord prolapse.
5. Locked twins.
6. Increase perinatal mortality.

6. Management:

• More attention to the woman with twins to reduce chance of complications.
• Rest at home or in hospital.
• Good diet (iron & folic acid).
• Labour should be induced at 40wks.

LABOUR:

• 1^st stage:
  • Not prolonged.
  • Pain reliever  (epidural analgesia).
  • Monitoring CTG.
  • I.V. drip (glucose 5%-10%).
  • Oxytocin if delay occurs.
  • C/S if no progress.
  • Elective C/S if first twin is transverse or conjoined.

• 2^nd stage:
  • Spontaneous delivery of the first twin usually occurs without problem.
  • If delay occurs, forceps or vacuum extraction may be used.
  • Pediatrician should be present.
  • An episiotomy is necessary.
  • After delivery of the first twin the lie of the second twin should be ascertained.
  • If the lie is transverse ECV is performed then ARM & syntocinon rate increased.
  • If membranes are ruptured & the lie is transverse internal podalic version & breech extraction is done to deliver the second twins.
  • The cord should be double clamped.
• 3^rd stage:
  • Risk of PPH is high so observe pt.
  • Active management of 3^rd stage.
  • Syntocinon.