SHARDA SCHOOL OF NURSING SCIENCE AND RESEARCH

ASSIGNMENT
ON
MULTIPLE PREGNANCIES

SUBMITTED TO SUBMITTED BY
MS. NEHA BARARI VARSHA SINGH
ASSOCIATE PROFESSOR MSC NURSING 2ND YEAR
OBG & GYNECOLOGY 2023308897
SSNSR

SUBMISSION DATE-

DEFINITION OF MULTIPLE PREGNANCIES:

When more than one fetus simultaneously develops in the uterus, 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
Simultaneous development of two fetuses is the uterus is the commonest variety of multiple
pregnancy.
It is of two types:
1. Dizygotic twins (80%), which results from fertilization of two ova.
2. Monozygotic twins (20%), which results from fertilization of a single ovum.
GENESIS OF TWINS: Dizygotic twins 80% (Syn: fraternal, uniovular) result from fertilization
of two ova, most likely ruptured from two distinct Graafian follicles usually of the same or one
from each ovary, by two sperms during a single ovarian cycle. Their subsequent implantation and
development differ little from those of a single fertilized ovum. The babies bear only fraternal
resemblance to each other (that of brothers and sisters from different births) and hence called
fraternal twins.
In Monozygotic twins 20% (Syn: identical, uniovular), the twinning may occur at different
periods after fertilization and this markedly influences the process of implantation and the
formation of the fetal membranes.
On rare occasion, the following possibilities may occur:
• If the division takes place within 72 hours after fertilization (prior to morula stage) the resulting
embryos will have two separate placenta, chorions and amnions (diamniotic-dichorionic or D/D-
30%).
• 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-66%).
• If the division occurs after 8th day of fertilization, when the amniotic cavity has already
formed, monoamniotic- monochorionic twin develops (M/M-3%).
On extremely rare occasions, division occurs after 2 weeks of the development of embryonic
disc resulting in the formation of conjoined twin (<1%) called - Siamese twin. Four types of
fusion may copagus (commonest) (ii) Pyopagus (posterior fusion) (ii) Craniopagus (cephalic)
(iv) lschiopagus (caudal).
Zygosity refers to the genetic makeup of twin pregnancy and chronicity indicates the pregnancy's
membrane status.
DETERMINATION OF ZYGOSITY: With the advent of organ transplantation, the
identification of the zygosity of the multiple fetuses has assumed much importance.
• Examination of placenta and membranes:
Dizygotic twins: (i) There are two placentae, either completely separated or more commonly
used as the m appearing to be one (9 out of 10). There is no anastomosis between the two fetal
vessels (ii) Each fetus is surround separate amnion and chorion (iii) As such, the intervening
membranes consist of 4 layers-amnion, chorion chorion and amnion.
Monozygotic twins : The twinning may occur at different periods after fertilization.
• If the division takes place within 72hours after fertilization (prior to morula stage) resulting
embryos will have two separate placenta, chorion, amnions (diamniotic- dichorionic)
If the division takes place between 4th and 8th day after the formation of inner cell mass when
chorion has already developed - diamniotic monochorionic twins develop.
• If division occurs takes place after 8th day of fertilization when amniotic cavity has already
formed (monoamniotic monochorionic twins)
• Division after two weeks of davit of embryonic disc resulting in the formation
of conjoined twin

INCIDENCE: The incidence varies widely. It is highest in Nigeria being 1 in 20 and lowest in
Far eastern countries being 1 in 200 pregnancies. In India, the incidence is about 1 in 80. While
the incidence of monozygotic twins remains fairly constant throughout the globe being 1 in 250,
it is the dizygotic twins which are for the wide variation of the incidence.

RISK FACTORS OF TWIN PREGNANCY

1. Increasing maternal age (30-35yrs)
2. Increasing parity (5 gravida onwards)
3. Nutritional factors
4. Pituitary gonadotropin
5. Infertility therapy
6. Assisted reproductive therapy
7. Genetic, hereditary
8. Race, b>w
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
Assisted Reproductive Technology
Terms
 Superfecundation is fertilization of two ova produced in the same menstrual cycle by
two spermatozoa deposited in two separate acts of coitus
 Superfetation is fertilization of two ova produced in two different menstrual cycles by
two separate spermatozoa. The development of one fetus over another fetus is possible
theoretically until the decidual space is obliterated until 12 weeks of pregnancy.
 Fetus acardiacus occurs only in monozygotic twins. Part of one foetus remains
amorphous and becomes parasitic without a heart.
 Vanishing twin serial USG imaging in multiple Pregnancy since early gestation has
revealed occasional death of one foetus and continuation of pregnancy with the
surviving one. The dead foetus (If within 14 weeks) simply vanishes by reabsorption.
The rate of disappearance could be to the extent of 40%
Diagnosis
History
 Recent administration of ovulation inducing drugs esp. gonadotropins for infertility
or pregnancy accomplished by ART are much stronger associates.
 Family history of twinning specially on maternal side.
Symptoms
Minor symptoms of normal pregnancy are exaggerated. 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
General examination
 Prevalence of anemia is more
 Unusual weight gain, not explained by preeclampsia or obesity
 Evidence of preeclampsia is a common association.
Abdominal examination
Inspection: Barrel shaped and the abdomen is unduly enlarged
Palpation
Height of uterus > period of amenorrhea
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
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/lambda sign)
• Pregnancy dating, Fetal anomalies
Fetal growth monitoring, Presentation and lie of fetuses
• Twin transfusion, placenta localization, Amniotic fluid volume.
Biochemical Tests:
 Levels of hCG in plasma and in urine are higher
 Maternal serum alpha-fetoprotein level: Elevated
 Unconjugated oestriol: approximately double

Complications
Maternal
During pregnancy
 Nausea and vomiting
 Anemia
 Pre-eclampsia (25%)
 Hydramnios (10%)
 Antepartum hemorrhage
 Malpresentation
 Preterm labour (50%)
 Mechanical distress
During labour
 Early rupture of membranes and cord prolapse
 Prolonged labour
 Increased operative interference
 Bleeding after the birth of first baby
 Postpartum hemorrhage
During puerperium
 Sub involution
 Infection Lactation failure
 Foetal Miscarriage
 Prematurity (80%)
 Growth problem (25%)
 Intrauterine death Asphyxia and still birth
 Foetal anomalies

Complications of mono chorionic twins

1)Twin-twin transfusion syndrome (TTTS) - It is a clinicopathological state exclusively met
with in monozygotic twins, where one twin appears to bleed into the other through some kind of
placental vascular anastomosis. Clinical manifestation of twin transfusion syndrome occur when
there is hemodynamic imbalance due to unidirectional deep arteriovenous anastomoses. As a
result the receptor in becomes larger with hydramnios,polycythemic,hyoertensive and
hypervolemic at the expense of the donor twin which becomes smaller with oligohydramnios
anaemic, hypotensive and hypovolemic The donor twin may appear "stuck" due to severe
oligohydramnios. Difference of haemoglobin concentration between the two, usually exceeds 5
gm% and estimated fetal weight discrepancy is 25% or more.

Management: Antenatal diagnosis is made by ultrasound with doppler blood flow study in the
placental vascular bed.(a) Repeated amniocentesis to control polyhydramnios in the recipient
twin is done. septostomy (making a hole in the dividing amniotic membrane). (c) Laser
photocoagulation to interrupt the anastomotic vessels on the chorionic plate can give some
success. (d) Selective reduction (feticide) of one twin is done when survival of both the fetuses is
at risk. The smaller twin generally has got better outcome. The plethoric twin runs the risk of
congestive cardiac failure and hydrops Congenital abnormalities (neural tube defects,
holoprosencephaly) are high (2-3 times).
(ii) Dead fetus syndrome-death of one twin (2-7%) is associated with poor outcome of the co-
twin (25%) specially in monochorionic placenta. The surviving twin runs the risk of cerebral
palsy, microcephaly, renal cortical necrosis and Dec This is due to thromboplastin liberated from
the dead twin that crosses via placental anastomosis to the living twin.
(iii) Twin reversed arterial perfusion (TRAP) is characterized by an 'acardiac perfused twin'
having blood supply from a normal co-twin via large arterio-arterial or vein to vein anastomosis
(Fig. 16.4B). In majority the co-twin dies (in the perinatal period) due to high output cardiac
failure. The arterial pressure of the donor twin being high, the recipient twin receives the 'used'
blood from the donor. The perfused twin is often chromosomally abnormal. The anomalous twin
may appear as an amorphous mass. Management of TRAP is controversial. Ligation of the
umbilical cord of the acardiac twin under fetoscopic guidance has been done.

Management
Antenatal management
The essence of successful outcome of a twin pregnancy is to make an early diagnosis. High
index of clinical suspicion and thorough ultra sound examination are the keys to the diagnosis. It
is useful to make early diagnosis and to detect Chorionicity, amniocity, fetal growth pattern and
congenital malformations

ADVICE:
• Diet: Increased dietary supplement is needed for increased energy supply to the extent of 300 K
Cal per day, over and above that needed in a singleton pregnancy. The increased protein demand
is to be met with
• Increased rest at home and early cessation of work is advised to prevent preterm labour and
other complications.
• Supplement therapy: (i) Iron therapy is to be increased to the extent of 100-200 mg per day. (ii)
Additional vitamins, calcium and folic acid (5 mg) are to be given, over and above those
prescribed for a singleton pregnancy.
• Interval of antenatal visit should be more frequent to detect at the earliest, the evidences of
anaemia. preterm labour or pre-eclampsia.

HOSPITALISATION:
•Routine hospital admission only for bed rest is not essential. However, bed rest even at home
from 24 weeks onwards, not only ensures physical and mental rest but also improves utero-
placental circulation. This results in-(1) increased birth weight of the babies (ii) decreased
frequency of pre-eclampsia (iii) prolongation of the duration of pregnancy.
To prevent preterm delivery, routine use of betamimetics or circlage operation has got no
significant benefit. Use of corticosteroids to accelerate fetal lung maturation is given (single
dose) to women with preterm labour <34 weeks. Twins develop pulmonary maturity 3-4 weeks
earlier than singletons.
• Emergency: Development of complicating factors necessitates urgent admission irrespective of
the period of gestation.

MANAGEMENT DURING LABOUR

Place of delivery: As the twin pregnancy is considered a 'high risk', the patient should be
confined in an equipped hospital preferably having an intensive neonatal care unit. Vaginal
delivery is allowed when both the twins are or at least the first twin is with vertex presentation
FIRST STAGE: Usual conduction of the first stage as outlined for a singleton fetus, is to be
followed with additional precautions:
• A skilled obstetrician should be present, An experienced anesthetist should be made available.
Presence of ultrasound in the labour ward is helpful. It makes both the external and internal
versions less difficult by visualizing the fetal parts.

• The patient should be in bed to prevent early rupture of the membranes.

Use of analgesic drugs is to be limited as the babies are small and rapid delivery may occur.
Epidural analgesia is preferred as it facilitates manipulation of second fetus should it prove
necessary.
• Internal examination should be done soon after the rupture of the membranes to exclude cord
prolapse
• An intravenous line with ringer's solution should be set up for any urgent intravenous
therapy, if required
Management of second stage of labour Twin
 Twin delivery should be undertaken/supervised by an obstetrician with adequate
experience
 Prepare room in advance:
 Twin delivery pack b. Instrumental delivery pack c. USS d. Oxytocin infusion
ready
The attendants should include:
a. Two midwives (One senior)
b. One HCA
c. The obstetric registrar and if required the consultant
d. Anesthetist
e. Two pediatricians
f. An ODA should be available immediately if required. (need not remain in the delivery room)
Prepare the mother. Keep her informed. Explain who will be present for delivery and their role.
Delivery of first twin with cephalic presentation can be undertaken by the attending midwife.
Indications for instrumental delivery are same as in singleton pregnancy. Twin 2 No specific time
interval needs to be set provided there is continuous electronic FHR monitoring which is
reassuring throughout.
1. Establish lie/presentation of 2nd twin by abdominal palpation, USS and vaginal examination.
Many transverse lies will correct themselves when the tone in the uterus returns after a period of
rest.
2. Ensure good fetal heart rate monitoring
3. Allow 5 to 10 minutes of rest for the mother.
4. If still transverse lie, perform external cephalic/podalic version and stabilize lie until
presenting part descends in the pelvis Internal podalicversion is hardly ever necessary; do not
attempt if you have never done this before!
5. If uterine contractions do not restart after 15-20’ commence a Syntocinon infusion @ 3mls/hr
after external version. .
6. Perform amniotomy if regular contraction and presenting part is in the pelvis. Thereafter
proceed to a vaginal delivery (cephalic or breech).
7. Do not haste, rush or panic in delivering second twin. As long as the fetal heart rate is
satisfactory, there is plenty of time for the second twin to place a suitable presenting part into the
maternal pelvis. In case of fetal heart rate deceleration of the second twin after birth of the first,
an immediate amniotomy is indicated, not a ‘crash’ section unless presenting part very high
8. The babies should be seen by the pediatricians immediately after birth.
Management of third stage of labour Once both the twins are delivered an appropriate
oxytocic should be given. Each placenta should be easily identified by suitably marked
instruments or by number of cord clamps. Deliver placentas by CCT. Observe for postpartum
hemorrhage. If epidural, watch for urinary retention.
Caesarean Section: Caesarean Section of multiple gestation presents anaesthetic and surgical
challenges due to the large uterus and the exaggerated physiological response to pregnancy.
Sometimes a vertical uterine incision is necessary when babies are in unusual or entwined
positions (discuss with consultant).

Management and Nursing Interventions

 Nutrition counseling
 Fetal evaluation
 Evaluate woman for signs and symptoms of obstetrical complication
 Preterm labor prevention: explain for hospitalization
 Encourage bed rest and hydration.
 Institute fetal monitoring and assist with tocolytic therapy, if ordered.
 Explain to the woman that mode for delivery depends on the presentation of the twins,
maternal and fetal status, and gestational age.
Intrapartum management

 Establish I.V. access

 Provide for electronic fetal monitoring for each fetus.
 Double setup is recommended for delivery.
 Availability of two units of crossmatched whole blood.
 I.V. access with large bore catheter.
 Surgical suite immediately available.
 An obstetrician and assistant experienced in vaginal births of twins.
  Best choice of anesthesia: epidural. Anesthesia provider capable of administering
general anesthesia.
 Neonatal team for each neonate present at birth for neonatal resuscitation.
 Pitocin induction/augmentation may be required secondary to hypotonic labor.
 Postpartum hemorrhage may occur due to uterine atony.
 Emotional support.
Nursing diagnosis
Anxiety
Deficient Knowledge Regarding High-risk Situation/Preterm Labor
Risk for Imbalanced Nutrition: Less/More than Body Requirements
Risk for Fetal Injury
Risk for Maternal Injury
Risk for Deficient Fluid Volume
Risk for Impaired Gas Exchange
TRIPLETS AND QUADRUPLETS
A triplet pregnancy produces three babies. The triplets may be identical, fraternal or mixed.
Being pregnant with triplets raises the risk of complications. Frequent checkups and specialized
care may lower this risk. The average pregnancy lasts 37 to 40 weeks when there’s one fetus. As
the number of fetuses increases, the duration of the pregnancy decreases. The average duration
for triplets is 32 weeks to 35 weeks.
Quadruplet pregnancy is a pregnancy state where four fetuses grow simultaneously inside a
mother's womb. Four fetuses developing in a womb is a challenge not only to the mother but to
the obstetrician who has to calculate every risk associated with such pregnancy.
Conclusion
It is the presence of more then one featus in the abdomen of the mother. Twin pregnancy is a
high risk one. Maternal and perinatal morbidity and mortality are significantly high compared to
a singleton pregnancy. Maternal risks such as hypertension and maternal mortality are 3- to 7-
fold higher in multiple pregnancies than in singleton pregnancies. Twin and triplet pregnancies
are associated with increased rates of IUGR, early pregnancy losses and premature delivery.

Summary
Multiple pregnancy often happens when 2 or more eggs are fertilized and implant in the uterus.
This is called fraternal twinning. These babies can be the same sex or the opposite sex. Fraternal
multiples are simply siblings conceived at the same time.
BIBLIOGRAPHY /REFERENCES
 Dutta D.C. Textbook of obstetrics, 8th edition Hiralal Konar; page no.200-
2011.
 Baskar Nimma, Midwifery and Obstetrical nursing, 2nd edition,
jaypee, New Delhi.
 Jacob Annamma, text book of midwifery and gynecological nursing, 3rd
edition, Jaypee, New Delhi.
 https://wisdom.nhs.wales/health-board-guidelines/swansea-bay-maternity-
file/multiple-pregnancy-antenatal-and-labour-management-of-abmu-
maternity-guideline-2017-pdf/
 https://www.slideshare.net/slideshow/multiple-pregnancy-
48053673/48053673
 https://www.sciencedirect.com/topics/medicine-and-dentistry/quadruplet-
pregnancy