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Multiple Pregnancy

Presented by

Varsha Sharma

MSc. Nursing 2nd year





IncidenceHellin’s Law – Twin = 1:!

Tri"le#s = 1:!$

%uadru"le#s =1:!&

M'n'(yg'#ic = )*+,1!!! -ir#hs

i(yg'#ic = /aries de"ending'n ma#ernal age0 race and

ge'gra"hical dis#ri-u#i'n



e#i'l'gy

ssis#ed re"r'duc#i'n #echniues

Increase "ari#y

Increase ma#ernal age

3amily his#'ry4re/i'us mul#i"le "regnancy

5rican race



"regnancy

1. i(yg'#ic , -in'/ular , 5ra#ernal

2. M'n'(yg'#ic , 6ni'/ular , iden#ical



Monozygotic / Uniovular /Identical

Dizygotic / binovular /fraternal

1.1,) #wins

2. 1 s"erm and 1 '/um

).Iden#ical

7. Ty"e '5 "lacen#ade"ends 'n #he #ime '5s"li##ing '5 em-ry'+.Incidence isinde"enden# '5 race0age0 "ari#y

1.2,) #wins

2. 2 s"erms and 2 '/a

). ich'ri'nic

iamni'#ic #wins

7. 2 se"ara#e "lacen#a"resen#

+. Incidence isde"enden# '5 race0 age0"ari#y0 and '/ula#i'n

inducing drugs





twins

1.ich'ri'nic iamni'#ic :

i. i/isi'n 'ccurs wi#h in 82 hrs '5 5er#ili(a#i'n

ii.May ha/e 2 di9 "lacen#as, single 5used

"lacen#aiii.icul# #' di9eren#ia#e 5'rm di(yg'#ic #wins

i/.;'#h -a-ies ha/e same se<

2.M'n'ch'ri'nic iamni'#ic:I. i/isi'n 'ccurs wi#h in 7 – days '5

5er#ili(a#i'n



). M'n'ch'ri'nic M'n'amni'#ic:

I. i/isi'n 'ccurs *12 days '5 5er#ili(a#i'n

7. >'n?'ined #wins:I. i/isi'n 'ccurs a5#er 1)#h day

II. Inc'm"le#e di/isi'n '5 em-ry'nic disc

III. Ty"es: *#h'rac'"agus

* 'm"hal'"hagus

*crani'"agus

*"y'"agus

*ischi'"agus



Clinical presentation

Symptoms • @ nausea0 /'mi#ing

• @ "ressure sym"#'ms:

c'ns#i"a#i'n0 "edal edema0 /aric'si#y '5 /eins0"al"i#a#i'ns0 "rec'rdial "ain

• 3a#igue0 indiges#i'n0 -acAache0 slee"lessness

• H,B '/erdis#ensi'n

• H,B "rema#ure la-'r• C<cessi/e 5e#al m'/emen#s

• 3undal heigh# 0 H,B '/ula#i'n inducing drugs



SI!"S • nemia

• Cdema

• -n'rmal Deigh# Eain

• 6#erine Heigh# F 4BE

I# may -e n'rmal si(e in case '5 -in'/ular #wins, when1 '5 #he -a-ies die in u#er'

Palpation

3eel 2 se"ara#e heads, F 2 "'les#uscultation

2 3HS wi#h di9erence '5 a# leas# 1! -ea#s heard 'n 2sides '5 u#erus -y 2 "e'"le0 a# leas# G inches away



'le '5 ul#ras'und

>'nrma#i'n '5 ch'ri'nici#y Twin "eaA sign , Lam-da sign = dich'ri'nic

"lacen#a

Iden#i5y #he num-er and si#e '5 "lacen#a0 5use'r se"ara#e

Lie and "resen#a#i'n '5 #win

mni'#ic Juid assessmen#











In#ra"ar#um c'm"lica#i'ns

4BM K c'rd"r'la"se

-ru"#i'n in #he2nd #win

In#erl'cAing '5#wins







Twin #' Twin Tras5usi'n Syndr'me



T$I"% T$I" T&#"S'USI("

S)"D&(M*



r#eri' /en'us anas#'m'seswi#h ne# J'w in 'ne direc#i'n..

Donor+arterial side,

recipient

•Se/ere I6E•"''r renal

"er5usi'n•nuria•se/ere'lig'hydramni's

•Hy"er/'lemia•4'lyuria wi#h"'lyhydramni's•>>3dea#h



Vanishing #win

>essa#i'n '5 cardiacac#i/i#y in a "re/i'usly/ia-le 5'e#us

Fetus

papyraceous…







>'rd en#anglemen#





Single 5e#al demise

m'n'ch'ri'nic

ea#h '5 'ne

#win

S-ift of bloodN'rmal#win

.0 ris1 of co%twin deat- /.0 ris1 ofneurological damage in surviving twin



>'ngeni#al an'malies

Structuralmalformations

C-romosomalanomalies

>'n?'in# #winscardiac 5e#us

nence"haly Tali"esisl'ca#i'n '5 hi"e#c..

'wn’s syndr'me



Conjoint twins

Always monozygotic

classifcation

Th'rac'"agus

>rani'"agus

'm"hal'"agus



4yg'"agus

ischi'"agus

4rena#al diagn'sis*#' c'unsel #he "aren#s 5'rm#" , #' "lan si#e K m'de '5 deli/ery



Acardiac oetus

N'rmal 5e#us,"um"#win

Minimal '<y. e<#rac#ed -y

l'wer "ar# '5 cardiac5e#us

#%#anastamosesin placenta

e

'<ygena#ed-l''d

6m-.

6m-.

3ully de '<ygena#e

6""er "ar# '5 5e#us 0n' gr'6m-.V2%2anastomosesin placenta

6m-.V



cardiac #wins





nence"haly



Managemen# '5 mul#i"le "regnancy

n#ena#al care :

C<#ra a##en#i'n K die#: a# leas# )!! Acal m're#han in n'rmal "regnancy

'u#ine ir'n and 5'lic acid

e#ailed an'maly scan 5'll'wed -y serialgr'w#h scan a# 20 )2 and )G weeA

H's"i#ali(a#i'n i5 sus"ec#ed "re#em



M'de '5 deli/ery

e"end 'n "resen#a#i'n '5 1s# #win

;'#h /er#e< , 1s# #win /er#e< –

/aginal deli/ery

Indica#i'n 5'r Clec#i/e LS>S*M're #han 2 5e#uses

*1s# #win mal"resen#a#i'n0 >4

*Scarred u#erus

*>'n?'in# #win

*I6E in dich'ri'nic #win

*TTTS



Cmergency LS>S :

*3e#al dis#ress

*c'rd "r'la"se in 1s# -a-y

*N'n "r'gress '5 la-'r*2nd #win is #rans/erse0 /ersi'n 5ailed a5#erdeli/ery '5 1s# #win



Managemen# during la-'ur 1s# s#age

1. e#ermine #he "resen#a#i'n '5 1s# #win

2. Main#ain "ar#'gram

). Cs#a-lish IV line

7. ;l''d gr'u"ing and cr'ss ma#ched+. >'n#in'us in#ra"ar#um #win >TE m'ni#'ring

G. nalgesic



Managemen# during la-'ur 2nd s#age

1.eli/ery '5 1s# #win

2.>lam" and cu# #he c'rd

).N'#e lie '5 #he 2nd #win deli/ered wi#hin 2! min

7.L'ngi#udinal lie a-d'minally K /aginally : S#ar# 2 uni#s '5 "i#'cin IV dri"

>e"halic 3i< #he head in#' "el/isM Kdeli/er #he 5e#us

;reech ssis#ed -reech deli/ery0 ;reech e<#rac#i'n



I5 2nd #win has #rans/erse lie :

• ssis#an# "er5'rms C>V.

• 3i< #he head in l'wer "'le '5 #he u#erus andacc'ucher "er5'rms c'n#r'lled BM ru"#ure'5 mem-rane

• I5 #his 5ails: d' I4V in#ernal "'dalic /ersi'n5'll'wed -y -reech e<#rac#i'n

• Br "r'ceed wi#h emergency LS>S

















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