MULTIPLE PREGNANCY

In multiple pregnancy there is more than one foetus in utero. In most situations it is a twin pregnancy but pregnancy involving more foetuses like triplets may be encountered.

Multiple pregnancy may be associated with the use of fertility drugs and generally with higher risk for adverse outcomes (antenatal, intrapartum, and postpartum) than for a singleton.

Clinical Features

  • The uterus is larger than dates
  • There are multiple foetal parts or more than two foetal poles.
  • There may be a family history of twins and on examination foetal heart rates can be identified at two different areas with a difference of 15 beats per minute.

Risk of multiple pregnancy

  • PET
  • Polyhydramnios
  • Anaemia
  • APH
  • PPH
  • Malpresentation
  • Congenital foetal anomalies
  • Premature labour.

Investigations

  • Definitive diagnosis is made by ultrasound, but where it is lacking a plain abdominal radiograph can be taken between 34 and 36 weeks.
  • Other investigations as for routine antenatal care.

Management – Antenatal Care

  • Preferably in a hospital “High Risk” clinic, levels 4–6.
  • Monthly haemoglobin check.
  • Administration of:
    • Ferrous sulphate 200mg TDS
    • Folic acid 5mg OD
  • Monitor for associated obstetric complications, e.g., pre eclamptic toxaemia, antepartum haemorrhage, anaemia, malpresentation.
  • Ultrasound at 34–36 weeks gestation (or radiography if not available) to determine:
    • Presentation of 1st twin.
    • Detect anomalies, e.g., conjoined twins.
  • Mode of delivery
    • Admission may be necessary to observe and manage for premature labour.
    • Bed rest while at home.

Management – Intrapartum

  • Mode of delivery determined by presentation of 1st twin:
    • If cephalic allow vaginal delivery.
    • Any other presentation or anomaly, then caesarean section.
  • Vaginal delivery:
    • Monitor as per normal labour (refer to normal labour and delivery).
    • After delivery of 1st twin the lie and presentation of the 2nd foetus is determined. Foetal heart also evaluated.
    • If longitudinal, cephalic and foetal heart are satisfactory, then perform ARM and await spontaneous delivery.
    • If lie is not longitudinal, do external cephalic version (ECV). If ECV fails, then do internal podalic version and perform assisted breech delivery after bringing down a leg and stabilizing the head.
    • If longitudinal lie and cephalic presentation with ruptured membranes but with inadequate contractions and stable foetal heart rate, then oxytocin at 5 units per 500ml at 30 drops per minute and deliver normally.

Management – Retained 2nd Twin

  • Perform abdominal and vaginal examination and assess: membranes – if intact rupture; lie and presentation; whether cervix oedematous.
  • Look for evidence of foetal and maternal distress and manage accordingly.
  • If assessment is favourable, then oxytocin and delivery. Caesarean section if evaluation is poor.

Management – 3rd Stage

  • Oxytocin 10 IU IM administered after delivery of 2nd twin.
  • Look for and anticipate postpartum haemorrhage.

Patient Education

  • Family planning
  • Infant feeding
  • Early antenatal visit at subsequent pregnancies.