MULTIPLE PREGNANCY

Multiple pregnancy is the term used to describe pregnancy with more than one fetus. The vast majority of such pregnancies are cases of twins. The rate of twinning in different populations is determined by racial predisposition to double ovulation and hence nonidentical twinning. Thus, among the Caucasian population, twins are found in 1 in 80 pregnancies. The ratio of binovular (dizygotic) twins, to monovular (monozygotic) twins, is around 3 to 1. In contrast, in West Africans, who have the highest rates in the world (1 in 44 pregnancies is a case of twins) the ratio of dizygotic to monozygotic twinning may be between 4-6 to 1. The lowest rates of twinning are seen in Asia. The incidence of twin pregnancy has risen slightly over the last 10 years. In contrast, the rate of triplets and higher order multiple pregnancy (quadruplets, sextuplets etc.) has increased dramatically. Theoretically by 'Heilin's rule' the incidence of triplets should be 1 in 802 (6400) and that of quadruplets 1 in 803 (512000). From 1982 to 1993 the incidence of multiple pregnancies rose dramatically due to the widespread introduction of assisted conception programmes encompassing ovulation induction and in vitro fertilisation.

KEHAMILAN GANDA Kehamilan ganda adalah istilah yang digunakan untuk menggambarkan kehamilan dengan lebih dari satu janin. Sebagian besar dari kehamilan tersebut merupakan kasus kehamilan kembar . Tingkat kelahiran kembar dalam berbagai populasi adalah berbeda, ditentukan oleh kecenderungan terjadinya ovulasi ganda pada ras tertentu dan karenanya akan menghasilkan kembar yang non identical. Dengan demikian , di antara populasi Kaukasia, angka kasus kehamilan kembar yang ditemukan adalah 1 dari 80 kehamilan. Rasio kembar binovular ( dizigotik ), terhadap monovular kembar (monozigot ) , adalah sekitar 3 berbading 1. Sebaliknya, di Afrika Barat , yang memiliki tingkat kehamilan ganda tertinggi di dunia ( 1 dari 44 kehamilan adalah kasus kembar ) rasio dizigotik untuk kembar monozigotik mungkin antara 4-6 berbanding 1. Tingkat kelahiran kembar terendah di temukan di wilayah Asia. Insiden kehamilan kembar telah meningkat sedikitnya selama 10 tahun terakhir . Sebaliknya, tingkat kembar tiga atau kehamilan kembar dengan jumlah janin yang lebih banyak dalam satu masa gestasi ( kembar empat, kembar enam dll ) telah meningkat dramatis. Dari tahun 1982 sampai 1993 kejadian kehamilan kembar meningkat secara dramatis karena pengenalan luas dari program konsepsi meliputi induksi ovulasi dan fertilisasi in vitro .

AETIOLOGY Monozygotic twinning appears to be a chance event and is poorly understood although the rate of monozygotic twinning is uniform throughout all populations. Dizygotic twinning is commoner in the female relations of women who are, or have had, dizygotic twins. There does not appear to be any male factor, familial or otherwise, which increases the rate of twin pregnancy. Twins are commoner in women of high parity and in those who are older at the time of conception. Dizygotic twinning is also commoner in women who are tall and in the obese. The importance of multiple pregnancy lies in the observation that almost all complications are commoner than in singleton pregnancies. The high incidence of prematurity and fetal abnormality in particular result in a sixfold increase in perinahtal mortality.

etiologi. Kembar dizigotik ditemukan pada kasus wanita yang memiliki hubungna darah dengan wanita lainnya yang pernah melahirkan kembar sebelumnya, dan biasanya tidak di pengaruhi oleh faktor yang dimiliki oleh ayah, keluarga atau sebaliknya, yang dapat meningkatkan terjadinya kehamilan kembar tersebut. Kembar biasa pada wanita paritas tinggi dan dalam pada mereka berada pada usia lebih tua pada saat terdadinya pembuahan. kembar dizigotik juga biasa ditemukan pada wanita yang tinggi dan mengalami obesitas. Pentingnya kehamilan ganda terletak pada pengamatan bahwa hampir semua komplikasi biasa dibandingkan kehamilan tunggal. Tingginya angka kejadian prematuritas dan kelainan pada janin menghasilkan terjadinya peningkatan risiko mortalitas perinatal sebesarenam kali lipat.

DIAGNOSIS IN EARLY PREGNANCY The diagnosis of multiple pregnancy may be suspected on history and clinical examination: a history of infertility treatment or severe hyperemesis in early pregnancy are suggestive. Suspicion may be further raised if the uterus if found to be large for dates.

DIAGNOSIS DALAM KEHAMILAN DINI Diagnosis kehamilan ganda dapat diduga pada riwayat ibu dan pemeriksaan klinis: riwayat penggunaan pengobatan infertilitas atau hiperemesis berat pada awal kehamilan merupakan suatu keadaan yang sugestif. Kecurigaan selanjutnya dapat dimunculkan jika rahim menjadi lebih besar atau pesat perkembangannya di bandingkan tanggal atau lamanya kehamilan..

Other causes of apparently abnormal uterine enlargement in early pregnancy are: (a) Mistaken Dates bleeding after conception being considered as a period. (b) Polyhydramnios rare in early pregnancy. (c) FibroidsThese tend to flatten and soften in pregnancy but may be irregular. (d) Abdominal Cyst It is usually possible to differentiate two masses. (e) Hydatidiform Mole Usually accompanied by staining. Urinary HCG excretion will be much elevated. (f) Retention of Urine 'Catheter will cure'. It may be associated with retroversion and incarceration of the uterus. Ultrasound examination in early pregnancy will differentiate these conditions and is the only method of diagnosing multiple pregnancy reliably.

Penyebab lain pembesaran uterus yang tampaknya tidak normal pada awal kehamilan adalah: (a) Keliru atau salah penafsiran tanggal kehamilan - perdarahan setelah pembuahan dianggap sebagai suatu period. (b) polihidramnion jarang ditemukan pada kehamilan awal. (c) Fibroid- tumor jinak yang terbentuk dalam lahir, biasanya berbentuk mendatar atau lunak namun juga bisa berbentuk irregular (d) Kista abdominal -Hal ini biasanya dimungkinkan untuk membandingkan 2 massa di dalam abdomen. (e) Mola Mole - Biasanya disertai dengan pewarnaan. Kadar HCG dalam urin akan mengalami elevasi. (f) Retensi Urin- dapat ditangani gengan pemasangan kateter urin. Keadaan ini Ini mungkin terkait dengan retroversi dan inkanserasi atau penahanana oleh rahim rahim. Pemeriksaan USG pada awal kehamilan akan membedakan kondisi ini dan merupakan satu-satunya metode mendiagnosis kehamilan ganda yang paling akurat.

DIAGNOSIS IN LATE PREGNANCY The uterus is more globular and larger than normal for the dates. Polyhydramnios may be present. It is commoner in monozygotic than in dizygotic twins. If there is no evidence of polyhydramnios, an apparent 'excess' of fetal parts may be noted. It may be difficult to define the lie of the fetuses but three fetal poles (head or breech) must be identified to be sure of the diagnosis. Clinical suspicion of twin pregnancy must always be confirmed by ultrasound, if this has not already been performed.

DIAGNOSIS DALAM KEHAMILAN MASA LANJUT Rahim menjadi lebih globular dan besar melebihi keadaan normal yang sesuai tanggal kehamilan. Rahim lebih bulat dan lebih besar dari normal tanggal. Polihidramnion mungkin hadir. Hal ini biasa di monozigot dibandingkan kembar dizigot. Jika tidak ada bukti polihidramnion, sebuah jelas 'kelebihan' bagian janin mungkin mencatat. Mungkin sulit untuk menentukan letak janin tapi tiga kutub janin (kepala atau sungsang) harus diidentifikasi untuk pastikan diagnosis. Kecurigaan klinis kehamilan kembar harus selalu dikonfirmasikan dengan ultrasound, jika hal ini belum sudah dilakukan.

COMPLICATIONS The major complications are illustrated below but it must be remembered that the so-called minor complications of pregnancy such as heartburn, varicose veins, haemorrhoids and other pressure effects may all add to the mother's burden.

MANAGEMENT OF MULTIPLE PREGNANCY Before 20 weeks Antenatal care is conducted in the usual fashion with particular attention to identifying the

complications mentioned above. A good diet is advised and iron and folic acid supplementation should be prescribed. Ultrasound enables an early diagnosis to be made but should not be shared too early with the patient as a significant number of apparently multiple pregnancies when scanned at 8 weeks are singleton pregnancies at 12 weeks as a result of fetal death. Threatened miscarriage is more likely to proceed to inevitable miscarriage in multiple pregnancy. Fetal abnormality is commoner in multiple pregnancies; AFP screening is of use in some respects since the normal range is twice that of a singleton pregnancy and elevated values are associated with the same abnormalities. Biochemical screening for Down's syndrome is not currently possible in multiple pregnancy. Detailed fetal assessment is usually offered around 18 to 20 weeks. Identification of abnormality in one of a set of twins presents a number of difficulties. The parents are presented with one of three choices: the first, is to await events. The second is to opt for termination of the pregnancy and sacrifice of the healthy fetus. The third option is selective feticide in which the heart of the abnormal fetus is injected with potassium chloride to cause asytole. Clearly the management of such problems is very difficult and requires considerable expertise.

MANAGEMENT OF MULTIPLE PREGNANCY (continued) After 20 weeks Routine hospital admission does not improve perinatal outcome although it may be indicated for either geographical reasons, if the patient lives some distance from hospital care, or social reasons, when admission for rest may be valuable. Complications, such as preterm labour and pre-eclampsia, should be managed as for singleton pregnancies but consideration given to the problems associated with multiple pregnancy. Placentography should be performed to exclude placenta praevia. When fetal compromise is suspected fetal monitoring may be more technically demanding but current cardiotocography equipment allows tracing of both babies simultaneously.

Regular assessment of fetal growth is indicated to identify IUGR. This is commoner in multiple pregnancy. When this occurs in one of twins, delivery may be required in that baby's interest. If both babies are mature this decision is straightforward. When preterm delivery is

indicated then the larger, appropriately grown, baby is put at risk of the complications of prematurity in the interest of its sibling. This is a problem unique to multiple pregnancy and can present ethical, emotional and practical difficulties. The degree of difficulty is influenced by gestational age; a growth discrepancy at 34 weeks gestation means that the risk to the larger fetus of early delivery, though not negligible, is relatively small in a well equipped obstetric unit. In contrast, such a problem in twins at 26 weeks gestation may result in loss of both babies from extreme prematurity. Another cause of growth discrepancy between twins is Twin to Twin Transfusion Syndrome. This condition, in which there are vascular anastomoses between the placentae of monochorionic twins, results when one baby acts as a blood donor to its twin. The result is an anaemic, growth restricted fetus and a polycythaemic, macrosomic twin which may develop hydrops. The ideal management when this occurs in early pregnancy is unclear. When the onset is later in pregnancy, delivery is indicated in the interests of both babies.

ZYGOSITY AND ITS DIAGNOSIS In singleton pregnancies the membranes surrounding the fetus are chorion and amnion. In dizygotic twinning each fetus will each have both membranes, i.e. the placentae will be dichorionic and diamniotic. In monozygotic twinning, if separation of the fetal poles occurs early enough, the placentae will be diamniotic and dichorionic. Later separation will result in each fetus being within its own amniotic sac but may share a chorion, a diamniotic, monochorionic placenta. When very late separation occurs both babies may share amnion and chorion.

The most extreme type of late separation of the fetal poles causes conjoined (so-called Siamese) twins. The finding on ultrasound examination of a pyramidal area of placental tissue at the site of insertion of the separating membranes between twins, the so-called Lambda sign, suggests a dichorionic placentation. Because of the comment above this is not synonymous with dizygosity.

LABOUR AND DELIVERY Malpresentations are common in twin pregnancy but in 75% of cases twin 1 presents by the vertex.

The lie of the second baby is unimportant until the first is born. Labour is usually straightforward though the higher incidence of malpresentation increases the risk of cord prolapse. Vaginal examination should be carried out when the membranes rupture. Both fetal hearts should be monitored, the first by a scalp electrode and the second externally, ideally using ultrasound cardiotocography. Epidural analgesia is ideal, if available, as it permits any necessary intervention, especially with the second twin, during delivery. This should take place in an operating theatre with appropriate facilities and staff available. In addition to the obstetrician and midwives, an anaesthetist and paediatrician should be present. After the delivery of the first baby the cord is double clamped in case there are monozygotic twins and a risk of the second baby bleeding from the cord of the first due to placental vascular anastomoses

When the first baby is delivered, the lie of the second is checked and if necessary corrected by external version to a vertex or a breech; if that is not possible then internal podalic version and breech extraction is performed

If the second baby has a satisfactory presentation and there is no evidence of fetal distress then, although the interval between delivery of first and second babies should not be prolonged, descent of the presenting part may be awaited. An oxytocin infusion may be commenced as uterine activity may reduce after delivery of twin 1. When the head or breech

has descended into the pelvis the membranes may be ruptured and delivery proceeds. If there is evidence of fetal distress then the second baby may be delivered more promptly by rupturing the second set of membranes and applying forceps or the ventouse, or, if required, internal podalic version and breech extraction may be performed. Active management of the third stage only begins at delivery of the anterior shoulder of the second baby. Rarely the first placenta is born before the second baby. Bleeding is not usually severe. The uterus is actively contracting and the reduction in size of the placental site and the pressure of the fetus on it helps to control the blood loss. Vigilance is required during the third stage to prevent atonic post-partum haemorrhage.

OTHER COMPLICATIONS Locked Twins Locked twins is a very rare condition in which parts of one interlock with the other causing an impasse. It most commonly occurs with the first as breech and the second as a vertex. The head of the second slips down with the shoulders of the first and prevents the engagement of the head of the first in the pelvis. Early recognition is essential as the condition has a high fetal mortality. The treatment is to push the lower head out of the pelvis to free the head of the first fetus and allow delivery. If displacement is not possible the first baby will die. A destructive procedure may be performed to allow delivery of the trunk and then the second twin. Such expertise is uncommon in the UK and the psychological sequelae to a destructive procedure (decapitation of twin 1) are significant in this population. Consequently, upon diagnosis caesarean section may be undertaken. If performed promptly this may also salvage twin 1. Conjoined twins are due to imperfect separation of monozygotic twins. Vaginal delivery is possible particularly when delivery is preterm. Nevertheless most authorities would advocate elective caesarean section in a major paediatric/maternity unit. Triplets and quadruplets have similar problems and difficulties. Premature labour is much commoner. The perinatal mortality rate is higher. Vaginal delivery is possible in triplet pregnancy although caesarean section remains the method of choice. Delivery by caesarean section is invariably the method of choice in quadruplet pregnancy.

Fetus Papyraceous Sometimes a twin does not develop but becomes amorphous or shrivelled and flattened. This is called fetus papyraceous or compressus. It may be readily apparent or may be found wrapped in the membranes of the placenta.

Obstetric Illustrated 6 ed. 2004