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DEFINITION

The development of two or more than two foetuses

simultaneously in a pregnant uterus is called multifoetal pregnancy

INCIDENCE
Highest rate of twins in Nigeria
Lowest rate in Japan In India ,1 in 80 pregnancies

TYPES OF TWINS
DIZYGOTIC OR BINOVULAR TWINS OR

FRATERNAL TWINS MONOZYGOTIC OR UNIOVULAR OR IDENTICAL TWINS

DIZYGOTIC TWINS
It is the commonest
Results from the fertilization of two ova either from

same or both the ovaries during a single ovarian cycle each by a separate sperm All dyzygotic twins have two placentae which are dichorionic and diamniotic

MONOZYGOTIC TWINS
Arises from a single fertilized oocyte by a single sperm

that subsequently divides true or identical twins

Conjoined twins
When splitting occurs after the 13th day of fertilization

.It results in the formation of conjoined twins

Thoracopagus

Omphalopagus

Pyopagus

Craniopagus

Ischiopagus

DETERMINATION OF ZYGOSITY

ETIOLOGY
Ethnicity
Hereditary predisposition High parity

Maternal age
Nutrition Iatrogenic; ART,ovulation induction by clomiphene

citrate or gonadotrophins Oral contraceptives

MATERNAL PHYSIOLOGICAL CHANGES


Increase in weight gain and cardiac output
Plasma volume is increased by an addition of 500 ml Anaemia and haemodilution

Increased feto protein level,tidal volume and

glomerular filteration rate

Diagnosis
History
Symptoms General examination

Abdominal examination

*Inspection *Palpation *Auscultation Internal examination

INVESTIGATIONS *Sonography

Twin peak sign

Radiography
Biochemical tests

*Maternal serum chorionic gonadotrophin *Maternal serum alpha feto protein *Unconjugated oestriol

DIFFERENTIAL DIAGNOSIS
Hydramnios
Big baby Fibroid or ovarian tumour with pregnancy

Ascites with pregnancy

Effects of twin pregnancy on mothers


There is an exaggerated adaptation of all body systems

of the mother specially of the cardiovascular system Cardiac output is higher Plasma volume during pregnancy is much greater Haematocrit and haemoglobin is lower than in singleton pregnancy

Plasma protein levels are lower


Severity of nausea and vomitting are increased Anaemia is common

Urinary infection is more common


Incidence of gestational hypertension is higher Increased frequency of antepartum haemorrhage

Effects of multiple pregnancy on foetus

*Dicordant twins

Vanishing twin
Acute intertwin transfusion Chronic intertwin transfusion

Superfetation
Superfecundation Fetus acardiacus

Fetus papyraceous

COMPLICATIONS
Maternal during pregnancy

*Nausea and vomitting *Anaemia *Pre-eclampsia *Hydramnios *Antepartum haemorrhage *Malpresentation *Preterm labour *Mechanical distress

During labour
Early rupture of membranes
Cord prolapse Increased operative interference

Bleeding
Postpartum haemorrhage

During puerperium
Subinvolution
Infection Lactation failure

FETAL COMPLICATIONS
Abortion
Prematurity Intra uterine death

Intra uterine growth restriction


Congenital anomalies Dicordant growth Twin twin transfusion Malpresentation Asphyxia and still birth

PROGNOSIS

management
Antenatal management

*Early diagnosis *Counselling


Management during labour