A condition in which there is more than one foetus in utero. Mostly twin pregnancy but others may be encountered, triplets, etc and these may be associated with use of fertility drugs. Multiple pregnancy generally carries a much higher risk (antenatal, intrapartum and postpartum) than a singleton.

Clinical Features

Uterus larger than dates. Multiple foetal parts or more than two foetal poles. Family history of twins. Foetal heart rates at two different areas with a difference of 15 beats per minute. Increased risk of; PET, polyhydramnios, anaemia, APH, PPH, malpresentation, congenital foetal anomalies, premature labour.

Investigations

• X-ray at 34-36 weeks

• Other investigations as for routine antenatal care

Definitive diagnosis can be made by ultrasonography.

Management - Antenatal

• Preferably in a hospital “High Risk” clinic

• Monthly Hb check

• Administration of:

- Ferrous sulphate 200 mg TDS

- Folic acid 5 mg OD

• Monitor for associated obstetric complications, e.g. PET. APH. anaemia, malpresentation

• X-ray at 34-36 weeks gestation (or ultrasound if available) to determine:

- presentation of first twin

- detect anomalies, e.g., co-joined 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 first 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 first twin the lie and presentation of the second 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 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 osytocin at 2 units per litre at 30 drops per minute

- CPD or other contraindication e.g. high parity must be excluded. Otherwise do a Caesarean section to expedite delivery at shortest possible interval which should be the overall goal.

• Retained second twin:

- Perform abdominal a vaginal examination and assess: membranes; if intact rupture, lie and presentation, whether cervix oedematous

- Look for evidence of foelal and maternal distress and manage accordingly

- If assessment favourable then oxytocin and delivery

- C/S if evaluation poor.

• Third Stage:

- Ergometrine IM administered after delivery of second twin

- Look for and anticipate post partum haemorrhage.

Patient Education

• Family planning

• Early ante-natal visit at subsequent pregnancies.