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BAB I

INTRODUCTION

Twin pregnancy is a pregnancy with two or more fetuses. It is a pregnancy


that get attention and often becomes a joyous occasion for the parents of the fetus and
society in general. But women who are pregnant without their baby will realize a
greater risk of very serious for the health.
In recent years, the number of multiple births has increased greatly. The birth
rate for twins in the United States has increased about 65 percent since 1980,
according to the National Center for Health Statistics. Other multiple births have
increased at an even higher rate for several reasons. Various factors affect the
frequency of twin pregnancies, as a nation, heredity, age, and maternal parity Second,
when the medical and technological methods used to treat infertility are successful,
they frequently result in multiple pregnancy.
In developed countries, two of the major causes of multiple gestation are
cessation of oral contraception and artificial ovulation induction. The latter is of
particular concern for higher-order multiple gestations (triplets and above) are
increasingly common

as a result of assisted reproductive technologies (ART).

Although these pregnancies are not at significantly increased risk from the ART, they
are at exceptional risk for immature or premature delivery and other morbidity and
mortality associated with higher-order multiple gestations.
Maternal morbidity and mortality are much higher in multiple than in
singleton pregnancy. There is increased frequency and severity of anemia; increased
occurrence of urinary tract infection; more preeclampsia-eclampsia, hydramnios, and
uterine inertia (overdistention); and a greater chance of hemorrhage (before, during,
and after delivery).
The perinatal mortality rate of twins is 4 6 times higher and for triplets much
higher again than for singletons because of prematurity and associated difficulties.
Indeed, as the number of fetuses rises, their average size and length of gestation
decrease. Moreover, intrauterine growth retardation (IUGR) is more common in all
multiple gestations (as opposed to singletons). Congenital abnormalities of all organ
systems are as high as 18% among twins . Other perinatal risks of multiple gestations
include abnormal presentation and position, hydramnios, hypoxia because of cord
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prolapse ( 5 times more common in multiple pregnancy), placenta previa, and


premature separation of the placenta after the first twin or operative manipulation.
Because of maternal and perinatal risk, many authorities recommend that no less than
qualified obstetricians care for twins and that maternal fetal consultation be utilized.
Additionally, triplet and higher birth order risk is such that maternalfetal specialists
should be involved in, or provide their care.
Therefore, diagnosis of early twin pregnancy early is right way, which needs
to be done. If the diagnosis of twin pregnancy was established, so many things and
aspects that need attention needs to be addressed.

BAB II
LITERATURE REVIEW

II.1 DEFINITION
Multiple pregnancy involves more than one embryo (fetus) in any one
gestation. Two independent mechanisms may lead to multiple gestation:
segmentation of a single fertile ovum (identical, monovular, or monozygotic) or
fertilization of separate ova by different spermatozoa (fraternal or dizygotic)
multiple pregnancy.1
II.2 ETIOLOGY of MULTIPLE FETUSES
Twin fetuses commonly result from fertilization of two separate ova and are
termed double-ovum, dizygotic, or fraternal twins. About a third as often, twins
arise from a single fertilized ovum that subsequently divides into two similar
structures, each with the potential for developing into a separate individual. These
twins are termed single-ovum, monozygotic, or identical twins. Either or both
processes may be involved in the formation of higher numbers of fetuses.
Quadruplets, for example, may arise from as few as one to as many as four ova.2

Picture 1. placental variation in twinning.

Dizygous : Double Ovum


About 75 % of twins are binovular. Two fetuses develop from the fertilization
or two ova liberated during the same menstrual cycle. The incidence of double
ovum twins is influenced by hereditary, race, maternal age, and parity. Each twin
has its own placenta, chorion and amniotic sac. When the ova are implanted near
each other, the two placentas may seem to fuse. The circulation, however, remain
completely separate. This children are fraternal twins. They resemble each other
only to the extent that siblings of the same age would. They maybe of different sex
and sometimes look entirely dissimilar. Wein-birgs role states that the number of
dizigous twin in any population is twice the number of twin of different sex ; the
reminder are monozigous. Dizigous twinning is the result of multiple ovulation
which maybe caused by high level of gonadotropic hormones over stimulating the
ovari. The artificial induction of ovulation by clomipenth or gonadotropin in
creases the chance of multiple pregnancy.3

Genesis of Monozygotic Twins


Evidence regarding the physiological basis of monozygotic twinning now
suggests that the division of the fertilized ovum may result from a delay in the
timing of normal developmental events. In humans, delayed ovum transport
through the fallopian tube increases the risk of twinning. Because progestational
agents and combination contraceptives decrease tubal motility, delayed tubal
transport and implantation are believed to increase the risk of twinning in
pregnancies conceived in close temporal proximity to contraceptive use . Minor
trauma to the blastocyst during assisted reproductive technology (ART) may

possibly lead to the increased incidence of monozygotic twinning observed in


pregnancies conceived in this manner.2
The outcome of the twinning process depends on when the division occurs.

Dichorionic diamniontic twins : In this case the division occurs at the


blastomere stage, no later than 2 to3 days after fertilization. The iner cell mass
has not yet been delineated. Separate embryos develop, undistinguishable at
birth from dizygous twins. Each twin has its own chorion, amnion, and
placenta. The latter may be separete or fused depending on the site of
implantation.

picture 2. Diamniotic, dichorionic placentation.

Monochorionic diamniotic twins : The split takes place at the blastocyst stage
between 4 and 6 days. The inner cell mass, which has been formed, divide in
two. The placenta has one chorion, but two amnions. Each twin lies in its own
sac.3

Picture 3. Diamniotic, monochorionic placentation.

Monochorionic monoamniotic twins : the division takes place in the primitive


germ disc at between 7 and 13 days. The amnion has already formed. The
twins lie in the same amniotic sac. Monoamniotic twins are rare

Picture 4. Monoamniotic, monoamniotic placentation.

Conjoined twinsmonochorionic monoamniotic : After the primitive streak of


the embryo has appeared and the cells of the germ disc have assumed an axial
arrangement (arround 14 days), complete separation does not occurs,and
conjoined twins can develop.
Because the fetuses are not separated by membranes, there is great possiblility
of knotting, tangling and strangulation of the umbilical cords. The resultant
anoxia may lead to fetal death. 3

Superfetation and Superfecundation


In superfetation, an interval as long as or longer than a menstrual cycle
intervenes between fertilizations. Superfetation requires ovulation and
fertilization during the course of an established pregnancy, which would
theoretically be possible until the uterine cavity is obliterated by the fusion of
the decidua capsularis to the decidua vera. Although known to occur in mares,
superfetation is as yet unproven to occur in humans. Most authorities believe
that the alleged cases of human superfetation result from marked inequality in
growth and development of twin fetuses of the same gestational age.
Superfecundation refers to the fertilization of two ova within the same menstrual
cycle but not at the same coitus, nor necessarily by sperm from the same male. 2

An instance of superfecundation, documented by Harris (1982), is


demonstrated in Figure 395. The mother was sexually assaulted on the 10th day
of her menstrual cycle and had intercourse 1 week later with her husband. She was
delivered of a black neonate whose blood type was A and a white neonate whose
blood type was O. The blood type of both the mother and her husband was O.
Terasaki and co-workers (1978) described the use of HLA typing to establish that
a specific set of dizygotic twins were sired by different fathers. 2
Risk factors for multifetal pregnancy can be divided into natural and induced.
Risk factors for natural multifetal pregnancy include advanced maternal age,
family history of dizygotic twins, and race. Induced multifetal pregnancies occur
following infertility treatment via the use of ovulation-inducing agents or
gamete/zygote transfer.4
Some of the factors that are associated with multiple pregnancy include:

Race. Black women have the highest rate of natural multiple pregnancy. Asian
women have the lowest.

Age. Older women are more likely to have a multiple pregnancy.

Family history. Women with multiple pregnancies in their families are more
likely to have a multiple pregnancy.

Prior pregnancy. Women who have given birth four or more times are more
likely to have a multiple pregnancy.

Fertility drugs. Some of these drugs cause a woman to ovulate more than one
egg a month, which increases the likelihood of multiple pregnancy.
Pregnancies of triplets, quadruplets and higher orders have increased
dramatically as a result of the use of fertility drugs.

Assisted reproductive technology (ART). Measures that implant more than one
embryo are more likely to produce a multiple pregnancy. These measures have
also increased the number of higher order pregnancies. 5

II.3 FREQUENCY of TWINS

The birth rate of monozygotic twins is constant worldwide (approximately 4


per 1000 births) and is largely indepentent of race, heredity, age, and parity. The
frequency was once thought to be independent of infertility theraphy, however,
there is now evidence that the incidence of zygotic splitting is increased
following ART. The incidence of dizygotic twinning, however, is influenced
remarkably by race, heredity, maternal age, parityand especially, fertility drugs.
Birth rates of dizygotic twins vary by race. The highest birth rate of dizygotic
twinning occurs in African nations, and the lowest birth rate of dizygotic
twinning occurs in Asia. The Yorubas of Western Nigeria have a frequency of 45
twins per 1000 live births, and approximately 90 percent are dizygotic.4

II.4 DIAGNOSIS of MULTIPLE PREGNANCY


1.

Suggestive findings :
a.

Familial history.

b.

The uterus and abdomen seem larger than expected for the period of
amenorrhea.

2.

c.

Uterine growth is more rapid than normal

d.

There is unexplainably excessive weight gain 3

Positive signs :1,3


a.

Palpation of two heads or two breeches.


When uterine palpation leads to the diagnosis of twins, it is
most often because two fetal heads have been detected, often in
different uterine quadrants. In general, however, before the third
trimester it is difficult to diagnose twins by palpation of fetal parts.
Even late in pregnancy it may be difficult to identify twins by
abdominal palpation, especially if one twin overlies the other, if the
woman is obese, or if hydramnios is present.

b.

Two fetal heart auscultated at the same time by two observers and
differing in rate by at least 10 beats per minute.

c.

X-ray of the abdoment shows two skeletons. These may appear by the
18th week or sooner, but a second skeleton cannot be ruled out until
the 25th week.

d.
3.

Ultrasonography demonstrates the presence of two or more fetal skulls.

The diagnosis of twins is not easy unless there is ahigh index of suspicion. The
frequency of preterm labor makes the diagnosis before the onset of labor even
less frequence.3

Another clinical suggestions of multiple pregnancy include the following:

Excessive maternal weight gain not explained by eating or edema;

Hydramnios;

Iron deficiency anemia;

Maternal reports of increased fetal activity.3

Laboratory findings
Commonly encountered laboratory findings in multiple pregnancy include:
abnormal elevation of maternal hCG and/or alphafetoprotein, moderate reduction
in Hct (also Hgb and RBC count, i.e., iron deficiency anemia), blood volume
increased over normal pregnancy values, and an increased incidence of glucose
intolerance. Cervicovaginal secretion of fetal fibronectin (Ffn) is a sensitive
predictor of preterm delivery in twins, but has low specificity. Thus, Ffn is best
used in conjunction with other criteria (e.g., sonographic evaluation of cervical
length). Currently, there is little Ffn data for higher-order multiples.1
Ultrasonografy
Sonography is vital in modern management of multiple gestations. Areas of
utility include: assisting in zygosity determination, detecting and assessing fetal
anomalies, determination of growth, assessing amniotic fluid, determining well
being, management of antenatal testing, and caring for uncommon complications.
Therefore, a standardized approach to sonographic evaluations is useful.
By careful ultrasonographic examination, separate gestational sacs can be
identified early in twin pregnancy. Subsequently, each fetal head should be seen in
two perpendicular planes so as not to mistake a cross section of the fetal trunk for
a second fetal head. Ideally, two fetal heads or two abdomens should be seen in
the same plane, to avoid scanning the same fetus twice and interpreting it as twins.
Ultrasonographic examination should detect practically all sets of twins. Indeed,

one argument in favor of ultrasonographic screening is earlier detection of


multiple fetuses.. Higher-order multiple gestations are more difficult to evaluate.
Even in the first trimester it can be difficult to determine the correct number of
fetuses and their position, which is important for nonselective pregnancy reduction
and essential for selective termination. Ultrasonographic examination should
detect practically all sets of twins. Indeed, one argument in favor of
ultrasonographic screening is earlier detection of multiple fetuses.
Multiple pregnancy may be demonstrated by vaginal ultrasonography before 6
weeks, and multiple pregnancy should be routinely detected by other scanning
methods at 8 weeks. A pitfall of multiple gestation sonography, particularly those
done at 6 weeks, is both undercounting and overcounting fetuses. Sonographic
visualization of the chorion(s) can be assessed as early as 67 weeks (after LMP),
with dichorionic being visualized earlier. Although reliable imaging of the amnion
is not usually possible before the 910th week. This determination is important
because of the disproportionate outcomes related to chorionicity and amnionicity.
Differential findings include: placental masses, septal thickness, twin peak sign,
as well as fetal gender. At 1620 weeks, a detailed sonographic anatomic survey
screens for congenital anomalies and provides a baseline for further testing.1
II.5 PRESENTATION and POSITION
With twins, all possible combinations of fetal positions may be encountered.
The most common presentations at admission for delivery are cephaliccephalic,
cephalicbreech, and cephalictransverse. Importantly, these presentations,
especially those other than cephaliccephalic, are unstable before and during labor
and delivery. Compound, face, brow, and footling breech presentations are
relatively common, especially when the fetuses are small, amnionic fluid is
excessive, or maternal parity is high. Prolapse of the cord is also common in these
circumstances. The presentation can often be ascertained by ultrasonography. If
any confusion about the relationship of the twins to each other or to the maternal
pelvis persists, a single anteroposterior radiograph of the abdomen may be
helpful.2

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II.6 ANTEPARTUM MANAGEMENT OF TWIN PREGNANCY


To reduce perinatal mortality and morbidity in pregnancies complicated by
twins, it is imperative that:
1.

Delivery of markedly preterm infants be prevented.

2.

Failure of one or both fetuses to thrive be identified and fetuses so afflicted be


delivered before they become moribund.

3.

Fetal trauma during labor and delivery be avoided.

4.

Expert neonatal care be available. 1

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Additional Needs in a Multiple Pregnancy


Nutrition
Women with a multiple pregnancy need more food, calories, protein, and
vitamins and minerals than women with a singleton pregnancy. Women who are
well nourished and of normal weight should be encouraged to consume 3,000 to
3,500 calories a day for twin gestations, 4,000 calories a day for triplets, and 4,500
or more for quadruplets. Iron is particularly important for blood volume expansion
to support multiple fetuses and placentas. Any pregnancy results in a measurable
increase in blood volume from increases in both plasma volume and red blood
cells. A 22% increase occurs as early as 8 weeks, with progressive increases seen
until 3234 weeks. The proportional increase in a multiple pregnancy is directly
related to the number of fetuses present. The vast majority of pregnant women in
the United States are prescribed a prenatal vitamin. Because of the increased
physiological demands and the additional nutrients required by multiple fetuses,
women with a multiple pregnancy almost always need to supplement their diet
with a multivitamin. Women can achieve the recommended higher calorie diets by
eating more of the same types of healthy food and by eating often. Women should
also be encouraged to drink plenty of water.
Weight Gain
Weight gain during pregnancy comes from the fetus, increased maternal blood
volume, uterine size, amniotic fluid, the placenta, colostrum, and fat storage.
recommends that women of normal weight should gain approximately 3545
pounds for twin gestations. Weight gain is increased and generally occurs earlier
and more rapidly in women with a multiple pregnancy. Some women report
weight gains as early as 8 weeks. Women considered underweight should gain 1
pound each week through 20 weeks gestation and 12 1/2 pounds per week for the
remainder of the pregnancy. Inadequate weight gain early in pregnancy is
associated with complications even if compensatory weight is gained later. Ideal
weight gains for triplets and higher-order pregnancies have not been well
researched. However, anecdotal evidence indicates that a 36-pound gain by week

12

26 is associated with higher birth weights and optimal outcomes in triplet


gestation .5
Monitoring for Potential Risks and Complications
Women pregnant with multiple fetuses are at an increased risk for numerous
problems during the antepartum period. Multiple gestations account for 1012%
of fetal deaths. Death can be caused by abnormal fetal or placental development,
cord compression, or other accidents. Although not all multiple births have
complications, women should be familiar with the warning signs of problems.
Below is a discussion of the most common complications of a multiple
pregnancy, the expected medical management, and the implications for the
childbirth educator and childbearing family.5
II.7 DELIVERY
Timing
The antepartum stillbirth rate in twins exceeds that of singletons, both per
fetus and, in particular, per pregnancy. Thus while awaiting the results of a
randomized trial in progress , it seems prudent to recommend elective delivery
at 3738 weeks when neonatal morbidity is lowest.
The large rise in stillbirths seen in population data at 38 weeks is artifactual,
reflecting gestational age at delivery not at intrauterine death. There is an
argument for delivering MC twins earlier, based on their high rate of
unexplained death rate in utero and the desire to avoid the consequences of fetal
death to its co-twin. Twins are not a contraindication to induction .6
Vaginal delivery
Mode of delivery has traditionally been decided on the presentation of the
first twin (cephalic in 70%, breech in 30%), and fetal growth and well-being.
Caesarean section has been advised where the first twin is breech, based on
extrapolation from the term breech trial, and the desire to avoid the rare
interlocking with head entrapment of a presenting breech above a second
cephalic twin. The presentation of the second twin is of little relevance until
after the birth of the first. Parturients with a previous Caesarean section are
probably best delivered by repeat Caesarean, because of greater risks of
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scardehiscence/rupture due both to uterine distension and to intrauterine


manipulation of the second twin.6
For vaginal delivery, continuous cardiotocography (CTG) of both twins is
facilitated by use of a dual channel recorder and/or a combination of internal and
external electrodes. Anintravenous line is sited, antacids given and blood drawn
for cross matching, in view of the increased incidence of Caesarean section and
post-partum haemorrhage. Augmentation may be used as in singletons. An
epidural is strongly advised in case internal manipulation of the second twin is
needed; if one is not sited, an anaesthetist will be required at delivery in case
general anaesthesia is required. The delivery of the first twin proceeds as for a
singleton. Its cord is clamped to prevent haemorrhage from the second twin along
any placental anastomoses. An experienced obstetrician discerns the presentation
of the second twin, either by abdominal and vaginal examination or increasingly
by transabdominal ultrasound. Oblique or transverse lies are then converted to
longitudinal. The membranes should be left intact to facilitate version.
External cephalic version may be used to manipulate the fetal head over the
pelvic inlet. However, internal podalic version and breech extraction is preferred
as the primary procedure as observational studies show that it is associated with a
higher chance of success and lower rate of fetal distress. One or preferably both
feet are grasped and brought down into the vagina followed by assisted breech
delivery with contractions and maternal effort. Although historical series
suggested that the risk to he second twin increased the greater the delay until its
delivery, intervals of >30 min are acceptable providing the CTG is satisfactory
and the presenting part is descending. Uterine inertia with a longitudinal-lying
second twin is corrected by oxytocin infusion. Fetal distress can be managed by
vento use delivery even if the head is high or breech extraction if podalic. The
already stretched vaginal tissues after birth of the first twin allow these procedures
in circumstances where they are normally contraindicated.
Caesarean section for a second twin is rarely indicated for disproportion,
usually only where the second twin is unexpectedly much bigger than the first,
and is associated with an increased complication rate compounding the
complications of vaginal and abdominal delivery .An oxytocin infusion is given
prophylactically in the third stage.6
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Vaginal Delivery of the Second Twin


As soon as the presenting twin has been delivered, the presenting part of the
second twin, its size, and its relationship to the birth canal should be quickly and
carefully ascertained by combined abdominal, vaginal, and at times intrauterine
examination. Ultrasonography is also valuable in some cases. If the fetal head or
the breech is fixed in the birth canal, moderate fundal pressure is applied and
membranes are ruptured. Immediately afterward, digital examination of the
cervix is repeated to exclude prolapse of the cord. Labor is allowed to resume,
and the fetal heart rate is monitored. With reestablishment of labor there is no
need to hasten delivery unless a nonreassuring fetal heart rate or bleeding
develops. Hemorrhage may indicate placental separation, which can be harmful
to both the fetus and the mother. If contractions do not resume within
approximately 10 minutes, dilute oxytocin may be used to stimulate
contractions.2
If the occiput or the breech presents immediately over the pelvic inlet but is
not fixed in the birth canal, the presenting part can often be guided into the
pelvis by one hand in the vagina while a second hand on the uterine fundus
exerts moderate pressure caudally. Alternatively, an assistant can maneuver the
presenting part into the pelvis using ultrasonography for guidance and to
monitor heart rate. Intrapartum external version of the noncephalic second twin
has also been described (Chervanak and co-workers, 1983).2
A presenting shoulder may be gently converted into a cephalic presentation.
If the occiput or the breech is not over the pelvic inlet and cannot be so
positioned by gentle pressure, or if appreciable uterine bleeding develops,
delivery of the second twin can be problematic.2
It is essential to have an obstetrician skilled in intrauterine fetal manipulation
and an anesthesiologist skilled in providing anesthesia to effectively relax the
uterus for vaginal delivery of a noncephalic second twin to obtain a favorable
outcome. To take maximum advantage of the dilated cervix before the uterus
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contracts and the cervix retracts, delay must be avoided. Prompt cesarean
delivery of the second fetus is preferred if no one present is skilled in the
performance of internal podalic version (described in the following section) or if
anesthesia that will provide effective uterine relaxation is not immediately
available.2
Caesarean section
Essentially the risks of vaginal delivery are increased in twins compared to
singletons, as are the risks of Caesarean section. A large international randomized
trial is underway to resolve the optimal mode of delivery in twins. In the interim,
it seems reasonable to offer women Caesarean section where otherwise suitable
for vaginal delivery. This is based on a high intrapartum section rate in twins,
with evidence from other trials suggesting that maternal morbidity from elective
section is comparable where the emergency rate exceeds one in three and
increasing recognition that the second twin has a chance of intrapartum related
death some five-fold higher than first twin or singletons .6
Cesarean section is recommended for monoamniotic twins because of the 10%
delivery loss from cord entanglement. Caesarean section has been advised where
the first twin is breech, based on extrapolation from the term breech trial, and the
desire to avoid the rare interlocking with head entrapment of a presenting breech
above a second cephalic twin. The presentation of the second twin is of little
relevance until after the birth of the first. Parturients with a previous Caesarean
section are probably best delivered by repeat Caesarean, because of greater risks
of scar dehiscence/rupture due both to uterine distension and to intrauterine
manipulation of these second twin.1

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Locked twins
Other standard indications for cesarean include: any birth number exceeding
twins (e.g., triplets), twins ,2500 g, or if the first twin is nonvertex . It is
recommended that all twin gestations be delivered in an operating room with full
preparation (including maternal abdominal preparation), equipment, and
personnel in attendance for cesarean section. The first twin may be delivered
vaginally if it presents by the vertex (situation A and situation B). A significantly
shorter first stage of labor (compared to singletons) may be anticipated.1
DELIVERY SITUATIONS ACCORDING TO
Situation
A
B
C

PRESENTATION OF TWINS
Twin A
Twin B
Vertex
Vertex
Vertex
Nonvertex
Nonvertex
Other (any)

%
40
40
20

A generous episiotomy reduces fetal cranial compression. With delivery of


the first fetus, clamp the cord promptly. Should there be twin-to-twin vascular
communication, a second monozygotic twin can exsanguinate through the first
cord. A vaginal examination immediately after the first delivery is performed to
identify a possible forelying or prolapsed cord and establish the position of the
second fetus. If B has continued as a vertex (situation A), a second vaginal
delivery may be performed.1
If the second fetus is anything but vertex (situation B), there are three
alternatives.

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Bringing the head into the inlet by external guidance (version), if successful,
allows labor to proceed for another vertex vaginal delivery.
Perform cesarean section immediately if external version is unsuccessful or if
the fetus is not a candidate for a vaginal breech delivery.
Complete a vaginal breech delivery if the external version is unsuccessful and
the fetus is a candidate for a vaginal breech delivery.

Rupture of the second sac (if present) is accomplished as late as possible to


avoid prolapse of the cord. Continuous electronic fetal monitoring of the second
twin is employed. Should fetal compromise supervene (e.g., persistent cord
compression or premature separation of the placenta) and the second twin cannot
be delivered easily or immediately, an immediate cesarean section is
recommended. The three major preventable causes of morbidity in twins are
immaturity, trauma, and manipulative delivery (with associated asphyxia), and
preventing their occurrence is a primary goal. To assist with care of the newborns,
a neonatologist or pediatrician should be in attendance.1
II.8 TREATMENT

AVOIDING MATERNAL COMPLICATIONS IN MULTIPLE PREGNANCY


A thoughtful approach is necessary for the mother with multiple gestations.
This plan begins with early diagnosis of multiple pregnancy. This goal may be
achieved by obtaining sonography (ideally on all and certainly on questionable
pregnancies) no later than 1216 weeks. A high-protein, high-vitamin diet; with
no limitation of weight gain assists in prevention of fetal intrauterine growth
retardation. Dietary supplements demonstrated to be useful in multiple
gestations include: a prenatal vitamin per day, folic acid of 1.0 mg per fetus per
day, supplemental iron preparations as indicated by hemogram and calcium to a
total intake of 1500 mg/day beneficially influences birth weight.
Because of the number of potential problems, it is common to examine the
patient with multiple pregnancy more often than most during pregnancy
(individualized, but in most cases at least twice as often). Physical activity is
usually limited to ensure adequate uterine blood flow (e.g., cancel regular

18

exercise programs). Frequent rest periods are initiated after the 24th week (e.g.,
1 week of bedrest at 26 weeks and again at 3233 weeks). Ultrasound
examinations and blood counts are obtained more frequently. Ultrasound
examinations for growth progress may be useful monthly from diagnosis until
the 32nd week, when both ultrasonography and BPP on each fetus may be useful
on a weekly basis. Cervical length sonography may be performed as often as
every other week in the latter half of pregnancy.1
Given the risk, consideration is given to deliver all patients with multiple
pregnancy in a tertiary medical facility if possible. Psychoprophylaxis is often
stressed, and the patient introduced to a support group. Additionally, patients
find literature concerning multiple gestation and preterm birth prevention
education helpful. At the time of delivery, increased blood loss may be
anticipated (hemorrhage is 5 times increased over singletons). Thus, seeking
donors acceptable to the patient in advance may be worthwhile. In cases where
one fetus delivers untenably early (e.g., 22 weeks), some now recommend
delaying delivery of the remaining fetuses (especially if membranes are intact)
in an attempt to decrease morbidity and mortality in the remaining fetuses.
Although the delayed delivery of remaining fetuses improves prognosis, there is
no consensus regarding technique or enough cases to demonstrate true statistical
relevance. In sum, care of the mother with a multiple pregnancy requires
enhanced sensitivity to, as well as frequent assessment of, maternal symptoms
and cervical status.1
PREVENTION OF FETAL COMPLICATIONS OF MULTIPLE GESTATION
Details concerning identifying congenital anomalies are noted previously
as are techniques to maximize fetal growth. Preventing early preterm delivery is
an objective best realized through maximizing maternal antenatal care. The
utilization of fetal fibronectin screening may be useful in detection of preterm
labor. Utilization of home uterine activity monitoring, salivary estriols, and other
modalities may be considered.
Cervical cerclage may delay preterm birth in selected cases. Indeed, some
now recommend this in triplet and higher-order gestations. Further study is
necessary, however, prior to recommending this approach.

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Tocolytic drugs to prevent early birth may be effective , however, these


agents must be used with great care in multiple gestation because of possible
maternal pulmonary edema. Appropriate fetal therapy is initiated if early
delivery is anticipated.1

II.9 TRIPLET or HIGHER ORDER GESTATION


Fetal heart rate monitoring during labor is challenging. A scalp electrode
can be attached to the presenting fetus, but it is difficult to ensure that the other
two triplets are each being monitored separately. With vaginal delivery, the first
infant is usually born spontaneously or with little manipulation. Subsequent
fetuses, however, are delivered according to the presenting part. This often
requires complicated obstetrical maneuvers such as total breech extraction with or
without internal podalic version or even cesarean delivery. Associated with
malposition of the fetuses is an increased incidence of cord prolapse. Moreover,
reduced placental perfusion and hemorrhage from separating placentas are more
likely during delivery.
For all these reasons, many clinicians believe that pregnancies complicated
by three or more fetuses are best delivered by cesarean delivery. Vaginal delivery
is reserved for those circumstances in which survival is not expected because the
fetuses are markedly immature or maternal complications make cesarean delivery
hazardous to the mother. Other clinicians believe that vaginal delivery is safe
under certain circumstances. For example, Alamia and colleagues (1998)
evaluated a protocol for vaginal delivery of triplet pregnancies in which the
presenting fetus was cephalic. A total of 23 sets of triplets were analyzed, and a
third of these were delivered vaginally. Neonatal outcomes were the same in the
vaginal and cesarean groups, with no morbidity and 100 percent fetal survival.
Grobman and colleagues (1998) and Alran and co-workers (2004) reported
vaginal delivery completion rates of 88 and 84 percent, respectively, in women
carrying triplets who underwent a trial of labor. Neonatal outcomes did not differ
from those of a matched group of triplet pregnancies delivered by elective
cesarean. As in any obstetrical procedure, the safety of vaginal triplet delivery
depends on the skill and experience of the operator.2
20

II.10 COMPLICATION
Multiple pregnancies are generally considered high-risk pregnancies.
Women pregnant with multiple fetuses are at an increased risk for numerous
problems during the antepartum period. Multiple gestations account for 1012%
of fetal deaths. Death can be caused by abnormal fetal or placental development,
cord compression, or other accidents.
Some of the complications are : 4,7

Preeclampsia

Gestational diabetes.
Gestational diabetes is defined as the abnormal metabolism of
carbohydrates during pregnancy, wherein the pancreas is unable to produce
enough insulin to move glucose into the cells for the production of energy.
The end result is hyperglycemia.

Uterine and placental abnormalities.

Iron deficiency anemia


The symptoms of iron deficiency anemia are similar to many of the
common complications associated with pregnancy, including fatigue,
lightheadedness, pale skin, and shortness of breath.

Preterm labor and premature birth


Prevention of Preterm Delivery : Several techniques have been applied
in attempts to prolong multifetal gestations. These include bed rest,
especially through hospitalization, prophylactic administration of betamimetic drugs, and prophylactic cervical cerclage.

Twin-to-twin transfusion.
Twin-to-twin transfusion syndrome (TTTS) is the result of an
intrauterine blood transfusion from one twin (donor) to another twin
(recipient). TTTS only occurs in monozygotic (identical) twins with a
monochorionic placenta. The donor twin is often smaller with a birth weight
20% less than the recipient's birth weight. The donor twin is often anemic
and the recipient twin is often plethoric with hemoglobin differences greater
than 5 g/dL.

Conjoined twins.
21

Incomplete late division of monozygotic twins produces conjoined twins.


Conjoined twins are connected at identical points and are classified
according to site of union.

Thoracopagus - Joined at chest (40%)

Xiphopagus/omphalopagus - Joined at abdomen (34%)

Pygopagus - Joined at buttocks (18%)

Ischiopagus - Joined at ischium (6%)

Craniopagus - Joined at head (2%)

Hyaline membrane disease


Twins born at fewer than 35 weeks' gestation are twice as likely to
develop hyaline membrane disease (HMD) as single birth infants born at
fewer than 35 weeks' gestation are.

Birth asphyxia/perinatal depression


Newborns from multiple gestation pregnancies have an increased
frequency of perinatal depression and birth asphyxia from a variety of
causes.

Vanishing twin syndrome


Early ultrasound diagnosis has revealed that as many as one half of all
twin pregnancies result in the delivery of only a single fetus. The second
twin vanishes. Intrauterine demise of one twin can result in neurologic
sequelae in the surviving twin. Acute exsanguination of the surviving twin
into the relaxed circulation of the deceased twin can result in intrauterine
CNS ischemia

Congenital anomalies/acardia/twin reversed arterial perfusion sequence


Acardia is a rare anomaly unique to multiple gestation. In this
condition, one twin has an absent or rudimentary heart. Twin reversed
arterial perfusion (TRAP) sequence occurs when an acardiac twin receives
all of the blood supply from the normal "pump" twin. This only occurs in
monochorionic twins. Blood enters the acardiac twin in a reversed perfusion
manner. Blood enters this fetus via an umbilical artery and exits via the
umbilical vein. The excessive demands on the normal "pump" twin can
cause cardiac failure in that twin.

22

Intrauterine growth retardation


It can occur because of inadequate nutrients, poor placental perfusion,
and unknown factors. Multiple fetuses do not grow at the same rate in utero
as singletons. In later pregnancy, differences in growth rates may be
attributed to fetal crowding. Also, one fetus may receive more nutrients
while the other fetus gets a smaller portion and grows more slowly.

II.11 DIFFERENTIAL DIAGNOSIS


Single large pregnancy, hydramnios, hydatidiform mole, abdominal or pelvic
tumors complicating singleton pregnancy, and complicated multiple gestation
(e.g., triplets) must all be considered in the diagnosis of multiple gestation.3.

II.12 PROGNOSIS
The prognosis of infants born from multiple gestations depends upon the
complications that develop. Some studies have reported that the risks of death,
chronic lung disease, and grade III/IV intracranial hemorrhage were similar in
twins and singletons. Other studies have reported a higher prevalence of
complications such as necrotizing enterocolitis, retinopathy of prematurity, and
patent ductus arteriosus in infants from multiple gestation versus singletons. 4

23

BAB III
CASE REPORT
I.

IDENTITY
PATIENT IDENTITY
Name

Ms. N

Age

22 years

Address

Jl. Salak II no.18 RT/RW 04/011, Pamulang, Kab.


Tangerang

Religion

Islam

Ethnic

Java

Occupation

Education

Junior High School

Entry date

3 desember 2009

PATIENTS HUSBAND
Name

Mr.S

Age

28 years

Ethnic

Betawi

Occupation

Ojeg

Education

Junior High School

I. ANAMNESIS
(Autoanamnesa, Desember 3 th 2009, 11.15 a.m )
1. Main complaint
Patients referred from the midwife came with G2P1A0 Pregnant at 40
weeks with multiple pregnancy.
2. History of present illness

24

Patients admitted 9 months pregnant. First Day of Last Menstrual


February 24th, 2009. Estimated day of confinement November 31st 2009.
Patients regular ANC at the health center midwives. Patients have had a
one-time ultrasound examination at 7 months gestation, when It was
considered normal.
Patients feel the contraction since 10 hours before came the hospital.
Contraction more and more frequently.

Mucus blood (+). According

to this pregnancy patients were higher compared with the first


pregnancy. This is felt more or less since the age of 5 months of
pregnancy Patient weight 40 kg before pregnancy, whereas patient
weight 52 kg now. No twin offspring
According to the patient, he often felt fetal movement not only in one
place, but in places different at the same time. The patient never
experienced shortness of breath during pregnancy older age, history of
swelling in the legs (-). History nausea and excessive vomiting in early
pregnancy denied.
3. Menstrual History
menarche at the age of 13 years, 28 days cycle, while 5 day period,
patients changing pads 2 3 times a day. No menstrual pain.
4. Marital Status
Marriage, Marriage in 2006
5.

History of Previous Pregnancy


1.

Normal, , 3 years old, 3000 gr, midwives , RB, healthy

2.

Presence pregnancy

6. History of contraception
Pill contraception
7. History of Past Disease
Hipertension (-), DM (-), Heart disease (-), Asthma (-), Allergies (-)

25

8. History of Family Disease


Hipertension (-), DM (-), Heart disease (-), Asthma (-),
II. PHISYCAL EXAMINATION
General Status
General condition

: moderate illness

Degree of consciousness

: Compos Mentis

Vital sign
Blood pressure

: 110/80 mmHg

Heart rate

: 100x/menit

Temperature

: 36,7 oC

RR

: 20 x/m

Eyes

: CA -/-, SI -/-.

Cor

: Regular S1-S2 , murmurs (-), gallop (-)

Pulmo

: Vesicular, Rh -/-, Wh -/-

Abdomen

: see the obstetric status.

Ekstremity

: warm exstremity, Edema -/-,

B. Obstetrics status
Abdomen
Inspection : longitudinal shape, striae gravidarum (+)
Palpation
1st Leopold

: Fundal height 40 cm, palpable a large part, round,


not bouncy and one part hard, round and bounce.

2nd Leopold

right

: palpable hard part as a board

left

: palpable hard part as a board

3rd Leopold

: palpated a large part, round, soft, not bouncy, and a


largepart, a round hard bouncy

4th Leopold

: 2/5

26

Fetal movement (+), Contraction 1x/10/15


EFW

: 4000 gr

Auscultation

: FHR 140 bpm dan 138 bpm

Anogenital
I

: v / u calm,

Io : portio livid, ostium open, fluor (-), fluxus (-)


VT : soft potsio , axial, 3cm thick, 4 cm,
membranes (+), head of the H I

III. PEMERIKSAAN PENUNJANG


1. USG
Gemelli fetal presentation looks head-breech both life.
Fetal I

: DBP = 8,8 cm , AC = 27 cm, FL = 6,37, EFW : 2100 gram.

Fetal II

: DBP = 8,5 cm, AC = 29,3 cm, FL = 6,2 cm, EFW : 2200 gram

Placenta in the fundus, ICA 3, fetal movement (+) active, insulation (+)
Impression : pregnant 35 36 weeks , Gemelli, presentation head breech,
both live.
2. Laboratorium Desember 3,2009
Hb

: 13,2 g/dl

Ht

: 42 %

Leucocytes : 7500 uL
Platelets

: 186.000 uL

Erythrocytes : 5,06 millions uL


VER/HER/KHER/RDW

Netrofil / Lmfosite / Monosite


Spot glucose blood

82,4 / 26,1 / 31,7 /13,4


:

85/13/32

: 63 mg/dl
27

Tipe of blood

: A +

URYNALISIS
Urobilinogen :

0,2

Protein

(+)

BJ

1,010

Bilirubin

(-)

Ketones

2+

Nitrite

6,5

Leukosit

+1

Glukosa

(-)

Color

yellow

Sedimen Urine
Epitel

+1

Leukosit

40-50 / magnified view field

Eritrosit

6-8 / magnified view field

Silinder

(-)

Kristal

(-)

Bakteri

(-)

Lain-lain

(-)

3. CTG
Desember 3, 2009
Fetal I :
Frekuensi dasar

155 bpm

Variability

5-20 bpm

Acceleration

(+)

Deceleration

(-)

Fetal movement

(+)

Contraction

(+)

28

Impression

reassuring

Fetal II :
Frekuensi dasar

150 bpm

Variability

5-15 bpm

Acceleration

(+)

Deceleration

(-)

Fetal movement

(+)

Contraction

(+)

Impression

reassuring

IV. WORKING DIAGNOSE


Mother

: G2P1A0 pregnancy 40 weeks


PK 1 active

Fetal

: Gemelli Presentation head breech, both live intrauterine.

V. PROGNOSIS
Mother

: Dubia

Fetal

: Dubia

VI. MANAGEMENT
Dx/
-

Observation vital sign, FHR, Contraction / hours.

Initial vaginal delivery re value 8 hours again (19.15)

Augmentation with oksitosin 5 Iu/500 RL titration until

Th/

adequate contraction.
-

Re value 3 hours again after adequate contraction

29

FOLLOW-UP
3 Desember 2009
08.00 a.m :
Attached oksitosin 5 IU/500 cc RL, titration started 8 dpm until adequate
contraction
09.00 a.m
Achieved adequate contraction with oksitosin 12dpm re value 4 hours later
01.00 p.m
S

: Contraction (+) , fetal movement (+)

: BP : 110/80 mmHg

HR : 88x/menit

RR : 18x/ menit.

T : 36,7

Obstetric Status : contraction : 3 x / 10/ 40 SRB ;


DJJ I : 140 bpm ; DJJ II : 145 bpm
Inspection

v/u calm,

Vaginal toucher

Portio thin, anterior, t 1 cm, dilatation 5 cm,

membranes
A

(+), head of the fetus I Hodge I-II

active I period of Gravidity in G2P1A0 40 weeks pregnancy, gemelli


cephalic breech presentation, both live intrauterine

Observe vital sign, contraction, FHR / hours

Re value 4 hours again

05.00 p.m
S

contraction more often, fetal movement (+)

general status in normal condition


BP : 110/80 mmHg

HR : 98x

RR : 20x/m.

T : 36,6

30

St. Obs : contraction : 4X/10/45 ; DJJ I : 140 bpm; DJJ II :146 bpm
I

: v/u calm

Vaginal toucher :
Soft Portio , axial, thick = 1 cm, dilatation 6 cm, membranes (+) / no
breaks, the head of the fetus I Hodge II, right anterior occiput
A

: Active I period of Gravidity in G2P1A0 40 weeks pregnancy, gemelli


cephalic breech presentation, both live intrauterine

Observe vital sign, contraction, FHR / hours

- Plan vaginal delivery re value of labor progress 4 hours again


09.00 p.m
S

contraction (+)

Ku/Kes : Baik / CM
BP : 120/90 mmHg

HR : 100x/menit

RR : 20x/ menit.

T : 37

St. Obs : contraction : 4X/10/45


DJJ I : 140 dpm;,DJJ II:148 dpm
I

: open v/u

Vaginal toucher :
Complete dilatation, fetus head I in H III, UUK right anterior,
A

: 2nd period labor of gravidity

: help in labour

31

09.00 p.m
Spontaneously born baby boy 2100gr / 45 cm A.S.: 8 / 9
Baby covered and dried
Umbilical cord is clamped and cut
Do check in:
In VT: Opening full, membranes (+) outstanding, palpable fetal breech II H I
performed external fixation with the baby still in position lengthwise
Spontaneous rupture of the membrane
Helping in labour
Pukul 09.40 p.m
the baby was born spontaneously bracht II: Men 2000gr / 45 cm U.S.: 8 / 9
Umbilical cord is clamped and cut
Babies dried and covered
Mother Oxytocin 10 IU was injected IM
Nice contraction
Do stretch the cord of control
Complete spontaneous birth of the placenta
Do massage fundus, contractions both
In exploration I found the perineum RG
Done hemostasis and perineorafi
Bleeding time III and IV 300 cc.
Observasi 2 jam PP :
TD

FN

RR

Contraction

TFU

Bleed. BAK spt

22.00

110/70

92

18

good

2 jbpst

22.15

110/70

92

19

good

2 jbpst

22.30

110/80

88

20

good

2 jbpst

22.45

110/70

80

21

good

2 jbpst

23.15

110/70

84

18

good

2 jbpst

32

23.45

110/70

88

17

bgood

2 jbpst

(+)

11.45 p.m
S

spontaneously BAK

general condition : CM/Baik


BP: 120/80

RR : 20x/m

HR: 88/

T:36,5

Stat generalis DBN


Stat. Obs.: TFU 2 jbpst, kontraksi baik
I: V/U calm, active bleeding (-)
A: P2 PP Spt Gemelli 2 hours ago, stable hemodynamil
P: Rdx/ Observe vital sign Mother
Observe sign of vagina bleeding.
Rth/ -diet TKTP
-higiene V/P
-motivasi KB dan ASI eksklusif
-mobilisasi dini

33

BAB IV
ANALISA KASUS
In this case upheld Aterm pregnant G2P1A0 diagnosis, fetal presentation Gemelli
cephalic - breech life intrauterine based on anamnesis, physical examination and
investigation.
Anamnesa
Anamnesis obtained from the patient is referred by health centers with G2P1A0 H
aterm with Gemelli. Information from the referral is important to know what the
problem is happening to patients. But such information must be sharpened again. So
on further anamnesa found that the pregnancy is felt by the mother is greater than the
first pregnancy and fetal movements felt more than one. This is consistent with
literature which states that "The amount exceeds the duration of amenorrhea of the
uterus, the uterus grows faster than the gestational age (> 4cm) and on repeated
examination (because there 10 times more common in twin pregnancy)".is
polihidramnion However, patients have abdominal enlargement is not suitable during
pregnancy was caused by the hidramnion.
Anamnesa of risk factors in these patients clearly have not obtained, the patient did
not have a twin family descendants and contraceptive histories obtained from patients
were taking contraceptive injection from the clinic. But the menstrual history obtained
from the regular menses and may think that the ovulatory cycle has proven the patient
has a son. So the use of birth control injection to patients only for spacing pregnancies
and not to induce ovulation.
Physical examination
Obtained from physical examination at the examination of fetal Leopold impression
gained 2 double and fetal heart sounds. This is consistent with the literature:
- Many small part palpable
- Palpable large part of more than 1 fetus
- Palpable 2 heads, 2 ass and one / two backs

34

- There were two heart beats, which were located far from the speed difference of at
least 10 pulse permenit
Examination Support
In laboratory tests found no anemia which is a complication of most normal and twin
birth. This happens probably because the patient's intake of good nutrition and
activities that routine pregnancy testing performed by the patient.
Of ultrasound investigation of the impression obtained G2P1A0 H Aterm, gemelli
fetal presentation cephalic-breech intrauterin both life. These checks can ensure the
existence of multiple pregnancies and can estimate the weight of the fetus. So that it
can predict whether there is a discrepancy fetal growth. Widespread use of imaging
has ultrasonografik greatly reduce the incidence of twin gestation detection not before
delivery.
Procedure
In these patients planned vaginal partus because fetuses in length with a presentation
cephalic-breech. As in the literature "When I was treated as usual when the first child
lying lengthwise. After the first baby was born, soon carried out and a vaginal
examination to determine the location and condition of the second fetus. When the
fetus in the location of elongated, broken membranes and amniotic fluid flowed
slowly to avoid prolapse funikuli. Patients recommended or performed meneran
controlled pressure on the fundus uteri, to the bottom of the fetus into the pelvis. The
second fetus rapidly descending to the bottom of the pelvis and was born
spontaneously due to impassable roads have been born first child. "
Both spontaneous vaginal birth with an Apgar score of good, but at the time of
delivery of the placenta, the amniotic membrane and chorion was not examined.
Membranes should be examined to determine this from the baby so zigositas known
risks that may occur in the fetus.
By the time the second baby intervals with the first baby was 25 minutes this is not in
accordance with the literature that says that birth spacing should be the first and
second baby was 5-15 minutes, because it was feared would happen uteroplasenter
insufficiency. However, eventually the second baby was born with Apgar scores good
enough (8 / 9).

35

BAB V
CONCLUSSION
Twin pregnancy today there are about 3% of all pregnancies, and twin two
fetuses found in approximately 25-30% of labor resulting from assisted reproductive
technologies . Maternal morbidity and mortality was higher in twin pregnancies than
singleton pregnancies because of preterm labor, bleeding, and pregnancy Induced
hypertension.
Disorders in infants is more common in twin pregnancies, especially in
monozygotic twins. Therefore, more attention needs to overcome the twin
pregnancies during antenatal, delivery and postnatal mothers and babies.
ANC in pregnant women should be done regularly so that if there complication the
mother and baby can be resolved early. Ultrasound during pregnancy at least 3X, 1X
in each trimester to detect abnormalities early in pregnancy and to monitor the welfare
of the fetus and to determine the birth process.

36

DAFTAR PUSTAKA

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Obstetri and Gynecologi. 10Th ed. New York : Medical Publishing Division ;
2006. P 367 378
2. Cunningham FG, Gant NF, Leveno KJ, Gilstrap LC, Hauth JC, Wenstrom KD, et al ,
editors. Williams obstetrics, 21st ed. New York: McGraw-Hill; 2001

3. Harry, Oxorn B.A, Oxorn- Foote Human Labor and Birth. 5 th . New York :
Mcgraw-Hill ; 2000
4. Zach T, Pramanik A. Multiple birth : emedicine. May 2006 [diakses pada 9
Feb2007]:[1hal.].diunduh dari: http://www.emedicine.com/med/topics342.htm
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6. Keith, Edmons. Multiple Pregnancy. In Dewhurts Textbooks of Obstetric &
Gynecology. 7 Th. London : Blackwell Publishing ; 2007. P : 166 176.
7. R. Pinglli, V. bomigboye, K. Jegede. Multiple Pregnancy a Blessing or a
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Education For Multiple Pregnancy.2005 ;14 : 26 -35

37