A multiple pregnancy is the development of two or more fetuses in a pregnant uterus. It is a high-risk pregnancy associated with significantly higher rates of maternal and perinatal morbidity (illness) and mortality (death).

Classification:

• Dizygotic twins (fraternal twins): results from fertilisation of two separate ova by two spermatozoa. The sex of the fetus may be same or different. The blood group is usually different In multiple dizygotic pregnancies; each fetus has its placenta (either separate or fused), amnion and chorion. In monozygotic multiple pregnancies, the situation is more complex depending on the timing of the division of the ovum.
  
• Monozygotic twin (identical twin): results from the division of a single zygote. The fetus always has the same sex, and they have one chorion and amnion, one placenta the blood group is always the same.

Family and personal history:

• Family history of twins particularly on the maternal side.
• History of ovulation inducing therapy.
• Excess maternal weight gain.
• Breathlessness during later months of pregnancy.
• Excessive vomiting, oedema.

Physical findings:

• A parus woman may present as a big abdomen.
• Anemia, PIH (Edema all over, hypertension, proteinuria).
• Fundal height is large for the date.
• Palpation of more than one head or breech.
• Two fetal heartbeats heard at the same time by two observers and differing in rate by at least 10 beats per minute.
• The ultrasound examination can give us a final diagnosis of a twin pregnancy.

Consequences:

A multiple pregnancy is considered high-risk because:

• Smaller babies: fetuses tend to be individually smaller than those in a singleton pregnancy because of greater demand for nutrients and slower in utero growth, i.e., light-for-dates. Monozygotic twins tend to be smaller than dizygotic twins.
• Increased risk of prematurity: the mean gestation for twins is 37 weeks and for triplets 31 weeks. In particular, there is a higher risk of spontaneous preterm birth if they have had a spontaneous preterm birth in a previous single pregnancy. There is insufficient evidence to support the use of vaginal progesterone, bed rest at home or in the hospital, cervical cerclage or oral tocolytics to prevent prematurity.
• Higher risk of congenital abnormality associated with multiple pregnancies
• Perinatal mortality rate for twins is significantly higher than single and even higher for triplets. Rates are higher for monochromic twins than dizygotic twins.
• Higher rate of maternal pregnancy-related complications, such as hyper emesis gravidarum, polyhydramnios, pre-eclampsia, anemia, ante partum haemorrhage.
• Higher rate of complications in labour - malpresentation, vasa praevia, cord prolapse, premature separation of the placenta, cord entanglement, postpartum hemorrhage.
• Pressure symptoms may occur in late pregnancy due to the increased weight and size of the uterus.

Management:

• During ANC time screening and refer to the health centre 30-34weeks.
• During labour, do not try to attempt to manage labour and deliver in the health post level , try to refer her urgently to a higher health institution.