Introduction

Twin pregnancies had by itself a very prominent place in human mythology since ancient times. Hindu mythology had enshrined the twins Luv & Kush, sons of Lord Ram. Ancient Rome was said to have been founded by the twins Remus and Romulus.1

Natural higher order multiple conceptions are usually uncommon. The reported incidence ranges from 0.01% to 0.07% of all pregnancies.2 Multiple births are much more common today than in the past. Throughout the world, the prevalence of twin pregnancies varies from approximately 2-20 /1000 live births. This surprising increase in multiple gestation rates can be explained by the social shift in women’s attitude regarding child bearing which has resulted in more women choosing to postpone child bearing in favour of work and career commitments. This delayed childbearing has resulted in an increased maternal age at conception, which in turn lead to infertility treatment such as ovulation induction, in vitro fertilization and intra cytoplasmic sperm injection as one of the predisposing factors of twin gestation, since fertility decreases with age.3

Multiple pregnancy is associated with higher risks for the mother and the babies singleton pregnancies. Women with multifetal pregnancies are at high risk of than miscarriage, anaemia, hypertensive disorders, postpartum haemorrhage, operative delivery and postnatal morbidity. The risk of pre-eclampsia for women with twin pregnancies is almost three times that for singleton pregnancies, while the risk for triplet pregnancies is increased by nine-fold. In general, maternal mortality associated with multiple pregnancy is 2.5 times that for singleton births. Women with multiple pregnancies are also more likely to have more marked symptoms of minor ailments of pregnancy (such as nausea and vomiting) than women with singleton pregnancies.4

Multiple pregnancy warrants special attention because they have considerable contribution to the maternal / perinatal morbidity/mortality as well in excess of that due to multiplication of singleton risk by fetal number.3 Overall complications occur in approximately 83% of twin pregnancies when compared to 25% in singleton pregnancies. Hence twin pregnancies are to be considered as high risk pregnancies. Vigilant obstetric care not only decreases the maternal morbidity and mortality but also helps to improves the fetal outcome.

Materials and Methods

Results and Discussion

In the present study, we considered twin and triplet pregnancies. The incidence of multifetal pregnancy was 1.55% in our institution for the year 2016. According to various studies conducted since the 1970s, the incidence of multifetal gestation was approximately 3%. Four of our subjects showed a positive family history, none of them had a past history of multiple pregnancy.

We noticed that the incidence of multiple pregnancy was highest in the age group 21-25yrs (55.6%)followed by the age group 26-30yrs(29.1%). The least incidence was seen in women above 31yrs(5.1%). The mean age calculated was 24.487. This may be due to the fact that majority of patients attending our outpatient department were of younger age group.

As for the incidence of multiple pregnancy with regards to the parity, we found that the highest incidence was among primigravidae (62.4%) and the least was in multi para with parity more than 3 (0.9%). The highest incidence may be because most of our patients were of younger age group and they were mostly primigravidae.

Highest incidence was for twins (113 cases) (96.6%). The incidence of triplets was (3.4%)(4 cases).

Dichorionic twin pregnancies had the highest incidence (72.6%) followed by monochorionic twins (25.6%).

In the present study we noticed that the maximum twin pregnancies were a result of spontaneous conception which was 75.2% followed by conceptions from ovulation induction with clomiphene citrate. Similar results were also noted in studies conducted by Amiben V. Gajera et al.5

57.3% of women never used any contraceptives, 30.8% used natural methods and 11.1% used barrier contraceptives. None of them used Oral Contraceptive Pills or Intrauterine Contraceptive Devices.

The incidence of polyhydramnios in our study was 1.7% and oligohydramnios was 14.5%. Both polyhydramnios and oligohydramnios were found in 0.9% which was a case of Twin Twin Tranfusion Syndrome. Since the incidence of Dichorionic Diamniotic twins were high in our study, oligohydramnios may be due to the independent risk factor for each twin.

Preterm labor complicated 25.6% of multiple pregnancies.(Figure 1) The incidence was comparable to those obtained from the studies conducted by Simi et al.6 The incidence were lower when compared to studies by Bhattacharya et al. (44%)and Bangal et al. (88%).7, 8

Figure 1

Antepartum maternal complications

In our study we found that 11.1% of multiple pregnancies were complicated by preterm premature rupture of membranes (Figure 1). This was similar to the study conducted by Wong L.9

Among the multiple pregnancies that we studied 4.3% were complicated by abruptio placentae and 0.9% were complicated by placenta praevia (Figure 1). The incidence of abruption placentae (3%) was comparable and placenta praevia (3%) was low when compared to the study conducted by Simi et al.6

Gestational hypertension complicated 12% of pregnancies (Figure 1). This was comparable to that of the study by Laine K et al. 10 (12.9%) and 0.9% were complicated by ecclampsia which was comparable to the study by Simi et al6 (0.5%).

In our study we found out that 12.8% of multiple pregnancies were complicated by gestational diabetes (Figure 1). Those on oral hypoglycemics was 6% and 0.9% were on insulin. 5.1% had gestational glucose intolerance. 0.9% had pre gestational diabetes. The incidences were comparable to the study conducted by Simi et al.6

The incidence of anaemia in our study was 34.2% (Figure 1). This incidence was higher when compared to the studies conducted by Simi et al. (21.5%).6

In our study 46.2% of women with multiple pregnancies delivered by 37 weeks of gestation, 32.5% delivered by 36 weeks, 7.7% delivered by 34 weeks and 13.7% delivered less than 34 weeks of gestation. This was comparable to the study conducted by Amiben V. Gajera et al5 (46% of the women delivered before 36 weeks of gestation and 18% delivered at 29 – 32 weeks of gestation.)

In our study 55.6% of multiple pregnancies were delivered by Lower segment Caesarian section(LSCS), whereas 39.2% delivered vaginally. 5.2% had operative vaginal deliveries with instruments (vacuum was used in 4.3% and forceps was used in 0.9%)(Figure 2).

Figure 2

Incidence of each mode of delivery

In our study, 17.9% of twin deliveries were complicated by postpartum haemorrhage. Out of the 21 cases of postpartum haemorrhage, 20 were medically managed and one of them required surgical intervention. The incidence was comparable to the study conducted by Simi et al. (17%).6

In the present study, 25% of vaginal deliveries were complicated by perineal tears which included 1^st degree tears of 4.3%, 3^rd degree tears of 4.3% and para urethral tears of 2.6%. Postnatal urinary retention was found in 2.6% of vaginal deliveries, 6% of mothers required catheterisation postnatally. All of them required catheterisation for < 1 week. Catheterization was done for atonic bladder. Those catheterised before caeserian section were not included in this group.

The need for antibiotics postpartum among multiple pregnancies were also studied. 72.6% of mothers required antibiotics, 9.4% required intra venous antibiotics.

Puerperal fever was noted in 17.1% of mothers and urinary tract infections were found in 4.3%. Those cases of fever were self limiting and may not be attributed to febrile morbidity.

Discordant growth among multiples were found in 32.5%, and in them significant discordancy (>25%) was found in 12%. This was comparable to the result of the study by Miller et al (16%)11

Incidence of twin transfusion syndrome in our study was found to be 0.9%. (1 case).

The incidence of prematurity among babies of multiple pregnancy was 53%.

In our study, the incidence of fetal loss was 3.4% (4 cases – 3 Intrauterine deaths and 1 Single fetal demise) 2.6% of the demise occurred in 30-35 weeks of gestation, and 0.9% between 20 –24weeks.

We found that in our study, the birth weights of 37.6%of 1^st babies and 36.8%of 2^nd babies lies within the group between 2 and 2.4kg. All the third babies of triplets were <2.5kg. The low birth weights can be attributed to increased incidence of prematurity and IUGR among multiple pregnancy. None of the babies weighed above 3.5kg. The incidence was low when compared to the study by Bangal et al. (showed an incidence of 82%).8

We found that in our study 83.18% of 1^st babies and 80.7% of 2^nd babies and all of the triplet babies required Neonatal Intensive care.

Out of the 94 first babies and 92 second babies and 4 third babies who required admission, 54.25% of 1^st babies and 54.38% of 2^nd babies were admitted because of prematurity, followed by hyperbilirubinemia. 75%of triplet babies were admitted due to prematurity.

95% of babies recovered. We had 7 Neonatal deaths (4 first babies and 3 second babies) 95.74% of 1^st babies and 96.74% of 2^nd babies recovered within 1 week.

Incidence of congenital anomalies was 5.1% for 1^st babies and 1.7% for 2^nd babies. This may also be due to an independent risk factor for babies in multiple pregnancy, majority being Dichorionic diamniotic pregnancy while Simi et al. reported 2.6%.6

During the postnatal visit, babies were checked for the adequacy of breast feeding, weight gain, otoacoustic emission testing and retinal examination. 85.58% of babies had adequate weight gain whereas 14.42% had weight gain <100g. 3.7% of 1^st baby,7.27% of 2^nd baby had abnormal otoacoustic emissions tests. With regard to the retinal examination test 2.78% of 1^st babies had abnormal test results.

We did not observe any maternal mortality in our study.

Conclusion

Multiple pregnancies should always be considered as high risk. Mothers carrying multifetal pregnancy should be properly counselled regarding all the complications and should be kept under constant monitoring.

Most of the complications in multiple gestations are usually preventable. High risk units in the obstetric ward and a well-developed neonatal intensive care set up would help to reduce the maternal, perinatal morbidity and mortality.

Inspite of all those advances, most of the complications remains the same, hence it needs further evaluation and necessary steps.

Source of Funding

None.

Conflict of Interest

None.