1.Muhammad Redzwan Bin Abdullah 081303583 Batch 25 Group E2

2. References http://www.rcog.org.uk/files/rcog-corp/uploaded-files/T51ManagementMonochorionicTwinPregnancy2008a.pdf http://emedicine.medscape.com/article/977234-overview Obstetric Today Hacker and Moores Essentials of Obstetrics and Gynecology 3. Definition Simultaneous development of more than one fetus inthe uterus 2 fetuses twins (commonest) Triplets, quadruplets etc 4. Incidence Hellins Law Twin = 1:80Triplets = 1:80 Quadruplets = 1:80 Monozygotic = 3-5/1000 births Dizygotic = varies depending on maternal age, race and geographical distribution 5. Aetiology Assisted reproduction techniques Increase parity Increase maternal age Family history Previous multiple pregnancy African race 6. Type of multiple pregnancy Dizygotic / binovular / fraternal 2. Monozygotic / Uniovular / identical 1. 7. Types of Monozygotic twins 1. Dichorionic Diamniotic : i. Division occurs with in 72 hrs of fertilization ii. May have 2 diff placentas/ single fused placenta iii.Difficult to differentiate form dizygotic twins iv.Both babies have same sex 2. Monochorionic Diamniotic: I. Division occurs with in 4 8 days of fertilization 8. 3. Monochorionic Monoamniotic: I. Division occurs 9-12 days of fertilization 4. Conjoined twins: I. Division occurs after 13th day II. Incomplete division of embryonic disc III. Types: -thoracopagus - omphalophagus-craniopagus -pyopagus -ischiopagus 9. Monozygotic / Uniovular / IdenticalDizygotic / binovular / fraternal1.1/3 twins1.2/3 twins2.1 sperm and 1 ovum2.2 sperms and 2 ova3.Identical3.Dichorionic Diamniotic twins4.Type of placenta depends on the time of splitting of embryo4.Presence of chorionic tissue between 2 amniotic sac5.Incidence is dependent of 5.Incidence is independent of race, age, parity, and race, age, parity ovulation inducing drugs 10. Clinical presentation Symptoms : nausea, vomiting pressure symptoms: constipation, pedal edema, varicosity of veins, palpitations, precordial painFatigue, indigestion, backache, sleeplessness H/O overdistension H/O premature labor Excessive fetal movements F/H, H/O ovulation inducing drugs 11. SIGNS : Anemia Edema Abnormal Weight Gain Uterine Height > POG It may be normal size in case of binovular twins/ when 1 of the babies die in utero Palpation: Feel 2 separate heads/ > 2 polesAuscultation : 2 FHS with difference of at least 10 beats heard on 2 sides of uterus by 2 people, at least 6 inches away 12. Role of ultrasound Confirmation of chorionicity Twin peak sign / Lambda sign = dichorionic placenta Identify the number and site of placenta, fuse orseparate Lie and presentation of twin Amniotic fluid assessment 13. Maternal Complication Antenatal : 1. Hyperemesis gravidarum 2. chances of abortion 3. hydramnios 4. PIH 5. Placenta previa, abruptio 6. Anemia 7. Exaggerated minor problems: pressure symptoms, etc 14. Intrapartum : 1. Prolonged labor (uterine inertia) 2. Malpresentation 3. Cord prolapse 4. Abruptio placenta for 2nd twin 5. PPH 15. Fetal complications 1. Preterm delivery 2. IUGR 3. Congenital Abnormalities 4. Cord abnormalities : 1. Single umbilical artery 2. Velamentous insertion 3. Cord entanglement 4. Cord prolapse 5. Monochorionic twins : 1. Discordant growth 2. Twin to twin syndrome 3. Single fetal Demise 16. Twin to Twin Trasfusion Syndrome 17. Twin to Twin Transfusion Syndrome Occur in 10-15% of monochorionic twins Mostly during 2nd trimester Due to imbalance of blood flow across placentalAV anastomosis Symptoms : sudden increase girth a/w extreme discomfort Signs : tense uterus with excessive liquor volume Ultrasound : Polyhydramnios in recipient.Oligohydramnios in donor 18. Donor twinRecipient twinHypovolemic & oliguric/anuricHypervolemic & polyuricResult in stuck twin phenomenon where the twin appears in a fixed position against uterine wallCan also develop HTN,hypertrophic cardiomegaly,disseminated intravascular coagulation,and hyperbilirubinemia after birthUltrasound may fail to visualize fetal bladder because of absent urineBoth twin can develop hydrops foetalis Donor can become hydropic because of anemia and high output heart failureRecipient becomes hydopic because of hypervolemia 19. Single Fetal Demise > in Monochorionic twin If one twin dies after 14wk,there is high risk ofneurological damage to survivor twin : due to thromboplastin release thrombotic arterial occlusion of ant & middle cerebral arteries multicystic encephalomalacia 20. Management of multiple pregnancy Antenatal care : Extra attention & diet: at least 300 kcal more than in normal pregnancy Routine iron and folic acid Detailed anomaly scan followed by serial growth scan at 28, 32 and 36 week Hospitalization if suspected pretem 21. RCOG recommended antenatal care DichorionicMonochorionic-Lead clinician with multidisciplinary team-Lead clinician with multidisciplinary team-US at 10-13wk : viability,chorionicity,NT:aneuploidyUS at 10-13wk : viability,chorionicity,NT:aneuploidy/T TTS-Structural anomaly scan at 20-22wk-US surveillance for TTTS and discordant growth at 16wk and then 2weekly-Serial fetal growth scan eg:24,28,32 then 2-4weekly-Structural anomaly scan 20-22wk (including fetal ECHO)-BP monitoring and urinalysis at 20,24,28 and then 2weekly-fetal growth scan 2wkly interval until delivery-Discussion of mothers/family needs relating to twins-BP monitoring and urinalysis at 20,24,28 then 2weekly 22. Timing of delivery Uncomplicated dichorionic by38 week Uncomplicated monochorionic by 37 week TTTS depend on current situation MCMA 32 week, by LSCS 23. Mode of delivery Depend on presentation of 1st twin Both vertex / 1st twin vertex vaginal delivery Indication for Elective LSCS -More than 2 fetuses -1st twin malpresentation, CPD -Scarred uterus -MCMA -Conjoint twin -IUGR in dichorionic twin -TTTS 24. Emergency LSCS :-Fetal distress -cord prolapse in 1st baby -Non progress of labor -2nd twin is transverse, version failed after delivery of 1st twin 25. Management during labour 1st stage 1.2. 3. 4. 5. 6.Determine the presentation of 1st twin Maintain partogram Keep NBM and establish IV line Blood grouping and cross matched Continous intrapartum twin CTG monitoring Analgesic 26. Management during labour 2nd stage 1. Delivery of 1st twin2. Clamp and cut the cord 3. Note lie of the 2nd twin (delivered within 20 min) 4. Longitudinal lie (abdominally & vaginally) :Start 2 units of pitocin IV drip Cephalic Fix the head into pelvisARM & deliver the fetus Breech Assisted breech delivery, Breech extraction 27. If 2nd twin has transverse lie : Assistant performs ECV. Fix the head in lower pole of the uterus and accoucher performs controlled ROM (rupture of membrane) If this fails: do IPV (internal podalic version) followed by breech extraction Or proceed with emergency LSCS 28. Thank You Copyrights not reserved. xx 2013-05-03