Date post: | 06-May-2015 |
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MULTIPLE PREGNANCY
By: Dr Syuhadah
Mentor: Dr Hasniza
MULTIPLE PREGNANCY Definition: Any Pregnancy in which 2 or
more embryos or fetuses occupy the uterus simultaneously
Increased incidence (assisted reproductive technology)
Twins account for about 1% of pregnancies
Hellins law (80 n-1)- Twins → 1 in 80- Triplets → 1 in 802 - Quadruplets → 1 in 803
PREDISPOSING CONDITIONS ↑maternal age and parity Assisted reproduction
techniques - Ovulation induction agents (gonadotropins)- In-vitro fertilization (IVF)
Family history
GENESIS OF TWINMonozygotic VS Dizygotic
TYPES OF TWINS Monozygotic twins (identical)
Originate by fertilization of single ovum by single sperm.
The twinning may occur at different periods after fertilization and this influences the process of implantation and the formation of the fetal membranes.
TYPES/CLASSIFICATION OF TWINNING
Monozygotic/ identical/uniovular
(1 zygote divide into 2) ~33%
Dichorionic Diamniotic
(cleavage of embryonic
egg <3days )~30%
MONOchorionic Diamniotic
(4-8days)~69%
MONOchorionic
MONOamniotic(9-12days)
~1%
MONOZYGOTIC @ UNIOVULAR
DIZYGOTIC @ BINOVULAR Dizygotic twins
(non-identical )
Results from fertilisation of two ova by two sperms.
Dichorionic and diamniotic twins.
CLINICAL PRESENTATIONA. History Taking Family history of multiple
pregnancy Recent infertility treatment Excessive nausea and
vomiting Excessive lower limb
swelling and varicosities Excessive fetal movement
and abdomen overdistension
Extremely fatigue
CLINICAL PRESENTATIONB. Physical Examination Anaemia & oedema Raised BP Uterus larger than dates Polyhydramnios (> in monozygotic
twins) Multiple fetal parts & poles > 1 heart sound with different rates Abnormal weight gain
WAYS TO DETERMINE ZYGOSITY, CHORIONICITY Zygosity
Ultrasound- => Gender discordance = dizygotic DNA fingerprinting, from amniotic fluid
sample (amniocentesis), placental tissue (chorionic villi sampling) and fetal blood (cordocentesis)
Chorionicity Characteristic of membrane(US)-
A: Thick amnion-chorion septum, Twin-peak sign (lamda sign)~dichorionic
B: Thin amnion-chorion septum, The "T sign" ~monochorionic
Why so important to differentiate???
Prenatal diagnosis of chorionicity is important as monochorionic pregnancies have increased rates and severity of all types of obstetric complications when compared with dichorionic pregnancies.
COMPLICATIONS
Maternal • ↑ Sx of early pregnancy (↑HCG)• Miscarriage • Anaemia (↑ Fe,folate & B12 )• Polyhydramnios (uniovular twins)• PIH (↑3-5x)• APH (placenta praevia)• PPH (uterine atony d2 over
stretching)• GDM (↑diabetogenic placental
hormones)• Ineffective labour
(malpresentation)• Thromboembolic ds (↑pelvic vein
compression)
Fetal
• Single fetal death• Preterm labour (d2
overdistended uterus, polyH, intrauterine infection)
• IUGR (discordant growth)• Stillbirth• Congenital abnormality • Twin to twin transfusion
syndrome• Asphyxia (cord
entanglement)• Intrauterine death
TWIN-TO-TWIN TRANSFUSION SYNDROME (TTTS)
TTTS is found in MCMA as well as MCDA pregnancies.
TTTS is more common in MCDA pregnancies than MCMA pregnancies, possibly reflecting that there are more protective artery–artery anastomoses in the latter.
Rarely (in approximately 5% of cases), the transfusion may reverse during pregnancy, with the donor fetus demonstrating features of a recipient fetus and vice versa
Unequal placental sharing and peripheral, ‘velamentous’ cord insertions are common in TTTS
Affects 10-15% of monochorionic twin pregnancies.
Pathophysiology: Result of transfusion of blood from donor
to recipient twin through abnormal artery-to-vein anastomoses in the placenta
The donor suffers hypovolaemia and hypoxia → IUGR, smaller in size, oligohydramnios & high output cardiac failure
The recipient fetus exhibit hypervolemia → large size, polyhydramnios, cardiomegaly, CCF
More than 90% ends in miscarriage/severe preterm delivery
To monitor: US doppler 2 weekly
Management:I. Laser coagulation – occlude the vascular
anastomosis between twins (presenting prior to 26weeks of gestation)
II. Amnioreduction every 1 - 2/52, drain amniotic fluid from recipient sac
III. Septotomy (cord entanglement risk)
IV. Anticipate preterm delivery – corticosteroid (promote fetal lung maturity
SINGLE FETAL DEMISE Occur in monochorionic twin Fetal demise <14weeks-not increase risk
on the survivor twin Confers risk to survivor twin if fetal
demise after 14 weeks. Dt transfer of thromboplastin from dead
twin > produce thrombotic arterial occlusion > occlusions of ant & mid cerebral arteries > multicystic encephalomalacia & neurologic damage.
Induce consumptive coagulopathy in mother.
MANAGEMENT OF MULTIPLE PREGNANCY
Antenatal Intrapartum
ANTENATAL MANAGEMENT
• All women with a multiple pregnancy should be offered an ultrasound examination at 10–13weeks of gestation to assess:
I. viabilityII. chorionicityIII. major congenital malformationIV. nuchal translucency for designation of
risk of aneuploidy and twin-to-twin transfusion syndrome.
DICHORIONIC TWINS
1. Ultrasound at 10–13 weeks: (a) viability; (b) chorionicity; (c) NT: aneuploidy
2. Structural anomaly scan at 20–22 weeks.3. Serial fetal growth scans e.g 24, 28, 32 and
then two- to four-weekly.4. BP monitoring and urinalysis at 20, 24, 28
and then two-weekly.5. 34–36 weeks: discussion of mode of delivery
and intrapartum care.6. Elective delivery at 37–38 completed weeks.7. Postnatal advice and support (hospital- and
community-based) to include breastfeeding and contraceptive advice
MONOCHORIONIC TWINS1. Ultrasound at 10–13 weeks: (a) viability; (b)
chorionicity; (c) NT: aneuploidy/TTTS2. Ultrasound surveillance for TTTS and discordant
growth: at 16 weeks and then two-weekly.3. Structural anomaly scan at 20–22 weeks (including
fetal ECHO).4. Fetal growth scans at two-weekly intervals until
delivery.5. BP monitoring and urinalysis at 20, 24, 28 and then
two-weekly.6. 32–34 weeks: discussion of mode of delivery and
intrapartum care.7. Elective delivery at 36–37 completed weeks (if
uncomplicated).8. Postnatal advice and support (hospital- and
community-based) to include breastfeeding and contraceptive advice.
ANTENATAL MANAGEMENT Dietary advice: adequate caloric intake to
meet increased demands, supplement of iron (60-80 mg /day), folic acid, calcium, vitamins
Monitor for infection, anaemia, PIH, preterm labour & malpresentation
Corticosteroid if strong possibility of preterm labour (for lung maturity)
CRITERIA FOR VAGINAL DELIVERY FULFILLED
1. Leading twin is cephalic
INTRAPARTUM MANAGEMENT OF TWINSCriteria for vaginal delivery fulfilled
Deliver the 1st twin
Clamp and cut the cord
Note lie of 2nd twin
Transverse lie Longitudinal lie
Attempt External Cephalic Version and vaginal delivery under GA
If unsuccessful C-section
Amniotomy with controlled oxytocin infusion if there is
uterine inertiaNote presentation
Vertex Breech
Vaginal delivery or optionally outlet forceps or
ventouse
Breech extraction or assisted breech
delivery
MANAGEMENT OF THIRD STAGE OF LABOUR
In PIH and cardiac disease: give oxytocin 10 unit i.m
Syntometrine 1 ml (5 unit oxytocin and 500 mcg ergometrine i.m) with delivery of anterior shoulder of 2nd baby
Placenta delivered with controlled cord traction In high risk of uterine atony and PPH, i.v
infusion 40 units oxytocin over 6 hours after delivery)
Episiotomy/perineal repair if needed
INDICATION OF CAESAREAN SECTIONi) ELECTIVE
1st baby non-cephalic especially shoulder
Conjoined twins Congenital abnormality
precluding safe vaginal delivery
IUGR in dichorionic twin Chronic TTTS Monoamniotic twin Placenta praevia Triplets or more Contracted pelvis Previous C-section Pre-eclampsia
ii) EMERGENCY Fetal distress Cord prolapse in 1st
baby Non-progress of
labour Collision of both
twins 2nd twin transverse,
version failed after 1st delivery of twin
THANK YOU….